Skills required to perform safe and successful cardiac catheterization can be learned via mentored simulation training and are transferable to actual procedures in the cath lab, according to a study published online October 9, 2012, ahead of print in Circulation: Cardiovascular Interventions. The findings also show that less proficient operators derive greater benefit from simulator training than those with greater technical expertise.

Neil Fam, MD, of St. Michael’s Hospital (Toronto, Canada), and colleagues randomized 27 cardiology trainees to mentored training on a virtual reality simulator (n = 12) or no simulator training (n = 15) from January 2010 to November 2011. The trainees were graded on technical performance, earning up to 44 points for separate fundamental tasks in performing cardiac cath, and on global performance, earning up to 48 points.

Technical, Global Performance Assessed

Among the 26 (96.3%) participants who completed the study, median technical performance scores at 1 week were higher compared with baseline in the simulator group (24 vs. 18; P = 0.008) but not the control group (20 vs. 18; P= 0.054). Thus, the median change in technical performance score was higher in the simulator group than the control group (6 vs. 1; P = 0.04).

In addition, median global performance scores were higher than baseline for both the simulator (24 vs. 17; P = 0.01) and control (20 vs. 18; P = 0.02) groups. While the simulator group showed greater improvement in global score compared with controls, the difference was not significant (5 vs. 2; P = 0.11).

Lower scores at baseline were associated with larger differences in postintervention scores between the simulator and control groups (technical performance P = 0.0006; global performance P < 0.0001). Furthermore, within the simulator group, novice trainees (< 50 cases) had lower baseline technical and global scores compared with experienced trainees (≥ 50 cases). The predicted intervention effect in both technical performance and global performance scores was higher in novice trainees compared with more experienced trainees.

Structured Curriculum, Feedback Are Advantages

Compared with conventional training methods which are “dependent on the random case mix of patients presenting to the catheterization laboratory,” simulation training involves a “structured learning curriculum comprising methodical exposure to fundamental procedural skills and clinical scenarios,” the authors write, adding that trainees are more easily able to ask questions and receive feedback in simulator training without putting an actual patient at risk.

Simulators are not new in cardiology training, they continue, and their potential benefits are well recognized, but “the evidence for transfer of these skills from the simulated environment to actual practice on patients has been mixed,” Dr. Fam and colleagues write. Reasons for this may include variability in simulator design and functionality, training and mentoring methods, means of assessment, and study endpoints.

According to the investigators, keys to ensuring performance improvement through simulator training include setting a proficiency benchmark that all trainees must reach, expert mentoring alongside the simulator device, and utilizing technical and global checklists that are representative of skills needed in an actual cath lab.

Future studies, they conclude, should be designed “to determine time and cost implications, and most efficient utilization of mentored simulator training as a complementary educational tool in general cardiology training programs.”

Expert Mentoring Needed, Too 

In an e-mail communication with TCTMD, Roberto De Ponti, MD, of the University of Insubria (Varese, Italy), said that “simulator training is superior to conventional training,” adding that it “is particularly useful in the early phase of the learning curve.”

In addition, adding an expert mentor to the training process is vital because “the tutor shows the procedure on the simulator and guides the first steps of the trainee, correcting the recurrent errors,” he said. “In most of the cases, a simulator cannot be the teacher by itself. It is a powerful tool in the hands of the teacher to teach the procedure and the trainee to learn it.”

The main advantages of the simulator include a shorter, more intensive training opportunity and the avoidance of “exposure of patients to the early phase of the learning curve,” Dr. De Ponti noted.

“Future research should be aimed at validating more complex simulators for interventional cardiovascular procedures and then assessing their clinical usefulness in randomized multicenter studies,” he concluded. “Time and resources for this are an issue, so far.”

Study Details

Participants in both groups were of similar age and had comparable training backgrounds, but there were fewer men in the simulator group than the control group (46% vs. 87%).

Simulator training was conducted using the Mentice Vascular Intervention Simulation Trainer (Mentice AB, Gothenburg, Sweden). A simulator is connected to a computer with dedicated software that generates 3-D models of the cardiovascular system. Through ports in the touch-sensitive device, trainees can insert, manipulate, and position catheters and other devices under virtual fluoroscopy that is visualized on a computer screen.

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