Simulation Training Superior for Learning Transseptal Catheterization

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Compared with conventional training, simulator training shortens the learning curve and produces superior performance among electrophysiology fellows learning transseptal catheterization, according to a small pilot study published in the July 19, 2011, issue of the Journal of the American College of Cardiology.

For the 2-center study, Roberto De Ponti, MD, of the University of Insubria (Varese, Italy), and colleagues randomized 14 fellows inexperienced in transseptal catheterization to undergo training via a computer-based simulator or a conventional hands-on approach in which tutors supervised trainees practicing on actual patients. After training, each fellow was required to act as the primary operator while performing the catheterization technique in 3 consecutive patients. Procedures were supervised and graded by an expert physician blinded to the fellows’ assigned training modalities.

Faster Learning, Better Performance

Baseline characteristics were well matched between the 2 training groups. The median time required to complete training was longer with the conventional method than with the simulator (30 vs. 4 days; P = 0.0175). Conventionally trained fellows all performed 5 tutored procedures, while simulator-trained fellows performed a median of 43 virtual procedures (range, 35-81). Based on their knowledge and skills, all trainees were judged ready to conduct transseptal catheterization independently.

A total of 42 procedures were performed by the 14 fellows following their training periods, with similar levels of case difficulty observed in both groups. No early or late complications occurred, although 1 procedure performed by a conventionally trained fellow was stopped by the supervisor after the operator failed to aspirate the transseptal sheath before contrast injection.

The study’s primary endpoint was a composite performance score. On a 100-point scale that considered workflow and other measures of ability, the simulator group had higher median performance scores than the conventional group (95 vs. 68; P = 0.0001). Moreover, conventionally trained fellows showed more variability in their performance and were more prone to mistakes: All 7 made recurrent errors (median 3), whereas only 3 fellows in the simulator-trained group made errors, each of which happened only once (P = 0.0006).

Unlike Patients, ‘You Cannot Hurt the Simulator’

Simulator training improved performance for 2 reasons, Dr. De Ponti told TCTMD in an e-mail communication: Virtual reality made it possible for trainees to be exposed to a higher number of procedures in a shorter time period, and the system helped trainees improve as they learned. “Trainees were able to test their independent performance (without immediate feedback by the tutor) during their training time, while later they received corrections by the tutor based on the report generated by the simulator,” he said. “This resulted in self-correction of their errors and improved the quality of learning.”

Importantly, this type of learning “cannot be easily replicated in patient-based procedures without endangering patients' safety,” Dr. De Ponti stressed.

In a telephone interview with TCTMD, Giora Weisz, MD, of Columbia University Medical Center (New York, NY), noted that transseptal catheterization is the sort of procedure that is particularly well-suited to simulator training. “Very few people know [the technique] and have the experience and numbers to do this procedure, so a simulator can really shorten the learning curve,” he said, adding that there is increasing interest in transseptal catheterization with the expansion of treatments for structural heart disease.

“The advantage of doing it with a simulator is that it is a relaxed environment. The trainee can do the procedure again and again and again, without a human being around. You cannot hurt the simulator,” Dr. Weisz commented. Although the system cannot fully capture the feel of working on a human being, it comes close, he said. For instance, although all the tools used with a simulator are real in their proximal part, the distal end is simulated.

Dr. Weisz added that an additional benefit to simulator training is that a good library of cases can provide experience with anatomical variation. However, he noted, the greatest benefit from simulator training occurs in the short term. “If you check the same fellows 10 years from now, they will be the same [regardless of their initial training method, but] it can really expedite the procedures and improve the safety and overall training process,” he said. “It’s a very positive thing.”

Trends in Training

Both Drs. De Ponti and Weisz agreed that less buzz surrounds simulators than in the past.

Dr. Weisz explained that this is partly because the technology is no longer considered novel. “People talk about new things. Simulators themselves have not changed much,” he noted. Another problem, he said, is that simulators are expensive, ranging from $100,000 to $250,000. Hospitals do not typically purchase them. Instead, device companies may organize courses or training may be provided at conferences.

The hype surrounding simulators hit its peak about 5 years ago, Dr. Weisz said, when carotid stenting first gained approval. Carotid device companies “infused a lot of resources into simulators because they needed them [to train operators in the new procedure]. This was very good for the simulation industry and development,” he noted.

But interest in simulators gradually waned, Dr. Weisz continued. Today, most simulation efforts have been directed into structural heart disease treatments, aortic valve interventions, and relatively rare procedures like stenting for abdominal aortic aneurysm.

Dr. De Ponti suggested that institutions can collaborate to cover the expense of training and to make sure the equipment is fully used. “It is hard to say what the scenario of medical education will be in 3 to 5 years’ time,” he said, but even so, “universities, hospitals, and educators should still allot some money for simulator training.”

In part, simulators may be less discussed now because there is less skepticism about them than there was 5 years ago, Dr. De Ponti said. And while the technology is being received with growing enthusiasm, its development in the field of cardiology is relatively slow, he added.

Study Details

Simulator training was conducted using the Procedicus VIST (Mentice AB, Gothenburg, Sweden; Biosense Webster, Diamond Bar, CA). 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 necessary devices under virtual fluoroscopy that is visualized on a computer screen.

 


Source:
De Ponti R, Marazzi R, Ghiringhelli S, et al. Superiority of simulator-based training compared with conventional training methodologies in the performance of transseptal catheterization. J Am Coll Cardiol. 2011;58:359-363.

 

 

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Disclosures
  • Dr. De Ponti reports serving as a consultant for Biosense Webster.
  • Dr. Weisz reports no relevant conflicts of interest.

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