Could virtual simulation improve trainees’ skills in cardiac catheterisation?


A pilot study, published in Circulation: Cardiovascular Interventions, found that mentored simulation may help less proficient cardiac catheterisation operators to improve their skills.

Akshay Bagai, Terrence Donnelly Heart Centre, St Michael’s Hospital, Toronto, Canada, and others wrote that the traditional apprenticeship approach of teaching cardiac catheterisation—of trainees practising on real cases and, after gradually learning the procedure, teaching the procedure to other trainees once they are proficient—adds time to  real-life procedures, which may lead to increased costs and decreased efficiency. They added: “Moreover, the catheterisation laboratory may not be the ideal educational environment, where training often occurs by chance, leading to increase in trainee stress, which may have a negative effect on the learning process.”

Bagai et al reported that virtual reality simulators have been shown to be effective in various areas of medicine (such as reducing intraoperative errors during laparoscopy) and that a variety of cardiac catheterisation simulators have been developed for interventional cardiologists for practising complex procedures, such as bifurcation lesions and chronic total occlusions. They noted: “The effectiveness of simulators in skill acquisition regarding diagnostic cardiac catheterisation has not be studied. The aim of this pilot study was to evaluate the effectiveness of mentored simulator training on skill acquisition and transferability of skills from a simulated environment to the cardiac catheterisation laboratory.”

In Bagai et al’s study, each of the 27 trainees, from an adult cardiology training programme rotating on a cardiac catheterisation service, performed two consecutive diagnostic cardiac catheterisation procedures under supervision. All procedures were restricted via the femoral arterial access site because the simulator used in the study only had a femoral access port. The trainees then received teaching in the form of a lecture on the tools most commonly used to perform cardiac catheterisation and teaching on the stepwise sequencing of the procedure. Afterward these initial phases of the study, participants were randomised to receive cardiac catheterisation simulation training (12) or no simulation training (15).

Participants in the simulator group used the Vascular Intervention Simulation Trainer (Mentice Vist), which is a high-fidelity cardiac catheterisation simulator that has a mechanical unit housed within a mannequin cover, a high-performance desktop computer, and two display screens. As well as receiving simulator training, participants also received mentored training until they reached a predesigned level of proficiency to be able to complete one procedure without being prompted or helped. All participants in the study, both in the control group and the simulator group, continued to received standard medical education with the traditional apprenticeship model.

Compared with the control group, the simulator group had a significantly greater improvement in their technical performance score compared with their baseline levels (p=0.04). They also had a greater improvement in their global rating score than the control group, but this difference was not statistically significant. Bagai et al reported: “The difference in post-intervention technical performance score between the simulator and control groups was greater for trainees with lower baseline scores compared with trainees with higher baseline scores (p=0.0006).” They added that the difference in improvement in global performance scores, between the simulator group and the control group, was also more evident in participants with lower baseline scores.

The authors commented: “Greater magnitude of benefit of simulator training was observed in trainees with less proficient at baseline, compared with more proficient trainees. These results are not surprising, given that skills learned and practised on the simulator were basic, fundamental skills to perform cardiac catheterisation and, therefore, trainees already proficient at baseline were less likely to improve as much as with the intervention.”

They added: “Further studies are required to determine time and cost implications, and most efficient utilisation of mentored simulator training as a complementary educational tool in general cardiology training programmes.”

Neil Fam, St Michael’s Hospital, Division of Cardiology, Toronto, Canada, co-author of the study, said to Cardiovascular News: “Traditionally, cardiac catheterisation has been learned via the apprenticeship model of ’see one, do one, teach one’. However, this exposes the patient to a small, but definite risk while the trainee is learning the procedure. Instead, having residents acquire the necessary technical and cognitive skills on a simulator leads to the development of a ’pre-trained novice’, who is better prepared to both perform and learn in the cath lab. Simulation training has been shown to improve technical skills and patient safety in surgery, and it makes sense that the same would hold true in the cath lab. The response from residents has been very enthusiastic, and given the positive results of our study, we have now incorporated simulation into our cardiac cath rotation.”