Training for minimally invasive cardiac surgery

Minimally invasive cardiac surgery has experienced a meteoric rise since its development in the 1990s. The first thoracic aortic stent graft was placed in July 1992, at Stanford (Calif.) University. Five years later, the Stanford group published their approach to mitral valve surgery through a right anterior thoracotomy. Just a year later, Dr. Alain Carpentier performed the first robotic-assisted mitral valve operation.1 There has been an explosion of new techniques, broadening the cardiac surgeon’s armamentarium far beyond the typical median sternotomy and occasional left thoracotomy.

While many of these techniques will undoubtedly become historical footnotes, it is clear that minimally invasive cardiac surgery is here to stay, as 20% of mitral repairs are performed with some element of minimally invasive technique. Similarly, thoracic endovascular aortic repair has become a well-established treatment for aneurysmal disease and dissection of the thoracic aorta, and is rapidly catching up with open repair as the treatment of choice.²

Training has also changed. The last decade brought a surge of applications to traditional fellowship programs, and the integrated thoracic surgery programs graduated their first trainees last year. With the variety of new operations and techniques, novel training formats, and professional goals for cardiothoracic surgery trainees, how can we be sure that young cardiac surgeons are learning the skills they need to succeed in the coming decades?

To ask how new surgeons should learn, you must start by asking what needs to be learned. After I asked a number of different surgeons in a variety of practice set-ups, the answer became obvious, and it is deceptively basic. The purpose of training is simply to ensure that each trainee can do all of the commonly performed operations of their specialty. This includes open valve and coronary surgery on the cardiac side, while for thoracic surgery, this includes all of the traditional lung and esophageal resections, chest wall and pleural operations, and importantly, the widely practiced VATS lobectomy. When I asked about more advanced VATS skills and minimally invasive cardiac skills, I was always told that those would be icing on the cake, as it were, to make a graduate more valuable to a potential employer. The first step in learning a minimally invasive operation is to understand the traditional, open approach, and VATS lung surgery is no different.

The VATS lobectomy has been a recent but well-received addition to the expected repertoire of graduates, and Dr. Chadrick Denlinger, associate professor of surgery at the Medical University of South Carolina, Charleston, allows his chief residents to take other trainees through the case, and expects that all new graduates can do one. Across the coast, Dr. Joseph Woo, newly appointed chair of cardiovascular surgery at Stanford, agrees. This expectation alone informs us that our specialty is dynamic and that the definition of an essential skill is in constant flux. On the other hand, cardiac surgery has no touchstone or standard minimally invasive procedure. However, Dr. Woo explains, the ABTS has set its recommendations in anticipation of the continued success of minimally invasive approaches to cardiovascular problems. The board doesn’t require mastery of any specific minimally invasive cardiac operation by the end of a training program, but it does require that we are exposed to a number of different endovascular and nontraditional approaches to coronary, valve, and aortic surgery. Coupled with our presumed mastery of the standard, open operations, we should then have the basic skills necessary to learn whatever minimally invasive operations we like, depending on our interests and our post-training mentorship.

Of course, the safety and efficacy of thoracic aortic stent grafting and minimally invasive mitral surgery have already been proven to some degree, and the operations aren’t going away anytime soon.^3,4 So what is stopping us from learning this stuff during our training? The answer is complicated. Dr. Woo cites the lack of visualization for two surgeons, the difficulty in preventing and controlling technical complications in a limited field, and the very nature the operations themselves.

Take, for example, the minimally invasive mitral valve repair. Its open counterpart requires a skill set that few trainees, if any, can claim mastery of until the very end of their training. The skill required, patient selection, and pathology treated make the operation sort of a "boutique" treatment. The patients that are offered right thoracotomy approach tend to be younger, less symptomatic, and with less complex disease. They have higher expectations. As Dr. Woo put it, "if you perform an absolutely perfect repair, then you’ve only done your job. But there is no way to do any better." With that sort of standard, many attending surgeons are hesitant to hand over the instruments to a trainee. Furthermore, not every resident’s technical ability lines up with what is required of that interest, and more importantly, not every resident is interested. Because of the highly specialized nature of the operation, the relatively smaller patient base, and the technical difficulty involved, it is often up to the highly motivated fellow or resident to gravitate to these repairs and seek out the training on their own.

Dr. James Fann, cofounder of the annual TSDA boot camp and a national surgical education leader, has some perspective on the matter. If residents are interested in gaining added endovascular or minimally invasive skills, he suggests, they first have to prove themselves in the operating room. When they’ve mastered the skills for an open technique and have proven they can get out of trouble, then an attending might feel comfortable letting them take on these more complex cases. It takes a combination of skill and interest – and as only a minority of trainees will have both, most training programs do not require that every TEVAR or mini-mitral be staffed with a resident.

It seems that simulation does not provide an easy shortcut beyond this approach, though it does have a role. To be honest, I expected Dr. Fann to preach the simulation gospel, and tell me about some incredible TEVAR or TAVR simulator he was getting ready to unveil, but his response was far more measured. "The role of simulation," he said, "is not to teach a resident how to operate. It is an adjunct – a tool that can be used to identify and address specific technical issues outside of the operating room." He reinforced the importance of mastering traditional surgical techniques before embarking on miniaturization. Simulation can help trainees operate more efficiently and effectively, but it cannot and should not replace mentored operative experience.

MICS simulation does exist, as anyone who has worked with Dr. L. Wiley Nifong and Dr. Randolph Chitwood’s high-fidelity tissue simulators for minimally invasive mitral valve repair knows. Simbionix USA (Cleveland) has just obtained FDA clearance for its TEVAR simulator that can be tailored to rehearse an upcoming case using a patient’s CT scan. On the lower end of the cost spectrum, a Dutch group and a separate Hannover group have developed low-cost, reproducible models of mini-mitral surgery that can be built from materials from a hardware store.⁵ Again, all of these tools are designed to be adjuncts to experiential training and mentorship, not mentors in and of themselves.

Residents can and should be exposed to TEVAR, TAVR, mini-mitral repair, and other less invasive approaches that are offered at their institution if they are interested. These, along with any other skills beyond traditional open techniques, make the surgeon better. More importantly, they help the trainee gain the basic wire and small incision skills they will need to learn quickly any newly developed operations that the changing specialty requires. They may not master the skills as a resident, but they are that much more prepared to hone those skills with their mentors when that time comes. In fact, the faculty I spoke with placed far more emphasis on mentorship after residency than aggressive residency training, simulation, and superfellowship as the key to gaining these advanced skills. Trainees should be soaking up all of the skills that they possibly can while they can, and if one is smart, ambitious, and skilled enough to become technically proficient at a more technically advanced skill, it certainly makes them a more desirable surgeon. For most of us, however, it is more important to realize that the training never truly ends, to take advantage of the opportunities afforded by residency, and to continue getting those reps in the OR.

References

1. Cardiac Surgery in the Adult, 4e. New York, N.Y.: McGraw-Hill; 2012.

2. J. Thorac. Cardiovasc. Surg. 2012; 144:612-16.

3. Circulation 2013;6:407-16.

4. Ann. Cardiothorac. Surg. 2013;2:744-50.

5. Interact. Cardiovasc. Thorac. Surg. 2013;16:97-101.

Minimally invasive cardiac surgery has experienced a meteoric rise since its development in the 1990s. The first thoracic aortic stent graft was placed in July 1992, at Stanford (Calif.) University. Five years later, the Stanford group published their approach to mitral valve surgery through a right anterior thoracotomy. Just a year later, Dr. Alain Carpentier performed the first robotic-assisted mitral valve operation.1 There has been an explosion of new techniques, broadening the cardiac surgeon’s armamentarium far beyond the typical median sternotomy and occasional left thoracotomy.

While many of these techniques will undoubtedly become historical footnotes, it is clear that minimally invasive cardiac surgery is here to stay, as 20% of mitral repairs are performed with some element of minimally invasive technique. Similarly, thoracic endovascular aortic repair has become a well-established treatment for aneurysmal disease and dissection of the thoracic aorta, and is rapidly catching up with open repair as the treatment of choice.²

Training has also changed. The last decade brought a surge of applications to traditional fellowship programs, and the integrated thoracic surgery programs graduated their first trainees last year. With the variety of new operations and techniques, novel training formats, and professional goals for cardiothoracic surgery trainees, how can we be sure that young cardiac surgeons are learning the skills they need to succeed in the coming decades?

To ask how new surgeons should learn, you must start by asking what needs to be learned. After I asked a number of different surgeons in a variety of practice set-ups, the answer became obvious, and it is deceptively basic. The purpose of training is simply to ensure that each trainee can do all of the commonly performed operations of their specialty. This includes open valve and coronary surgery on the cardiac side, while for thoracic surgery, this includes all of the traditional lung and esophageal resections, chest wall and pleural operations, and importantly, the widely practiced VATS lobectomy. When I asked about more advanced VATS skills and minimally invasive cardiac skills, I was always told that those would be icing on the cake, as it were, to make a graduate more valuable to a potential employer. The first step in learning a minimally invasive operation is to understand the traditional, open approach, and VATS lung surgery is no different.

The VATS lobectomy has been a recent but well-received addition to the expected repertoire of graduates, and Dr. Chadrick Denlinger, associate professor of surgery at the Medical University of South Carolina, Charleston, allows his chief residents to take other trainees through the case, and expects that all new graduates can do one. Across the coast, Dr. Joseph Woo, newly appointed chair of cardiovascular surgery at Stanford, agrees. This expectation alone informs us that our specialty is dynamic and that the definition of an essential skill is in constant flux. On the other hand, cardiac surgery has no touchstone or standard minimally invasive procedure. However, Dr. Woo explains, the ABTS has set its recommendations in anticipation of the continued success of minimally invasive approaches to cardiovascular problems. The board doesn’t require mastery of any specific minimally invasive cardiac operation by the end of a training program, but it does require that we are exposed to a number of different endovascular and nontraditional approaches to coronary, valve, and aortic surgery. Coupled with our presumed mastery of the standard, open operations, we should then have the basic skills necessary to learn whatever minimally invasive operations we like, depending on our interests and our post-training mentorship.

Of course, the safety and efficacy of thoracic aortic stent grafting and minimally invasive mitral surgery have already been proven to some degree, and the operations aren’t going away anytime soon.^3,4 So what is stopping us from learning this stuff during our training? The answer is complicated. Dr. Woo cites the lack of visualization for two surgeons, the difficulty in preventing and controlling technical complications in a limited field, and the very nature the operations themselves.

Take, for example, the minimally invasive mitral valve repair. Its open counterpart requires a skill set that few trainees, if any, can claim mastery of until the very end of their training. The skill required, patient selection, and pathology treated make the operation sort of a "boutique" treatment. The patients that are offered right thoracotomy approach tend to be younger, less symptomatic, and with less complex disease. They have higher expectations. As Dr. Woo put it, "if you perform an absolutely perfect repair, then you’ve only done your job. But there is no way to do any better." With that sort of standard, many attending surgeons are hesitant to hand over the instruments to a trainee. Furthermore, not every resident’s technical ability lines up with what is required of that interest, and more importantly, not every resident is interested. Because of the highly specialized nature of the operation, the relatively smaller patient base, and the technical difficulty involved, it is often up to the highly motivated fellow or resident to gravitate to these repairs and seek out the training on their own.

Dr. James Fann, cofounder of the annual TSDA boot camp and a national surgical education leader, has some perspective on the matter. If residents are interested in gaining added endovascular or minimally invasive skills, he suggests, they first have to prove themselves in the operating room. When they’ve mastered the skills for an open technique and have proven they can get out of trouble, then an attending might feel comfortable letting them take on these more complex cases. It takes a combination of skill and interest – and as only a minority of trainees will have both, most training programs do not require that every TEVAR or mini-mitral be staffed with a resident.

It seems that simulation does not provide an easy shortcut beyond this approach, though it does have a role. To be honest, I expected Dr. Fann to preach the simulation gospel, and tell me about some incredible TEVAR or TAVR simulator he was getting ready to unveil, but his response was far more measured. "The role of simulation," he said, "is not to teach a resident how to operate. It is an adjunct – a tool that can be used to identify and address specific technical issues outside of the operating room." He reinforced the importance of mastering traditional surgical techniques before embarking on miniaturization. Simulation can help trainees operate more efficiently and effectively, but it cannot and should not replace mentored operative experience.

MICS simulation does exist, as anyone who has worked with Dr. L. Wiley Nifong and Dr. Randolph Chitwood’s high-fidelity tissue simulators for minimally invasive mitral valve repair knows. Simbionix USA (Cleveland) has just obtained FDA clearance for its TEVAR simulator that can be tailored to rehearse an upcoming case using a patient’s CT scan. On the lower end of the cost spectrum, a Dutch group and a separate Hannover group have developed low-cost, reproducible models of mini-mitral surgery that can be built from materials from a hardware store.⁵ Again, all of these tools are designed to be adjuncts to experiential training and mentorship, not mentors in and of themselves.

Residents can and should be exposed to TEVAR, TAVR, mini-mitral repair, and other less invasive approaches that are offered at their institution if they are interested. These, along with any other skills beyond traditional open techniques, make the surgeon better. More importantly, they help the trainee gain the basic wire and small incision skills they will need to learn quickly any newly developed operations that the changing specialty requires. They may not master the skills as a resident, but they are that much more prepared to hone those skills with their mentors when that time comes. In fact, the faculty I spoke with placed far more emphasis on mentorship after residency than aggressive residency training, simulation, and superfellowship as the key to gaining these advanced skills. Trainees should be soaking up all of the skills that they possibly can while they can, and if one is smart, ambitious, and skilled enough to become technically proficient at a more technically advanced skill, it certainly makes them a more desirable surgeon. For most of us, however, it is more important to realize that the training never truly ends, to take advantage of the opportunities afforded by residency, and to continue getting those reps in the OR.

References

1. Cardiac Surgery in the Adult, 4e. New York, N.Y.: McGraw-Hill; 2012.

2. J. Thorac. Cardiovasc. Surg. 2012; 144:612-16.

3. Circulation 2013;6:407-16.

4. Ann. Cardiothorac. Surg. 2013;2:744-50.

5. Interact. Cardiovasc. Thorac. Surg. 2013;16:97-101.

Minimally invasive cardiac surgery has experienced a meteoric rise since its development in the 1990s. The first thoracic aortic stent graft was placed in July 1992, at Stanford (Calif.) University. Five years later, the Stanford group published their approach to mitral valve surgery through a right anterior thoracotomy. Just a year later, Dr. Alain Carpentier performed the first robotic-assisted mitral valve operation.1 There has been an explosion of new techniques, broadening the cardiac surgeon’s armamentarium far beyond the typical median sternotomy and occasional left thoracotomy.

While many of these techniques will undoubtedly become historical footnotes, it is clear that minimally invasive cardiac surgery is here to stay, as 20% of mitral repairs are performed with some element of minimally invasive technique. Similarly, thoracic endovascular aortic repair has become a well-established treatment for aneurysmal disease and dissection of the thoracic aorta, and is rapidly catching up with open repair as the treatment of choice.²

Training has also changed. The last decade brought a surge of applications to traditional fellowship programs, and the integrated thoracic surgery programs graduated their first trainees last year. With the variety of new operations and techniques, novel training formats, and professional goals for cardiothoracic surgery trainees, how can we be sure that young cardiac surgeons are learning the skills they need to succeed in the coming decades?

To ask how new surgeons should learn, you must start by asking what needs to be learned. After I asked a number of different surgeons in a variety of practice set-ups, the answer became obvious, and it is deceptively basic. The purpose of training is simply to ensure that each trainee can do all of the commonly performed operations of their specialty. This includes open valve and coronary surgery on the cardiac side, while for thoracic surgery, this includes all of the traditional lung and esophageal resections, chest wall and pleural operations, and importantly, the widely practiced VATS lobectomy. When I asked about more advanced VATS skills and minimally invasive cardiac skills, I was always told that those would be icing on the cake, as it were, to make a graduate more valuable to a potential employer. The first step in learning a minimally invasive operation is to understand the traditional, open approach, and VATS lung surgery is no different.

The VATS lobectomy has been a recent but well-received addition to the expected repertoire of graduates, and Dr. Chadrick Denlinger, associate professor of surgery at the Medical University of South Carolina, Charleston, allows his chief residents to take other trainees through the case, and expects that all new graduates can do one. Across the coast, Dr. Joseph Woo, newly appointed chair of cardiovascular surgery at Stanford, agrees. This expectation alone informs us that our specialty is dynamic and that the definition of an essential skill is in constant flux. On the other hand, cardiac surgery has no touchstone or standard minimally invasive procedure. However, Dr. Woo explains, the ABTS has set its recommendations in anticipation of the continued success of minimally invasive approaches to cardiovascular problems. The board doesn’t require mastery of any specific minimally invasive cardiac operation by the end of a training program, but it does require that we are exposed to a number of different endovascular and nontraditional approaches to coronary, valve, and aortic surgery. Coupled with our presumed mastery of the standard, open operations, we should then have the basic skills necessary to learn whatever minimally invasive operations we like, depending on our interests and our post-training mentorship.

Of course, the safety and efficacy of thoracic aortic stent grafting and minimally invasive mitral surgery have already been proven to some degree, and the operations aren’t going away anytime soon.^3,4 So what is stopping us from learning this stuff during our training? The answer is complicated. Dr. Woo cites the lack of visualization for two surgeons, the difficulty in preventing and controlling technical complications in a limited field, and the very nature the operations themselves.

Take, for example, the minimally invasive mitral valve repair. Its open counterpart requires a skill set that few trainees, if any, can claim mastery of until the very end of their training. The skill required, patient selection, and pathology treated make the operation sort of a "boutique" treatment. The patients that are offered right thoracotomy approach tend to be younger, less symptomatic, and with less complex disease. They have higher expectations. As Dr. Woo put it, "if you perform an absolutely perfect repair, then you’ve only done your job. But there is no way to do any better." With that sort of standard, many attending surgeons are hesitant to hand over the instruments to a trainee. Furthermore, not every resident’s technical ability lines up with what is required of that interest, and more importantly, not every resident is interested. Because of the highly specialized nature of the operation, the relatively smaller patient base, and the technical difficulty involved, it is often up to the highly motivated fellow or resident to gravitate to these repairs and seek out the training on their own.

Dr. James Fann, cofounder of the annual TSDA boot camp and a national surgical education leader, has some perspective on the matter. If residents are interested in gaining added endovascular or minimally invasive skills, he suggests, they first have to prove themselves in the operating room. When they’ve mastered the skills for an open technique and have proven they can get out of trouble, then an attending might feel comfortable letting them take on these more complex cases. It takes a combination of skill and interest – and as only a minority of trainees will have both, most training programs do not require that every TEVAR or mini-mitral be staffed with a resident.

It seems that simulation does not provide an easy shortcut beyond this approach, though it does have a role. To be honest, I expected Dr. Fann to preach the simulation gospel, and tell me about some incredible TEVAR or TAVR simulator he was getting ready to unveil, but his response was far more measured. "The role of simulation," he said, "is not to teach a resident how to operate. It is an adjunct – a tool that can be used to identify and address specific technical issues outside of the operating room." He reinforced the importance of mastering traditional surgical techniques before embarking on miniaturization. Simulation can help trainees operate more efficiently and effectively, but it cannot and should not replace mentored operative experience.

MICS simulation does exist, as anyone who has worked with Dr. L. Wiley Nifong and Dr. Randolph Chitwood’s high-fidelity tissue simulators for minimally invasive mitral valve repair knows. Simbionix USA (Cleveland) has just obtained FDA clearance for its TEVAR simulator that can be tailored to rehearse an upcoming case using a patient’s CT scan. On the lower end of the cost spectrum, a Dutch group and a separate Hannover group have developed low-cost, reproducible models of mini-mitral surgery that can be built from materials from a hardware store.⁵ Again, all of these tools are designed to be adjuncts to experiential training and mentorship, not mentors in and of themselves.

Residents can and should be exposed to TEVAR, TAVR, mini-mitral repair, and other less invasive approaches that are offered at their institution if they are interested. These, along with any other skills beyond traditional open techniques, make the surgeon better. More importantly, they help the trainee gain the basic wire and small incision skills they will need to learn quickly any newly developed operations that the changing specialty requires. They may not master the skills as a resident, but they are that much more prepared to hone those skills with their mentors when that time comes. In fact, the faculty I spoke with placed far more emphasis on mentorship after residency than aggressive residency training, simulation, and superfellowship as the key to gaining these advanced skills. Trainees should be soaking up all of the skills that they possibly can while they can, and if one is smart, ambitious, and skilled enough to become technically proficient at a more technically advanced skill, it certainly makes them a more desirable surgeon. For most of us, however, it is more important to realize that the training never truly ends, to take advantage of the opportunities afforded by residency, and to continue getting those reps in the OR.

References

1. Cardiac Surgery in the Adult, 4e. New York, N.Y.: McGraw-Hill; 2012.

2. J. Thorac. Cardiovasc. Surg. 2012; 144:612-16.

3. Circulation 2013;6:407-16.

4. Ann. Cardiothorac. Surg. 2013;2:744-50.

5. Interact. Cardiovasc. Thorac. Surg. 2013;16:97-101.