From Bench to Reality: Development of Simulation, 3D Printing, and Air-Pilot-Training Concept Course for Endoscopic Mitral Valve Surgery

Endoscopic mitral valve repair is one of the most difficult procedures to learn. The learning curve is steep. This steep learning curve has partially to do with the fact that the operation is done with long-shafted instruments, with surgeon looking at the monitor rather than into the wound. Acquiring endoscopic skills with long-shafted instruments is a process that no one can escape from, and acquiring these skills in patients is not logical or efficient.

In 2012, the author wrote a project to develop a high-fidelity minimally invasive mitral valve simulator. Fidelity in simulation has traditionally been defined as ‘the degree to which the simulator replicates reality (1). Obviously, a simulation platform should be realistic and mimic the set-up of a procedure. Additional to this and fundamental to learning, is the need for feedback. There is no efficient learning without feedback and it has been shown that if the feedback is given in an objective and reproducible manner the learning process is more efficient (2). Therefore, the aim of the project was to create a platform that was realistic and that could provide feedback regarding the skills that one would like to develop, a platform that one could use to train oneself objectively and repeatedly in a reproducible manner.

In 2013, a prototype was developed and the author used the prototype to start the endoscopic mitral valve program and used it during the start-up of the program to refine his own skills. Because of the success of the platform, the group received funding from Maastricht University Medical Center in The Netherlands to develop an industrialized platform. An engineering group was assembled to actualize the author’s ideas. This group was able to create a high-fidelity simulator that provides a platform on which endoscopic skills can be trained repeatedly and objectively. Additionally, the simulator provides objective assessment and feedback, which is essential in any simulator-based training. The disposable mitral valve developed by the author’s group is made of special silicone that provides a true suturing experience.

The group was awarded the European Association for Cardio-Thoracic Surgery’s (EACTS) Techno-College Innovation Award in 2014, and a video on the innovation was published on CTSNet in 2014 (3). In this video, the author envisioned using this platform to train surgeons and also to use it for preoperative planning, applying the 3D technology. Ever since, the group has tried to bring this innovation and these visions from bench to reality. They recently published the process of the development of this simulator in The Journal of Thoracic and Cardiovascular Surgery to stimulate development in this field. Ninety-nine senior surgeons during various educational programs validated the platform for training of minimally invasive mitral valve surgery (4).

Additionally, the group developed a process for modeling and three-dimensional (3D) printing of different mitral valve diseases for procedural planning and simulation based on 3D transesophageal echocardiography (TEE), and they published these results recently in the European Journal of Cardio-Thoracic Surgery. Disposable, 3D-printed, pathological, silicone replica valves can be mounted into the simulator so that one can also be trained in any repair technique on any pathology of the mitral valve (5). Another publication also provided the proof of concept for the use of 3D printing and simulation for planning procedures in prospective patients (6).

In 2015, the EACTS Endoscopic Port-Access Mitral Valve Repair Drylab Training was founded using the high-fidelity simulators. This course has been organized 15 times in Maastricht. The course was designed based on the latest educational science and is structured like an air-pilot-training concept course, starting with technical and theoretical pre-assessment and two subsequent days of intensive training on simulators, mixed with interactive presentations and videos regarding all aspects of the endoscopic mitral repair program. The course ends with technical and theoretical post-assessment.

The aim of the course is to provide a formula of success for those who would like to start the endoscopic program and provide education based on standard manner. For example, the high-fidelity mitral valve simulator was used to develop a suturing map for placement of the annuloplasty ring with minimal tissue manipulation and maximal visual exposure. The suturing map could be helpful for less experienced surgeons who are starting to learn the techniques of minimally invasive mitral valve surgery (7).

The group has already trained over 100 surgeons, and their preliminary analyses show very promising results for skill development using the simulator. They will present the results of the endoscopic mitral course during the 99^th Annual Meeting of the American Association for Thoracic Surgery in Toronto, Canada (8). The upcoming dates for the course can be found on the EACTS Academy website, and the author looks forward to welcoming those interested in Maastricht.

References

1. Beaubien J, Baker DP. The use of simulation for training teamwork skills in health care: how low can you go? Qual Saf Health Care. 2004;13(Suppl 1):i51-i56.
2. Cates CU, Gallagher AG. The future of simulation technologies for complex cardiovascular procedures. Eur Heart J. 2012;33(17):2127-2134.
3. Sardari Nia P, Daemen J, Maessen JG. Development of a high-fidelity minimally invasive mitral valve surgery simulator. J Thorac Cardiovasc Surg. 2019;157(4):1567-1574.
4. Sardari Nia P. High-Fidelity Minimally Invasive Mitral Valve Repair Simulator. CTSNet, Inc. URL: https://www.ctsnet.org/article/high-fidelity-minimally-invasive-mitral-valve-repair-simulator. Published September 15, 2014. Accessed March 18, 2019.
5. Daemen JHT, Heuts S, Olsthoorn JR, Maessen JG, Sardari Nia P. Mitral valve modelling and three-dimensional printing for planning and simulation of mitral valve repair. Eur J Cardiothorac Surg. 2019;55(3):543-551.
6. Sardari Nia P, Heuts S, Daemen J, et al. Preoperative planning with three-dimensional reconstruction of patient’s anatomy, rapid prototyping and simulation for endoscopic mitral valve repair. Interact Cardiovasc Thorac Surg. 2017;24(2):163-168.
7. Sardari Nia P, Olsthoorn J, Heuts S, Maessen J. Suturing map for endoscopic mitral valve repair developed on high-fidelity endoscopic simulator. Multimed Man Cardiothorac Surg. 2018. doi: 10.1510/mmcts.2018.038.
8. Sardari Nia P, Heuts S, Daemen J, Olsthoorn J, Chitwood WR Jr, Maessen J. Simulation-based training for endoscopic mitral valve repair: an air-pilot training concept in action. 99th Annual Meeting of the American Association for Thoracic Surgery. 2019;Abstract 241.

Peyman Sardari Nia is the inventor of the simulator that is commercialized by Maastricht University Medical Center, The Netherlands.

Acknowledgements

For realization of simulation platform

The author gratefully acknowledges R. Verhoeven, R. Van Veen, S. Overeem, and J. Riddenhof from the Technical Medicine of University Twente, Enschede, The Netherlands, for their contribution to the development of the first prototype in 2013. He also gratefully acknowledges Instrument Development, Engineering & Evaluation (IDEE), Maastricht University, The Netherlands for their technical support for final design in 2014.

For support of the whole project

Jos Maessen, Head of the Department of Cardiothoracic Surgery in Maastricht

Samuel Heuts, Jean Daemen, and Jules Olsthoorn, residents and researchers at Maastricht University Medical Center

For support of the EACTS course

The EACTS Council and Office

Invited faculty during the years: Fredriech Mohr, Randolph Chitwood, Patrick Perier, Martin Misfeld, Robert Klautz, Ludwig Muller, Thomas De Kroon, Mohammad Bentala, Wolfgang Buhre, Sebastiaan Streukens, Yuri Ganushchak