1

Introduction

Simulator-based training offers the potential to provide high-yield training in diagnostic and interventional cardiology without added risk to the patient. The appeal of virtually unlimited practice in a patient free, risk-free training environment is evident by the rapid adoption of simulator training nationwide . The advantages of this technology have been recognized by numerous teaching consortiums, most notably the Accreditation Council of Graduate Medical Education (ACGME), which now recommends simulation training for numerous specialties as well as the Society for Cardiovascular Angiography and Intervention . There are numerous examples of successful implementation of this training methodology in general surgery, neurosurgery, vascular surgery and interventional radiology . The utility of this as an evaluation method has also been assessed for experienced cardiologists for high-risk endovascular procedures .

The use of simulator-based teaching in cardiology has unfortunately lagged behind other procedural specialties. In this study we sought to evaluate the utility of the AngioMentor ™ as an introductory tool for novice cardiology fellows prior to hands-on exposure and training in the cardiac catheterization laboratory.

2

Methods

Seven first-year cardiology fellows were introduced to the Simbionix AngioMentor ™ (Simbionix USA, Cleveland, Ohio, USA) at the start of their fellowship training. None of the fellows had previous exposure to angiography or endovascular training, and none of the fellows had previous exposure to simulator-based training. The AngioMentor ™ uses actual catheters and wires that are introduced through a port, allowing the simulator to capture the movements of both wire and catheter in a three-dimensional space. For this protocol, only femoral access was simulated. A Judkins Left (JL4) and a Judkins Right (JR4) catheter were used as the simulated diagnostic catheter. Visual angle manipulations simulating a typical C-arm along with fluoroscopic images were monitored on an adjacent screen.

After completing a brief step-by-step tutorial to become familiar with the technical features of the machine, each participant performed a full diagnostic catheterization simulation. Each simulation starts with a brief patient clinical summary and electrocardiogram. Next the fellow proceeded to the interactive portion of the simulation, which consisted of a full diagnostic coronary angiogram.

The interactive portion of the study was organized into three phases. Phase one consisted of the seven 1st year fellows performing 4 distinct simulated cases consisting of one benchmark case that was completed before (on Day 1) and after (Day 2) 3 practice cases. In other words, after the initial benchmark case on Day 1, each fellow was allowed to train further by completing 3 additional AngioMentor ™ simulations similar to the initial one, albeit with different culprit coronary artery lesions. One day later, each participant was reassessed with the initial benchmark case. Engagement of both right and left main coronary arteries was performed in standard views of each artery (left anterior oblique cranial, left anterior oblique caudal, right anterior oblique cranial, right anterior oblique caudal views for the left system; right anterior oblique and left anterior oblique views for the right system). Objective performance criteria measured includes total procedural time, total contrast used, and total fluoroscopy time.

In phase 2, three 3rd year training (expert) fellows were given the benchmark AngioMentor ™ simulation to perform. Third year expert fellows were given the same step-by-step tutorial and practice cases prior to completing the benchmark cases. Two iterations were completed by the 3rd years and the average of the total procedure time, total contrast used and total fluoroscopy time was measured and compared to the benchmark study completed by the 1st years after practice simulations.

The third phase of the study was completed after 9 months of 1st year cardiology curriculum. At this time 1st year fellows had experienced 2 months of diagnostic and percutaneous interventions at the University of Illinois at Chicago and Advocate Christ Medical Center in Oak Lawn, IL. During this time, each fellow was exposed to 80–120 diagnostic and interventional coronary procedures that include a mixture of femoral and radial approach. Three 1st year fellows volunteered to be retested on the benchmark study. Objective measures recorded from the benchmark study included total procedure time, total contrast used, and total fluoroscopy time. As with the first two phases, each fellow used exactly 2 diagnostic catheters and 1 guidewire for the procedures.

All analyses were performed using the nonparametric Mann–Whitney U test by SAS statistical software, version 9.2 (SAS Institute Inc., Cary, North Carolina). Data expressed as median ± interquartile range (IQR), rounded to the second or 1 ml. The criteria used for statistical significance was p < 0.05. All investigators have read and agree to the manuscript as written. The investigators are solely responsible for the design and conduct of this study, all study analyses, and the drafting and editing of the report and its final contents.

2

Methods

Seven first-year cardiology fellows were introduced to the Simbionix AngioMentor ™ (Simbionix USA, Cleveland, Ohio, USA) at the start of their fellowship training. None of the fellows had previous exposure to angiography or endovascular training, and none of the fellows had previous exposure to simulator-based training. The AngioMentor ™ uses actual catheters and wires that are introduced through a port, allowing the simulator to capture the movements of both wire and catheter in a three-dimensional space. For this protocol, only femoral access was simulated. A Judkins Left (JL4) and a Judkins Right (JR4) catheter were used as the simulated diagnostic catheter. Visual angle manipulations simulating a typical C-arm along with fluoroscopic images were monitored on an adjacent screen.

After completing a brief step-by-step tutorial to become familiar with the technical features of the machine, each participant performed a full diagnostic catheterization simulation. Each simulation starts with a brief patient clinical summary and electrocardiogram. Next the fellow proceeded to the interactive portion of the simulation, which consisted of a full diagnostic coronary angiogram.

The interactive portion of the study was organized into three phases. Phase one consisted of the seven 1st year fellows performing 4 distinct simulated cases consisting of one benchmark case that was completed before (on Day 1) and after (Day 2) 3 practice cases. In other words, after the initial benchmark case on Day 1, each fellow was allowed to train further by completing 3 additional AngioMentor ™ simulations similar to the initial one, albeit with different culprit coronary artery lesions. One day later, each participant was reassessed with the initial benchmark case. Engagement of both right and left main coronary arteries was performed in standard views of each artery (left anterior oblique cranial, left anterior oblique caudal, right anterior oblique cranial, right anterior oblique caudal views for the left system; right anterior oblique and left anterior oblique views for the right system). Objective performance criteria measured includes total procedural time, total contrast used, and total fluoroscopy time.

In phase 2, three 3rd year training (expert) fellows were given the benchmark AngioMentor ™ simulation to perform. Third year expert fellows were given the same step-by-step tutorial and practice cases prior to completing the benchmark cases. Two iterations were completed by the 3rd years and the average of the total procedure time, total contrast used and total fluoroscopy time was measured and compared to the benchmark study completed by the 1st years after practice simulations.

The third phase of the study was completed after 9 months of 1st year cardiology curriculum. At this time 1st year fellows had experienced 2 months of diagnostic and percutaneous interventions at the University of Illinois at Chicago and Advocate Christ Medical Center in Oak Lawn, IL. During this time, each fellow was exposed to 80–120 diagnostic and interventional coronary procedures that include a mixture of femoral and radial approach. Three 1st year fellows volunteered to be retested on the benchmark study. Objective measures recorded from the benchmark study included total procedure time, total contrast used, and total fluoroscopy time. As with the first two phases, each fellow used exactly 2 diagnostic catheters and 1 guidewire for the procedures.

All analyses were performed using the nonparametric Mann–Whitney U test by SAS statistical software, version 9.2 (SAS Institute Inc., Cary, North Carolina). Data expressed as median ± interquartile range (IQR), rounded to the second or 1 ml. The criteria used for statistical significance was p < 0.05. All investigators have read and agree to the manuscript as written. The investigators are solely responsible for the design and conduct of this study, all study analyses, and the drafting and editing of the report and its final contents.