title: Simulation and skills training in mitral valve surgery.
abstract: OBJECTIVE
  Limited exposure and visualization and technical complexity have affected resident training in mitral valve surgery. We propose simulation-based learning to improve skill acquisition in mitral valve surgery.
  
  
  METHODS
  After reviewing instructional video recordings of mitral annuloplasty in porcine and plastic models, 11 residents (6 integrated and 5 traditional) performed porcine model mitral annuloplasty. Video-recorded performance was reviewed by attending surgeon providing audio formative feedback superimposed on video recordings; recordings were returned to residents for review. After 3-week practice with plastic model, residents repeated porcine model mitral annuloplasty. Performance assessments initially (prefeedback) and at 3 weeks (postfeedback) were based on review of video recordings on 5-point rating scale (5, good; 3, average; 1, poor) of 11 components. Ratings were averaged for composite score.
  
  
  RESULTS
  Time to completion improved from mean 31 ± 9 minutes to 25 ± 6 minutes after 3-week practice (P = .03). At 3 weeks, improvement in technical components was achieved by all residents, with prefeedback scores varying from 2.4 ± 0.6 for needle angles to 3.0 ± 0.5 for depth of bites and postfeedback scores of 3.1 ± 0.8 for tissue handling to 3.6 ± 0.8 for suture management and tension (P ≤ .001). Interrater reliability was greater than 0.8. In this sample, composite scores of first-year integrated and traditional residents were lower than those of senior level residents; comparatively, third-year integrated residents demonstrated good technical proficiency.
  
  
  CONCLUSIONS
  Simulation-based learning with formative feedback results in overall improved performance of simulated mitral annuloplasty. In complex surgical procedures, simulation may provide necessary early graduated training and practice. Importantly, a "passing" grade can be established for proficiency-based advancement.
authors.affiliation: Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif 94305, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Joyce
authors.forename: Tanvir S
authors.initials: TS
authors.lastname: Dhillon
authors.forename: Anthony D
authors.initials: AD
authors.lastname: Caffarelli
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Joyce
authors.forename: Dimitrios N
authors.initials: DN
authors.lastname: Tsirigotis
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Burdon
authors.forename: James I
authors.initials: JI
authors.lastname: Fann
mesh_terms: D000818:Animals; D006348:Cardiac Surgical Procedures / Q000193:education*; D002983:Clinical Competence; D004503:Education, Medical, Graduate / Q000379:methods*; D030141:Feedback, Psychological; D006801:Humans; D007396:Internship and Residency; D007858:Learning; D008943:Mitral Valve / Q000033:anatomy & histology / Q000601:surgery*; D008953:Models, Anatomic; D023421:Models, Animal; D009048:Motor Skills; D013552:Swine; D013997:Time Factors; D014741:Video Recording