Open heart surgery can be challenging even for well-trained cardiac surgeons. Before operating on live patients, surgeons must be well trained in order to achieve sufficient skills initially and then continuous practice to maintain surgical excellence. There is a need for realistic training models to achieve this,Reference Kwolek and Crawford1, Reference Khairy2 but there remains a gap between using simulators and practising the art of cardiovascular surgery. Skills learnt in an animal-based laboratory are noted by Reuthebuch et alReference Reuthebuch, Lang, Groscurth, Lachat, Turina and Zund3 as being limited and restrictive because of animal protection organisations. Use of the operating room for training is now being closely evaluated to advance patient safety, and the quality and efficiency in the development of surgical skills is key before performing surgical intervention on patients.Reference Kuhls, Risucci, Bowyer and Luchette4–Reference Ault, Rosen and Ault7 The ability to transfer skill sets between simulation and human surgery depends on the similarity between the two environments.Reference Sadaba, O’Regan and Kappetein8 A few cardiovascular training models exist today. Mostly, these models are artificial and represent only parts of the heart.Reference Matsumura, Hayashi, Hamada, Shibata, Horie and Endo9–Reference Kutschka18 There are few models that allow the learner to practise on the heart in its entirety while holding the heart in place as is found in the human body. The purpose of this paper is to introduce the MAVID heart holder, a superior model for resident training, demonstration purposes, and use in surgical research.
Background
The MAVID heart holder can position a cadaver heart in place in a way that one would find in the human body, thereby providing the opportunity to practise cardiovascular techniques approximating the complexity and difficulty as if in the operating room. Examples of operative exposure can be seen in Figures 1–6. The system display of the MAVID heart holder, as seen in Figure 1, is established with a cadaver heart. The MAVID heart holder comprises four right-angled posts attached to a metal plate with multiple holes to account for variations in heart size and exposure. Right-angled posts can be attached to the inferior caval vein, superior caval vein, pulmonary arteries, and aorta by simple sutures to stabilise the heart for a procedure that can be performed by the learner. The aortotomy is shown in Figure 2. The ventriculotomy and aortic valve exposure can be seen in Figure 3, and the coronary artery exposure is seen in Figure 4. A right atrial view, as seen in Figure 5, is the most frequently used approach to atrial septal defects, perimembranous ventricular septal defects, and all defects opening to the inlet of the right ventricle.Reference Backer and Mavroudis19 A left atrium and mitral exposure is seen in Figure 6.
MAVID heart holder system display.
MAVID heart holder operative exposure: aortotomy.
MAVID heart holder operative exposure: ventriculotomy and aortic valve exposure.
MAVID heart holder operative exposure: coronary artery exposure.
MAVID heart holder operative exposure: right atrial view.
MAVID heart holder operative exposure: left atrium and mitral exposure.
The MAVID heart holder is a series of retractors and studs embedded into a metal platform by which a cadaver heart may be secured in place in a way that one would find in the human body.Reference Mavroudis20 Various devices are available to assist in the training of surgeons. KutschkaReference Kutschka18 uses a box-type platform to secure artificial organs; LoorReference Loor15 presents a portable box-type platform simulating complexities of cardiothoracic suture and in the practice of tying. ChamberlainReference Chamberlain13 uses an animated silicon model, whereas Liu et alReference Liu, Yan, Zhou, Li and Li11 work with a pneumatic artificial simulator, and Ramphal et alReference Ramphal, Craven and Coore16 work with a computer-controlled tissue-based simulator. These and other simulators have provided realistic learning environments for improvement; however, it is desirable to have as realistic a model as possible to approximate the complexity of human physiology.Reference Trehan, Kemp and Yang21 A formal cardiac surgery simulation curriculum was found to be feasible based on needs assessment.Reference Baker, Sinha and Sullivan22 Training could be further advanced in a stepwise manner to include proficiency-based training with the above-mentioned simulators, with the ultimate progression to training on the MAVID heart holder, and finally to perform procedures on live patients.
The advantage over other existing methods is that the MAVID heart holder uses real tissue and does not distort the organ at attachment sites. It offers superior stability as well as the ability to manipulate the organ during presentation and dissection for the most realistic training before performing in the operating room.Reference Mavroudis20 The MAVID heart holder can be used with other solid organs such as the lung, liver, and kidney. The principles are the same – namely, to fix the structures in place and simulate real physiologic conditions. In order to achieve this, repositioning of the retractors and struts can be implemented with different structures on the board.
Training with the MAVID heart holder has the potential to shorten learning time to acquire skills and achieve proficiency before live cases, enhance levels of patient safety and outcomes, and reduce costs. McGaghie et alReference McGaghie, Issenberg, Cohen, Barsuk and Wayne23 found simulation-based medical education with deliberate practice to have better results than traditional clinical education alone. The use of surgical training by way of organ procurement produced statistically significant improvements in the knowledge of anatomy and technique.Reference Ahmed and Chung24 The use of vascular tissue models also produces statistically significant improvements in comfort levels, and sessions have been rated as highly worthwhile.Reference Ault, Rosen and Ault7
Concerns for patient safety, service, and outcomes are at the forefront of our healthcare system. At a time when cardiovascular procedures are becoming increasingly complex and training methods are becoming more restrictive, a surgical training programme outside the operating room is a vital necessity.Reference Cates and Gallagher25 Simulation-based learning will become integral to enhancing training and educationReference Fox26 and in providing valuable experience for both novices and experts because tissue-based simulation is the closest to live surgical cases.Reference Fann, Feins, Hicks, Nesbitt, Hammon and Crawford27
Summary
The MAVID heart holder is an organ holder primarily designed for holding the heart in an anatomic position for the purpose of surgical simulation and education. The device is simple to use, can be adjusted to organ size, and has necessary instrumentation for surgical simulation and education with any solid organ. The MAVID heart holder will help to close the gap between surgical performance in the laboratory and that in the operating room by providing the most realistic learning to achieve surgical proficiency before performing procedures on live patients while enhancing patient safety and outcomes.
Acknowledgements
None.
Financial Support
Dr. Constantine Mavroudis has a financial interest in the production and sale of the MAVID heart holder.
