High-Risk Coronary Lesions Simulation Training

Mark A. Turco, MD, FACC
Mark A. Turco, MD, FACC
Dr. Turco, there’s an increasing focus on simulation training. Could you describe simulation training and why it’s becoming more widely used? Simulation training provides hands-on training in a true-to-life but risk-free environment with immediate feedback. By that I mean that it allows for the development of practitioners’ skills without risk to the patient. Advanced devices and treatments are continuously introduced to the marketplace with newer and more advanced endovascular procedures aimed at treatment of higher risk patient groups and new anatomy. Simulation provides safe, accessible training that didactic training, device inservicing and demonstration cases can’t equal. And in simulation, we see an evolution from mere device training to procedural training, including treatment decisions and appropriate device selection. Simulation also helps to standardize training approaches for new devices and their indications. Why is high-risk coronary lesions simulation training relevant? It’s relevant because what we do in the cath lab continues to evolve. With the advent of drug-eluting stent (DES) technology, physicians are treating more complex lesions. But with these newer technologies comes the need for enhanced technique and device selection. For example, the long-term DES results allow a comfort level for us to address more difficult cases such as multi-vessel and long diffuse disease. The high-risk coronary lesion courseware by Boston Scientific, puts forth algorithms by which the operator can select treatment strategies, device selection, and pharmacologic options as they relate to real-life patient scenarios commonly experienced in the cath lab. The simulation is relevant because it also incorporates complications and possible outcomes of decisions made during the procedure. Can you tell us more about the specific cases that the high-risk lesions courseware simulates? Yes. The courseware enables you to perform two high-risk cases. Case One is a tortuous anatomy Type C* lesion in the right coronary artery (RCA). Case Two is a complex multi-vessel case. These two cases were included because they're common challenges experienced in the cath lab. The RCA case was developed because in real life, we’re now treating older patients with more diffuse disease and calcium. And, as previously stated, we are able to treat more multi-vessel cases due to DES adoption. You made a distinction earlier between device training and procedural training. Could you elaborate? Well, procedural training is more than just the device you select and how you use it. Education on a procedure includes assessment, treatment strategy, pharmacologic choices, and device selection. Proper technique is also important. Technique is important when speaking about deployment of a drug-eluting stent. For example, edge detection software allows the operator to see if balloon injury has occurred outside the proximal or distal margins of the stented segment during the simulated case. Boston Scientific’s high-risk coronary lesion program designed using Medical Simulation Corporation’s software allows you to make the organic decisions that you'd make during a real case. You can go down natural decision pathways, and incur possible outcomes based on the choices made during the procedure. In addition, this procedural training approach integrates key learnings on device technique. As a result, physicians hone their skills during the course of the simulation. What is the value of simulation training and who benefits? The greatest value of simulation training is that it’s hands-on yet entirely risk-free. Physicians can simulate the use of the current and new technologies. In particular, physicians newer in their practice may experience high-risk cases and complications that might take months or years to encounter in the cath lab. Fellows and physicians two or three years out of their fellowships can test-drive the treatment strategies they might pick for complicated cases. Veteran physicians can re-familiarize themselves with existing devices such as debulking tools, while also testing the treatment strategies they're currently using to address high-risk cases. The value to nurses and techs is that they can experience the challenges first-hand that interventional cardiologists deal with daily. For example, they may better understand why physicians ask for particular products, particular sizes or why certain drugs need to be readily available. And because techs may set up devices such as the Rotablator® System, it gives them a refresher on the importance of vessel preparation, burr selection and technique. As patient complexity increases, the medical community must be prepared to address and treat more challenging cases. As technology improves and the cath lab becomes more sophisticated, we have to be committed to enhancing our skill set in order to provide the best possible patient care. Simulation training provides an innovative educational venue to enhance skills and ultimately contribute to patient care. Sponsored by Boston Scientific Corporation. * The American College of Cardiology and American Heart Association define high-risk lesions (Type C) as: low success, 20 mm in length); excessive in tortuosity of proximal (i.e., near) segment; extremely angulated segments, >90; total occlusion >3 months old; inability to protect major side branches; degenerated vein grafts with friable (i.e., easily fragmented, fragile) lesions. These types of lesions place patients at greater risk.