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تنجم الأزمات الصادمة عن الحوادث الشديدة والمفاجئة وغير المتوقعة، مما يؤدي إلى حدوث صدمة انفعالية كبيرة تسيطر على الفرد بشكل مؤقت، وتعد الأزمات الصادمة رد فعل لحدث يهدد الجوانب الأساسية للحياة. قد تكون الأزمات صادمة لأسباب عديدة، مثل موت شخص عزيز أو الإصابة بمرض أو إعاقة شديدة أو الفصل من العمل أو التعرض لعنف شديد قد يؤدي إلى الإصابة النفسية، وبالإضافة إلى ذلك، يمكن أن تؤدي الحوادث والكوارث التي تصيب مجموعات كبيرة من الأفراد إلى الأزمات صادمة، وغالبًا ما تكون معالجة هذه الأزمات والتعامل معها أمر مؤلم ويتطلب مجهودًا كبيرًا.، وهدف البحث الى بناء مقياس الازمات ،واتبعت الباحث المنهج الوصفي بالاسلوب المسحي لمعالجة المشكلة, وتالف مجتمع البحث من ( 33 ) تدريسيا وكانت اهم الاستنتاجات هناك تفاوت في كيفية استخدام الاساليب من قبل التدريسيين في حين اهم التوصيات ضرورة وجود فريق عمل في الجامعة والكليات متدرب على كيفية التعامل مع الازمات .

Aim: we are assessing MPFL reconstruction whether isolated or accompanied by lateral release and / or tibial tubercle transfer in management of patellofemoral instability to achieve the best results in terms of stability and return to physical activity. Methodolgy: 25 patients suffering from patellofemoral instability were included in this study. They were all suffering from recurrent/habitual dislocations or first time dislocators with traumatic history and/or failed conservative management. Surgeries addressing their pathologies included MPFL reconstruction, whether isolated or accompanied by lateral patellar release and/or tibial tubercle transfer. The decision making process of the appropriate surgery depends on the aetiology of the instability whether it is a soft tissue such as MPFL tear or a bony aetiology such as shallow trochleas and bony malalignment. Results: Clinical Evaluation was performed via Kujala-Lysholm-Tegner scores which were used to compare their preoperative statuses with their postop results at 3, 6&9 months intervals, as well as their return to physical activity. There was a significant improvement in patients’ scores evident by a Lysholm score P-value less than 0.05 with a preoperative mean score of 44.60 and a postoperative score of 91.88.

The aim of this study is to investigate the ability of postmortem computed tomography (PMCT) to distinguish intraperitoneal decomposition gas from pneumoperitoneum due to intestinal perforation. This retrospective study investigated the factors affecting intraperitoneal gas in two groups of 14 decedents as detected by postmortem CT performed in the Department of Legal Medicine of Hamburg University. The first group died with a cause of death associated with intestinal perforation, and the second group with other different natural causes of death. These factors include postmortem interval, gas volume, gas distribution, radiology alteration index (RAI), and pneumoperitoneum-associated pathology. The findings of this study showed the appearance of specific gas distribution patterns and a significant increase in gas volumes in the cases of intestinal perforation. Moreover, postmortem interval and the pneumoperitoneum-associated pathology could help distinguish postmortem-generated gas from pneumoperitoneum. Based on the findings of this study, we propose that these findings can improve the proper detection of intestinal perforation cases in the future.

OBJECTIVES Across Europe there are significant variations in the fundamental structure and content of cardiothoracic surgery (CTS) training programmes. Previous efforts have been made to introduce a Unified European Training System, which outlined the fundamentals of the ideal programme and supported a paradigm shift from an apprenticeship to a competency-based model. This article’s goal was to define key structural, administrative and executive details of such a programme to lay the foundations for the standardization of cardiothoracic surgical training across Europe. METHODS The European Association for Cardiothoracic Surgery Residents Committee had previously conducted a residents’ training survey across Europe in 2020. Training curricula from the twelve most represented countries across Europe were either searched online or obtained from the countries’ national trainee representative and reviewed by the committee. Information was collated and placed into one of the following categories to develop the position paper: (i) selection of eligible candidates, (ii) guidance for an outcome-based syllabus, (iii) documentation and evaluation of training progress, (iv) mandatory rotations and training courses, (v) number of independent or assisted cases and (vi) requirements and quality assurance of teachers. RESULTS An independent professional body should promote an outcome-based syllabus and take responsibility for the training programme’s quality assurance. Trainees should be selected on merit by an open and transparent process. Training should be delivered within a defined period and supervised by an appointed training committee to ensure its implementation. This committee should review the trainees progression regularly, provide feedback and offer trainees the opportunity to experience various training environments and trainers. A common electronic portal be used by trainees to record their agreed objectives and to evidence their completion. Trainees should regularly attend specialty-relevant courses and conferences to promote professional and academic development. The end of training is reached when the formal requirements of the training programme are met and the trainee is able to perform at the level expected of a day-1 independent surgeon. CONCLUSIONS This article defines the key structural, administrative, and executive principles for CTS training. Programmes are encouraged to review and modify their training curricula, if necessary, to ensure the delivery of high-quality, standardized, outcome-orientated CTS training across Europe.

Aortic and mitral bioprosthesis are the gold standard treatment to replace a pathological native valve. However, bioprostheses are prone to structural valve degeneration, resulting in limited long-...

OBJECTIVES The hands-on surgical training course utilizes 3-dimensional (3D)-printed heart models to simulate complex congenital heart operations. This study aimed to validate a model and assessment tool in the simulation of 2 techniques of the Norwood operation and investigate whether technical performance improves following rehearsal with or without proctor presence. METHODS Five ‘experienced’ and 5 ‘junior’ surgeons performed 2 techniques of the Norwood operation on 3D-printed models of hypoplastic left heart syndrome. Performances were retrospectively assessed by 10 raters with varying experience in congenital heart surgery (CHS) (Medical Doctorate versus non-Medical Doctorate). Assessments were made with the procedure-specific Hands-On Surgical Training-CHS tool. Results were analysed for technical performance and rater consistency. Following validation, 30 surgeons (24 with proctor guidance and 6 with training videos and objective feedback only) simulated the Norwood operation twice. RESULTS Performance scores were consistently higher for experienced surgeons and raters discriminated clearly between the experienced and junior surgeons (P ≤ 0.001). The hands-on surgical training-CHS tool showed high inter-rater (0.86) and intra-rater (0.80) reliability among all raters. Scores for both experienced and junior surgeons were highly consistent across all raters, with no statistically significant difference (P = 0.50). All surgeons successfully performed the Norwood operation. Sixty attempts were scored in total. Eighty-seven percentage (26/30) of surgeons’ scores (mean: attempt 1 = 92, attempt 2 = 104) and times [mean: attempt 1 = 1:22:00, attempt 2 = 1:08:00 (h:mm:ss)] improved between the 2 attempts by 9% and 15% respectively (P ≤ 0.001). Total scores of all surgeons in the non-proctored subgroup (6) improved by 15% on average (mean: attempt 1 = 86, attempt 2 = 105, P = 0.002). CONCLUSIONS Procedure-specific assessment tools can be developed to evaluate technical performance for complex CHS simulation and be performed reliably by non-expert raters. Rehearsal both under supervision and independently leads to technical skill improvement further supporting its value in CHS training.

Objective Data supporting the use of hands-on simulation in congenital heart surgery are promising but primarily qualitative. This study aimed to demonstrate if there was an objective improvement in time and technical performance of the arterial switch procedure on 3-dimensional printed heart models by surgeons using a validated assessment method. Methods A total of 30 surgeons of varying experience performed the arterial switch procedure twice on 3-dimensional printed models with transposition of the great arteries during the Hands-on Surgical Training courses. Surgeons' performances were recorded and retrospectively assessed for both time and performance using the Hands-on Surgical Training-Congenital Heart Surgery tool, a validated procedure-specific assessment tool for the arterial switch. Results A total of 60 videos were scored. Eighty percent of surgeons (24/30) had improved from their first attempt. The mean total score of the first attempt performance compared with the second was 103 and 120, respectively, with a mean difference in score of 17 (95% confidence interval, 10-24). All surgeons were statistically significantly quicker in their second attempt. The mean time for the first attempt compared with the second was 1 hour, 28 minutes, 4 seconds and 1 hour, 5 minutes, and 45 seconds, respectively, with a mean difference of 0 hours, 22 minutes, 19 seconds (95% confidence interval, 0 hours, 15 minutes, 22 seconds to 0 hours, 25 minutes, 34 seconds). Conclusions This is the first study to demonstrate an objective improvement in time and technical performance of the arterial switch procedure on 3-dimensional printed heart models. This supports the evidence that simulation in the form of deliberate practice with constructive, objective feedback is fundamental in the training of future congenital heart surgeons. These simulations and assessments should be incorporated to create structured, standardized training curricula within congenital heart surgery.

Background: Cerebral venous thrombosis (CVT) is a long-term debilitating vascular brain disease with high morbidity and mortality. Plasma levels of D-dimer are shown to be elevated and sensitive for the diagnosis of cerebral venous thrombosis (CVT). Objective: To evaluate the usefulness of plasma D-dimer levels in diagnosis of cerebral venous thrombosis. Patients and methods: This case-control study was conducted on two groups, patient group (40 patients) with CVT, and control group (10 patients) without CVT. All patients were subjected to full history and complete general and neurological examination focusing on headache either isolated or with symptoms of increased intracranial pressure (nausea/vomiting, papilledema, visual disturbance, disturbance of consciousness), focal motor deficit, cranial nerve palsy, or seizure. Fundus examination was done to detect papilledema and brain MRI and MRV to detect CVT, and determine the affected sinus. D-dimer levels were measured by the rapid sensitive D-dimer assay. The study was done at Department of Neurology, Al-Hussein and SayedGalalUniversityHospitals, Cairo, Egypt. Results: Among patient group, 30 (75%) patients were females, while 10 (25%) patients were males, and the mean of age was 27.4 years. The common presenting symptom was headache with blurred vision in 21 (52.5%) patients, followed by focal seizures in 10 (25%) patients. The most common sinus involved was right (Rt.) transverse sinus in 14 (35%) patients. Twenty-seven (67.5 %) patients had papilledema. D-dimer test was positive in 39 (97.5%) patients in patient group, while in the control group 1 patient (10%) was positive and 9 patients (90%) were negative. Conclusion: Raised D-dimer level was often helpful for early diagnosis of CVT and an important screening tool to determine the early need of neuroimaging in patients who were suspected to have CVT. Negative D-dimer test did not exclude CVT, but indicated that acute CVT was very unlikely.

Congenital heart surgery is a technically demanding specialty resulting in a prolonged training period. With the growing expectation of perfect patient outcomes, there is a need for improved training methods by implementing simulation. We assess the utilization of simulation in the training of congenital heart surgeons and discuss its future implications. A keyword-based PubMed literature search was conducted for hands-on surgical simulation in congenital heart surgery. The abstracts/titles of the search were reviewed and papers using simulation specific to congenital cardiac surgery were selected. Studies that did not include surgeons operating on the simulator, or did not incorporate assessment methods were excluded. Analysis included the problem addressed, simulator-type, methodology, assessment methods, results, benefits/limitations, and reproducibility. Five papers fulfilled our selection criteria of hands-on surgical simulation in congenital heart surgery with an assessment of the simulator or procedural performance. One simulation used animal models and 4 utilized 3D-printed models. Simulators covered either single or multiple complex procedures. All studies highlight usefulness of simulation; however, only 1 study has been replicated with >10 participants. The studies demonstrate how hands-on surgical simulation is possible within congenital heart surgery. Although primarily proof of concept studies, the next step would involve using a greater number of participants and demonstrate how repetition and deliberate practice will improve outcomes. Congenital heart surgery is one of the most technically demanding surgical specialties; therefore, we should lead the way in utilizing simulation to complement the training of our surgeons as we face the challenges ahead.

OBJECTIVES To demonstrate that improvement in technical performance of congenital heart surgical trainees during ventricular septum defect (VSD) closure simulation translates to better patient outcomes. METHODS Seven trainees were divided into 2 groups. Experienced-fellows group included 4 senior trainees who had performed >5 VSD closures. Residents group consisted of 3 residents who had never performed a VSD closure. Experienced-fellows completed 3 VSD closures on real patients as a pretest. Both groups participated in a 4-week simulation requiring each participant to complete 2 VSD closures on three-dimensional printed models per week. One month later, all trainees returned for a post-test operation in real patients. All performances were recorded, blinded and scored independently by 2 cardiac surgeons using the validated Hands-On Surgical Training–Congenital Heart Surgery (HOST-CHS). Predefined surgical outcomes were analysed. RESULTS The median HOST-CHS score increased significantly from week 1 to 4 [50 (39, 58) vs 73 (65, 74), P CONCLUSIONS Deliberate practice using simulation translates to better performance and surgical outcomes in real patients. Residents who had never completed a VSD closure could perform the procedures just as safely and effectively as their senior colleagues following simulation.

Congenital heart surgery (CHS) is technically demanding, and its training is extremely complex and challenging. Training of the surgeon's technical skills has relied on a preceptorship format in which the trainees are gradually exposed to patients in the operating room under the close tutelage of senior staff surgeons. Training in the operating room is an inefficient process and the concept of a learning curve is no longer acceptable in terms of patient outcomes. The benefits of surgical simulation in training of congenital heart surgeons are well known and appreciated. However, adequate surgical simulation models and equipment for training have been scarce until the recent development of three-dimensionally (3D) printed models. Using comprehensive 3D printing and silicone-molding techniques, realistic simulation training models for most congenital heart surgical procedures have been produced. Newly developed silicone-molded models allow efficient CHS training in a stress-free environment with instantaneous feedback from the proctors and avoids risk to patients. The time has arrived when all congenital heart surgeons should consider surgical simulation training before progressing to real-life operating in a similar fashion to the aviation industry where all pilots are required to complete simulation training before flying a real aircraft. It is argued here that simulation training is not an option anymore but should be a mandatory component of CHS training.

Summary OBJECTIVES With reductions in training time and intraoperative exposure, there is a need for objective assessments to measure trainee progression. This systematic review focuses on the evaluation of trainee technical skill performance using objective assessments in cardiothoracic surgery and its incorporation into training curricula. METHODS Databases (EBSCOHOST, Scopus and Web of Science) and reference lists of relevant articles for studies that incorporated objective assessment of technical skills of trainees/residents in cardiothoracic surgery were included. Data extraction included task performed; assessment setting and tool used; number/level of assessors; study outcome and whether the assessments were incorporated into training curricula. The methodological rigour of the studies was scored using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS Fifty-four studies were included for quantitative synthesis. Six were randomized-controlled trials. Cardiac surgery was the most common speciality utilizing objective assessment methods with coronary anastomosis the most frequently tested task. Likert-based assessment tools were most commonly used (61%). Eighty-five per cent of studies were simulation-based with the rest being intraoperative. Expert surgeons were primarily used for objective assessments (78%) with 46% using blinding. Thirty (56%) studies explored objective changes in technical performance with 97% demonstrating improvement. The other studies were primarily validating assessment tools. Thirty-nine per cent of studies had established these assessment tools into training curricula. The mean ± standard deviation MERSQI score for all studies was 13.6 ± 1.5 demonstrating high validity. CONCLUSIONS Despite validated technical skill assessment tools being available and demonstrating trainee improvement, their regular adoption into training curricula is lacking. There is a need to incorporate these assessments to increase the efficiency and transparency of training programmes for cardiothoracic surgeons.

During the COVID-19 pandemic, performing a surgeon’s duties has become challenging while adhering to social distancing mandates. To aid in the continuity of healthcare services, rapid implementation of digital communication tools became a necessity. This is an account of experiences using digital communication platforms, namely Microsoft Teams and Zoom, for clinical and educative purposes in the field of Cardiothoracic Surgery in the UK. While enabling ongoing virtual clinical meetings, conferences and learning opportunities for residents with little face-to-face contact, are these digital communication platforms keeping us connected or isolated?

Three-dimensional (3D) printed models are widely accepted for use in training of various surgical procedures for congenital heart disease; however, their physical properties have been considered suboptimum for procedures. We created silicone molded models produced using a novel "parting and assembly" strategy and compared their suitability for hands-on training with that of conventional 3D printed models.Computed tomography imaging data from 2 patients with transposition of the great arteries were used. The heart was divided into multiple parts (atria, ventricles, great arteries, coronary arteries, and valves), and molds of each part were created. The parts reproduced by silicone molding were assembled using an adhesive agent. In an online course, 2 silicone molded models and 1 3D printed model were used for training of 34 surgeons. A questionnaire was distributed to these surgeons aimed at assessing the suitability of the models for the arterial switch operation (ASO).The silicone molded models showed excellent anatomic detail, high elasticity, and high resistance to tearing. The cost per model, based on the production of 50 models, was slightly higher for the silicone molded models compared with the 3D printed models. All 26 surgeons who completed the questionnaire reported that the silicone molded models provided sufficient anatomic information, but only 19% said the same for the 3D printed models. All surgeons also considered the silicone models to be realistic when passing a needle, cutting vessels, suturing, and excision of the coronary buttons, as opposed to46% for the 3D printed models.Silicone molding of models for the ASO is feasible by applying a "parting and assembly" strategy. Silicone molded models provide excellent physical properties that are far superior to those of 3D printed models for surgical simulation.

Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures.We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed.Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay.In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Researches on Internet Banking (IB) in the context of Yemen is still lacking which creates the necessity to conduct such a study to investigate the adoption level of IB services. Thus, this study aims at examining and investigating the factors influencing the adoption of IB among banks’ customers in Yemen through the use of the UTAUT theory. The framework of this study comprises one endogenous variable the intentions to use IB services) and five exogenous variables in which the exogenous variables consist of effort expectancy, performance expectancy, trust, social influence, and awareness. The identified moderators in this study are the role of age and experience that influence the intentions of banks’ customers to use and adopt IB services. The survey questionnaire was distributed to a sample that consists of 354 bank customers and the returned data was screened and then analyzed using structural equation modeling (SEM) to investigate the correlations and relationship among variables. Meanwhile, the indirect impact of the moderating variables was investigated using multiple-group analysis (MGA). The results of this study revealed that effort expectancy, performance expectancy, awareness, and trust have a significantly positive impact on customers’ intention to adopt IB services in Yemen. However, the social influence showed no significant effect on IB services. Moreover, the age and experience variables showed a moderating impact on customers’ intention to adopt IB services in Yemen.

The present paper aims to evaluate the sedimentological model of the study Cenomanain sequence in terms of electrofacies interpretation and depositional facies architecture to reveal the spatial distribution of the reservoir facies characterization. The influence of depositional lithofacies types on reservoir characterization of the Cenomanian Bahariya Formation and Abu Roash “G” Member was investigated using the integration of available core data and petrophysical evaluation from seven wells in Alam El-Shawish East Oil Field, North Western Desert, Egypt. Careful log interpretation and correlation enable differentiation of the study sequence into ten sedimentary cycles. The stacking of the recognized facies types in the available cored interval, form fifteen depositional facies associations from which fluvial, estuarine and shoreline-shallow shelf models were constructed. This facies information has been used to calibrate the log response, particularly the gamma-ray trends, as an aid to interpret the depositional environment of the non-cored intervals. However, the generalized log pattern shows micro-variations in log shape and trend based on the location relative to depositional environment and consequently major modified gamma-ray patterns were proposed depending on the cored facies architecture. Therefore, precautions must be taken into consideration in extrapolating the present patterns to any similar heterogeneous sequence due to the effects of variable diagenetic and facies type constraints on log response. It is indicated that hydrocarbons could be accumulated within shoreface and barrier tidal inlet complex near or within the depositional sequence boundary surfaces along the Upper Bahariya Member and the upper unit of Abu Roash “G” Member. The associated fine siliciclastics (mudstone and shale) of tidal lagoon and/or shoreface delta facies may be acted as local source rock and trap seals. Based on reservoir characterization data supplemented by well logs interpretation of the cored and non-cored intervals, further reservoir beds could be recommended as potential prospecting targets.

The COVID pandemic has had huge implications for training in cardiothoracic surgery. The reduction in training opportunities has led to concerns from trainees globally regarding the impact on their learning and their training progression. Surgical simulation is effective in the development of technical skills in cardiothoracic surgery with numerous examples of low and high-fidelity simulators. Despite this the incorporation of such methods into training curricula worldwide is seldom. Core fundamentals are required to successfully implement surgical simulation into training programmes, which includes; commitment from trainers, regular sessions and structured feedback. Few programmes have demonstrated the successful incorporation of surgical simulation and there is a growing acceptance of its place in the speciality. As we recover from this challenging period it may be the right opportunity to evolve how we train our current and future trainees by incorporating hands-on simulation as a fundamental part of the cardiothoracic curriculum.

There are a number of techniques used in the surgical treatment of supravalvular aortic stenosis with excellent results; however, junior surgeons’ experience may be limited due to its rare nature. Simulation with 3D-printed models provides a safe platform for surgeons to rehearse surgical techniques prior to patient application but must replicate all features of surgical anatomy. Here, we describe how software manipulation can be used to accurately reproduce the surgical anatomy in supravalvular aortic stenosis and be used to train surgeons in 2 different techniques.

BACKGROUND We aimed to examine the rationale and assess risk of additional cardiopulmonary bypass (CPB) episodes, and specifically, re-institution of CPB for reintervention, in congenital heart surgery. METHODS AND RESULTS We retrospectively reviewed all children undergoing cardiac surgery with CPB at one institution (2014-2016). Tetralogy of Fallot was excluded as the annulus-sparing surgical strategy involves planned intraoperative revision. The final cohort of 922 patients was stratified: single CPB run (CPB=1, n=771); >1CPB without revisions (CPB>1NR, n=77) for reperfusion, bleeding, or intractable arrhythmias; and >1CPB with revision (CPB>1R, n=74). Successful revisions were defined as: those resulting in at most mild residual lesions, did not induce new lesions, did not require postoperative revision, and did not result in mortality prior to discharge. Forced revisions were defined as revisions for unacceptable hemodynamics or failure to wean from CPB. Outcomes of interest were in-hospital mortality, complications, need for postoperative revision, and a composite (death, stroke, ECMO, arrest, and leaving OR with open chest). Predictors of the composite outcome were assessed by logistic regression. Mean age was 2.9±4.5 years, 54% were male and mean RACHS was 2.5±0.8. In CPB>1R, 18 (24%) required 2 or 3 revisions. Revisions were valvular in 34 (46%) and forced in 51 (69%) patients. Success with a single revision occurred in 22 (30%) and by the final attempt in 32 (43%) patients. One patient's lesion worsened as a result of the revision. When comparing CPB=1 vs CPB>1NR vs CPB>1R, outcomes with significant differences included: stroke, arrest, postoperative revision, open chest upon leaving OR, and the composite outcome (Table 1). In-hospital death, re-exploration, need for ECMO, and hospital stay were similar (Table 1). Among CPB>1R patients, 12 (16%) required postoperative revision. Logistic regression identified revision as a predictor of the composite outcome with greatest effect seen in 2 revisions: 1: OR=2.39 (95% CI: 1.35, 4.21) p=0.002, 2: OR=3.68 (95% CI: 1.26, 10.74) p=0.02, 3: OR=1.23 (95% CI: 0.25, 12.23) p=0.8. Additionally, CPB runs=3 was associated with the composite outcome: OR=2.25 (95% CI: 1.00, 5.05) p=0.048. A trend towards CPB runs = 4 was seen while CPB runs=2 was not correlated with the composite outcome. CONCLUSION Revisions are uncommon, and most are forced. Revisions frequently do not eliminate residual lesions, occasionally require additional postoperative revisions, but are not associated with increased early mortality. Revisions and >2 CPB runs were associated with greater risk of the composite outcome. Those for non-forced reasons should likely be considered with caution.

Various congenital heart diseases are associated with malalignment of a part of the ventricular septum. Most commonly, the outlet septum is malaligned toward the right or left ventricle. Less commonly, the whole or a major part of the ventricular septum is malaligned in relation to the atrial septal plane. Although the pathological conditions associated with ventricular septal malalignment have been well recognized, the descriptions are often confusing and sometimes incorrect. In this pictorial essay, we introduce our systematic approach to the assessment of malalignment type ventricular septal defects with typical case examples. The systematic approach comprises description of the essential features of malalignment, including the following: (1) the malaligned part of the ventricular septum, (2) the reference structure, (3) the mechanism of malalignment, (4) the direction of malalignment, and (5) the severity of malalignment.

The monthly in-house Hands-On Surgical Training (HOST) program was incorporated into the congenital heart surgery (CHS) curriculum for surgical trainees within our institution. This study evaluated whether there was an improvement and retention of technical skills throughout the curriculum via objective assessment methods.Twelve 3-dimensional-printed surgical heart models were included into the year-long curriculum. The monthly sessions were attended by all trainees and staff surgeons. Proctors demonstrated the operation on a model, which was followed by 2 attempts by each trainee. Attempts were recorded for objective assessment. On completion of the curriculum trainees repeated 4 procedures an additional 2 times after a delay to assess skill retention.Twelve sessions were completed by 7 trainees within the curriculum. Objective assessments were performed in 7 sessions. Eighty-one percent of trainees' scores improved between the 2 attempts, with a mean improvement of 13% (attempt 1: HOST-CHS score of 79, attempt 2: HOST-CHS score of 89; P .001). Similarly, 91% of procedural times improved by a mean of 25% (attempt 1, 1:22:00 [hours:minutes:seconds]; attempt 2, 1:01:21; P.001). During individual procedure analysis, statistical significance remained in 3 of 7 procedures (P.05). Four procedures were assessed for skill retention after a delay (2-14 months). Scores decreased by 4% in 47% of trainees during attempt 3 (attempt 2: HOST-CHS score of 94, attempt 3: HOST-CHS score of 91; P = .34) but improved in 79% during attempt 4 (attempt 3: HOST-CHS score of 91, attempt 4: HOST-CHS score of 99; P = .004), matching their previous performance.The monthly HOST course was successfully incorporated into a training curriculum for CHS surgeons using objective assessments to measure technical performance. Trainees demonstrated an improvement across all evaluated procedures and retained their skills when reassessed after a delay highlighting its value in CHS training.

Background The Hands-On Surgical Training in Congenital Heart Surgery (HOST-CHS) program using 3D printed heart models has received positive feedback from attendees. However, improvements were necessary in the simulator set up to replicate the ergonomics experienced in the operating room. This paper illustrates the development of a dynamic chest wall and operating table simulator to enhance the simulation experience. Methods The simulator was designed to address the limitations with the existing set up. This included a suboptimal operating position, unrealistic surgical exposure and limitations in illuminating the operative field and recording procedures. A combination of computer-aided design and various 3D-printing techniques were used to build the components. The simulator’s usefulness was evaluated by surgeons who attended the 5th annual HOST course via a questionnaire. Results The simulator consists of three components; an operating table simulator which allows height adjustment and pitch-and-roll motion; a suture retraction disc, which holds sutures under tension to improve exposure; and a pediatric chest wall cavity to replicate a surgeon’s access experience during surgery. Nineteen surgeons completed the questionnaire. All surgeons agreed that the addition of the simulator was acceptable for surgical simulation and that it helped replicate the ergonomics experienced in the operating room. Conclusions The inclusion of the HOST-CHS simulator adds value to simulation in congenital heart surgery (CHS) as it replicates the view and exposure a surgeon experiences. Improvements like these will help develop high-fidelity simulation programs in CHS, which could be utilized to train surgeons globally.

Objective Over the last decade medical students’ interest in pursuing surgery as a career has declined. This is more apparent in high-specialized specialities such as congenital heart surgery (CHS). Early hands-on simulation has shown to have a positive impact on medical students’ interest in pursuing surgery, however, its incorporation into medical school curricula is lacking. This study aimed to evaluate the impact of incorporating medical students as surgical assistants during the Hands On Surgical Training course in CHS. Methods Local preclinical medical students were invited to participate as surgical assistants during the 5th annual Hands On Surgical Training course in CHS. Among those who responded to the invitation, students were randomly selected and allocated to assist a congenital heart surgeon. All selected students attended an assistants’ session prior to the course to familiarize themselves with assisting and to practice basic surgical skills. At the end of both courses students completed a questionnaire based on Likert 5-point scale to evaluate the courses’ usefulness. Results Fifteen medical students completed the questionnaires. All reported a beginner level of understanding of congenital heart disease. All students were highly satisfied with using 3D-printed models to help their understanding of congenital heart disease (4.80 ± 0.41) and agreed that the sessions improved their assisting skills (4.93 ± 0.26). All expressed a desire to attend similar sessions in the future and agreed that surgical simulation inclusion into medical school curricula would enhance learning (5.00 ± 0.00). Interest in pursuing a career in CHS increased from 33% (5) to 87% (13) by the end of the course. Conclusions Integration of preclinical medical students into surgical simulation increases interest in pursuing highly specialised surgical specialities such as CHS. Early exposure and the incorporation of such simulation programs into medical school curricula will likely improve surgical skill acquisition and may enable students to be better informed when selecting future career choices.