The role of simulator training for skills aquisition in coronary angiography

Introduction: Coronary angiography (CA) is one of our most common invasive techniques in medicine today and is used to investigate coronary anatomy and pathology. The method is crucial and lifesaving in diagnosing acute coronary syndromes and so far not interchangeable to any other modality. The skills of performing a CA are compulsory for the general cardiologist according to present international guidelines but the methods for achieving these skills are not well defined. CA is a relatively safe procedure but complications occur, particularly during training. Simulators are proposed to be safe alternatives to achieve necessary skills but the methods for their use are not described. The aim of this thesis was to demonstrate that simulator training improve CA skills in real life. To be able to recommend simulators for skills acquisition, transferability from virtual reality to real life catheterization lab must be demonstrated, i.e. transfer validity. Methods and results: Study I. The aim was to explore factors related to proficiency in CA and to construct learning curves to describe the improvement in CA skills over time. Swedish Coronary Angiography and Angioplasty Registry (SCAAR) was used to track experts and novel operators in CA and to compare their performances. Fluoroscopy time turned out to be the only solid marker for proficiency demonstrating a learning curve in the beginners group who reached expert level after 150 CAs. Complications were more frequent during training and were associated to fluoroscopy time. Study II. The concept of simulator constructs validity, i.e. to demonstrate that the simulator can measure the differences it is supposed to measure was explored in study II. Twenty- four participants with three different levels of proficiency in CA performed five consecutive virtual reality CAs each in the simulator. Three different levels of skills in the simulator were demonstrated that corresponded to their proficiency level. Beginners had a fourf