Applying the Principles of Deliberate Practice to Train Complex Aortic Root Surgery: Development of the Aortic Root Module of the Early Exposure and Assessment (EASE) Training Program

Objectives: Aortic root surgery has a significant learning curve. These procedures can be trained in simulations. The amount and intensity of “deliberate practice” is a predictor of expert-level performance in nonsurgical and surgical domains. Deliberate practice is characterized as purposeful, focused, and intense. It has the specific goal to improve performance. We developed an aortic root training curriculum applying the principles of deliberate practice.

Methods: The aortic root procedure was divided into component tasks: (1) exposition, (2) aortic root preparation, (3) myectomy (morrow), (4) aortic root enlargement (Manouguian/Rittenhouse), (5) construction of a mechanical valved conduit, (6) implantation of the conduit, and (7) reconstruction of a coronary ostia using a 6-mm PE graft. In three training workshops with 25 participants (students, residents, and fellows), the curriculum was validated and adapted.

Results: Based on the training workshop experience, 18 video tutorials were created that showed surgical techniques and completion times for each surgical task. A training box for self-organized training sessions on porcine hearts was developed, including a LED ring light and a smartphone/webcam holder for videotaping. A scoring system was devised to assess surgical performance (dimensions handling, motion, tissue, product, and time to completion) in video recordings. Marked differences in basic surgical skills were seen between students, residents, and fellows. An entry assessment test (stich simulation of 16 stiches on a prosthetic graft) was devised to categorize participants into performance groups I, II, and III. A basic surgical techniques part was added to the curriculum as the first component task (needle control, stich angles, and instrument handling). A 30-page training workbook was created.

Conclusion: The principles of deliberate practice can be applied to surgical training programs. For effective training, component tasks of surgical procedures are defined, performance targets are set, and trainees are categorized into entry performance levels. Detailed print and video material has to be provided to define target performance and skills. Training basic surgical skills remains an important component of every surgical simulation. Feedback is given through comparison of videotaped training performances with video tutorials and during regular instructed workshops. A target simulation performance should be defined before trainees perform real cases in patients.

No conflict of interest has been declared by the author(s).