Simulation a new frontier in training in congenital heart disease
Year: 2025
Type: article
Abstract: The population of patients with congenital heart disease (CHD) is extremely heterogeneous,1 spanning a wide spectrum of varying ages from newborns to adults. Patients may suffer from simple or complex malformation both in their natural history and following intervention that live behind variable degrees of residual lesions, sequelae, and complications. This heterogeneity demands long, structured training pathways in cardiology and in cardiac surgery. For cardiac surgeons in particular, full autonomy is often not achieved before the age of 45–50 years.2 Even in cardiology, technological advances in diagnostics and particularly in the percutaneous treatment of structural and arrhythmic diseases require highly specialized training that cannot be quickly or causally acquired. Traditional training, based on progressive exposure to increasingly complex clinical cases, must combine solid theoretical principles with practical preparation. Today, these training models are no longer adaptable to current epidemiological realities. Regions such as Africa where the demand for care exceeds the supply, necessitating rapid training of capable new professionals.3 Conversely, in many Western countries including Italy, the declining of birth rates has reduced the number of newborns with CHD and the incidence of the most complex conditions.4,5 Earlier and more accurate prenatal diagnosis of a severe malformation contribute to further to this shift as many couples opt for termination of pregnancy.5 Simultaneously, adults with previously operated CHD have progressively increased,6 and they often require complex medical management and reinterventions that for obvious reasons, are handled by more senior surgeons. The result is a concrete risk: when the experienced professionals retire, their successors may not yet have acquired comparable expertise. This scenario underscores a pressing need: to deliver high-quality training while reducing learning times without compromising safety, ethics, or patients’ outcomes. This ambitious challenge requires fully leveraging new technologies.7–12 In recent years, simulation systems have steadily expanded, enabling trainees to gain practical experience in controlled environments. However, despite multiple local initiatives, training in CHD simulation remains largely non-standardized and fragmented. At present, simulation exposure is often centre-dependent, country-dependent, and discipline-dependent (surgery vs. cardiology vs. imaging), resulting in uneven access and heterogeneous skill acquisition. There is no harmonized curriculum defining minimal simulation exposure, no agreed procedural volume requirements, and no shared competency benchmarks or certification pathways based on simulation tools. In other words, simulation is increasingly recognized as necessary, yet it remains largely ungoverned—risking perpetuation of training inequities precisely when epidemiology is making real-world case exposure less predictable. A range of advanced simulation techniques is currently available. Virtual and augmented reality programs integrated with artificial intelligence, can recreate scenarios for showing and teaching the manual skills required to perform various procedures, including cardiac surgery and interventional cardiology.7,8 However, these techniques remain costly and not readily accessible. Among the valuable simulation modalities, the introduction and ongoing development of 3D printing techniques have marked a turning point in simulation for CHD.9–13 Using CT, MRI, and even echocardiographs, datasets, it is now possible to obtain highly accurate 3D replicas of both normal and pathological cardiac anatomy.10,11 These models are useful for surgeons to learn techniques subsequently applied in the real-world setting11 and are equally valuable for training cardiologists. 3D models enable in-depth anatomical analysis, particularly in complex malformations.10 This facilitates interpretation of images from different diagnostic techniques and can support the planning of various procedures. Cardiology also benefits from simulation systems enabling learning of essential manoeuvres such as pericardiocentesis, as well as the performance of echocardiographic examinations. Finally the learning role of simulated clinical cases cannot be overlooked.12 This practice is useful for refining decision-making skills and for exercising clinical reasoning in a protected, repeatable manner. We illustrate the value of simulation techniques in training and professional development by sharing experiences from two our educational projects. Launched in 2023, the Aesculapius project13 targets cardiac surgeons from developing countries with limited resources and specialists shortages. The programme—totally free—offers 5-day residential courses combining theoretical sessions with hands-on practice using 3D models to learn correction of both simple and complex malformation. A second training project, also launched in 2023, focuses on echocardiography in CHD. The 3-day programmes combine theoretical lectures with practical exercises on neonatal simulator mannequins enabling transthoracic and transoesophageal studies on normal and pathological hearts, alongside analysis of several echocardiographic clips. These experiences support a shift that CHD training should now follow: moving from time-based apprenticeship to competency-based training pathways, in which simulation precedes patient exposure and progression is guided by objective performance metrics. Tools such as OSATS provide a robust framework to define measurable endpoints, enabling structured feedback and transparent progression. In this context, simulation-defined milestones could be formally integrated into curricula across disciplines, including: (i) anatomy recognition and spatial understanding; (ii) stepwise procedural execution; (iii) error recognition and recovery strategies; and (iv) multidisciplinary communication and decision-making under pressure. All of the above strongly underscores that simulation, in all its forms, is now an indispensable tool for training professionals dedicated to CHD. Interestingly, the major cardiac surgical societies now recommend introducing simulation techniques into the training programmes.12 Despite its potential, significant obstacles remain regarding the management, costs, and organization of simulation activities. The central question is who should assume these responsibilities. Specialization schools and scientific societies should take a leading role in this process; however, to date, at least in the Italian context, such initiatives are isolated and uncoordinated and frequently fee-based. To move from innovation to impact, CHD simulation training must transition from opportunistic adoption to a standardized educational strategy. This requires a shared curriculum, defined competency benchmarks, and accreditation models capable of ensuring similar access and comparable outcomes across centres and countries. The creation of multidisciplinary, accredited training centres is the most effective response to these challenges, providing standardized structures accessible to all professionals involved in CHD. Standardization should not reduce flexibility but just guarantee a minimum level of competence. Simulation, in all its forms, is now an indispensable tool for training professionals in CHD: ‘Beyond technical proficiency, simulation reinforces patient safety culture and may mitigate medico-legal risks associated with insufficient training in rare/complex cases’. Simulation, however, from optional must become a standard, and rigorously assessed components of educational pathways. Without coordinated action by professional societies, accreditation bodies, and institutions, expertise dilution is inevitable, and training gaps will rise, as experienced senior operators retire, and complex adult CHD cases increase. The responsibility lies with major societies (ESC, AEPC, EACTS, ECHSA, ASE) and training institutions to lead this transformation, establishing multidisciplinary, accredited simulation centres that ensure equal, high-quality preparation for all involved in CHD management. We thank Bambini Cardiopatici nel Mondo and European Heart for Children for sponsoring and organizing the Aesculapius Project and the Echocardiograph training; and Fondazione Anna Maria Sechi per il Cuore for supporting the Long-Lasting Aesculapius Project in Africa. Alessandro Frigiola (Conceptualization), Roberto Ferrari (Writing—review & editing), and Gabriele Vignati (Writing—original draft) No founding for this study.
Institutions: IRCCS Policlinico San Donato, University of Ferrara
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,390
OpenAlex ID: W7128368420