<div>Title: Comment on: Virtual Reality, e-Learning, and Global Cardiac
Surgical Capacity-Building</div><div>Running Title: Comment VR and e-Learning</div><div>Authors:</div><div>Carlo Maria Rosati, MD<sup>1</sup>; Omar M. Lattouf, MD PhD FACC
FACS<sup>1</sup></div><div>Affiliation:</div><div><sup>1</sup> Mount Sinai Morningside, 1111 Amsterdam Avenue, New
York, NY 10025</div><div>Corresponding Author:</div><div>Omar M. Lattouf, MD PhD FACC FACS</div><div>Professor of Cardiovascular Surgery, Mount Sinai Icahn School of
Medicine</div><div>Professor Emeritus, Emory University</div><div>Mount Sinai Morningside, 1111 Amsterdam Avenue, New York, NY 10025</div><div>Email: omar.lattouf@mountsinai.org</div><div>No conflicts of interest.</div><div>Word count: 745</div><div>Disparities between higher and lower income countries in terms of
accessibility to cardiac surgical care are appalling and reducing them
is the commendable focus of interest of a growing series of initiatives.</div><div>Training a cardiac surgeon is notoriously a long and intensive process
where “textbook knowledge”, technical skills, clinical judgement and
the ability to work within a team are all fundamental ingredients, that
have to be mastered individually, as well as combined together.</div><div>The Authors of this manuscript<sup>1</sup> are addressing the
very important topic on how to train the next generation of cardiac
surgeons from low- and middle-income countries. Besides more
“traditional” challenges (such as the cost of travelling and living in
high-income countries to receive on-site surgical training, and the high
competition for cardiac surgery training positions), the ongoing COVID
pandemic has added new ones, such as increased burdens on healthcare
systems and international travel restrictions.</div><div>The concepts offered by the Authors challenge the “age-old” training
methodology, which has proven to be effective in producing safe,
competent and innovative operators and educators.
As cardiac surgeons have led their colleagues in all medical specialties
in bringing new technologies within our system of training and practice,
it is hard to convince ourselves to change. That said, the concepts put
forth by the Authors must not be ignored, and the currently available
technologies, together with the unexpected implications of the pandemic,
can form the basis for the evolution of global cardiac surgical
training.</div><div>Online learning and mentoring are powerful tools that are growing
exponentially and should be well-known and accessible to all cardiac
surgery trainees around the world. A few examples are:</div><ul><li>CTSNet</li><li>Podcasts, such as the series by the Thoracic Surgery Residents
Association and the Society of Thoracic Surgeons</li><li>The new eBook by the Society of Thoracic Surgeons</li><li>Smart phone apps with clinical practice guidelines, such as the
American College of Cardiology/American Heart Association and the
European Society of Cardiology</li><li>Online simulation training modules/courses, such as “My Virtual
Anastomosis” by Prof. Paul Sergeant</li><li>Congenital Heart Academy</li></ul><div>All major cardiac surgery meetings - including those of the Society of
Thoracic Surgeons (STS), the American Association for Thoracic Surgery
(AATS), the European Association for Cardio-Thoracic Surgery (EACTS),
International Coronary Congress, etc. - are taking place in a virtual
format. While such online format cannot replace the camaraderie and
networking impact of in-person meetings, it is a great opportunity to
reduce the cost to attend and to make such meetings accessible to every
cardiac surgeon in every country of the world, without the need for
long-distance travelling.</div><div>Interviews for training positions and jobs and meetings for shared
clinical care and research collaborations are routinely done in a
virtual format.</div><div>These are all new possibilities that can only help bring high-quality
cardiac surgical training to low- and middle-income countries.</div><div>As far as actual “hands-on” training is concerned, the restrictions
imposed by the COVID pandemic on international mobility are an added
obstacle with an extremely high impact. While the development and
distribution of vaccines holds promise for a “return to normalcy”, it
is not possible to foretell exactly for how long more such restrictions
will be in place. We believe that, in the current situation, but also in
the long term, it will be key to strengthen the role that experienced
cardiac surgeons, who are already practicing in each country, have in
training the next generations. It is essential to develop strong
collaborations among national and international (such as STS, AATS and
EACTS) cardiac surgical societies to “train the trainers” and give
them the tools and support that are necessary to guarantee high-quality
on-site hands-on training in each country. This is not an easy goal to
accomplish. We congratulate the Authors on their commitment towards the
fundamental topic of global cardiac surgery and we support and encourage
such initiatives without any hesitation.</div><div>Reference</div><div>Vervoort D, Fiedler A. Virtual Reality, e-Learning, and Global Cardiac
Surgical Capacity-Building. J Card Surg 2021. In Press.</div>