EDITORIAL COMMENT Expert Article Analysis for: Novel augmented physical simulator for the training of transcatheter cardiovascular interventions Role of simulators on structural training Mehmet Cilingiroglu MD 1,3 | Konstantinos Marmagkiolis MD 1,2 1 Department of Cardiology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA 2 HCA Northside Hospital, St. Petersburg, FL, USA 3 Bahcesehir University, School of Medicine, Istanbul, Turkey Correspondence Mehmet Cilingiroglu, University of Texas, MD Anderson Cancer Center, Houston, TX 77030. Email: cilingiroglumehmet@gmail.com Key Points • Structural heart interventions are a rapidly evolving field in the treatment of complex heart diseases. • While the number of dedicated fellowship pro- grams keep increasing, there are important limita- tions on the number and diversity in certain structural heart procedures. • Procedural specific simulation technology offer a safer, comprehensive and controlled training opportunity. Over the last two decades, structural heart disease (SHD) interven- tions have emerged as a new field in interventional cardiology. Several accredited interventional cardiology fellowships offer an additional advanced fellowship year on structural interventions. However, despite the increase in SHD centers, major issues still exist in the wide variation in which structural procedures are performed (balloon mitral or pulmonic valvuloplasty, perivalvular leak repair, ventricular septal defect or patent ductus arterioles closure, coronary fistula occlusions, transcaval puncture, etc.). 1 Moreover, experienced operators with geographic, time, and financial constraints may not be able to safely introduce novel structural procedures in their institutions. Simulators have played an important role on medical education over the years. There has been a worldwide shift from theoretical toward experiential “hands-on” learning. 2 Computer-based or hybrid simulators artificially represent a complex real-world condition and allow the development of procedural skills via comprehensive practi- cal training in a more controlled environment. In this edition of Catheterization and Cardiovascular Interventions, Zimmermann et al demonstrate their experience with the transseptal puncture (TSP) simulator. A computed tomography-based, three- dimensional (3D) printed replica of the cardiovascular system, armored with silicon phantoms, replaceable septum, and realistic fluoroscopic and echocardiographic imaging, created an almost real- life experience in a zero-risk environment with a good haptic feed- back, realism of fluoroscopy scores as well as with a good usability by the operators. 3 However, the realism of transesophageal echocar- diogram images was rated the lowest. The authors acknowledged the absolute need for upgrading the system to make it optimal for trainees to be able to see both the classic tenting of the septum and access of the needle into the left atrium with optimal confirmation and confidence. While this study demonstrates the potential role of TSP simulation in an early system, simulation systems require further optimization and fine-tuning to make the simulation procedure more equivalent to the live procedure. Other simulation systems such as patient-specific cardiac phan- toms for Mitraclip training and procedural planning purposes have also been used. 4 The evolution of 3D printing today allows the realistic representa- tion of anatomic variations and rare structural or congenital heart defects. Moreover, as we enter the age of artificial intelligence, there is an increased need for skillful medicine-machine interaction. Simula- tors allow the exposure to challenging anatomy, rare events like emer- gencies, and unusual clinical syndromes. 5 They can artificially place trainees in critical cases where fast decision-making and application of theoretical knowledge and critical thinking are required without supervision of senior staff. We are entering into a new era of structural education where simulators will play an invaluable role. Traditional teaching with live didactic sessions and live cases can now be accessed online at the comfort of office or home. There is an increased need for hands-on only course to achieve optimization of procedural skills. Structural heart interventions training require sophisticated hands-on simulators for the less frequent procedures to achieve optimally trained operators. ORCID Mehmet Cilingiroglu https://orcid.org/0000-0003-3795-8645 Konstantinos Marmagkiolis https://orcid.org/0000-0001-9620- 7142 Received: 2 April 2020 Accepted: 4 April 2020 DOI: 10.1002/ccd.28914 1210 © 2020 Wiley Periodicals, Inc. Catheter Cardiovasc Interv. 2020;95:1210–1211. wileyonlinelibrary.com/journal/ccd