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BackgroundMinimally invasive mitral valve surgery (MIMVS) is increasingly performed, but outcomes such as repair rate, mortality and survival likely depend on expertise. Still, the definition of a high-volume centre varies in the literature and lacks an evidence-based substantiation. Consequently, this study aims to determine the volume–outcome relation in MIMVS in conjunction with a volume threshold, in order to define ‘high-volume centres’, applying a novel statistical concept.MethodsThe study was preregistered in PROSPERO (CRD42022376293, registered 26 November 2022). A systematic search was applied to three databases, including consecutive patients undergoing MIMVS. Studies describing patients undergoing transcatheter procedures were excluded. Restricted cubic spline analyses were applied and the elbow method was used to retrieve the threshold volume. Long-term outcomes were analysed using reconstructed Kaplan-Meier curves and a novel statistical concept to assess the volume–outcome relation for time-to-event outcomes was applied. The primary outcome was early mortality, secondary outcomes were repair rate, stroke, and long-term survival, freedom from reoperation, and freedom from more than moderate mitral regurgitation. Leave-one-out analyses were performed for sensitivity purposes.ResultsData from 68 unique centres were included (n=23 495 patients). Early mortality was 1.3% (95% CI 1.1% to 1.6%), without a statistically significant non-linear relation for this endpoint, nor for stroke. There was a statistically significant volume–outcome relation for mitral valve repair rate (p=0.018). Based on the repair rate, the threshold to define a high-volume centre was 60 cases/year (number needed to treat to prevent a replacement ≤7). A significant volume–outcome relation was observed for long-term outcomes as well, with a threshold of 53 and 54 cases/year for long-term survival and freedom from reoperation, respectively. These results were robust across the sensitivity analyses for the various endpoints.ConclusionsThe threshold to define a high-volume centre ranges between 53 and 60 cases/year based on repair rate, long-term survival and freedom-from reoperation. These findings have the potential to facilitate centralisation of MIMVS.PROSPERO registration numberCRD42022376293.

ObjectivesDifferentiation between normal and abnormal features of vascular ageing is crucial, as the latter is associated with adverse outcomes. The normal aortic ageing process is accompanied by gradual luminal dilatation and reduction of vessel compliance. However, the influence of age on longitudinal aortic dimensions and geometry has not been well studied. This study aims to describe the normal evolution of aortic length and shape throughout life.MethodsA total of 210 consecutive patients were prospectively enrolled in this cross-sectional single-centre study. All subjects underwent CT on a third-generation dual-source CT scanner. Morphometric measurements, including measurements of segmental length and tortuosity, were performed on three-dimensional models of the thoracic aorta.ResultsThe length of the thoracic aorta was significantly related to age (r=0.54) and increased by 59 mm (males) or 66 mm (females) between the ages of 20 and 80 years. Elongation was most pronounced in the proximal descending aorta, which showed an almost 2.5-fold length increase during life. The lengthening of the thoracic aorta was accompanied by a marked change of its geometry: whereas the aortic apex was located between the branch vessels in younger patients, it shifted to a more distalward position in the elderly.ConclusionsThe normal ageing process is accompanied by gradual aortic elongation and a notable change of aortic geometry. Part II of this two-part article investigates the hypothesis that excessive elongation could play a role in the occurrence of acute aortic dissection.

OBJECTIVES There is a lack of guidance and scant learning resources for left-handed (LH) cardiac surgery residents and surgeons. No objective data exists to evaluate the reality of the training experience of LH cardiac surgeons and residents. METHODS A 32-question survey was designed for LH cardiac surgeons and residents. The survey questions were aimed towards understanding the experiences of LH cardiac surgeons and residents in order to identify and determine where the challenges of LH in cardiac surgery lie. The survey was disseminated by the European Association for Cardio-thoracic Surgery (EACTS) through online platforms, social media and the EACTS website. RESULTS 74 total responses were gathered from the survey; 73% were true LH operators. During residency, 78.1% of LH cardiac surgery residents had no access to LH faculty. Of those with LH mentors, only 53.3% were supportive and helped teach LH techniques. As trainees, 49.3% considered coronary artery bypass grafting anastomosis to be the most difficult portion of LH technique. Upon initiating independent practice, LH cardiac surgeons consider being LH an advantage in comparison to residency. CONCLUSIONS In LH cardiac surgery, there is a lack of tailored surgical exposure, training guidance, standardization, learning tools and teaching resources. Training resources for LH cardiac surgeons and residents should be developed. Left-handedness (LH) has been antagonized throughout history. Graphical Abstract

ObjectiveManagement of thoracic aortic aneurysms (TAAs) comprises regular diameter follow-up until the indication criterion for prophylactic surgery is reached. However, this approach is unable to predict the majority of acute type A aortic dissections (ATAADs). The current study aims to evaluate the diagnostic accuracy of ascending aortic diameter, length and volume for occurrence of ATAAD.MethodsThis two-centre observational cohort study retrospectively screened 477 consecutive patients who presented with ATAAD between 2009 and 2018. Of those, 25 (5.2%) underwent CT angiography (CTA) within 2 years before dissection onset. Aortic diameter, length and volume of these patients (‘pre-ATAAD’) were compared with those of TAA controls (n=75). Receiver operating curve analysis was performed to evaluate the predictive accuracy of the three different measurements.Results96% of patients with pre-ATAAD did not meet the surgical diameter threshold of 55 mm before dissection onset. Maximal aortic diameters (45 (40–49) mm vs 46 (44–49) mm, p=0.075) and volume (126 (95–157) cm3 vs 124 (102–136) cm3, p=0.909) were comparable between patients with pre-ATAAD and TAA controls. Conversely, ascending aortic length (84±9 mm vs 90±16 mm, p=0.031) was significantly larger in patients with pre-ATAAD. All three parameters had an area under the curve of >0.800. At the 55 mm cut-off point, the maximal diameter yielded a positive predictive value (PPV) of 20%. While maintaining same specificity levels, measurements of aortic volume and length showed superior diagnostic accuracy (PPV 55% and 70%, respectively).ConclusionMeasurements of aortic volume and length have superior diagnostic accuracy compared with the maximal diameter and could improve the timely identification of patients at risk for ATAAD.

OBJECTIVES The increase in the complexity of operations, the rising quest for improved outcomes and the scrutiny of surgical practice and its associated complications have led to a decreased educational value of in-patient surgical training within cardiac surgery. Simulation-based training has emerged as an adjunct to the apprenticeship model. In the following review, we aimed to evaluate the currently available evidence regarding simulation-based training in cardiac surgery. METHODS A systematic database search was conducted as per PRISMA guidelines, of original articles that explored the use of simulation-based training in adult cardiac surgery programs in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to 2022. Data extraction covered the study characteristics, simulation modality, main methodology and main outcomes. RESULTS Our search yielded 341 articles, of which 28 studies were included in this review. Three main areas of focus were identified: (i) validity testing of the models; (ii) impact on surgeons’ skills; and (iii) impact on clinical practice. Fouteen studies reported animal-based models and 14 reported on non-tissue-based models covering a wide spectrum of surgical operations. The results of the included studies suggest that validity assessment is scarce within the field, being carried out for only 4 of the models. Nonetheless, all studies reported improvement in trainees’ confidence, clinical knowledge and surgical skills (including accuracy, speed, dexterity) of trainees both at senior and junior levels. The direct clinical impact included initiation of minimally invasive programmes and improved board exam pass rates, and creating positive behavioural changes to minimize further cardiovascular risk. CONCLUSIONS Surgical simulation has been shown to provide substantial benefits to trainees. Further evidence is needed to explore its direct impact on clinical practice. Traditionally, cardiac surgeons have been acquiring their surgical skills through a practical apprentice model, basing their training on patients in the operating room.

ObjectivesProphylactic surgery for prevention of acute type A aortic dissection (ATAAD) is reserved for patients with an ascending aortic aneurysm ≥55 mm. Identification of additional risk predictors is warranted since over 70% of patients presenting with ATAAD have a non-dilated aorta or an aneurysm that would not have met the diameter criterion for preventative surgery. Aim of the study was to evaluate ascending aortic elongation as a risk factor for ATAAD and to compare aortic lengths between ATAAD patients and healthy controls.MethodsAortic lengths and diameters of ATAAD patients were measured on three-dimensional modelled computed tomography and adjusted to predissection dimensions in this cross-sectional single-centre study. Logistic regression was used to evaluate the relation between ATAAD and aortic dimensions. Lengths of different aortic segments were compared with a healthy control group using propensity score matching.ResultsTwo-hundred and fifty patients were included in the study (ATAAD, n=40; controls, n=210). Ascending aortic length and diameter proved to be independent predictors for ATAAD (OR=5.3, CI 2.5 to 11.4, p<0.001 and OR=8.6, CI 2.4 to 31.0, p=0.001). Eighty patients were matched based on propensity scores (ATAAD n=40, controls n=40). The ascending aorta was longer and more dilated in ATAAD patients compared with healthy controls (78.6±8.8 mm vs 68.9±7.2 mm, p<0.001, 34.4 mm ±3.2. vs 39.4 mm ±5.7, p<0.001, respectively). No differences were found in lengths of the aortic arch and descending aorta.ConclusionsAscending aortic length could serve as an independent predictor for ATAAD. Future studies addressing indications for prophylactic surgery should also investigate aortic length.

OBJECTIVES We introduced statistical twin as aggregates of multiple virtual patients’ data throughout the treatment at any chosen time point. The goal of this manuscript was to provide the proof of concept of statistical twin by evaluating the feasibility of detection of distinctive aggregates of patients throughout the perioperative trajectory (prerequisite for development of statistical twin). METHODS We used a retrospective validated cohort of all comers with mitral valve disease treated (2014–2020) at a tertiary academic hospital. The end point was overall survival based on the decision of the heart team. We applied two-step cluster analysis to detect distinct aggregated virtual patients throughout the process of care. RESULTS The cluster procedure resulted in 5 distant clusters with relatively equal numbers of patients. Effects of the treatment (surgery, transcatheter or optimal medical therapy) on survival were as follows: For optimal medical therapy, the expected survival ranged from 95% to 96% in 30 days to 58% to 75% in 10 years independent of baseline characteristics. However, for transcatheter interventions, the 5-year survival was 60–92% and was dependant on the initial characteristics of the virtual patient. Furthermore, survival following an uncomplicated operation of normal duration was higher through all observation periods. The aggregated virtual patients of cluster 5 would have a better survival rate at all times if the intervention were done by a dedicated surgeon. CONCLUSIONS It is possible to detect distinctive aggregates of virtual patients based on baseline characteristics and to capture the impact of perioperative events and external and other factors at multiple time points throughout the postoperative phase. The guiding principle in the allocation of treatment for cardiovascular interventions is risk assessment, which is based primarily on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the Society of Thoracic Surgeons (STS) score [1, 2].

The integration of artificial intelligence (AI) into surgery raises significant ethical concerns, including the impact on autonomy, human authority and the patient–doctor relationship. This study underscores the need for a multidisciplinary approach to navigate these ethical dilemmas, involving stakeholders from various fields. A comprehensive literature review up to March 2024 was conducted to assess the ethical implications of AI applications in surgery. This included an examination of data privacy, informed consent, algorithmic bias, the role of advanced robotics, and the impact on surgeons’ decision-making. The study also considered the development of autonomous surgical robots and their ethical implications. The review highlights that while AI can enhance surgical precision and improve clinical decision-making, it also poses several ethical challenges. AI’s ability to support decision-making risks undermining surgeons’ autonomy and judgement, raising concerns about over-reliance on technology. Issues such as data privacy, algorithmic bias and equitable access to AI-driven tools were identified as key ethical concerns. Autonomous surgical robots, while promising, introduce complex questions about accountability and liability, particularly when unexpected outcomes occur. Effective integration of AI into surgical practices demands the development of ethical frameworks that respect both the capabilities of AI and the irreplaceable value of human judgement. Balancing technological advancement with ethical integrity is essential to safeguard patient-centred care and ensure equitable access to AI benefits in healthcare.

Introduction Congenital heart disease (CHD) represents the most common group of congenital anomalies, constitutes a significant contributor to the burden of non-communicable diseases, highlighting the critical need for improved risk assessment tools. Artificial intelligence (AI) holds promise in enhancing outcome predictions for congenital cardiac surgery. This study aims to systematically review the utilization of AI in predicting post-operative outcomes in this population. Methods Following PRISMA guidelines, a comprehensive search of Pubmed, Scopus, and Web of Science databases was conducted. Two independent reviewers screened articles based on predefined criteria. Included studies focused on AI models predicting various post-operative outcomes in congenital heart surgery. Results The review included 35 articles, primarily published within the last four years, indicating growing interest in AI applications. Models predominantly targeted mortality and survival ( n  = 16), prolonged length of hospital or ICU stay ( n  = 7), postoperative complications ( n  = 6), prolonged mechanical ventilatory support time ( n  = 4), with additional focus on specific outcomes such as peri-ventricular leucomalacia ( n  = 2) and malnutrition ( n  = 1). Performance metrics, such as area under the curve (AUC), ranged from 0.52 to 0.997. Notably, these AI models consistently outperformed traditional risk stratification categories. For instance, in assessing the risk of morbidity and mortality, the AI models demonstrated superior performance compared to conventional methods. Conclusion AI-driven prediction models show significant promise in improving outcome predictions for congenital heart surgery. They surpass traditional risk prediction tools not only in immediate postoperative risks but also in long-term outcomes such as 1-year survival and malnutrition. Further studies with robust external validation are necessary to assess the practical applicability of these models in clinical settings. The protocol of this review was prospectively registered on PROSPERO (CRD42024550942).