Who took away my aortic valve?

Surgical aortic valve replacement (SAVR) performed by a surgeon in training has been traditionally a standard procedure that in its level of complexity demonstrates one of the most approachable operations to accomplish first steps towards independent operating. In the last 2 decades, the landscape of on-site training in the operating theatre has changed due to multiple developments, which were influenced by innovations, patients’ expectations and political decisions. Focused on the pathology of the aortic valve, numerous possibilities of surgical and interventional treatment have been developed in support of patient-orientated individual options. These include the classical full sternotomy, minimally invasive approaches and transcatheter solutions. However, classical SAVR, as demonstrated in national registries, continues to play a stable role in the daily life of cardiac surgeons as the gold standard treatment. Considering the necessity to teach future surgeons, a new approach needs to be found to meet the expertise requirements for the changing landscape of various treatment options. The results of Dimagli et al. demonstrate a decreasing number of teaching cases from 41% to 25% from 1996 to 2017, reflecting the experience of other studies [1, 2]. How can we master the major obstacles that occurred through the last decades to deliver practical education for aortic valve treatment today and in 2030? At first glance, the advent of transcatheter aortic valve replacement (TAVR) in the early 2010s seemed to play an important role in the decreasing number of trainee cases. Reviewing 3 large national registries, in contrast, the number of SAVR remains stable and even shows an increase in the UK database per year [3–5]. The introduction of TAVR, however, has impacted the demographics, clinical characteristics, and risk profiles of patients undergoing SAVR at least in the USA. SAVR is likely to be reserved for younger patients who are willing to receive a mechanical valve and for patients in need of concomitant procedures [6]. In addition, Dimagli et al. [1] found that, in the most recent years, patients undergoing SAVR were more likely to be older and present with more comorbidities without having an impact on patients’ outcomes, when the first operator was a trainee. Hence, the average patient referred for open surgery shifted towards either a complex high-risk patient where TAVR reaches its limitations or into a lower-risk patient who can be potentially operated through a minimally invasive keyhole technique. This divergence carries the risk that SAVR becomes rather a high-specialist procedure performed by experienced surgeons instead of remaining a training opportunity. The approval for TAVR in low-risk patients will soon reach the Guideline Committees and be formulated on paper. Inevitably, the divergence of either low- or high-risk patients for SAVR will be influenced by the upcoming decade of transcatheter experience. The introduction of sutureless aortic valves into daily practice opened the door for mini-sternotomies and right anterior thoracotomies, access routes that are here to stay also keeping the patients’ expectations in mind. For minimally invasive aortic valve replacement, there is limited data considering the involvement of surgeons in training. Soppa et al. demonstrated that a standardized training approach with meticulous supervision ensures an adequate progression of technical skills in trainees performing minimally invasive AVR. Short-term data were comparable to the outcome of operations performed by consultants [7]. A structured training including surgeons, anaesthetists and perfusionist including lectures, simulation and assistance of live cases has been effectively used prior to the initiation of minimally invasive aortic valve programmes, with particular emphasis on mentorship. Consequently, the learning curve can be shortened despite the increasing complexity [8]. Both publications promote the idea of early training in minimally invasive surgery initially as second or first assistant and finally as primary operator being involved actively in the knowledge transfer. Minimally invasive approaches should not become a disadvantage to embark on aortic valve replacement but may encourage the teachers to involve trainees by offering more experience to shorten the learning curve for both as a team approach. In addition to the increasing complexity and the advent of new technologies, there have been calls for greater transparency within healthcare across the UK leading to government-mandated publication of named surgeon-specific outcome data. The influence on the training is difficult to measure and was not fully taken into consideration during the introduction of the documentation [9]. Thus, consultants may guard their performance outcomes and opt for reducing trainee autonomy in operative procedures. The inclusion of training cases into the dataset and regular audits help prevent a negative impact on training. A desirable change would be a feedback mechanism into hospital education quality metrics that surgeons who are trainers will have the training they undertake accredited. Also, breaking the silence during the consent process about the participation of trainees as supervised operators may surprisingly contribute to surgical independence, but certainly is a sensitive topic to be addressed in the patient communication. Dimagli et al. [1] provide supporting literature regarding the safety of supervised trainee practice despite increasing morbidity of patients that might help to counterbalance any potential concerns from consultants that trainee operating may adversely impact on their published outcome. However, unit-specific statistics can remain a stumbling block for internal education such as transfusion and pacemaker rates, which are usually considered a less important outcome that is rarely mentioned in education-related publications but influences on the results of consultants [10]. If active teaching is not rewarded, the willingness to provide cases for trainees will not increase. The classical SAVR performed through full sternotomy as a trainee procedure has been affected by various developments in the last 2 decades. This must not demotivate current and future generations to embark on new technologies and embrace change by actively searching for exposure not only in SAVR but also in TAVR. The training programme must be adjusted with regard to the knowledge transfer, practical exposure and relation to the mentor to reward teaching as one of the most important duties a surgeon can deliver to the next generation. More prospective studies supporting long-term outcome and quality of surgical procedures performed by trainees especially using new technology and access routes are necessary.