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The most conventional cardiac procedures, including percutaneous coronary interventions, coronary artery bypass grafting, transcatheter aortic valve implantation, and surgical aortic valve replacement, are among the most often studied procedures in the literature. Primary and secondary end points that are helpful to assess quality of care, relatively easy to define: 30-day mortality and the major cardiovascular adverse events, like myocardial infarction, heart failure, stroke, bleeding requiring reexploration, are among themost important ones. With thismanuscript, the authors present a rather “provocative” paper entitled “Proximalized Total Arch Replacement Can Be Safely Performed by Trainee.”1While the teachers have to be congratulated for their ability to teach, but also for the excellent results obtained following this particular procedure, there is no doubt that the idea to directly teach residents in aortic arch surgery outside of a dedicated and defined overall training program, requires some comments. Japanese patients, of course not all, are much more often slender and their chest anatomy is much more comfortable than that encountered in the majority of European or North American patients. Their aortic arch, the first author made this observation several times when visiting Japanese institutions, is quite anterior in the chest and often relatively easily accessible. I recognize that it is of paramount importance that trainees receive the possibility to learn with experienced attending surgeons how to handle not only the aortic arch but also the aortic root and the ascending aorta in patients presenting with aortic aneurysms and with aortic dissection. In particular, teaching will not only include the purely manual part of the surgery, which may be technically challenging and requires precision, but also all particularities associated with deeper hypothermia, circulatory arrest, and cerebral protection are unforgiving of error. Years ago, while discussion on a paper of the IRAD (International Registry of Aortic Dissection) group that reported the results following repair of aortic dissection was ongoing, a well-known aortic expert was claiming that early mortality hadnot significantlydecreasedduring thepast10years.Oneof the reasons discussed was that younger attending surgeons, without sufficient training, were often left alone to manage this complex situation when it happens during nights and weekends. From this perspective, the present paper appears reasonable but the ideal way to teach this complex surgery would be to start with elective repair of the ascending aorta, then composite graft replacement, and finally total aortic arch repair (TAR) under optimal supervision. The next step would logically be the same procedures in an emergency setting. Of particular, as noted in the present paper is the fact that the attending surgeon who had performed 500 cardiac cases had a record of 100 TARs. This means that every fifth cardiosurgical procedure was an aortic arch repair. Such numbers are most probably neither representative for European nor for North American conditions. It is surprising to read that some trainees had personal experience as operating surgeon with approximatively 50 cardiac cases, while others had operated 3 cases only before they were performing a total arch repair. I believe, this would be totally inconceivable in the majority of teaching institutions. I personally would not support a TAR as the third operative procedure for a younger trainee, and I do not see any reasonable advantage tobypass the usual steps of training. Inpatientswitha zone-2TAR, themostdifficult part to assist would be the anastomosis to the left subclavian artery. The authorsavoidthisstepbyperforminganextra-anatomicbypass, leading the graft through the thorax and perform a more comfortable anastomosis outside. This is a debatable policy. Finally, the duration of circulatory arrest was significantly longer in patients operated by trainees; while this is

Teaching Cardiac Surgery: A Major Contemporary Issue in the Academic Institutions