Commentary: The End of the Learning Curve Is the Beginning of Good Judgment

Commentary to: Malik MI, Loshusan BR and Chu MWA. Learning curve analysis of minimally invasive mitral valve repair. Innovations 2025; 20: 297–303. DOI: 10.1177/15569845251337406

But according to the old adage “good judgment comes from experience and experience from bad judgment.”

Learning curves in surgery are used to identify the end of improvisation and the beginning of standardization. There are several ways institutions and individual surgeons can accelerate the transition. The most common method is to undergo thorough and detailed training by a master of the field, delving into theoretical knowledge, practical skills, and learning complication management. The most effective training takes place within the boundaries of the home institution as it enables a smooth transfer of knowledge from one generation to the next under the same conditions. Alternatively, technical and theoretical knowledge can be acquired through external fellowships at centers of excellence under the guidance of mentors with established expertise. In addition, establishing a minimally invasive program in a new department requires repetitive onsite proctoring to minimize the risk of incorrect patient selection and the occurrence of complications.

The time period related to the establishment and standardization of a new surgical program in an organization goes along with a certain learning curve. This can be steep or shallow depending on the difficulty and reproducibility of the technique used. In their study, Malik et al. investigate the learning curve of minimally invasive mitral valve repair over a 15-year period, focusing on clinical outcomes and technical failure endpoints. ¹ The study emphasizes the importance of mitral repair quality rather than just avoiding complications. The case series includes 362 consecutive patients operated on by a single surgeon over 16 years, with data being stratified into 3 tertiles. Despite the low case load of 24 patients per year, the results show significant improvements in cross-clamp time, cardiopulmonary bypass time, and hospital length of stay across tertiles. ¹ According to the authors, optimal repair outcomes can be achieved after approximately 60 to 85 operations. This is in accordance with previous publications showing that a minimum of 75 video-assisted ² and 60 robotic mitral surgery procedures are required for optimal outcomes. ³ Moreover, a frequency of at least 1 case per week has been related to lower rates of complications and shorter operative times. ²

Although the current study provides a glimpse into the journey of a surgeon, it cannot be used as a benchmark for current practice for several reasons. First, a single surgeon’s practice is by definition prone to case study bias and cannot be used to inform institutional decision-making. Second, simulation training has the potential to increase manual dexterity and decrease operative times, thereby reducing the risk of complications. Nowadays, mentees have the opportunity to use 3-dimensional (3D) printed copies of a true pathology originating from the echocardiography dataset and train mitral repair for the next day’s patient. ⁴ In addition, after the standardization of 3D visualization, training has reached another dimension. In our hands, the addition of 3D technology as part of a quality improvement program has reduced both operative times and complications. ⁵

More importantly, improvements in visualization allowed the development of a pilot–copilot principle. This is based on a specific workflow that allows the operator and the assistant to stay on the same patient side and work together by looking at the same 3D screen. This principle allows both operators to share the same picture (Supplemental Video 1), thus avoiding the mirror image that occurs if they stand opposite to each other (Supplemental Video 2). By sharing the same image, complex procedures can be performed. The possibility of changing roles during the procedure allows the assistant to perform parts of the operation under the direct guidance of an experienced operator, like a copilot does in a cockpit under the supervision of an experienced pilot. ⁶ This principle paves the way to a more standardized technique, which moves the result of the operation from a single operator to an operating team. At the end of the day, it is not the performer who defines quality but the performance itself.