Comparing Early and Long-Term Outcomes of "Truly Autonomous" Senior Resident-Led with Consultant-Led Cardiac Surgery: A 10-Year Propensity-Matched Study.

Abstract

Objectives: Cardiac surgery demands substantial technical skill and intraoperative judgement. Residents must develop operative autonomy in preparation for independent consultant practice. However, current challenges, including working hour restrictions, shorter training programmes, reduced operative exposure, and increasing case complexity, limit opportunities for skill development. This study evaluated the safety of "truly autonomous" cardiac surgery performed by senior residents without direct consultant supervision.

Methods: Data for all adult cardiac surgeries between January 2015 and December 2024 were extracted from our institutional database. All resident-led cases undertaken without direct consultant supervision (group R) were identified and 1:1 propensity-score matched with consultant-led cases (group C) using the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II covariates. In-hospital outcomes (mortality, complications, length of stay) and long-term survival were compared.

Results: A total of 16 945 procedures were undertaken during the study period. After applying inclusion and exclusion criteria, matching yielded 803 pairs, giving a study population of 1 606 patients. Groups had comparable demographics, preoperative characteristics, risk scores and cardiopulmonary bypass and cross-clamp times. Consultants undertook significantly more combined and aortic cases, with residents performing more isolated CABG and isolated valve procedures. Groups had similar in-hospital outcomes and long-term survival. In a subgroup analysis of emergency operations, groups had similar outcomes.

Conclusions: Truly autonomous cardiac surgery by senior residents demonstrated comparable in-hospital and post-discharge outcomes to consultant-led cases. Even in emergency procedures, senior residents achieved comparable outcomes to matched consultant-led cases. Our study shows truly autonomous operating in appropriately selected cases to be feasible and safe, providing evidence-based justification for progressive independence in cardiac surgical training.