Printing the future of surgical education: a randomized trial of digital tools in cardiovascular training

Three-dimensional (3D) technology has become an important tool in modern medicine, offering applications that improve education and interventions (1). In clinical practice, 3D imaging and printing enable the creation of patient-specific anatomical models that assist in preoperative planning, allowing surgeons to better visualize complex structures and rehearse procedures before entering the operating room (1,2). In medical education settings, 3D models provide realistic, hands-on learning experiences that improve anatomical understanding and surgical skills. Additionally, it can be used to design custom implants, prosthetics, and medical devices, promoting personalized care and improving patient outcomes in other specialties. Surgical education has long relied on the apprenticeship model, in which trainees progress through stages of assisting, performing under supervision, and eventually operating independently (3,4). While Halsted’s transformation of this model into a structured residency system marked a major milestone in surgical training, modern demands for precision, patient safety, and efficiency, especially with the integration of novel technologies such as 3D printing and digital simulation, continue to drive its evolution. The training of cardiovascular surgeons specifically has always posed unique challenges for medical educators (5). Over the past two decades, active learning strategies such as case-based learning (CBL), problem-based learning (PBL), and team-based learning (TBL) have enriched medical curricula by promoting reasoning, collaboration, and clinical integration (6-8). Yet, these models remain constrained by their reliance on two-dimensional (2D) representations of anatomy and their inability to fully prepare learners for the 3D complexity of surgical practice. The recent study by Zhao et al., Digital clinical teaching of cardiovascular surgery supported by precision imaging and 3D printing technology: A randomized parallel-controlled trial, provides timely and compelling evidence for the transformative role of digital tools in surgical education (9). Their work demonstrates that supplementing active learning with digital reconstructions and 3D-printed models can substantially improve student outcomes across theoretical knowledge, clinical skills, and self-perceived competencies.

Zhao and colleagues randomized 80 clinical medicine students undertaking internships in the Department of Cardiac and Great Vessels Surgery at The Second Hospital of Hebei Medical University into two groups: a digital teaching group that received instruction supported by precision imaging and 3D printing, and a control group taught using a blended C-P-TBL (case-, problem-, and team-based learning) framework. Students in the digital cohort consistently outperformed their peers. Theoretical exam scores averaged 86.3 versus 80.3 (P=0.004), while clinical skills scores reached 87.9 versus 83.1 (P=0.006). More importantly, digital training enhanced self-learning ability, problem analysis, and most notably spatial imagination, a skill fundamental to surgical navigation. Satisfaction was high across both groups, but slightly greater in the digital arm (97.5% vs. 87.5%). While teamwork and communication skills did not differ significantly, the digital approach succeeded in complementing knowledge acquisition with tangible gains in spatial understanding (9).

These findings align with the literature underscoring the pedagogical value of immersive and interactive digital tools. Previous studies have shown that 3D models, whether digital or printed, enhance comprehension of complex congenital heart disease, aid in surgical planning, and improve retention of anatomical knowledge compared to traditional 2D methods (10). Yoo et al. emphasize that 3D models are sufficiently advanced for routine use in congenital heart surgery training, they advocate for low-cost, task-specific models for skills such as vascular anastomosis and defect closure to help early-career surgeons refine technical dexterity before performing on patients (11). 3D printing has reached a maturity level that supports its incorporation into standardized surgical education (11). Lee et al. demonstrated the feasibility of producing 3D-printed models of coronary artery anomalies from cardiac CT data, which were rated highly by both clinicians and researchers for anatomical clarity and clinical usefulness (12). The models accurately depicted complex coronary anatomy and were found to complement traditional imaging, enhancing understanding of anomalies, highlighting the potential of 3D printing as a valuable educational and preoperative planning tool in cardiovascular surgery (12).

Moreover, according to Effiom et al., cardiothoracic surgery in Africa remains costly and largely inaccessible, with most patients relying on out-of-pocket payments despite limited incomes. While 3D printing offers immense potential for improving surgical planning, training, and outcomes, its adoption may initially increase costs, underscoring the need for cost-benefit analyses and supportive health insurance frameworks. Focusing on affordable, patient-centered applications can enable sustainable integration of 3D printing, ultimately enhancing surgical care and innovation across the continent (13). Our recent systematic review on the use of 3D technology in congenital heart surgery synthesized the growing body of evidence supporting 3D printing and modeling as valuable tools in complex surgical planning. One of the most compelling findings from our analysis was the significant reduction in operative time reported in surgeries by 22.25 minutes in favor of the 3D printing group [95% confidence interval (CI): 49.95–5.80 minutes] and change in surgical decisions in 35 of 75 cases (95% CI: 26.6–77,0%). The use of patient-specific 3D models allowed surgeons to anticipate anatomical variations and define surgical strategies before entering the operating room (14). This preoperative familiarity led to a more efficient intraoperative decision-making, reduced cardiopulmonary bypass duration, and potentially improved postoperative outcomes. Ravi et al. evaluated the first-year experience of an in-hospital 3D printing service, finding that patient-specific anatomic models estimated to save around 30 minutes of procedure room time per patient, equating to nearly $2,900 in theoretical savings (15).

Several strengths of Zhao et al. study deserve emphasis. First, the randomized parallel-controlled design adds rigor to educational research, a field often criticized for reliance on descriptive or single-institutional reports. Although the sample size was modest, the randomized design still provides strong methodological rigor, lending credibility to the study’s conclusions. Second, the combination of objective measures (such as theoretical and clinical examinations, with subjective evaluations of self-reported ability and satisfaction, provides a comprehensive assessment of learning outcomes. Third, the 3D models derived from patient imaging can be reused across sessions, which demonstrates cost-effectiveness overcoming the scarcity of complex cases for training and enhancing exposure to rare pathologies (9).

However, the single-center design, potential instructor bias, and/or assessment bias, as well as uncertainty regarding the validity of the simulated assessments as surrogates for operative competence, may limit the interpretation and generalizability of the results. Despite these limitations, 3D printing has several applications in surgery. Moreover, the scalability of digital teaching offers potential for distribution. Virtual reality, augmented reality, and artificial intelligence-driven platforms are already reshaping how medical students and residents engage with education, particularly anatomy and surgical simulation (16). Institutions with limited access to cadaveric dissection or advanced surgical exposure may adopt 3D printing to provide comparable training experiences (17).

One of the main questions is how digital education can lead to better learning outcomes. Several plausible hypotheses exist, and a potential mechanism is that the superior results observed in the group using digital teaching strategies may be, at least in part, due to increased motivation and engagement among students. The use of 3D reconstructions and printed models appears to make learning more interactive, concrete, and visually stimulating, fostering curiosity and a sense of discovery. This active experience reinforces intrinsic motivation, enhances self-confidence, and strengthens the perception of mastery, factors that translate into better theoretical and practical performance. The positive impact of digital technologies on medical education may not derive solely from technical innovation, but also from their ability to motivate and engage students in the learning process. Maybe simpler strategies, for institutions without access to digital resources, could involve the incorporation of active learning methods that also foster engagement and motivation, such as PBL, small-group teaching, and flipped classrooms. Curricular reform and modernization of medical education are urgently needed to achieve better outcomes for patients (18). Finally, while increased learner confidence and perceived mastery are highlighted as benefits of 3D-supported education, we also need to consider cognitive biases such as the Dunning-Kruger effect, particularly in early learners, and emphasize the need for future studies linking perceived competence to objective performance and clinical transfer. In a recent study, it was demonstrated that students generally overestimated (35.5%) or underestimated (46.0%) their performance, with only 18.5% accurately assessing themselves. There was also a strong negative correlation between self-assessment and actual performance ρ=−0.590 (P<0.001), indicating that students with lower scores tended to overestimate their abilities (19).

The study by Zhao et al. provides strong evidence that digital teaching supported by precision imaging and 3D printing can significantly enhance the education of future cardiovascular surgeons. Their randomized trial demonstrates not only improved knowledge and skills but also elevated spatial imagination and learner satisfaction. While some challenges remain, findings mark a clear step toward a hybrid future in surgical education. As surgical practice continues to evolve toward precision, minimally invasive approaches, and technological integration, so too must surgical teaching. Digital tools can be powerful complements that bridge longstanding gaps in spatial visualization and applied learning. By embracing such innovations, medical educators can better prepare the next generation of medical students and even cardiovascular surgeons.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Cardiovascular Diagnosis and Therapy. The article has undergone external peer review.

Peer Review File: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-aw-546/prf

Funding: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil (CAPES) (funding code 001), Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-aw-546/coif). D.S.Y. and C.H.B.O. received research grants from CAPES. C.T.M. received research grants from FAPERJ and CNPq. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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