Vasileios Leivaditis, Roman Gottardi, Andreas Maniatopoulos, Francesk Mulita, Charalampia Pylarinou, Spyros Papadoulas, Κωνσταντίνος Νικολακόπουλος, Ioannis Panagiotopoulos, Efstratios Koletsis, Manfred Dahm, Anastasios Sepetis
BACKGROUND: Cardiothoracic surgery is among the most technologically advanced and resource-intensive medical specialties, placing it at the intersection of rapid digital innovation and growing demands for environmental sustainability. Addressing these parallel pressures requires integrated strategies that reconcile clinical excellence with ecological responsibility. METHODS: This narrative review synthesizes PubMed-indexed literature published over the past two decades, supplemented by relevant policy documents and guidelines. The review examines digital transformation and sustainability initiatives in cardiothoracic surgery through the lens of the twin transformation framework, which conceptualizes digitalization and sustainability as interdependent and mutually reinforcing processes. RESULTS: Key domains of digital transformation include artificial intelligence and big data-driven decision-making, robotic and minimally invasive surgical techniques, digital twins and simulation-based training, telemedicine and remote monitoring, and interoperable electronic health records. Sustainability-related themes encompass the substantial environmental burden of operating rooms, green surgical practices, sustainable procurement, and hospital-level decarbonization strategies. Emerging evidence suggests that aligning digital technologies with sustainability objectives can improve clinical outcomes, enhance operational efficiency, and reduce environmental impact. However, current evidence is largely derived from pilot studies and single-center experiences. CONCLUSIONS: Twin transformation offers a coherent and forward-looking framework for the future evolution of cardiothoracic surgery, demonstrating that digital innovation and sustainability can be synergistic rather than competing goals. While significant challenges remain-including high implementation costs, limited long-term data, and fragmented regulatory frameworks-integrating digital health technologies with sustainable practices represents a promising pathway toward high-quality, efficient, and environmentally responsible cardiothoracic care.