Objective: The significance of concomitant hemi-arch aortic reconstruction in the setting of aortic root replacement is largely unknown. In this first multi-institutional study, the clinical impact of concomitant hemi-arch aortic reconstruction at the time of aortic root replacement was reviewed. Methods: From 2004 to 2021, 1869 patients underwent aortic root replacement and ascending aorta replacement at 2 major academic centers: 1116 with concomitant hemi-arch aortic reconstruction (aortic root replacement/hemi-arch aortic reconstruction) and 753 without hemi-arch aortic reconstruction (aortic root replacement/ascending aorta). Procedure and propensity score matching resulted in 698 pairs, which were compared. The primary end point was in-hospital mortality. Results: Mean age at operation was 56.8 ± 14.7 years and similar between groups (P = .984). Median cardiopulmonary bypass time (P < .001) and aortic crossclamp time (P < .001) were longer for aortic root replacement/hemi-arch aortic reconstruction. Patients receiving aortic root replacement/hemi-arch aortic reconstruction were more likely to need intra-aortic balloon pump support postoperatively (6.3% [44] vs 2.4% [17], P < .001). Permanent neurologic dysfunction occurred in 31 patients (4.5%) undergoing aortic root replacement/hemi-arch aortic reconstruction and 15 patients (2.2%) undergoing aortic root replacement/ascending aorta (P = .02). In-hospital mortality for patients receiving aortic root replacement/hemi-arch aortic reconstruction was 5.0% (35) and 2.6% (18) for patients receiving aortic root replacement/ascending aorta (P = .02). Ten-year survival was 79% versus 74% for hemi-arch aortic reconstruction versus aortic root replacement groups, respectively (P = .06). Conclusions: Clinical outcomes after both aortic root replacement/ascending aorta or with concomitant hemi-arch aortic reconstruction are excellent. Concomitant hemi-arch aortic reconstruction was associated with a higher rate of postoperative stroke and in-hospital mortality. The decision to perform hemi-arch aortic reconstruction at the time of aortic root replacement should be considered carefully and must be individualized in a patient-specific manner for optimal outcomes.

Objective: The purpose of this study was to examine the longitudinal safety and efficacy of hybrid coronary revascularization (HCR) in a large cohort of patients with multivessel coronary artery disease (CAD). Methods: From 2009 to 2020, 561 consecutive patients (median age 64.0 years, predicted risk of mortality 1.3% ± 1.8%, 403 with 2-vessel disease and 158 with 3-vessel disease) underwent a planned HCR procedure with a robot-assisted off-pump left internal mammary artery to left anterior descending (LIMA-LAD) coronary artery bypass graft (CABG) combined with percutaneous coronary intervention (PCI) of non–LAD vessels. Multivariable regression analysis was used to identify risk factors for short-term and longer-term outcomes. Results: Operative mortality and stroke occurred in 4 (0.7%) and 5 patients (0.9%), respectively. Postoperative angiography revealed LIMA patency in 415 of 425 patients (98%). Median follow-up was 4.5 years and was 93% complete. Repeat revascularization occurred in 44 patients (8%) at a median of 2.7 years. Freedom from repeat revascularization and survival at 5 years was similar between patients with 2-vessel and 3-vessel disease ( P = 0.73 and P = 0.19, respectively). Completely revascularized patients had 5-year survival of 91% versus 64% for incompletely revascularized patients (hazard ratio = 3.8, P < 0.001). Age ( P = 0.03), renal failure ( P < 0.001), and history of myocardial infarction ( P = 0.01) were risk factors for late adverse events. Conclusions: HCR is a safe and effective minimally invasive alternative to conventional CABG or multivessel PCI with a low incidence of late repeat revascularization and mortality. HCR can be safely applied to carefully selected patients with either 2-vessel or 3-vessel CAD; however, incomplete revascularization may result in lower long-term survival.

Objective Valve-sparing root replacement (VSRR) is associated with excellent short- and long-term outcomes. Although typically offered in young patients, VSRR is performed over a wide age range, including into the eighth decade of life. This study analyzed the influence of age and preoperative comorbidities on operative outcomes, reoperation, and survival following VSRR. Methods From 2004 to 2021, 780 patients underwent VSRR in an academic database. VSRR was performed using the David V reimplantation technique. A discriminating age cutoff for the effect of age on long-term survival was determined by Contal and O'Quigley methods and patients were divided into 2 groups based on age at time of surgery. Results The optimal age cutoff for patients undergoing VSRR was found to be 65 years; 16% were aged 65 years or older at time of surgery. Overall, in-hospital mortality was 1.5% and was significantly higher among the group of patients older than age 65 years (4.1% vs 1.1%; P = .03). The cumulative incidence of reoperation of the aortic valve or proximal aorta was similar between the group of patients aged 65 years and older and patients younger than age 65 years (5% vs 6%; P = .28). Overall, 10-year survival was 89% and significantly worse among the patients aged 65 years and older (76% vs 92%; P < .0001). Age 65 years and older was an independent risk factor for late mortality (hazard ratio, 1.04; 95% CI, 1.01-1.07; P = .003). Conclusions VSRR can be performed with low operative mortality and excellent freedom from reoperation across age groups. In patients aged 65 years and older, serious consideration should be given when deciding on VSRR, especially in the setting of aortic dissection.

Abstract Disclosure: L.A. Gonzalez Ramirez: None. Z. He: None. J.N. Binongo: None. H.E. Huneault: None. A. Ramirez Tovar: None. J.A. Welsh: None. M.B. Vos: Consulting Fee; Self; Boehringer Ingelheim, Prosciento, Target Real World Solutions, Intercept Pharmaceuticals, INC, Novo Nordisk. Grant Recipient; Self; Target Real World Solutions. Mixed meal tolerance tests (MMTTs) are functional assessments that may identify metabolic dysregulation earlier than fasting tests during the progression to metabolic dysfunction-associated steatotic liver disease (MASLD). Although standards to conduct MMTTs in adults are readily available, the knowledge gap for children is quite large. Furthermore, conducting this type of study in children is challenging because they are less tolerant of long fasting intervals, long periods of testing, and early morning visits that interrupt school attendance. The objective of this study was to assess if conducting an MMTT in a non-fasting state will equally identify variance in the metabolic response of triglycerides (TG) between healthy children and those living with MASLD when compared to a 12-hour fasting MMTT. We collected blood samples every two hours in our 2-day randomized crossover feeding study. During each visit, 9 children with MASLD and 10 healthy controls aged 10 to 18 y underwent 1 standardized MMTT after a 12-hour overnight fasting (breakfast), followed by 2 standardized MMTTs in a non-fasting state (lunch and dinner). Participants were randomized to receive a glucose or fructose beverage at visit 1 and the other at visit 2. For uniformity, we only used data from the glucose beverage visit. We found that TG levels were statistically higher in the MASLD participants when compared to the non-MASLD group at each time point (p= 0.01). The maximum TG metabolic response peak for each MMTT was higher and more delayed in the MASLD group compared to the non-MASLD group. Within groups, postprandial TG level patterns were not significantly different when comparing breakfast, lunch, and dinner. Although TG levels varied throughout the day, the pattern after every meal was similar. These findings suggest that it is possible to identify differences in the TG metabolic response between children living with MASLD and healthy participants in the postprandial state. The results from our study also support the use of non-fasting MMTTs when examining TG metabolism in children, though further research to validate these findings is needed. Presentation: 6/1/2024

Individuals with cystic fibrosis (CF) have dysfunctional intestinal microbiota and increased gastrointestinal (GI) inflammation also known as GI dysbiosis. It is hypothesized that administration of high-dose cholecalciferol (vitamin D3) together with a prebiotic (inulin) will be effective, and possibly additive or synergistic, in reducing CF-related GI and airway dysbiosis. Thus, a 2 x 2 factorial design, placebo-controlled, double-blinded, pilot and feasibility, clinical trial was proposed to test this hypothesis. Forty adult participants with CF were block-randomized into one of four groups: 1) high-dose oral vitamin D3 (50,000 IU weekly) plus oral prebiotic placebo daily; 2) oral prebiotic (12 g inulin daily) plus oral placebo vitamin D3 weekly; 3) combined oral vitamin D3 weekly and oral prebiotic inulin daily; and 4) oral vitamin D3 placebo weekly and oral prebiotic placebo. The primary endpoints included 12-week changes in the microbial bacterial communities, gut and airway microbiota richness and diversity before and after the intervention. This pilot study examined whether vitamin D3 with or without prebiotics supplementation was feasible, changed airway and gut microbiota, and reduced dysbiosis, which in turn, may improve health outcomes and quality of life of patients with CF.

Objective: Reoperation after aortic root replacement (ARR) is associated with increased operative risk and complexity. This study evaluated clinical outcomes and reoperation rates in patients undergoing ARR. Methods: From 2004 to 2021, 2700 adult patients underwent an ARR in a 2-institution database. Among 2542 surviving patients, 705 patients who had a history of previous cardiac surgery as well as 11 patients who underwent transcatheter aortic valve replacement after index ARR were excluded. Among the finalized cohort of 1826 patients, 88 (4.8%) underwent a reoperation (REDO) on the aortic valve or proximal aorta (root/ascending) a mean of 3.1 years after index ARR whereas 1738 (95%) did not undergo reoperation (no-REDO). A subgroup analysis was performed among those undergoing reoperation by indication including valve dysfunction (48%), endocarditis/graft infection (33%), and aortic aneurysm/dissection/rupture (12%). Reoperative indication was unknown in 6 patients (7%). Results: The REDO group was younger at time of index ARR (52 vs 58 years, P < .0001) and had more bicuspid aortic valves (56% vs 37%, P = .0003). Most patients underwent modified Bentall ARR (61%), whereas 38% underwent a valve-sparing root replacement. Index root operations were similar between groups. At time of reoperation, 53% underwent aortic valve replacement and 35% underwent redo root replacement. Long-term survival was similar between REDO and no-REDO groups (80% vs 85%, P = .26) and reoperation was not a risk factor for late mortality (hazard ratio, 1.31; P = .26); however, REDO ARR was a risk factor for late mortality (hazard ratio, 2.41; P = .02). Conclusions: The incidence of aortic valve and/or proximal aorta reoperation after index ARR is relatively low at 4.8%; however, root reoperation is a risk factor for late mortality.

BACKGROUND:The pathophysiology and behavior of acute type B intramural hematoma (TBIMH) is poorly understood. The purpose of this study is to characterize the pathophysiology, fate, and outcomes of TBIMH in the endovascular era.METHODS:A retrospective analysis of a US Aortic Database identified 70 patients with TBIMH from 2008 to 2022. Patients were divided into groups and analyzed based upon subsequent management: early thoracic endovascular aortic repair (TEVAR; Group 1) or hospital discharge on optimal medical therapy (OMT) (Group 2).RESULTS:Of 70 total patients, 43% (30/70) underwent TEVAR (Group 1) and 57% (40/70) were discharged on OMT (Group 2). There were no significant differences in age, demographics, or comorbidities between groups. Indications for TEVAR in Group 1 were as follows: 1) Penetrating atheroscletoic ulcer (PAU) or ulcer-like projection (n = 26); 2) Descending thoracic aortic aneurysm (n = 3); or 3) Progression to type B aortic dissection (TBAD) (n = 2). Operative mortality was zero. No patient suffered a stroke or spinal cord ischemia. During the follow-up period, 50% (20/40) of Group 2 patients required delayed surgical intervention, including TEVAR in 14 patients and open repair in 6 patients. Indications for surgical intervention were as follows: 1) Development of a PAU / ulcer-like projection (n = 13); 2) Progression to TBAD (n = 3), or 3) Concomitant aneurysmal disease (n = 4). Twenty patients did not require surgical intervention. Of the initial cohort, 71% of patients required surgery, 9% progressed to TBAD, and 19% had regression or stability of TBIMH with OMT alone.CONCLUSIONS:The most common etiology of TBIMH is an intimal defect. Progression to TBAD and intramural hematoma regression without an intimal defect occurs in a small percentage of patients. An aggressive strategy with endovascular therapy and close surveillance for TBIMH results in excellent short-term and long-term outcomes.

BACKGROUND The impact of acute aortic dissection of the chronically dissected distal aorta is unknown. This study sought to describe the incidence and characteristics of the triple-lumen aortic dissection and its impact on survival. METHODS From 2010 to 2021, a query of a single-institution aortic database identified 1149 patients with chronic distal aortic dissection. Thirty-three (2.9%) patients with at least 3 distinct lumens and 2 separate "primary" intimal tears were identified by analysis of contrast-enhanced cross-sectional imaging. Triple-lumen patients were exactly matched with a cohort of double-lumen patients on a 1:1 ratio using 5 preoperative variables, and outcomes between the groups were assessed. RESULTS The median age at time of initial dissection in patients with a triple-lumen dissection was 46 years. Initial dissection was a type A in 33% and a type B in 67% of patients. The median time from initial dissection to triple-lumen diagnosis was 4.2 years. On diagnosis of the triple-lumen aorta, 85% of patients required urgent aortic repair for rapid growth (36%), aortic diameter double dagger 55 mm (30%), malperfusion (6%), intractable pain (6%), and rupture/type A (6%). Thirtyday mortality after triple lumen dissection was 12%. CONCLUSIONS Acute-on-chronic distal dissection resulting in a triple-lumen aorta should be classified as a "complicated" type B dissection as these patients typically have large aneurysms and a high incidence of rapid false lumen expansion requiring urgent surgical repair. (Ann Thorac Surg 2024;117:923-31) (c) 2024 by The Society of Thoracic Surgeons. Published by Elsevier Inc.

Background: Cystic fibrosis (CF) is a multi-organ disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR). Individuals with CF often have gastrointestinal (GI) dysbiosis due to chronic inflammation and antibiotic use. Previous studies suggested a role for vitamin D in reversing the GI dysbiosis found in CF. Objective: To explore the potential role of a combination of high-dose oral cholecalciferol (vitamin D3) and fermentable dietary fiber, inulin, to impact bacterial composition, richness, and diversity of intestinal and airway microbiota in adults with CF. Methods: This was a 2 x 2 factorial, double-blinded, placebo-controlled, randomized, pilot clinical trial in which adults with CF received oral cholecalciferol (vitamin D3) (50,000 IU/week) and/or inulin (12 g/day) for 12 weeks. Thus, there were 4 study groups (n = 10 subjects per group); 1) placebo 2) vitamin D3 3) inulin 4) vitamin D3 plus inulin. Stool and sputum samples were collected at baseline (just before) and after the intervention and were analysed using 16S ribosomal RNA gene sequencing for gut and airway microbiota composition. Statistical analyses assessed alpha and beta diversity to evaluate microbial community changes. Results: Of a total of 254 screened participants, 40 eligible participants were randomized to one of the 4 treatment arms. Participants receiving vitamin D3 plus inulin exhibited greater changes in microbiome indexes in both intestinal and airway relative to those in the other study groups. Specific taxonomic changes supported the potential beneficial influence of this combination to mitigate both intestinal and airway dysbiosis in adults with CF. Conclusion: This pilot study established that the combination of oral vitamin D3 and the prebiotic inulin was well tolerated over 12 weeks in adults with CF and altered gut and airway bacterial communities. Future research appear warranted to define clinical outcomes and the role of microbiota changes therein with this approach.

BACKGROUND:Transfemoral transcatheter aortic valve replacement (TF-TAVR) has proven superior to alternative access. However, some patients evaluated for TF-TAVR are unfit secondary to peripheral arterial disease (PAD). Peripheral intravascular lithotripsy (IVL) can facilitate femoral access. This study aimed to characterize optimal lesions that can be treated with IVL. METHODS:Single-center, retrospective analysis of an institutional database, queried from 1/2018 through 7/2023 for all patients who underwent TAVR. Patients who received IVL-facilitated transfemoral access were analyzed. RESULTS:Of 2862 TAVR cases identified, 92 (3.2 %) underwent lithotripsy. The IVL-facilitated cohort had a mean age of 78 ± 9.2 years and 45 % were female. The right common iliac artery was most treated (47). Most IVL was performed with 7-mm balloons (73.9 %). All cases were successful. 30-day mortality was 1.1 % (1/92). CONCLUSIONS:In our cohort, complications after IVL-facilitated TF-TAVR were more common with small vessel diameter (≤4.7 mm), significant luminal loss (>50 % stenosis), and heavy calcium burden (arc calcification >180°). The findings support the use of IVL to expand the population of patients who can undergo TF-TAVR without the increased risks associated with the various forms of alternative access. SUMMARY FOR ANNOTATED TABLE OF CONTENTS:IVL-facilitated TF-TAVR is safe and feasible. Despite its introduction to TAVR clinical practice in 2018, IVL-facilitated TF-TAVR is not regularly performed and could increase the population of patients eligible for TF-TAVR.

Background:Radiation exposure during invasive cardiovascular procedures remains an important health care issue. Lead aprons and shields (LAS) are used to decrease radiation exposure but leave large portions of the body unshielded. The Rampart IC M1128 is a portable radiation shielding system that may significantly attenuate radiation exposure. Methods:Catheterization laboratory teams were randomized in a 1:1 fashion to perform elective invasive cardiovascular procedures utilizing either traditional LAS or the Rampart IC M1128. Radiation exposure was measured using real-time dosimetry monitoring in prespecified anatomic locations on 3 operators (position 1: first operator/fellow; position 2: second operator/attending; and position 3: catheterization laboratory nurse/technologist). Radiation exposure was measured on a per-case basis. Results:In total, 100 consecutive cases were randomized in this study (47 Rampart; 53 LAS). There was no difference in fluoroscopy time (12.3 minutes for Rampart vs 15.4 minutes for LAS; P = .52), dose area product (288 Gy⋅cm2 for Rampart vs 376.5 Gy⋅cm2 for LAS; P = .52), or scatter radiation (38.8 mRem for Rampart vs 46.8 mRem for LAS; P = .61) between the groups. There was significantly lower total body radiation (in milliroentgen equivalent man) exposure using the Rampart than that using LAS for each team member: position 1-0.1 mRem for Rampart vs 2.2 mRem for LAS; P < .001; position 2-0.1 mRem Rampart vs 3.2 mRem LAS; P < .001; and position 3-0.0 mRem for Rampart vs 0.8 mRem for LAS; P < .001. Conclusions:During routine clinical procedures, the Rampart system significantly decreases total body radiation exposure compared with traditional LAS.

OBJECTIVES: To examine short- and long-term outcomes of patients with moderate-to-severe aortic insufficiency (AI) undergoing either a Bentall aortic root replacement (ARR) or valve-sparing root replacement (VSRR).METHODS: A two-centre retrospective database of patients undergoing ARR from 2004 to 2021 was reviewed. Patients <18 years old were excluded. A total of 1527 adult patients underwent Bentall ARR (n = 1150, 75%) or VSRR (n = 377, 25%). Propensity score matching based on preoperative comorbidities was used and 195 matched pairs were identified. Perioperative outcomes, reoperation rates, recurrence of AI and long-term survival were evaluated.RESULTS: ARR patients had more concomitant ascending aortic replacement (35% vs 20%, P = 0.002) and shorter cardiopulmonary bypass (189 vs 233 min, P < 0.0001) and aortic cross-clamp (170 vs 204 min, P < 0.0001) times than the VSRR group. Postoperatively, outcomes were similar between groups, including stroke (3% vs 2%) and in-hospital mortality (1.5% vs 2.1%), all P > 0.05. Indications for and rates of reoperation (4% vs 5%, P = 0.62) of the aortic valve and proximal aorta were similar between ARR and VSRR groups with reoperations occurring a mean of 3.2 years after initial root replacement. The ARR group had less moderate-to-severe AI than the VSRR group (1.6% vs 14%, P = 0.002) a mean of 3 years after surgery. Ten-year survival was similar between ARR (84%) and VSRR (82%) (P = 0.69) groups.CONCLUSIONS: Both ARR and VSRR can be performed with acceptable short- and long-term outcomes in patients with moderate-to-severe AI.

Clinical outcomes following various surgical intervention strategies for aortic root and valve pathology during repair of acute type A aortic syndromes were studied and compared. From 2004 to 2019, 634 patients underwent acute type A aortic repair. Patients were divided into 4 groups: Valve Resuspension (n = 456), Isolated Valve Replacement (AVR) (n = 24), Valve and Root Replacement (ROOT) (n = 97), and Valve Sparing Root Replacement (VSRR) (n = 57). The primary endpoint was midterm survival and multivariable risk factor analysis was performed. The mean age was 55.4 ± 13 years, 424 (67

BACKGROUND Emergency CABG is often omitted from current research, and volumes as well as outcomes are unknown. The purpose of this research is to examine national trends in emergency CABG. METHODS The STS national adult cardiac surgical database was queried from 2005-2017 for patients who underwent emergency and emergency salvage isolated CABG procedures, and 92607 patients were included for analysis. Generalized linear mixed models were used to assess time trends, taking into account the clustering effect of region. RESULTS Over the study period, volumes of emergency and emergency salvage CABG declined from 7991 cases/year to 6916 cases/year. Emergency and emergency salvage cases accounted for approximately 4.9% of all CABG procedures performed nationwide in 2005 and 4.1% in 2017. Predicted risk of mortality declined in the entire patient cohort over time from 12% to 8% (p < 0.0001). Rates of important postoperative morbidities also declined including prolonged intubation, re-exploration for haemorrhage, and postoperative pneumonia (p < 0.001). Observed to expected (O/E) mortality rates rose over the study period from 0.81 to 1.06 as overall PROM declined from 9.3% to 7.6%. Emergency salvage CABG rates also declined over the course of the study from 358 cases/year to 323 cases/year. The O/E ratios for mortality increased for emergency salvage CABG during the study from 1.16 to 1.66, and emergency salvage mortality rates averaged 46.5%. CONCLUSIONS The volume of patients undergoing emergency and emergency salvage CABG in the US has declined. Increases in mortality are largely driven by emergency salvage cases, and the predicted risk of mortality algorithm may not accurately reflect the risk involved for these patients.

Objective: The impact of previous aortic root replacement (True-Redo) versus any previous operation (Any-Redo) on outcomes after reoperative aortic root replacement (redo-ROOT) is largely unknown. In this first multi-institutional study, the clinical impact True-Redo versus Any-Redo in the setting of redo-ROOT was reviewed. Methods: From 2004 to 2021, 822 patients underwent redo-ROOT at 2 major academic centers: 638 Any-Redo and 184 True-Redo. Matching based on preoperative demographics and concomitant operations resulted in 174 matched pairs. An independent risk factor analysis was performed to determine risk factors for early and late mortality. Results: Patients in the True-Redo group were younger, at 49.9 ± 15.1 versus 55.3 ± 14.7 years, P < .001. Concomitant operations were largely similar between the 2 groups, P > .05. Median cardiopulmonary bypass time (P < .001) and aortic crossclamp time (P = .03) were longer for True-Redo group. In-hospital mortality was 13% (109) and was without significant difference between groups, P = .41. Ten-year survival was 78% versus 76% for True-Redo versus Any-Redo groups respectively, P = .7. Landmark survival analysis at 4 years' postoperatively on the matched groups found that patients in the True-Redo group had improved survival outcomes (P = .046). Risk factors of in-hospital mortality consisted of older age (P < .0001), lower ejection fraction (P = .02), and male patient (P = .0003). Conclusions: Clinical outcomes following redo-ROOT are excellent. Performance of a True-Redo-ROOT does not result in worse in-hospital morbidity or mortality and has improved survival benefit at midterm follow-up when compared with patients in the Any-Redo group. The decision to perform a redo-ROOT must be taken seriously and must be individualized in a patient-specific manner for optimal outcomes.

BACKGROUND Previous studies have evaluated the learning curve to achieve competency in robotic-assisted coro-nary artery bypass grafting (CABG) but have not identified thresholds for mastery. Robotic-assisted CABG isa minimally invasive alternative to sternotomy CABG. The purpose of this study was to evaluate the short-and long-term outcomes of this procedure and to estimate the threshold for achieving mastery. METHODS From 2009 to 2020, 1000 robotic-assisted CABG procedures were performed at a single institution. Robotic left internal mammary artery (LIMA) harvest followed by off-pump, LIMA-left anterior descending artery grafting using a 4-cm thoracotomy was performed. Short-term outcomes were obtained from The Society of Thoracic Surgeons data-base, and long-term follow-up was obtained by telephone questionnaires from dedicated research nurses for all patients more than 1 year from surgery. RESULTS Mean patient age was 64 +/- 11 years, Society of Thoracic Surgeons predicted risk of mortality was 1.1% +/- 1.5%, and 76% (758) of patients were men. Thirty-day mortality occurred in 6 patients (0.6%; observed-to-expected ratio, 0.53), 5 patients (0.5%) experienced a postoperative stroke, and postoperative LIMA patency was 97.2% (491/ 505). Mean procedure time decreased from 195 minutes to 176 minutes, and conversion to sternotomy decreased from 4.4% (22/500) to 1.6% (8/500) after 500 cases. Short-term outcomes suggested expertise was reached between 250 and 500 cases. Long-term follow-up was completed in 97% of patients (873/896) with a median follow-up of 3.9 years (interquartile range, 1.8-5.8), and the overall survival rate was 89% (777). CONCLUSIONS Robotic-assisted CABG can be performed safely with excellent results even during a surgeon's early experience. However the learning curve to achieve mastery is longer than required to achieve competency, with a threshold of approximately 250 to 500 cases.

Purpose: Oral mucositis (OM) is a common, debilitating complication of conditioning regimens for hematopoietic stem cell transplantation (HSCT). Supersaturated calcium phosphate rinse (SCPR) and palifermin have shown efficacy in preventing severe OM. However, whether their efficacy differs is unknown. We aimed to compare the efficacy of SCPR and palifermin in HSCT patients receiving myeloablative conditioning. Methods: A comprehensive review of our institutional database was performed to identify patients who received myeloablative-conditioning therapy over 5 years. All HSCT patients who received radiotherapy-based myeloablative conditioning and received either palifermin or SCPR within the study period were included. Most patients received Fludarabine, Busulfan, and total body irradiation (FBT). Patients were divided into two groups based on the OM prophylactic agent received. The primary outcome is prevalence of severe OM (WHO Grade 3 and 4). The secondary outcomes are a prevalence of all-grade OM and WHO Grade 4 OM. These outcomes were compared between the two groups. Results: We identified 26 patients who received SCPR and 122 patients who received palifermin for OM prophylaxis. The prevalence of World Health Organization (WHO) Grade 3 or 4 OM was significantly lower in the palifermin group (57% vs. 100%, p = 0.01). In addition, the palifermin group had lower WHO Grade 4 OM (22% vs. 62%, p = 0.0006). The overall prevalence of OM was not significantly different between the two groups (86% for palifermin group vs. 100% for SCPR arm, p = 0.15). Subgroup analyses demonstrated improved outcomes with palifermin, regardless of age, sex, disease status, donor type, and primary diagnosis. Conclusion: When compared to SCPR, the use of palifermin is associated reduced severity of OM in HSCT patients receiving radiotherapy-based myeloablative conditioning.

BACKGROUND Patient-reported outcomes (PROs) assessment is a necessary component of surgical outcome assessment and patient care. This study examined the success of routine PROs assessment in an academic-based thoracic surgery practice.METHODS PROs, measuring pain intensity, physical function, and dyspnea, were routinely obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System (PROMIS) on all thoracic surgery patients beginning in April 2018 through January 2021. Questionnaires were administered electronically through a web-based platform at home or during the office visit. Completion rates and barriers were measured.RESULTS A total of 9725 thoracic surgery office visits occurred during this time frame. PROs data were obtained in 6899 visits from a total of 3551 patients. The mean number of questions answered per survey was 22.4 +/- 2.2. Overall questionnaire completion rate was 65.7%. A significant decline in survey completion was noted in April 2020, after which adjustments were made to allow for questionnaire completion through a mobile health platform. Overall monthly questionnaire completion rates ranged from 20% (April 2020) to 90% (October 2018). Mean T scores were dyspnea, 41.6 +/- 12.3; physical function, 42.7 +/- 10.5; and pain intensity, 52.8 +/- 10.3.CONCLUSIONS PROs can be assessed effectively in a thoracic surgery clinic setting, with minimal disruption of clinical activities. Future efforts should focus on facilitating PROs collection from disadvantaged patient populations and scaling implementation across programs.

BACKGROUND Esophagectomy is an important, but potentially morbid, operation used to treat benign and malignant conditions that may significantly impact patient quality of life (QOL). Patient-reported outcomes (PROs) are measures of QOL that come directly from patient self-report. This study characterizes patterns of change and recovery in PROs in the first year after esophagectomy. METHODS Longitudinal QOL scores measuring physical function, pain, and dyspnea were obtained from esophagectomy patients during all clinic visits. PRO scores were obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System from April 2018 to February 2021. Mean PRO scores over 100 days after surgery were compared with baseline PRO scores using mixed-effects modeling with compound symmetry correlational structure. RESULTS One hundred three patients with PRO results were identified. Reasons for esophagectomy were malignancy (87.4%), achalasia (5.8%), stricture (5.8%), and dysplasia (1.0%). When comparing mean PRO scores at visits <= 50 days after surgery with preoperative PRO scores, physical function scores declined by 27.3% (P<.001), whereas dyspnea severity and pain interference scores had increased by 24.5% (P<.001) and 17.1% (P<.001), respectively. Although recovery occurred over the course of the 100 days after surgery, mean physical function scores and dyspnea scores were still 12.7% (P=.02) and 26.4% (P=.001) worse, respectively, than mean preoperative levels. CONCLUSIONS Despite declines in QOL scores immediately after esophagectomy, recovery back toward baseline was observed during the first 100 days. These findings are of considerable importance when counseling patients regarding esophagectomy, tracking recovery, and implementing quality improvement initiatives. Further long-term follow-up is needed to determine recovery beyond 100 days. (C) 2023 by The Society of Thoracic Surgeons