Hi, everyone. My name is Anas Hashem and I'm a third year resident at Rochester General Hospital. Thank you, everyone, for this opportunity to present our work. So today I'll be talking about the rate and predictors of trifecta structural bioprosthetic valve deterioration and failure over a five-year follow-up period. It's a single sentence study that was done at Rochester General Hospital and special thanks to my supervisor, Dr. Depta. I have no disclosure to report. In terms of the outline, I'll talk quickly about the background and then we'll go further and discuss our study. So the aortic valve and aortic stenosis generally is the second most prevalent heart valve disorder and it's the most common reason for a surgical aortic valve replacement in developed countries. There has been dramatic change over the last 60 years in terms of the surgical aortic valve intervention. As you can see here, in 1952, there was the first artificial aortic valve that was invented reciprocating bowling cage. In 1960, after having the cardiopulmonary bypass that was invented, they were able to do the first mechanical valve replacement. In terms of the bioprosthetic valve, they came out later and then we had the trifecta valve bioprosthetic that was approved in 2011 and then in 2016, there was an upgrade trifecta GT valve. So as we can see here from the trend, we can see over the last two decades, from 2000 to 2020, there was a progressive increase in the bioprosthetic valve utilization as compared to meanwhile, there was a drop in the mechanical valve use and it makes sense because with mechanical valve, that requires placing patients on Warfarin and unfortunately, not everything goes as we wish. So there are many studies that have shown that trifecta valve is associated with higher rates of structural valve deterioration and failure. There was the Figura et al, they included almost 1,060 patients and they found that structural valve deterioration was higher among patients who underwent trifecta valve replacement and the rate was 27.9%. And therefore, given all of the previously mentioned data, we wanted to study the rates of structural valve deterioration and failure at our center. And we wanted also to study if there are any predictors for the failures. So for the methodology, it's a retrospective observational cohort single center clinical study. It was conducted from 2014 to 2019 for those who underwent SAVR using trifecta valve prosthesis. The total number of patients that we included initially were 300 and then we followed the inclusion criteria which included all adults aged between 18 to 90, those who were followed for at least three years, and those who had a baseline echocardiogram which is preoperative and then day of surgery, then immediately postoperatively, and then the most recent echocardiogram. So basically three echocardiograms, our main focus is on the immediate and the most recent. The exclusion criteria, those who we lacked to follow up within five years, those who did not have an echocardiogram, and those who died in the outpatient or they were lost to follow up. In terms of the definition, we depended on the Fokura et al. with some modification. Basically we divided them into structural valve deterioration and structural valve failure. For the deterioration, we further classified them into echocardiographic deterioration and clinical deterioration. For the echocardiographic deterioration, we looked at the increase in the mean pressure gradient across the valve for more than 20 from the immediate to the most recent echo and a decrease in the Doppler velocity index of more than 0.15 in the follow-up echocardiography without any clinical symptoms, of course. In the clinical SVD, we included those with echocardiography, and on top of that they had the clinical symptoms or at least got similar close numbers to these and had symptoms. For structural valve failure, any patients who had valve deterioration requiring replacement. So in terms of the data collection, we had two pairs of residents who collected the data and if there were any conflicts, we had a senior author who reviewed them. We took the ethical concentration and obtained an IRB approval for our study. So the results here, we have 271 patients in our analysis, the rest were excluded given the inclusion criteria we had. And then the mean age was 71 years. The percentage of male were 57.9%, and this table one shows the further characteristics of the baseline characteristics of our patients. So here, aortic stenosis was present in 207, which was the most common indication for SAVR. In terms of the operative characteristics, 109 had isolated trifecta valve replacement, 99 had a concomitant CABG, and then we can see here the rest of the list here. For the trifecta valve size, most commonly we use 23 millimeter followed by 21. In terms of the echocardiographic evaluation, we checked the mean duration between the immediate to most recent echo and it was around five years plus or minus 0.7 years. And the baseline preoperative echo was around 53%. You can see here the findings between the immediate post-operative echo and the most recent echo. I want to show you the parity test analysis that we performed here. So this is the ejection fraction between the preoperative and immediately post-operative, no significant change. Between the immediate post-operative to the most recent, there was a significant increase in the ejection fraction, and also from the baseline too. In terms of the peak velocity, it went up from the immediate post-operative to the most recent. That can be from the increase in the ejection fraction or maybe stenosis or narrowing in the valve. The mean difference was around 0.15. In terms of the mean pressure gradient, it went up also from the IPE to MRE, and it went up approximately by 1.7. In terms of the Doppler velocity index, it went down by 0.037. It's a small change, but it's significant. In terms of the results, we have structural valve deterioration rate around 23.2%. We included the echocardiographic structural valve deterioration and the clinical. In terms of echocardiographic changes, we compared between those who had structural valve deterioration versus those without structural valve deterioration. We found that the delta pressure gradient was significantly higher among those who had structural valve deterioration, around 7.9, with the delta Doppler velocity index was significantly lower among those who had structural valve deterioration, which makes sense. In terms of the structural valve failure, we had around 4.8 patients who had a failed valve requiring a replacement, and these were the indication for the valve failure. The mean duration for valve failure was around 38 months, approximately like three years. And this is the Table 2 shows the echocardiographic characteristics for structural valve failure. In terms of the predictors for valve deterioration, unfortunately, none of the baseline characteristics predicted the structural valve deterioration. We included all of these characteristics, as you can see. This is a quick central illustration for our study. And then the limitations. We know that first, it's a retrospective observation study. It has a lot of bias in it. The second thing is that some patients were lost to follow-up. We had only 271 patients who underwent trifecta. The follow-up range between three to five years, we're not sure if that's sufficient, it would have been better if we follow-up up to 10 years. And then also, we think that the sample size was underpowered to predict the outcomes. In summary, we have our study that was done among patients who underwent trifecta, and we followed up them for five years. The structural valve failure was 4.8, structural valve deterioration was around 23.2. The majority of structural valve deterioration were not clinically significant, except in six patients. And that concludes our study. Thank you so much. Hello, everyone. My name is Omar Obaidat. I'm a BGY2 resident from North Florida Internal Medicine, Gainesville, Florida. Thank you for this opportunity to share our research in this meeting. So our research is about exploring the impact of diabetes mellitus on left ventricular assisted device outcome in inpatient sitting. We used NIS data, which is a large database that includes most of the discharge from all over the United States, which is good representative for the real-world data of the LVAD patient in the States. So in this study, we aim to investigate the mortality for diabetes for LVAD patient. Also we explored the influence of diabetes on the cost of hospitalization, and we assessed the impact on the length of hospital stay. We all know that diabetes is a major risk factor for cardiovascular diseases in general, especially MI and heart failure. There is some study that reported diabetes as a relative contraindication for both LVAD and heart transplantation. This is what brought the idea of exploring this from real-world data to see if there is actually a difference between patient with diabetes and without diabetes on the mortality cost and hospital stay. So as we said, we used the National Inpatient Database. It's a retrospective study. We included data from 2016 to 2019. Why is that? Because there was a change in coding in 2015, in June. There was transition from ICD-9 to ICD-10, and this can cause problem with the analysis, so we decided to include only the data that has ICD-10 codes. We included all patient above 18 and have LVAD. We divided them into two groups based on the diabetes. The definition of diabetes was based on the ICD-10 codes. We don't have any idea how they diagnosed diabetes, so this might be one of the bias of this study. We looked up to multiple variables, including the demographic characteristics of the patient, age, sex, ethnicity, also the zip code, and multiple comorbidities, especially cardiovascular comorbidities, including MI, arrhythmias, also respiratory like COPD and CKD, also CVA. With our analysis, we used STATA for multivariant logistic regression and t-test. So for a study population, we found that patients with diabetes have a significantly higher age compared to patients without diabetes. The age for diabetic group was 65.64 in comparison to non-diabetic, 62.72. Most of them was white patient. There was no statistical significant difference, and there was no significant difference like the sex. Patients with diabetes have higher comorbidity in general, especially they have higher CKD, higher CVA, and higher obesity. Patients with non-diabetes have significantly higher MI. This might give us an idea that patients with diabetes and MI were excluded from having LVAD in the inpatient setting. There is an important thing that I forget to mention in the exclusion criteria. We excluded all patients who underwent a transplant in the index hospitalization because this can affect the mortality. We found that in a fully adjusted model that include every single comorbidity variable that we have and every demographic characteristic, that patients with LVAD have no significant difference between diabetic patient and non-diabetic with the odd ratio of 0.931. They actually have lower cost of admission and lower length of hospital stay. When we adjusted only for cardiovascular risk factors, patients with diabetes have better outcome than non-diabetic patient. Also, they still have lower cost of admission and lower length of stay. So, why this finding is important? Because, as I said earlier, that there is a lot of study that said patients with diabetes has worse outcome early and late outcome, like after the hospitalization. Based on this data, a lot of patients who have diabetes and require LVAD were excluded from having this that might be life-sustaining treatment. This gives an idea that we need to do more research that will explore the impact of diabetes more on patients with LVAD and heart transplantation. There is a lot of limitation as we used a database. We don't have like a clinical variable. As I said, we don't have the A1C of the patient. We don't have any idea about the control of diabetes. We don't have the hemoglobin. As we know that patients with LVAD have risk of bleeding, have risk of anemia. We don't have any of that. We only explored the short-term outcome. We don't have any idea how those patients do after like a year or two. So, we need more research on that. And we cannot know the cause of death on this database. So, if the patient die from other thing than things related to heart or LVAD, this can cause a bias and increase in the mortality rate. We cannot use this study to generalize the result outside the United States or even to patients with heart failure in general who require transplantation. So, in conclusion, there was no significant difference in hospital mortality in patients with diabetes who require LVAD. And there is a potential for optimizing care for patients with diabetes and have severe heart failure who require either LVAD or heart transplantation. So, we need a long-term outcome for LVAD patient. And we need to assess diabetic management impact on the outcome. These two are lack on this study. Good morning and thank you for giving me the opportunity to participate in 2023 CHEST annual meeting. Today, I'll present the comparative analysis of pulmonary function changes after lobectomy in lung cancer patients according to preoperative smoking status. I'm Junsung Lee, Clinical Fellow of Seoul National University Bundang Hospital. Before the presentation, I clearly promised there's nothing to disclose any other conflict of interest in this study. The decrease in pulmonary function after lung cancer surgery is inevitable. However, the amount of changes in lung function vary depending on the perioperative clinical conditions. For example, as far as we know, lobectomy decreased more than limited resection, thoracotomy decreased more than minimal invasive surgery, and patients who had postoperative complications decreased more than those who didn't experience complications. However, the relationship between perioperative smoking behavior and pulmonary function changes after lung cancer surgery remains unclear. Given the inevitable decrease in pulmonary function after the surgery, the prevention of accelerated decline through smoking session may require serious attention. We hypothesize that if current smokers try to maintain smoking session after lung cancer surgery, the recovery of lung function would be comparable to that of non-smoker. So we compare the longitudinal pulmonary function changes in patients who did not smoke after lobectomy for lung cancer based on the preoperative smoking status. From January 2011 to December 2020, patients who underwent lobectomy for non-small cell lung cancer and continued to stop smoking at least one year after the surgery were included for the study. After excluding patients with incomplete pulmonary function data and formal smokers, the medical records of 1,216 patients were finally reviewed and grouped according to preoperative smoking status. According to preoperative smoking status. After categorizing patients into never and current smoker, preservation rate of EPI-B1 and EPI-BC was compared between the two group. Current smokers were defined as patients who had continued to smoke even at the time of the first outpatient visit. Preservation rate was calculated by the ratio of postoperative pulmonary function values to baseline pulmonary function values. Postoperative follow-up was conducted at three months, six months, and 12 months intervals and smoking behaviors were checked through patient self-reported commands. The primary endpoint was to compare the six month and 12 months preservation rate of EPI-B1 and EPI-BC between the two groups. Subgroup analysis was conducted according to the resected lobes. Here is the result. Among total study cohort, 354 patients were current smokers. The current smokers were higher proportion of male and COPD along with lower baseline pulmonary function compared with the never smokers. Perioperative characteristics demonstrated the patients who underwent thoracotomy were higher in the current smokers. Besides, the instance of pulmonary complications were also significantly higher in the current smokers. From now on, the preservation rate for EPI-B1 and EPI-BC in total and subgroup cohort will be presented from this slide. In total study cohort, the preservation rate of EPI-B1 was 91.5% at six month and 92.1% at 12 months in the current smokers, which showed favorable outcomes compared with the never smokers. However, the preservation rate of EPI-BC was similar between the two groups. In upper lobectomy group, the preservation rate of EPI-B1 was significantly better in the current smoker than never smoker. The difference in preservation rate of EPI-B1 was 3% at six month and 2% at 12 months postoperatively. However, the preservation rate of EPI-BC showed no difference between the two groups. In contrast to the upper lobectomy group, lower lobectomy group revealed no difference in the preservation rate of EPI-B1 and EPI-BC. Among the upper lobectomy group, patients underwent right upper lobectomy showed better recovery of EPI-B1 in the current smokers compared with the never smokers. In the current smokers, the preservation rate of EPI-B1 was 91.5% at six month and 92.1% at 12 months respectively. However, the preservation rate of EPI-BC was similar between the two groups. In left upper lobectomy, the preservation rate of EPI-B1 was consistently higher but does not show statistical meaningful outcomes in the current smokers. In conclusion, despite lower baseline pulmonary function and higher instance of thoracotomy and postoperative functions after lobectomy, postoperative complications, the recovery of pulmonary function after lobectomy might be comparable in the current smokers if smoking sessions persist after the surgery. These favorable outcomes were more prominent in patients who underwent upper lobectomy, especially in cases of upper lobectomy. There are several limitations in this study. First, it was retrospective longitudinal trunk review that was conducted at single center. Secondly, perioperative smoking behaviors might be inaccurately reported because this information solely depended on patients' self-reported outcomes rather than objective methods such as nicotine levels. Lastly, because our study excluded patients with incomplete follow-up data, selection bias could have influenced clinical outcomes. Thank you for your attention. And if you have any questions, please contact me. So I'm gonna be talking about how we try to optimize our outcomes by combining two things. One is an enhanced recovery after surgery program, protocol, as well as the awake VATS technique, which I'll describe. I'm the chair of cardiothoracic surgery at Sharp Grossmont, and I head up the minimally invasive institute out in San Diego. Dr. Nadur is one of our pulmonologists, and Dr. Bagheri, who couldn't make it with us, unfortunately, is a resident in downstate. They wouldn't give him the time off to come, unfortunately. My disclosures, I do some consulting work for these companies, but they are not relevant to this study. Lesson objectives were to basically highlight how we can optimize recovery after implementing ERAS protocols with AVATS. First of all, what is AVATS? Some people may not understand it or know it. It's basically doing traditional VATS surgical procedures, lobectomies, segmentectomies, decortications, and whatnot, through a single-port incision under a local anesthetic, using a three-level intercostal block, as well as some background presidex for sedation. It minimizes and eliminates the use of a general anesthetic, allowing surgical pool to expand to people who could otherwise not tolerate a general anesthetic, people with poor pulmonary function, for example. And we eliminate a lot of the co-usage lines and epidurals and central lines, foleys, all of that. It first presented the AVATS procedure out in Croatia at the World Congress about 12 years ago. And the very first procedure, I didn't do it to try to be a cowboy. It was actually not even my patient. I was seeing a cabbage for a wound check, and her husband told me his story. And he was a 56-year-old male with a three-centimeter peripheral lung cancer, biopsy-proven, who had a pneumonectomy when he was 22 because of a motorcycle accident. And he continued to smoke after the pneumonectomy. And he had extensive COPD, and he had a preoperative FEV1 of 0.58. Had a CAT scan that showed no mediastinal adenopathy in a pet that was otherwise negative other than the tumor, but he was deemed inoperable. They were up in LA. They saw two facilities there, and they were turned down for surgery, and he ended up going on to get chemotherapy, followed up by traditional radiation that was switched over to CyberKnife. And unfortunately, neither approach really affected the tumor. It kept growing, and he went back to his primary surgeon up there, who again said, you can't have surgery. And he was kind of telling me this case here. And we ended up, initially, my initial inclinations was to agree with the other surgeons, but it kind of dawned on me that the lungs don't have pain fibers. The chest wall does, and the mediastinum does, but the lungs themselves don't. And so we got IRB approval, and we did awake VATs, and basically a wide-wedge resection on this guy. He went home on post-operative day number two, no complications, and he's disease-free 12 years later. It got me thinking about the ability of doing cases under this technique, and so we expanded it to other things. The benefits of the AVATs, it allows people who would otherwise not be considered surgical candidates into the surgical arena, people with poor pulmonary function. It has the other benefits of traditional VATs, like limiting skin and muscle division, lower intraoperative bleeding rates, shorter length of stay, shorter anesthesia time, and you don't have as much trauma to your immune system, so you can theoretically get on to chemotherapy quicker. First published it at the Journal of Cardiothoracic Surgery when we had about 483 patients were just south of 2,800 cases now. It has obviously the benefits of traditional VATs, as well as the ability to expand it to other patients, and it preserves your immune system, so it helps limit infections post-operatively. Let's see if we can get this to play. Wait while you're on the operating table. I'm tennis reporter Joe Little. It's a matter of tailoring the operation to the patient. Sharp Grossmont Cardiothoracic Surgeon, Eric Klejian, helped pioneer a technique that keeps patients awake while he operates on their lungs or esophagus. We're calling it AVATs. It stands for Awake Video Assisted Thoracic Surgery. Dr. Klejian said today that patients who use local anesthesia instead of general recover faster from their procedure. It is an option in certain patients. And people who can't have general anesthesia because of other medical issues can finally be treated. Joe Little. So the technical aspect of the AVATs is that all the cases are done with a three-level intercostal block that I do myself, not by anesthesia. I first do a little skin wheel, put a scope in, and make sure that I'm not penetrating the pleural space when I'm doing the block. We eliminate central lines and epidurals. We only had seven A-lines placed, and only 129 patients had Foley catheters. All were done with a single-port incision to help minimize post-operative pain requirements. And they all go on to get IV acetaminophen, and if their kidney function allows, to get some Ketorolac as well. And we implement the ERAS program, which I'll go over, to help minimize all of the other side effects, including nausea and respiratory drive issues and altered sensorium. The procedures that were done in the 2,300 cases that I'm reporting here included lobectomies, segments, bi-segments, wedges, decorts, bronchopleural fistula repair, diaphragmatic cases, esophageal resection and repairs, bolectomies, pericardectomy, child duct repairs, and pleurodesis. And they were fairly sick patients. A lot of comorbidities, hypertension, the typical blue plate special in terms of the comorbidities that we see. But the real striking point is the last bullet point. 852 had FEV1s less than 0.5. So it really kind of opens up the surgical option in these patients. In terms of the ERAS program, it's divided into preoperative, intraoperative, and post-operative phases. The preoperative protocol includes patient education. A lot of this is mental. And so the nurse practitioners in all of it tell them that you're gonna go home in a day. People have the preconceived notion that thoracic surgery is a big ordeal and they're kind of expecting a seven day hospital stay. And you gotta get that out of their mind and tell them that this is gonna be a one or two day hospital stay. We implement a smoking cessation program and shower and skin prep before surgery. We optimize the diets if we have the luxury of time before surgery, upwards of 10 days, including antioxidant and carb drinks. Preoperative spirometry usage to get them implemented on using the spirometer before surgery even. Thromboprophylaxis, we revise our NPO status. We keep the gut in play. A lot of people do NPO after midnight. I think that there's a lot of data that shows that you can prevent infections and the whole aspiration issue is not an issue with the AVATs. So we keep them able to eat solids up to four hours before surgery and clears up to two hours before surgery. Multimodal anti-emesis protocols, we correct any anemia, malnutrition, and try to optimize their pulmonary status with inhalers and whatnot. Preventative oral care, because you can have a lot of postoperative infection with people with bad teeth. And exercise program before surgery. Intraoperatively, obviously, antibiotic uses prior to incision. We use clippers instead of shaving to minimize infection. We implement the AVATs techniques, which I'll go over shortly. We avoid lines, which can carry with it issues, line infections, folies with UTIs and whatnot. Avoid salt and fluid overload. Prevent and manage AFib. Initiate pain control at the completion of the operation in the OR. So the first dose of Toradol is started in the OR before the patient even wheels out. We use Presidex for sedation. Early on, I was using Versed, and the reason I switched over to Presidex is that at the end of the resection, with the camera still in the chest, I could wake up the patient. Mr. Smith, wake up and give me a cough. The camera's still in the chest, I could visualize air leaks. I could go in at the time of surgery and fix them. So the air leak rate really plummeted down, and if I need to put any sealants on, I'll apply it at that time. Apply some Pro-Gel onto it, maybe put some stitches into it, and with that, I stopped using regular chest tubes after surgery, assuming that bleeding's not an issue. I put in a 12 French pigtail catheter, and it's a lot better tolerated post-operatively. We avoid general anesthetics as well, because when you're coming out of an anesthetic, what typically happens is you buck, and that increase in intrathoracic pressure can actually have a detrimental effect on your staple lines and whatnot, and an air leak that you may not see in the OR will manifest in the PACU. And that is eliminated with the AVATs. Post-operatively, multimodal approaches in terms of pain control, they're limited to two doses of morphine post-operatively, and then four doses of Tylenol with codeine. After that, they're going on to non-steroidals. IV acetaminophen is used across the board. We go very early to rescue therapy for emesis, again, to help preserve the bucking effect that you typically see after surgery, but also just it's better outcomes if the patient is not crippled by nausea or vomiting. We go on to clears right away and advance their diet. I want them usually, typically eating by hour four after surgery. Cough lozenges, again, to prevent coughing. Thromboprophylaxis, early ambulation, we want them walking at the latest two hours after surgery. Aggressive spirometer usage, early chest tube removal, usually within 12 to 24 hours. PT and OT are implemented as well as pulmonary rehab. There's a check board that the patient has to check off at the bedside of everything that he's done throughout the course of his day. The type of cases included wedges. We had 584 lobectomy or segmentectomies in our length of stay, was 1.2 days. 58 of them were done as ambulatory cases where they came in and went home that evening. There were 658 decortications with the length of stay of about 2.1 days, as well as a smattering of other procedures, including some esophageal work and diaphragmatic rupture work. This is typically how it's done. The patient has a face mask. I modify the position based upon where the lesion is. Most of the time it's with a small bump under one side and a small incision. Initially, when I was doing traditional VATs, it was the McKenna approach, basically, the three port and all of that. Limited now down to a single incision and I do this modified anterior approach in the case that emergent intubation is required, but knock on wood, we haven't had to have any yet. It would be easier for them to intubate in a modified position as opposed to a full lateral. And we've had no conversions to a general anesthetic or intubation. Most of the tubes come out by hour 12 usually and by getting that tube out, patients can ambulate quicker. They're more likely to use their spirometer, so your rate of pneumonias, nosocomial pneumonias and DVTs and all of that stuff go down. We aggressively treat the nausea and the pain and we did have some AFib post-operatively, mainly in the lobectomies, but also some in the decorts. They were all medically managed. They did not require cardioversion. We had two IV site phlebitis, no strokes or acute or delayed pneumos, DVT, pulmonary emboli, UTIs, pneumonia or six-month readmits. So we conclude by combining the ERAS protocol with the AVATs technique, you can really optimize outcomes and get patients home quickly and decrease your length of stay and increase patient satisfaction. And I think with that, I'm gonna stop. Good morning, everyone. My name is Anupama Singh. I'm a thoracic oncology research fellow at Brigham and Women's Hospital. Thank you to the society for giving us the opportunity to present today on our work regarding shape-sensing robotic ion bronchoscopy. I have no relevant financial disclosures. The objective of this talk will be to review our data and our experience using this technology at our institution. And our aim was to identify predictors of successfully diagnosing and reaching the target lesions. Last year, we had presented our data regarding our experience with Veron. And so we had reviewed 439 patients who were undergoing EMN-guided bronchoscopy from January 2018 to November 2021 at our institution. We had a success rate of reaching the target lesions around 83% of the time, and our diagnostic yield rate was around 63%. Main adverse events included pneumothorax, referral for IR biopsy, and referral for surgical biopsy with the percentage breakdowns that you can see there. And we had found that the presence of a bronchus sign and larger target lesions were significantly associated with our success at reaching and diagnosing the lesions. We didn't see any difference with prone positioning or with peripheral lesions. Our institution then acquired the shape-sensing robotic ion bronchoscopy in late 2021. And so that's the data that I'll present now. We conducted a retrospective chart review of 239 cases from November 2021 to January 2023. All the procedures were performed by a single surgeon under general anesthesia, and all the biopsy techniques were the same for each case as well. So we started off with a 23-gauge needle aspiration followed by brushings for cytology, and then transbronchial lung biopsy and bronchioalveolar lavage. Radial EBUS and fluoroscopy were used as adjuncts for each case, but we also then added cone beam CT if CT body diversion occurred, which was more common if lesions were smaller, peripherally located, or close to the diaphragm. We also added CBCT if we found eccentric lesions on radial EBUS in order to attempt a concentric view, as you can see in the example pictures below. We started using the Siemens Artist Fino CBCT at our institution in May 2022, and then we also conducted regression analysis to identify any predictive factors of improving diagnostic yield in achieving targeting the target lesions. So of the 239 cases, 321 lesions were biopsied in total. Our overall diagnostic yield was around 78%, and our success rate in reaching the target was 97% compared with the VRON, which was 82%, as I had shown earlier. And all malignant lesions in our case were considered diagnostic unless they were proven false positive by surgical resection. Non-malignant lesions were considered diagnostic if follow-up imaging demonstrated regression or resolution, or a stable lesion on follow-up imaging for more than one year, or if the cause was confirmed by an alternative sampling method, such as surgical biopsy. Non-diagnostic lesions were those that showed atypia or at most showed benign bronchial or alveolar tissue. The average age of the patients in our cohort was around 68 years, predominantly female at 64%, and predominantly white patients. 22% had a history of thoracic surgery, 18% had a history of chest radiation, and 16% had a history of prior chemotherapy. The average target size in our population was 1.9 centimeters, and the bronchocyte was present around 83% of the time. Approximately 15% of the lesions were located in the central one-third or hilar region, and 45% were located in the outer one-third. Most of the lesions were in the right lung, and most of them were pure solid. And approximately 58 lesions, or 18% of the entire lesion cohort, were eccentric on radial EPUS. When we did a univariate analysis to identify factors that were associated with diagnostic yield, we found that the presence of eccentric lesions were associated with decreased odds of achieving a diagnosis. The presence of a bronchus sign was associated with improved odds. And when we broke the lesion sizes down into two categories, so those that were greater than or equal to one centimeter, and those that were less than one centimeter, we found that the smaller lesions were associated with decreased odds of achieving a diagnosis. When we broke the lesion sizes down into these subcategories that you see here, we didn't achieve statistical significance among the categories, but we did notice improved diagnostic yield as the lesion got larger. Otherwise, there was no difference that was seen when we examined ground glass versus solid lesions, or whether it was peripherally located or centrally located. As I mentioned earlier, we used CBCT if we found eccentric lesions on radial EPUS, or if CT body diversion had occurred. So in our cohort, we used CBCT for 70 cases. 12 of those 70 were for lesions that were undetectable on radial EPUS, and of those 12 lesions, CBCT allowed for successful adjustment of the target for one of those lesions and subsequent diagnosis. And eccentric lesions were 58 of the 70. Using CBCT, we were able to obtain a successful concentric view for 16 of those 58 lesions, and then achieved a diagnosis for 13 of those 16. Four patients in our cohort, so approximately 1.7% experienced some sort of an adverse event. One patient required a chest tube for a right pneumothorax. Another one was found to have a trace left apical pneumothorax in the PACU and did not require a chest tube. And two patients experienced bleeding from their lung parenchyma, which was successfully controlled with epinephrine, but these two procedures were subsequently aborted. There were 71 non-diagnostic cases in our cohort. And this pie chart just shows the breakdown of how those lesions were ultimately diagnosed or what their current follow-up status is. So approximately 25%, so 18 lesions, were diagnosed via surgical biopsy, followed by 19% that are currently undergoing watchful waiting, 14% that were clinically diagnosed as not malignancy, and then 15% that were clinically diagnosed as malignancy. Only 9% of the cases were diagnosed via CT-guided biopsy. We lost three patients for follow-up, but otherwise our median follow-up was around four months. And when we combine the data in the pie chart that you see here, 21 of those cases were diagnosed clinically, and 36 were diagnosed by a procedure ultimately. So in conclusion, when we use the shape-sensing robotic ion bronchoscopy at our institution, we found improved diagnostic yield rate with larger lesions, concentric lesions, and if the bronchus sign was present. Our overall diagnostic yield rate was around 78% when we combined robotic ion with fluoroscopy and radial EBUS. We do need further investigation regarding cone beam CT because our results vary depending on lesion sizes and the location of the lesion depending on the lobe or side of the lung. And we're also now starting to use cryobiopsy instead of forceps biopsy. We noticed from our experience that cryobiopsy resulted in better tissue sampling, especially for eccentric lesions, and it was also easier to navigate into the smaller airways to obtain a better diagnosis. Thank you for your time. I'm happy to take any questions.

shape-sensing robotic ion bronchoscopy

diagnosing

target lesions

diagnostic yield

lesion size

bronchus sign

eccentric lesions

cone beam CT