Introduction of transcatheter edge-to-edge repair in patients with congenital heart disease at a children's hospital.

BACKGROUND: Atrioventricular valve regurgitation (AVVR) is a devastating complication in children and young adults with congenital heart disease (CHD), particularly in patients with single ventricle physiology. Transcatheter edge-to-edge repair (TEER) is a rapidly expanding, minimally invasive option for the treatment of AVVR in adults that avoids the morbidity and mortality associated with open heart surgery. However, application of TEER in in CHD and in children is quite novel. We describe the development of a peri-procedural protocol including image-derived pre-intervention simulation, with successful application to four patients. AIMS: To describe the initial experience using the MitraClip system for TEER of dysfunctional systemic atrioventricular valves in patients with congential heart disease within a pediatric hospital. METHODS: A standardized screening and planning process was developed using cardiac magnetic resonance imaging, three dimensional echocardiography and both virtual and physical simulation. Procedures were performed using the MitraClip G4 system and patients were clinically followed post-intervention. RESULTS: A series of four CHD patients with at least severe AVVR were screened for suitability for TEER with the MitraClip system: three patients had single ventricle physiology and Fontan palliation, and one had repair of a common atrioventricular canal defect. Each patient had at least severe systemic AVVR and was considered at prohibitively high risk for surgical repair. Each patient underwent a standardized preprocedural screening protocol and image-derived modeling followed by the TEER procedure with successful clip placement at the intended location in all cases. CONCLUSIONS: The early results of our protocolized efforts to introduce TEER repair of severe AV valve regurgitation with MitraClip into the CHD population within our institution are encouraging. Further investigations of the use of TEER in this challenging population are warranted.

Lipidomic Profiling of Colorectal Lesions for Real-Time Tissue Recognition and Risk-Stratification Using Rapid Evaporative Ionization Mass Spectrometry.

OBJECTIVE: Rapid evaporative ionization mass spectrometry (REIMS) is a metabolomic technique analyzing tissue metabolites, which can be applied intraoperatively in real-time. The objective of this study was to profile the lipid composition of colorectal tissues using REIMS, assessing its accuracy for real-time tissue recognition and risk-stratification. SUMMARY BACKGROUND DATA: Metabolic dysregulation is a hallmark feature of carcinogenesis; however, it remains unknown if this can be leveraged for real-time clinical applications in colorectal disease. METHODS: Patients undergoing colorectal resection were included, with carcinoma, adenoma and paired-normal mucosa sampled. Ex vivo analysis with REIMS was conducted using monopolar diathermy, with the aerosol aspirated into a Xevo G2S QToF mass spectrometer. Negatively charged ions over 600 to 1000 m/z were used for univariate and multivariate functions including linear discriminant analysis. RESULTS: A total of 161 patients were included, generating 1013 spectra. Unique lipidomic profiles exist for each tissue type, with REIMS differentiating samples of carcinoma, adenoma, and normal mucosa with 93.1% accuracy and 96.1% negative predictive value for carcinoma. Neoplasia (carcinoma or adenoma) could be predicted with 96.0% accuracy and 91.8% negative predictive value. Adenomas can be risk-stratified by grade of dysplasia with 93.5% accuracy, but not histological subtype. The structure of 61 lipid metabolites was identified, revealing that during colorectal carcinogenesis there is progressive increase in relative abundance of phosphatidylglycerols, sphingomyelins, and mono-unsaturated fatty acid-containing phospholipids. CONCLUSIONS: The colorectal lipidome can be sampled by REIMS and leveraged for accurate real-time tissue recognition, in addition to riskstratification of colorectal adenomas. Unique lipidomic features associated with carcinogenesis are described.

Social Processing in Eating Disorders: Neuroimaging Paradigms and Research Domain Organizational Constructs.

PURPOSE OF REVIEW: Social and environmental factors have been related to both symptom expression of disordered eating in individuals and changes in the prevalence of eating disorders (EDs) in populations. Neural differences in processing social information may contribute to EDs. This review assesses the evidence for aberrant neural responses during social processing in EDs. RECENT FINDINGS: This review examines how constructs within the social processing domain have been evaluated by neuroimaging paradigms in EDs, including communication, affiliation, and understanding of both oneself and others. Differences related to social processing in EDs include altered processing for self-relevant stimuli, in the context of identity, valence, expectations, and affiliative relationships. Future work is needed to integrate how differences in processing social stimuli relate to alterations in cognitive control and reward as well as specific disordered eating symptoms.

Validation of Ultrasonic Harmonic Scalpel for Real-Time Tissue Identification Using Rapid Evaporative Ionization Mass Spectrometry.

In this study, we integrate rapid evaporative ionization mass spectrometry (REIMS) with the Harmonic scalpel, an advanced laparoscopic surgical instrument that utilizes ultrasound energy to dissect and coagulate tissues. It provides unparalleled manipulation capability to surgeons and has superseded traditional electrosurgical tools particularly in abdominal surgery, but is yet to be validated with REIMS. The REIMS platform coupled with the Harmonic device was shown to produce tissue-specific lipid profiles through the analysis of porcine tissues in both negative and positive ionization modes. Comparison with other methods of electrosurgical dissection, such as monopolar electrosurgery and CO2 laser, showed spectral differences in the profile dependent on the energy device used. The Harmonic device demonstrated major spectral differences in the phospholipid region of m/z 600-1000 compared with the monopolar electrosurgical and CO2 laser-generated spectra. Within the Harmonic REIMS spectra, high intensities of diglycerides and triglycerides were observed. In contrast, monopolar electrosurgical and laser spectra demonstrated high abundances of glycerophospholipids. The Harmonic scalpel was able to differentiate between the liver, muscle, colon, and small intestine, demonstrating 100% diagnostic accuracy. The validation of the Harmonic device-mass spectrometry combination will allow the platform to be used safely and robustly for real-time in vivo surgical tissue identification in a variety of clinical applications.

The Osteogenic Potential of Brown Seaweed Extracts.

Marine drugs hold significantly more promise than their terrestrial counterparts, which could help to solve the current shortfall in treatments for osteoporosis and other bone related diseases. Fucoxanthin is the main carotenoid found in brown seaweed, and has many perceived health benefits, including potential bone therapeutic properties. This study assessed the osteogenic potential of pure fucoxanthin and crude extracts containing both fucoxanthin and phenolic fractions (also cited to have osteogenic potential) isolated from two intertidal species of brown seaweed, Laminaria digitata and Ascophyllum nodosum. In vitro studies were performed using a human foetal osteoblast cell line (hFOBs) and primary human bone marrow stromal cells (hBMSCs). The results found pure fucoxanthin inhibitory to cell proliferation in hFOBs at higher concentrations, whereas, the crude extracts containing both polyphenols and fucoxanthin showed the ability to scavenge free radicals, which masked this effect. None of the extracts tested showed strong pro-osteogenic effects in either cell type tested, failing to support previously reported positive effects.

A critical review of analytical methods used for the chemical characterisation and quantification of phlorotannin compounds in brown seaweeds.

INTRODUCTION: Phlorotannins, the phenolic compounds found in brown seaweeds, are a unique and diverse class of compounds showing a huge potential for food and pharmaceutical applications. OBJECTIVE: This review will give an account of the colorimetric assays used and a discussion of their quantitative and qualitative analytical shortcomings. It will also discuss other more complex and modern analytical chemistry methods that are currently being developed to study phlorotannins. The purpose of this review is to increase awareness of these bioactive compounds and promote further development of robust analytical methods for use in biology, food science, pharmacology and biomedical and cosmeceutical sciences. RESULTS: Whilst the biological activity and huge commercial potential of the phlorotannins has been widely reported throughout the literature, the chemical structures and reactivity of these compounds is still not well understood. The phlorotannin content of seaweed is usually characterised using colorimetric assays. However, although these methods give a reasonable overall estimation of the total phenolic content, they lack precision and specificity. CONCLUSION: This review highlights the strengths and weaknesses of commonly used colorimetric assays. Novel techniques are highlighted using more selective chemistry to identify this class of compounds.

A Multidisciplinary Transition Consult Service: Patient Referral Characteristics.

PURPOSE: Children's hospitals must provide developmentally appropriate care to increasing numbers of young adults with complex healthcare needs as they transition to adult-oriented care. This article describes the patients, service, and short-term outcomes of an interprofessional healthcare transition (HCT) consult team comprised of nurses, social workers, a community health worker, and physicians. DESIGN AND METHODS: The Adult Consult Team's tiered population framework stratifies patients by medical complexity. The team coordinates HCT services for patients with the highest complexity. Patients at least 18 years old are eligible if they have at least two specialists or an intellectual or developmental disability (IDD). Through a comprehensive medical and psychosocial assessment, the team prepares patients/families for adult-oriented healthcare. RESULTS: The Adult Consult Team received 197 referrals from July 2017 to June 2018. Patients had at least two specialists (73%), IDD (71%), technology dependence (e.g., gastrostomy tube, 37%) and Medicaid insurance (57%). The team assisted patients seen in its outpatient clinic with navigating mental health services (39%), insurance issues (13%), IDD services (15%), and the guardianship process (37%) and creating comprehensive care plans. CONCLUSIONS: The Adult Consult Team transferred 30 patients with medical complexity to adult primary and specialty care, significantly improving pediatric inpatient and outpatient capacity for pediatric-aged patients. A broad range of young adult medical, psychosocial, legal, educational, and vocational needs were addressed. PRACTICE IMPLICATIONS: An interprofessional team approach can help large pediatric healthcare systems address the multi-faceted needs of patients who are medically and psychosocially complex as they enter adulthood.

Recruitment of PI4KIIIß to coxsackievirus B3 replication organelles is independent of ACBD3, GBF1, and Arf1.

UNLABELLED: Members of the Enterovirus (poliovirus [PV], coxsackieviruses, and human rhinoviruses) and Kobuvirus (Aichi virus) genera in the Picornaviridae family rely on PI4KIIIß (phosphatidylinositol-4-kinase IIIß) for efficient replication. The small membrane-anchored enteroviral protein 3A recruits PI4KIIIß to replication organelles, yet the underlying mechanism has remained elusive. Recently, it was shown that kobuviruses recruit PI4KIIIß through interaction with ACBD3 (acyl coenzyme A [acyl-CoA]-binding protein domain 3), a novel interaction partner of PI4KIIIß. Therefore, we investigated a possible role for ACBD3 in recruiting PI4KIIIß to enterovirus replication organelles. Although ACBD3 interacted directly with coxsackievirus B3 (CVB3) 3A, its depletion from cells by RNA interference did not affect PI4KIIIß recruitment to replication organelles and did not impair CVB3 RNA replication. Enterovirus 3A was previously also proposed to recruit PI4KIIIß via GBF1/Arf1, based on the known interaction of 3A with GBF1, an important regulator of secretory pathway transport and a guanine nucleotide exchange factor (GEF) of Arf1. However, our results demonstrate that inhibition of GBF1 or Arf1 either by pharmacological inhibition or depletion with small interfering RNA (siRNA) treatment did not affect the ability of 3A to recruit PI4KIIIß. Furthermore, we show that a 3A mutant that no longer binds GBF1 was capable of recruiting PI4KIIIß, even in ACBD3-depleted cells. Together, our findings indicate that unlike originally envisaged, coxsackievirus recruits PI4KIIIß to replication organelles independently of ACBD3 and GBF1/Arf1. IMPORTANCE: A hallmark of enteroviral infection is the generation of new membranous structures to support viral RNA replication. The functionality of these "replication organelles" depends on the concerted actions of both viral nonstructural proteins and co-opted host factors. It is thus essential to understand how these structures are formed and which cellular components are key players in this process. GBF1/Arf1 and ACBD3 have been proposed to contribute to the recruitment of the essential lipid-modifying enzyme PI4KIIIß to enterovirus replication organelles. Here we show that the enterovirus CVB3 recruits PI4KIIIß by a mechanism independent of both GBF1/Arf1 and ACBD3. This study shows that the strategy employed by coxsackievirus to recruit PI4KIIIß to replication organelles is far more complex than initially anticipated.

Increased long chain acyl-Coa synthetase activity and fatty acid import is linked to membrane synthesis for development of picornavirus replication organelles.

All positive strand (+RNA) viruses of eukaryotes replicate their genomes in association with membranes. The mechanisms of membrane remodeling in infected cells represent attractive targets for designing future therapeutics, but our understanding of this process is very limited. Elements of autophagy and/or the secretory pathway were proposed to be hijacked for building of picornavirus replication organelles. However, even closely related viruses differ significantly in their requirements for components of these pathways. We demonstrate here that infection with diverse picornaviruses rapidly activates import of long chain fatty acids. While in non-infected cells the imported fatty acids are channeled to lipid droplets, in infected cells the synthesis of neutral lipids is shut down and the fatty acids are utilized in highly up-regulated phosphatidylcholine synthesis. Thus the replication organelles are likely built from de novo synthesized membrane material, rather than from the remodeled pre-existing membranes. We show that activation of fatty acid import is linked to the up-regulation of cellular long chain acyl-CoA synthetase activity and identify the long chain acyl-CoA syntheatse3 (Acsl3) as a novel host factor required for polio replication. Poliovirus protein 2A is required to trigger the activation of import of fatty acids independent of its protease activity. Shift in fatty acid import preferences by infected cells results in synthesis of phosphatidylcholines different from those in uninfected cells, arguing that the viral replication organelles possess unique properties compared to the pre-existing membranes. Our data show how poliovirus can change the overall cellular membrane homeostasis by targeting one critical process. They explain earlier observations of increased phospholipid synthesis in infected cells and suggest a simple model of the structural development of the membranous scaffold of replication complexes of picorna-like viruses, that may be relevant for other (+)RNA viruses as well.

Temporal patterns of fucoxanthin in four species of European marine brown macroalgae.

Brown seaweeds are a rich source of carotenoids, particularly fucoxanthin, which has a wide range of potential health applications. Fucoxanthin fluctuates within and among seaweeds over time, frustrating efforts to utilise this resource. Thus, we require comprehensive analyses of long- and short-term concentrations across species in field conditions. Here, we used High Performance Liquid Chromatography to compare fucoxanthin content in four brown macroalgae, Ascophyllum nodosum, Fucus serratus, Fucus vesiculosus and Saccharina latissima, monthly for 1 year. F. serratus and F. vesiculosus had significantly higher fucoxanthin content (mg/g), which was highest in Spring (0.39 ± 0.04) and Autumn (0.45 ± 0.04) [mean (± SE)]. Two species, A. nodosum and F. serratus, were collected monthly at the same location for a further two non-consecutive years. For both A. nodosum and F. serratus, a significant interaction effect of seasons and years was identified, highlighting that there is variation in fucoxanthin content among and within species over time. We also show that fucoxanthin content differs significantly among months even within seasons. Therefore, it is not sufficient to assess fucoxanthin in single months to represent seasonality. We discuss how weather, nutrients and reproduction may have driven the seasonal variation, and reveal patterns of fucoxanthin concentration that can provide information concerning its availability for many important medical functions.

Metabolic profiling stratifies colorectal cancer and reveals adenosylhomocysteinase as a therapeutic target.

The genomic landscape of colorectal cancer (CRC) is shaped by inactivating mutations in tumour suppressors such as APC, and oncogenic mutations such as mutant KRAS. Here we used genetically engineered mouse models, and multimodal mass spectrometry-based metabolomics to study the impact of common genetic drivers of CRC on the metabolic landscape of the intestine. We show that untargeted metabolic profiling can be applied to stratify intestinal tissues according to underlying genetic alterations, and use mass spectrometry imaging to identify tumour, stromal and normal adjacent tissues. By identifying ions that drive variation between normal and transformed tissues, we found dysregulation of the methionine cycle to be a hallmark of APC-deficient CRC. Loss of Apc in the mouse intestine was found to be sufficient to drive expression of one of its enzymes, adenosylhomocysteinase (AHCY), which was also found to be transcriptionally upregulated in human CRC. Targeting of AHCY function impaired growth of APC-deficient organoids in vitro, and prevented the characteristic hyperproliferative/crypt progenitor phenotype driven by acute deletion of Apc in vivo, even in the context of mutant Kras. Finally, pharmacological inhibition of AHCY reduced intestinal tumour burden in ApcMin/+ mice indicating its potential as a metabolic drug target in CRC.

Effect of Phlorotannins from Brown Seaweeds on the In Vitro Digestibility of Pig Feed.

Phlorotannins have been reported to have positive effects on pig health, including improved gut health and digestibility. In this study, we investigate the effect of phenolics found in two brown seaweeds, Ascophyllum nodosum and Fucus serratus, on in vitro dry matter digestibility of seaweeds and commercial pig feed. Phlorotannin extracts and whole seaweeds were supplemented into pig feed to test their effect on digestibility. Solid-phase extraction was used to purify the phenolics to phlorotannins. The results showed a slight decrease in the digestibility of pig feed that was found to be significant when phlorotannin extracts were added from either seaweed. However, when whole A. nodosum was added to the pig feed, the effect on digestibility was less pronounced. Specifically, no significant difference in digestibility was observed at inclusion rates up to 5%, and thereafter results varied. A difference in digestibility was also observed in the same species at the same inclusion rate, collected from different seasons. This suggests that other compounds, e.g., polysaccharides, are having an effect on digestibility when whole seaweeds are supplemented to animal feed. This research has also highlighted the need to base supplementation on phenolic concentration as opposed to a standardised percentage inclusion of seaweeds to ensure that digestibility is not adversely affected.

Polyphenols from Brown Seaweeds as a Potential Antimicrobial Agent in Animal Feeds.

Seaweeds offer a natural source of antimicrobials that may help curb antibiotic resistance in livestock. The antibacterial activity of phlorotannin extracts isolated from two brown seaweeds Ascophyllum nodosum and Fucus serratus was tested. The mechanism of action of phlorotannin extracts against Escherichia coli O157, Salmonella agona, and Streptococcus suis was elucidated by observing cell membrane permeability and intracellular adenosine triphosphate (ATP). The two extracts were effective at killing three foodborne pathogens without negatively affecting the pig intestinal cells. A. nodosum minimum inhibitory concentration (MIC) range for the different pathogens was between 1.56 and 0.78 mg/mL, whereas F. serratus was 3.13 mg/mL for all pathogens tested. A. nodosum was found to be much more potent compared to F. serratus. The difference in potency in the seaweeds may be a result of the phlorotannins' structural linkages. The antimicrobial properties of the seaweed extracts tested may provide alternative and complementary treatments to antibiotics and zinc oxide in animal feeds. The seasonal screening was performed on both species to assess the availability of phenolics throughout the year using two quantification methods, the Folin-Ciocalteu (FC) assay and quantitative nuclear magnetic resonance (NMR). The variation between the methods highlights the challenges involved in the quantification of complex phenolic structures. However, both methods show that the phenolics are subject to seasonal variation, which may prove problematic to the animal feed industry.

The Effect of Ensiling on the Nutritional Composition and Fermentation Characteristics of Brown Seaweeds as a Ruminant Feed Ingredient.

Ensiling could be an effective method to preserve seaweeds for animal feed applications, however, there is limited scientific knowledge in this area. Seaweeds are a promising ruminant feed ingredient, in part due to the content of phenolic compounds, which are receiving considerable interest as alternative antimicrobial agents in feed. The aim of the study was to compare the effect of ensiling on the nutritional composition and fermentation characteristics of two brown seaweed species, Fucus vesiculosus (FV) and Saccharina latissimi (SL) with or without the use of a Lactobacillus plantarum (LAB) inoculant. The effect of ensiling on the stability of phlorotannin was also investigated using nuclear magnetic resonance (NMR). After harvesting, the seaweeds were wilted for 24 h and subsequently ensiled in laboratory-scaled silos for 90 days. SL silage showed a stronger fermentation pattern (pH < 4), dominated by lactic acid (50-60 g/kg Dry Matter (DM)), and a slightly higher acetic acid content compared to FV silages (p < 0.05). The fermentability of FV was limited (pH > 4.8) with low lactic acid production (<5 g/kg DM). The addition of the LAB inoculant showed no effect on the fermentation process but a modest effect on the chemical composition of both species was observed after the 90-day ensiling period. The results showed no losses in the nutrient content of FV after ensiling, however losses in the Crude Protein (CP, -32%), ash (-36%), Neutral Detergent Fibre (NDF, -77%) and Acid Detergent Fibre (ADF, -58%) content of SL were observed. The ensiling process had a limited effect on the in vitro true dry matter digestibility and phenolic content of either species. Therefore, ensilage may be a suitable preservation method for the use of brown seaweeds as a ruminant feed; however, species-specific differences were observed.

Acute metabolic actions of the major polyphenols in chamomile: an in vitro mechanistic study on their potential to attenuate postprandial hyperglycaemia.

Transient hyperglycaemia is a risk factor for type 2 diabetes and endothelial dysfunction, especially in subjects with impaired glucose tolerance. Nutritional interventions and strategies for controlling postprandial overshoot of blood sugars are considered key in preventing progress to the disease state. We have identified apigenin-7-O-glucoside, apigenin, and (Z) and (E)-2-hydroxy-4-methoxycinnamic acid glucosides as the active (poly)phenols in Chamomile (Matricaria recutita) able to modulate carbohydrate digestion and absorption in vitro as assessed by inhibition of α-amylase and maltase activities. The latter two compounds previously mistakenly identified as ferulic acid hexosides were purified and characterised and studied for their contribution to the overall bioactivity of chamomile. Molecular docking studies revealed that apigenin and cinnamic acids present totally different poses in the active site of human α-amylase. In differentiated Caco-2/TC7 cell monolayers, apigenin-7-O-glucoside and apigenin strongly inhibited D-[U-14C]-glucose and D-[U-14C]-sucrose transport, and less effectively D-[U-14C]-fructose transport. Inhibition of D-[U-14C]-glucose transport by apigenin was stronger under Na+-depleted conditions, suggesting interaction with the GLUT2 transporter. Competitive binding studies with molecular probes indicate apigenin interacts primarily at the exofacial-binding site of GLUT2. Taken together, the individual components of Chamomile are promising agents for regulating carbohydrate digestion and sugar absorption at the site of the gastrointestinal tract.

Mild extraction methods using aqueous glucose solution for the analysis of natural dyes in textile artefacts dyed with Dyer's madder (Rubia tinctorum L.).

Madder (Rubia tinctorum L.) has been widely used as a red dye throughout history. Acid-sensitive colorants present in madder, such as glycosides (lucidin primeveroside, ruberythric acid, galiosin) and sensitive aglycons (lucidin), are degraded in the textile back extraction process; in previous literature these sensitive molecules are either absent or present in only low concentrations due to the use of acid in typical textile back extraction processes. Anthraquinone aglycons alizarin and purpurin are usually identified in analysis following harsh back extraction methods, such those using solvent mixtures with concentrated hydrochloric acid at high temperatures. Use of softer extraction techniques potentially allows for dye components present in madder to be extracted without degradation, which can potentially provide more information about the original dye profile, which varies significantly between madder varieties, species and dyeing technique. Herein, a softer extraction method involving aqueous glucose solution was developed and compared to other back extraction techniques on wool dyed with root extract from different varieties of Rubia tinctorum. Efficiencies of the extraction methods were analysed by HPLC coupled with diode array detection. Acidic literature methods were evaluated and they generally caused hydrolysis and degradation of the dye components, with alizarin, lucidin, and purpurin being the main compounds extracted. In contrast, extraction in aqueous glucose solution provides a highly effective method for extraction of madder dyed wool and is shown to efficiently extract lucidin primeveroside and ruberythric acid without causing hydrolysis and also extract aglycons that are present due to hydrolysis during processing of the plant material. Glucose solution is a favourable extraction medium due to its ability to form extensive hydrogen bonding with glycosides present in madder, and displace them from the fibre. This new glucose method offers an efficient process that preserves these sensitive molecules and is a step-change in analysis of madder dyed textiles as it can provide further information about historical dye preparation and dyeing processes that current methods cannot. The method also efficiently extracts glycosides in artificially aged samples, making it applicable for museum textile artefacts.

Isolation and extraction of ruberythric acid from Rubia tinctorum L. and crystal structure elucidation.

Madder (Rubia tinctorum L.) has been exploited as a dye throughout history. The roots of the plant are very rich in the highly coloured glycosidic compounds ruberythric acid and lucidin primeveroside, alongside the corresponding aglycons which can be readily formed by deglycosylation, particularly during extraction. Supported by (1)H and (13)C NMR data, the conclusive X-ray crystal structure of the natural dye ruberythric acid is presented for the first time. The solid state structure revealed extensive intermolecular hydrogen bonding interactions between the sugar moieties in the unit cell, but only intramolecular hydrogen bonding through the hydroxyquinone groups. There is also some additional π-π stacking from the anthraquinone moiety.

The impact of hybrid coronary revascularization on hospital costs and reimbursements.

BACKGROUND: Hybrid coronary revascularization (HCR) combines a minimally invasive, left internal mammary artery-left anterior descending coronary artery (LAD) bypass with percutaneous intervention of non-LAD vessels for patients with multivessel coronary disease. The financial implications of HCR have not been compared with off-pump coronary artery bypass (OPCAB) through sternotomy. METHODS: The contribution margin is a fiduciary calculation (best hospital payment estimate--total variable costs) used by hospitals to determine fiscal viability of services. From 2010 to 2011, 26 Medicare patients underwent HCR at a single United States institution and were compared with 28 randomly selected, contemporaneous Medicare patients undergoing multivessel OPCAB. All HCR patients underwent a robotic-assisted, sternal-sparing, off-pump, left internal mammary artery-LAD anastomosis plus percutaneous intervention to non-LAD vessels. A linear regression model was used to compare fiscal and utilization outcomes of HCR to OPCAB adjusted for hospital length of stay and The Society of Thoracic Surgeons Predicted Risk of Mortality score. RESULTS: On regression analysis controlling for overall length of stay and Predicted Risk of Mortality score, the contribution margin (+$8,771, p<0.0001) was greater for HCR than for OPCAB. Despite higher total cost for HCR compared with OPCAB (+$7,026, p=0.001), the total variable cost (+$2,281, p=0.07) was not significantly different. Best payment estimates (+11,031, p<0.0001) and Medicare reimbursements (+$8,992, p=0.002) were higher for HCR than for OPCAB, and there was a reduction in blood transfusion (-1.5 units, p<0.0001), ventilator time (-10 hours, p=0.001), and postoperative length of stay (-1.2 days, p=0.002) for the HCR group. CONCLUSIONS: Compared with OPCAB, HCR results in a greater contribution margin for hospitals. This may result from higher reimbursement as well as improved resource utilization postoperatively, which may offset more expensive procedural costs associated with HCR.