{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,27]],"date-time":"2026-06-27T08:37:06Z","timestamp":1782549426687,"version":"3.54.5"},"reference-count":32,"publisher":"MDPI AG","issue":"21","license":[{"start":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T00:00:00Z","timestamp":1761609600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Objective: Textbook outcome (TO) is a multidimensional composite quality metric that integrates several desirable short-term outcomes into a single measure representing the \u201cideal\u201d perioperative course. Unlike traditional indicators that focus narrowly on mortality or single complications, TO captures the complexity of cardiothoracic care, encompassing oncologic adequacy, absence of major complications, avoidance of reintervention and readmission, and timely discharge. Methods: In this systematic review, we synthesize evidence on the definition, incidence, determinants, prognostic impact, and limitations of TO across cardiothoracic surgery (lung and esophageal resections, lung transplantation, cardiac surgery, and adult heart transplantation) in accordance with the PRISMA guidelines. Results: Reported achievement rates range from 24% to 66% in thoracic series, 30% after Norwood palliation, 37\u201345% after adult heart transplantation, and 52% in a contemporary national cohort of lung transplantation, with wide between-center variability. Achieving TO is consistently associated with improved overall and disease-free survival, lower costs, and enhanced benchmarking. Determinants of failure include inadequate lymph node dissection, prolonged operative time, advanced comorbidity, pretransplant organ support, and socioeconomic disadvantage. Heterogeneity of definitions, limited incorporation of patient-reported outcomes, and equity concerns remain barriers to its successful use. Outside transplantation, benchmarking of TO in adult cardiac procedures (e.g., CABG\/valve) remains limited and non-standardized. Conclusions: We argue for harmonized, procedure-specific core TO sets aligned with widely available registry fields, integration of equity-sensitive risk adjustment, and prospective validation. TO is poised to become a cornerstone metric of quality assessment and improvement in cardiothoracic surgery.<\/jats:p>","DOI":"10.3390\/jcm14217660","type":"journal-article","created":{"date-parts":[[2025,10,30]],"date-time":"2025-10-30T03:44:39Z","timestamp":1761795879000},"page":"7660","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Beyond Mortality: Textbook Outcome as a Novel Quality Metric in Cardiothoracic Surgical Care"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5417-6392","authenticated-orcid":false,"given":"Dimitrios E.","family":"Magouliotis","sequence":"first","affiliation":[{"name":"Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, PA 19096, USA"},{"name":"Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vasiliki","family":"Androutsopoulou","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Prokopis-Andreas","family":"Zotos","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5321-5828","authenticated-orcid":false,"given":"Ugo","family":"Cioffi","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Milan, 20157 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3595-7307","authenticated-orcid":false,"given":"Fabrizio","family":"Minervini","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, Luzern Kanton Hospital, 6000 Luzern, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Noah","family":"Sicouri","sequence":"additional","affiliation":[{"name":"Department of Neuroscience Pittsburgh Campus, University of Pittsburgh, Pittsburgh, PA 15260, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dimitrios","family":"Zacharoulis","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9439-3946","authenticated-orcid":false,"given":"Andrew","family":"Xanthopoulos","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University of Thessaly, Biopolis, 41110 Larissa, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4459-7721","authenticated-orcid":false,"given":"Marco","family":"Scarci","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare, National Health Service (NHS) Trust, London W2 1NY, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Zotos, P.-A., Androutsopoulou, V., Scarci, M., Minervini, F., Cioffi, U., Xanthopoulos, A., Athanasiou, T., and Magouliotis, D.E. 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