Background: China has witnessed a rapid increase in the volume of coronary artery bypass grafting (CABG) but substantial gaps in the performance for CABG across the nation. The present study aimed to investigate the change in CABG performance after years of quality improvement measures in a national registry in China. Methods: The study included 66 971 patients who underwent isolated CABG in a cohort of 74 tertiary hospitals in China between January 2013 and December 2018. Data were collected from the Chinese Cardiac Surgery Registry. Outcomes were in-hospital mortality and postoperative length of stay. Five process measures for surgical technique and secondary prevention were also analyzed. We described the changes in the overall performance and interhospital heterogeneity across the years. Results: The in-hospital mortality declined from 0.9% in 2013 to 0.6 in 2018, with a risk-adjusted odds ratio of 0.66 (95% CI, 0.46–0.93; P <0.001). The standard mean difference for risk-standardized mortality rate between hospitals in the lowest and highest quartile narrowed from 1.63 in 2013 to 1.35 in 2018. The median (interquartile range) hospital-level rate of using arterial graft increased from 93.9% (86.0%–97.8%) to 94.6% (83.3%–99.2%), but the difference was not statistically significant. Meanwhile, the rate of free from blood transfusion increased from 17.0% (2.6%–32.0%) to 34.1% (8.8%–52.9%). The hospital-level rate of prescribing β-blockers at discharge significantly increased from 82.8% (66.7%–90.3%) to 91.1% (82.1%–97.1%), statin from 75.8% (55.7%–88.9%) to 88.9% (75.0%–96.0%), and aspirin from 90.3% (83.9%–95.2%) to 95.3% (88.9%–98.1%). Conclusions: In the Chinese Cardiac Surgery Registry, there were notable improvements in the treatment process related to CABG and decline of in-hospital mortality with reduced interhospital heterogeneity.
BackgroundWith increasing surgical workload, it is common for cardiac surgeons to perform coronary artery bypass grafting (CABG) after other procedures in a workday. To investigate whether prior procedures performed by the surgeon impact the outcomes, we compared the outcomes between CABGs performed first versus those performed after prior procedures, separately for on-pump and off-pump CABGs as they differed in technical complexity.MethodsWe conducted a retrospective cohort study of patients undergoing isolated CABG in China from January 2013 to December 2018. Patients were categorised as undergoing on-pump and off-pump CABGs. Outcomes of the procedures performed first in primary surgeons’ daily schedule (first procedure) were compared with subsequent ones (non-first procedure). The primary outcome was an adverse events composite (AEC) defined as the number of adverse events, including in-hospital mortality, myocardial infarction, stroke, acute kidney injury and reoperation. Secondary outcomes were the individual components of the primary outcome, presented as binary variables. Mixed-effects models were used, adjusting for patient and surgeon-level characteristics and year of surgery.ResultsAmong 21 866 patients, 10 109 (16.1% as non-first) underwent on-pump and 11 757 (29.6% as non-first) off-pump CABG. In the on-pump cohort, there was no significant association between procedure order and the outcomes (all p>0.05). In the off-pump cohort, non-first procedures were associated with an increased number of AEC (adjusted rate ratio 1.29, 95% CI 1.13 to 1.47, p<0.001), myocardial infarction (adjusted OR (ORadj) 1.43, 95% CI 1.13 to 1.81, p=0.003) and stroke (ORadj 1.73, 95% CI 1.18 to 2.53, p=0.005) compared with first procedures. These increases were only found to be statistically significant when the procedure was performed by surgeons with <20 years’ practice or surgeons with a preindex volume <700 cases.ConclusionsFor a technically challenging surgical procedure like off-pump CABG, prior workload adversely affected patient outcomes.
Aims Current guidelines recommend a heart team in the decision making for patients with complex coronary artery disease (CAD). However, the decision-making stability of these teams has not been evaluated and the optimum protocol is unknown. We assessed inter-team agreement for revascularization decision-making and influencing factors to inform the development of a heart team protocol. Methods and results This sequential, explanatory mixed methods study included (1) a cross-sectional quantitative study to assess inter-team agreement on treatment strategy for retrospectively enrolled complex CAD patients and (2) a qualitative study that used semi-structured interviews with heart team members to identify factors influencing decision-making discrepancy. We randomly selected 101 complex CAD patients. Sixteen specialists were randomly assigned to 4 heart teams to make decisions for these patients. The primary outcome kappa of inter-team decision-making agreement was moderate (kappa 0.58). Factors influencing decision-making were generated through inductive thematic analysis and were summarized by 3 themes (specialist quality, team composition, meeting process) and 10 subthemes. Recommendations of heart team implementation were generated based on qualitative and quantitative data at 5 levels: specialist selection, specialist training, team composition, team training, and meeting process. A detailed protocol on the integration of guidelines, previous experience and recommendations was generated to establish and deploy a qualified heart team. Conclusions Agreement between heart teams for revascularization decision-making in complex CAD patients was moderate. Potential factors associated with decision discrepancies were summarized and recommendations were generated. A detailed heart team protocol was designed and should be validated in future.
Background: Previous studies have always focused on the impact of various meteorological factors on bacillary dysentery (BD). However, only few studies have investigated the effects of climate and air pollutants on BD incidence simultaneously. This study aimed to investigate the effects of temperature and air pollutants on BD in Lanzhou. Methods: Daily data of BD cases and environmental factors from 2014 to 2017 were collected. A generalized additive model (GAM) was conducted to explore the relationship between environmental factors and BD. Then a distributed lag non-linear model (DLNM) was developed to assess the lag and cumulative effect. Furthermore, this study explored the variability across gender and age groups. Results: A total of 7102 cases of BD were notified over the study period. High temperature can significantly increase the risk of BD during the whole lag period, temperature has different exposure effects on different genders and age groups. With 9℃ as the reference value, each 1℃ rise in temperature result in a 4.8% (RR=1.048, 95%CI: 0.996, 1.103) increase in the number of cases BD at lag 0 day. With 50μg/m3 as the reference value, each 5μg/m3 rise in PM2.5 caused a 11.3% (RR=1.113, 95%CI: 1.066, 1.162) increase in the number of BD cases at lag 0. Low concentration of PM10 in the lag of 10-14 days can significantly increase the risk of BD, while high concentration PM10 in the lag of 6-14 days can significantly increase the risk of BD. Conclusions:Temperature, PM2.5 and PM10 are closely related to the incidence of bacillary dysentery. Our findings suggest adaptation plans that target vulnerable populations in susceptible communities should be developed to reduce health risks.
While evidence-based clinical guidelines recommend chordal-sparing mitral valve replacement, rather than mitral valve repair, in patients with severe ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting, there are no similar recommendations for patients undergoing left ventricular reconstruction (LVR). This study aimed to compare the clinical outcomes of mitral valve repair and replacement in patients undergoing LVR complicated by more than moderate IMR.Methods: In this single-center cohort study, a total of 74 consecutive patients who underwent LVR and mitral valve surgery (repair group: 59; replacement group: 15), during the period from March 2000 to March 2021 at Fuwai Hospital (Beijing, China) were retrospectively enrolled. Survival rates were calculated with the Kaplan-Meier method and compared using the log-rank test. Univariate Cox analysis was performed to evaluate possible confounders, followed by adjustment in multivariate analysis. The primary outcome was survival free of major adverse cardiovascular and cerebrovascular events (MACCE).Results: Median follow-up time was 59.4 months. Compared with mitral valve replacement, mitral valve repair was associated with increased risk of perioperative use of ventricular assist device (22.0% vs. 0, P = 0.045). There was no difference in overall survival (hazard ratio (HR), 1.10; 95% confidence interval (CI), 0.31-3.93; P logrank = 0.888) and MACCE-free survival (HR, 1.54; 95% CI, 0.65-3.65; P logrank = 0.319), even after multivariate Cox regression (HR, 1.35; 95% CI, 0.37-4.88; P Cox = 0.646; and HR, 1.41; 95% CI, 0.57-3.44; P Cox = 0.455, respectively). Furthermore, while no differences were observed in ejection fraction and left ventricular end-diastolic diameter on follow-up echocardiography, mitral valve repair was associated with an increased risk of recurrent mitral regurgitation (P = 0.041).Conclusions: In patients undergoing LVR complicated by more than moderate IMR, both concomitant mitral valve repair and replacement can be successfully achieved with comparable overall and MACCE-free survival outcomes; however, mitral valve replacement may be superior to mitral valve repair for persistent correction of mitral dysfunction.
Background : Previous studies have always focused on the impact of various meteorological factors on bacillary dysentery (BD). However, only few studies have investigated the effects of climate and air pollutants on BD incidence simultaneously. This study aimed to investigate the effects of temperature and air pollutants on BD in Lanzhou. Methods: Daily data of BD cases and environmental factors from 2014 to 2017 were collected. A generalized additive model (GAM) was conducted to explore the relationship between environmental factors and BD. Then a distributed lag non-linear model (DLNM) was developed to assess the lag and cumulative effect. Furthermore, this study explored the variability across gender and age groups. Results: A total of 7102 cases of BD were notified over the study period. High temperature can significantly increase the risk of BD during the whole lag period, temperature has different exposure effects on different genders and age groups. With 9℃ as the reference value, each 1℃ rise in temperature result in a 4.8% (RR=1.048, 95%CI: 0.996, 1.103) increase in the number of cases BD at lag 0 day. With 50μg/m 3 as the reference value, each 5μg/m 3 rise in PM2.5 caused a 11.3% (RR=1.113, 95%CI: 1.066, 1.162) increase in the number of BD cases at lag 0. Low concentration of PM10 in the lag of 10-14 days can significantly increase the risk of BD, while high concentration PM10 in the lag of 6-14 days can significantly increase the risk of BD. Conclusions: Temperature, PM2.5 and PM10 are closely related to the incidence of bacillary dysentery. Our findings suggest adaptation plans that target vulnerable populations in susceptible communities should be developed to reduce health risks.
IntroductionA multidisciplinary heart team approach has been recommended by revascularisation guidelines, but how to organise and implement the heart team in a standardised way has not been validated. Inter-team and intra-team decision instability existed in the guideline-based heart team protocol, and our standardised heart team protocol based on a mixed method study may improve decision stability. The objective of this study is to evaluate the effect of the standardised heart team protocol versus the guideline-based protocol on decision-making stability in stable complex coronary artery disease (CAD).Methods and analysisEighty-four eligible interventional cardiologists, cardiac surgeons or non-interventional cardiologists from 26 hospitals in China have been enrolled. They will be randomised to a standardised heart team protocol group or a guideline-based protocol group to make revascularisation decisions for 480 historic cases (from a prospective registry) with stable complex CAD. In the standardised group, we will establish 12 heart teams based on an evidence-based protocol, including specialist selection, specialist training, team composition, team training and a standardised meeting process. In the guideline-based group, we will organise 12 heart teams according to the guideline principles, including team composition and standardised meeting process. The primary outcome is the overall percent agreement in revascularisation decisions between heart teams within a group. To demonstrate the clinical implication of decision-making stability, we will further explore the association between decision stability and 1-year clinical outcomes.Ethics and disseminationThe study was approved by the Institutional Review Board (IRB) of Fuwai Hospital (No. 2019-1303). All participants have provided informed consent and all patients included as historic cases provided written informed consent at the time of entry to the prospective registry. The results of this trial will be disseminated through manuscript publication and national/international conferences, and reported in the trial registry entry.Trial registration numberNCT05039567.
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