Association of carotid duplex ultrasonography screening with stroke and mortality among patients undergoing coronary artery bypass grafting.

OBJECTIVE: Selection criteria for carotid duplex ultrasonography screening (DUS) before coronary artery bypass grafting (CABG) is primarily based on limited observational analysis, and the risks associated with carotid artery stenosis (CAS) detected by this approach to preoperative DUS are uncertain. This study aimed to determine the association of carotid DUS with stroke and mortality among patients undergoing CABG. METHODS: Adult patients with coronary artery disease who underwent isolated CABG or CABG with concomitant valvular or congenital procedure were identified. CHA2DS2-VASc score was assessed before CABG, and patients were recorded as high risk if they had a score of 3 or higher. The primary outcomes were stroke and all-cause mortality. Secondary outcomes included ischemic stroke, non-ischemic stroke, transient ischemic attack, and cardiovascular mortality. RESULTS: Among 8958 patients who underwent CABG, 70.9% (n = 6347) received carotid DUS preoperatively (low-risk, 57.3%; high-risk, 42.7%). In the low-risk cohort, there was no significant difference in the risk of stroke (20.7 per 1000 patient-years for CAS vs 13.1 per 1000 patient-years for no CAS; adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 0.78-1.68) or mortality (20.5 per 1000 patient-years for CAS vs 16.8 per 1000 patient-years for no CAS; aHR, 1.33; 95% CI, 0.97-1.83) at 15 years. In the high-risk cohort, CAS was associated with significantly higher risks of stroke at 30 days (433.2 vs 279.5 per 1000 patient-years; aHR, 1.92; 95% CI, 1.00-3.70) and mortality at 15 years (38.4 vs 32.7 per 1000 patient-years; aHR, 1.25; 95% CI, 1.01-1.57) compared with no CAS. CONCLUSIONS: CAS did not impact the incidence of stroke or mortality in the low-risk cohort who underwent CABG. However, in the high-risk cohort, CAS was associated with a significant increase in the risks of 30-day stroke and 15-year mortality, indicating selective carotid DUS is necessarily recommended for these patients.

Comparing simultaneous hybrid ablation with stand-alone thoracoscopic surgical ablation for the treatment of non-paroxysmal atrial fibrillation: a prospective randomized controlled trial.

AIMS: Advanced atrial fibrillation (AF) is currently a dilemma for electrophysiologists when choosing a minimally invasive treatment strategy. Previous studies have demonstrated the outcome of either catheter ablation or thoracoscopic surgical ablation (SA) is unsatisfactory in these patients. Whether hybrid ablation (HA) could improve outcomes in these patients is unknown. The purpose of this study was to evaluate the clinical efficacy of HA for the treatment of advanced AF. METHODS AND RESULTS: A randomized controlled trial was designed to enrol patients with persistent AF (PerAF) and enlarged left atrium or long-standing persistent AF (LSPAF) who were randomized to HA or thoracoscopic SA at a 1:1 ratio. The primary endpoint was freedom from any recurrence of AF off antiarrhythmic drugs (AADs) 12 months after operation. The primary endpoint was monitored by 7-day electrocardiogram monitoring devices. One hundred patients were enrolled. The mean age was 58.5 ± 7.6 years, and the mean left atrial diameter (LAD) was 50.1 ± 6.1 mm. At 12 months, freedom from AF off AADs was recorded in 71.4% (35/49) of patients in HA group and 45.8% (22/48) in SA group [odds ratio 2.955, 95% confidence interval (1.275-6.848), P = 0.014]. HA significantly reduced patients' AF burden (30.2% in SA group and 14.8% in HA group, P = 0.048) and the LAD (mean differences: -5.53 ± 4.97 mm in HA group and -3.27 ± 5.20 mm in SA group, P = 0.037) at 12 months after operation. CONCLUSION: In patients with PerAF and enlarged left atrium or LSPAF, HA achieved better freedom from AF after 1 year of follow-up compared with thoracoscopic SA.

Long-Term Outcomes of Bioprosthetic and Mechanical Valve Replacement for Patients Aged between 50 and 70 Years.

Background: The choice between bioprosthetic and mechanical valves for aortic valve replacement (AVR) and mitral valve replacement (MVR) among patients aged 50-70 years is controversial. We compared the long-term outcomes of patients using bioprosthetic or mechanical valves to provide clinical evidence for valve selection. Methods: From 2002 to 2007, patients aged 50-70 years who underwent isolated AVR or MVR at the Fuwai Hospital were enrolled. After inverse probability-weighted (IPW) propensity balancing, we evaluated long-term mortality, stroke, and bleeding events between patients receiving mechanical and biological prostheses for MVR or AVR. Results: A total of 1639 patients were included in the study, including 1181 patients undergoing MVR (median follow-up: 11.6 years) and 458 patients undergoing AVR (median follow-up: 11.4 years). After IPW adjustment, there was no significant difference in long-term mortality and stroke rate between patients using bioprosthetic and mechanical valves for MVR [mortality: log-rank p = 0.802; stroke: log-rank p = 0.983] and AVR [mortality: log-rank p = 0.815; stroke: log-rank p = 0.537]. Landmark analysis at 12.5 years yielded significantly lower mortality in the patients receiving mechanical valves compared with bioprosthetic valves in the MVR cohort (p = 0.028). Patients receiving mechanical aortic valves displayed an increased risk of bleeding compared with those who received bioprosthetic aortic valves [Hazard Ratio (95% Confidence interval): 2.51 (1.06-5.93) p = 0.036]. Conclusions: For patients aged 50-70, there was no significant difference in overall long-term mortality between mechanical and bioprosthetic valve recipients. Patients receiving mechanical valves for MVR displayed lower mortality after 12.5 years follow-up. For AVR, bioprosthetic valves were associated with a lower risk of bleeding.

Effect of a smartphone-based intervention on secondary prevention medication prescriptions after coronary artery bypass graft surgery: The MISSION-1 randomized controlled trial.

BACKGROUND: Studies found that patients who underwent coronary artery bypass grafting (CABG) often fail to receive optimal evidence-based secondary prevention medications. We evaluated the effectiveness of a smartphone-based quality improvement effort on improving the prescription of medical therapies. METHODS: In this cluster-randomized controlled trial, 60 hospitals were randomized to a control arm (n = 30) or to an intervention arm using smartphone-based multifaceted quality improvement interventions (n = 30). The primary outcome was the prescription of statin. The secondary outcomes were prescription of beta-blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker (ACE inhibitor or ARB), and optimal medical therapy for eligible patients. RESULTS: Between June 1, 2015 and September 15, 2016, a total of 10,006 CABG patients were enrolled (5,653 in 26 intervention and 4,353 in 29 control hospitals, 5 hospitals withdrew). Statin prescribing rate was 87.8% in the intervention arm and 84.4% in the control arm. We saw no evidence of an effect of intervention on statin prescribing in the intention-to-treat analysis (odds ratio [OR], 1.31; 95% confidence interval (CI), 0.68-2.54; P = .43) or in key patient subsets. The prescription rates of ACE inhibitor or ARB and optimal medical therapy were comparable between study groups, while beta-blocker was more often prescribed in the intervention arm. Post hoc analysis demonstrated a greater increase in statin prescribing rate over time in the intervention arm. CONCLUSIONS: A smartphone-based quality improvement intervention compared with usual care did not increase statin prescribing for patients who received CABG. New studies focusing on the best practice of this technique may be warranted.

Feasibility of using deep learning to detect coronary artery disease based on facial photo.

AIMS: Facial features were associated with increased risk of coronary artery disease (CAD). We developed and validated a deep learning algorithm for detecting CAD based on facial photos. METHODS AND RESULTS: We conducted a multicentre cross-sectional study of patients undergoing coronary angiography or computed tomography angiography at nine Chinese sites to train and validate a deep convolutional neural network for the detection of CAD (at least one ≥50% stenosis) from patient facial photos. Between July 2017 and March 2019, 5796 patients from eight sites were consecutively enrolled and randomly divided into training (90%, n = 5216) and validation (10%, n = 580) groups for algorithm development. Between April 2019 and July 2019, 1013 patients from nine sites were enrolled in test group for algorithm test. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were calculated using radiologist diagnosis as the reference standard. Using an operating cut point with high sensitivity, the CAD detection algorithm had sensitivity of 0.80 and specificity of 0.54 in the test group; the AUC was 0.730 (95% confidence interval, 0.699-0.761). The AUC for the algorithm was higher than that for the Diamond-Forrester model (0.730 vs. 0.623, P < 0.001) and the CAD consortium clinical score (0.730 vs. 0.652, P < 0.001). CONCLUSION: Our results suggested that a deep learning algorithm based on facial photos can assist in CAD detection in this Chinese cohort. This technique may hold promise for pre-test CAD probability assessment in outpatient clinics or CAD screening in community. Further studies to develop a clinical available tool are warranted.

Elevated postoperative serum uric acid is associated with major adverse events following coronary artery bypass grafting.

BACKGROUND: Few data are available on the association between postoperative serum uric acid (SUA) level and poor survival in patients undergoing coronary artery bypass grafting (CABG). We evaluated the relationship between postoperative SUA and major adverse cardiac and cerebrovascular events (MACCE) among patients undergoing CABG. METHODS: This study used data from 1614 consecutive patients undergoing CAGB at Fuwai Hospital (Beijing, China) from 2011 to 2015. Patients were stratified into statistical quartiles of postoperative SUA (between 6 and 18 hours after cardiac surgery): less than 203.7, 203.7 to 254.1, 254.1 to 316.6, and ≥316.6 µmol/L. The association of postoperative SUA with MACCE (ie, death, myocardial infarction [MI], stroke, or repeat revascularization) and the composite endpoint of mortality/MI were assessed. RESULTS: Patients had a mean age of 60.3 ± 8.4 years, and 79.3% were male. During mean follow-up of 2.5 ± 0.7 years, MACCE occurred in 201 (12.5%) patients. In separate multivariable regression models, postoperative SUA level was positively associated with in-hospital MACCE (highest vs lowest SUA quartile: odds ratio [OR]: 2.40; 95% confidence interval [CI]: 1.29, 4.48; P = .006) and in-hospital composite endpoint of mortality/MI (OR: 2.88; 95% CI: 1.45, 5.72; P = .003), respectively. And elevated postoperative SUA level was independently associated with MACCE (Hazard ratio [HR]: 1.70; 95% CI: 1.12, 2.57; P = .01) and the composite endpoint of mortality/MI (HR: 2.42; 95% CI: 1.32, 4.43; P = .004) respectively within 3 years after CABG. CONCLUSIONS: Elevated postoperative SUA level is associated with poor clinical outcomes after CABG. Patients with high postoperative SUA levels after CABG might require to be closely monitored.

Three-Dimensional Texture Feature Analysis of Pulmonary Nodules in CT Images: Lung Cancer Predictive Models Based on Support Vector Machine Classifier.

To extract texture features of pulmonary nodules from three-dimensional views and to assess if predictive models of lung CT images from a three-dimensional texture feature could improve assessments conducted by radiologists. Clinical and CT imaging data for three dimensions (axial, coronal, and sagittal) in pulmonary nodules in 285 patients were collected from multiple centers and the Cancer Imaging Archive after ethics committee approval. Three-dimensional texture feature values (contourlets), and clinical and computed tomography (CT) imaging data were built into support vector machine (SVM) models to predict lung cancer, using four evaluation methods (disjunctive, conjunctive, voting, and synthetic); sensitivity, specificity, the Youden index, discriminant power (DP), and F value were calculated to assess model effectiveness. Additionally, diagnostic accuracy (three-dimensional model, axial model, and radiologist assessment) was assessed using the area under the curves for receiver operating characteristic (ROC) curves. Cross-sectional data from 285 patients (median age, 62 [range, 45-83] years; 115 males [40.4%]) were evaluated. Integrating three-dimensional assessments, the voting method had relatively high effectiveness based on both sensitivity (0.98) and specificity (0.79), which could improve radiologist diagnosis (maximum sensitivity, 0.75; maximum specificity, 0.51) for 23% and 28% respectively. Furthermore, the three-dimensional texture feature model of the voting method has the best diagnosis of precision rate (95.4%). Of all three-dimensional texture feature methods, the result of the voting method was the best, maintaining both high sensitivity and specificity scores. Additionally, the three-dimensional texture feature models were superior to two-dimensional models and radiologist-based assessments.

Association Between Infection and Thrombosis After Coronary Artery Bypass Grafting: A Cohort Study.

OBJECTIVE: Surgery-related infection remains a major complication for patients undergoing cardiac surgery, and its association with thrombosis is unclear. This study aimed to examine the association of postoperative infection with thrombosis and major adverse cardiovascular and cerebral events (MACCEs) in patients undergoing coronary artery bypass grafting (CABG). DESIGN: Retrospective cohort study. Multiple variable regression analyses were performed. SETTING: The study was performed at a single institution. PARTICIPANTS: All patients underwent CABG. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Perioperative and postoperative follow-up data relating to all CABG patients from January 2001 to August 2006 were queried from institutional electronic medical records of Fuwai Hospital, Beijing, China. Patients were divided into 2 groups according to whether they experienced infection. The study population comprised 75 patients who experienced infection and 2,926 control patients. Primary outcomes were a composite outcome of perioperative thrombosis and long-term thrombosis-related complications. Secondary outcomes were 5-year MACCEs postoperatively, including death, myocardial infarction, target vessel revascularization, and stroke. Risk factors for infection included older age, higher level of creatinine, chronic lung disease, cardiopulmonary bypass time, aortic cross-clamp time, history of renal failure, cardiopulmonary bypass, left ventricular assist device or intra-aortic balloon pump, length of stay in the intensive care unit, and duration of tracheal intubation. Infection increased the odds of perioperative thrombosis by 5.132-fold (95% confidence interval [CI] 2.040-12.911; p < 0.0001) compared with control. However, infection was not associated with a significant increase in MACCEs (hazard ratio 1.855, 95% CI 0.929-3.704; p = 0.080). Age was associated with a significant increase in MACCEs (hazard ratio 1.040, 95% CI 1.026-1.054; p < 0.0001). CONCLUSION: There is an association between postoperative infection and perioperative thrombosis after CABG. Several specific management modalities were associated with controlling infection risk, which offers targets for future quality improvement.

Contourlet-based hippocampal magnetic resonance imaging texture features for multivariant classification and prediction of Alzheimer's disease.

The study is aimed to assess whether the addition of contourlet-based hippocampal magnetic resonance imaging (MRI) texture features to multivariant models improves the classification of Alzheimer's disease (AD) and the prediction of mild cognitive impairment (MCI) conversion, and to evaluate whether Gaussian process (GP) and partial least squares (PLS) are feasible in developing multivariant models in this context. Clinical and MRI data of 58 patients with probable AD, 147 with MCI, and 94 normal controls (NCs) were collected. Baseline contourlet-based hippocampal MRI texture features, medical histories, symptoms, neuropsychological tests, volume-based morphometric (VBM) parameters based on MRI, and regional CMgl measurement based on fluorine-18 fluorodeoxyglucose-positron emission tomography were included to develop GP and PLS models to classify different groups of subjects. GPR1 model, which incorporated MRI texture features and was based on GPG, performed better in classifying different groups of subjects than GPR2 model, which used the same algorithm and had the same data as GPR1 except that MRI texture features were excluded. PLS model, which included the same variables as GPR1 but was based on the PLS algorithm, performed best among the three models. GPR1 accurately predicted 82.2% (51/62) of MCI convertors confirmed during the 2-year follow-up period, while this figure was 53 (85.5%) for PLS model. GPR1 and PLS models accurately predicted 58 (79.5%) vs. 61 (83.6%) of 73 patients with stable MCI, respectively. For seven patients with MCI who converted to NCs, PLS model accurately predicted all cases (100%), while GPR1 predicted six (85.7%) cases. The addition of contourlet-based MRI texture features to multivariant models can effectively improve the classification of AD and the prediction of MCI conversion to AD. Both GPR and LPS models performed well in the classification and predictive process, with the latter having significantly higher classification and predictive accuracies. Advances in knowledge: We combined contourlet-based hippocampal MRI texture features, medical histories, symptoms, neuropsychological tests, volume-based morphometric (VBM) parameters, and regional CMgl measurement to develop models using GP and PLS algorithms to classify AD patients.

Efficacy of Long-Term ß-Blocker Therapy for Secondary Prevention of Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery.

BACKGROUND: Conflicting results from recent observational studies have raised questions concerning the benefit of ß-blockers for patients undergoing coronary artery bypass grafting (CABG). Furthermore, the efficacy of long-term ß-blocker therapy in CABG patients after hospital discharge is uncertain. METHODS AND RESULTS: The study included 5926 consecutive patients who underwent CABG and were discharged alive. The prevalence and consistency of ß-blocker use were determined in patients with and without a history of myocardial infarction (MI). ß-Blockers were always used in 1280 patients (50.9%) with and 1642 patients (48.1%) without previous MI after CABG. Compared with always users (n=2922, 49.3%), the risk of all-cause death was significantly higher among inconsistent ß-blocker users (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.50-2.57), and never using ß-blockers was associated with increased risk of both all-cause death (HR, 1.42; 95% CI, 1.01-2.00) and the composite of adverse cardiovascular events (HR, 1.29; 95% CI, 1.10-1.50). In the cohort without MI, the HR for all-cause death was 1.70 (95% CI, 1.17-2.48) in inconsistent users and 1.23 (95% CI, 0.76-1.99) in never users. In the MI cohort, mortality was higher for inconsistent users (HR, 2.14; 95% CI, 1.43-3.20) and for never users (HR, 1.59; 95% CI, 1.07-2.63). Consistent results were obtained in equivalent sensitivity analyses. CONCLUSIONS: In patients with or without previous MI undergoing CABG, the consistent use of ß-blockers was associated with a lower risk of long-term mortality and adverse cardiovascular events. Strategies should be developed to understand and improve discharge prescription of ß-blockers and long-term patient adherence.

Analysis of Dyakonov surface waves existing at the interface of an isotropic medium and a conductor-backed uniaxial slab.

In this paper, Dyakonov surface waves (Dyakonov SWs) existing at the interface between a semi-infinite isotropic medium and a conductor-backed uniaxial slab are analyzed with the help of an exponential-matrix method. The boundary conditions at the interface are formulated using eigenvalues and eigenvectors of two partnering media. Based on this, the existence region of Dyakonov SWs is formulated and proven to be highly dependent on the thickness of the uniaxial slab. Some relevant characteristics of the propagating Dyakonov SWs, such as the distribution of the propagation constant, and the electric- and magnetic-field distributions, are introduced and investigated. In addition, this method can be applied to analyze other finite thickness structures.

Administrative Model for Profiling Hospital Performance on Coronary Artery Bypass Graft Surgery: Based on the Chinese Hospital Quality Monitoring System.

BACKGROUND: We aimed to develop an administrative model to profile the performance on the outcomes of coronary artery bypass grafting across hospitals in China. METHODS AND RESULTS: This retrospective study was based on the Chinese Hospital Quality Monitoring System (HQMS) from 2016 to 2020. The coronary artery bypass grafting cases were identified by procedure code, and those of 2016 to 2017 were randomly divided into modeling and validation cohorts, while those in other years were used to ensure the model stability across years. The outcome was discharge status as "death or withdrawal," and that withdrawal referred to discharge without medical advice when patients were in the terminal stage but reluctant to die in the hospital. Candidate covariates were mainly identified by diagnoses or procedures codes. Patient-level logistic models and hospital-level hierarchical models were established. A total of 203 010 coronary artery bypass grafts in 699 hospitals were included, with 60 704 and 20 233 cases in the modeling and validation cohorts and 40 423, 42 698, and 38 952 in the years 2018, 2019, and 2020, respectively. The death or withdrawal rate was 3.4%. The areas under the curve were 0.746 and 0.729 in the patient-level models of modeling and validation cohorts, respectively, with good calibration and stability across years. Hospital-specific risk-standardized death or withdrawal rates were 2.61% (interquartile range, 1.87%-3.99%) and 2.63% (interquartile range, 1.97%-3.44%) in the modeling and validation cohorts, which were highly correlated (correlation coefficient, 0.96; P<0.001). Between-hospital variations were distinguished among hospitals of different volumes and across years. CONCLUSIONS: The administrative model based on Hospital Quality Monitoring System could profile hospital performance on coronary artery bypass grafting in China.

Epicardial left atrial appendage clipping versus direct oral anticoagulant to reduce stroke risk in non-paroxysmal atrial fibrillation (LAA-CLIP): rationale, design and study protocol for a multicentre randomised controlled trial.

INTRODUCTION: The prevalence of atrial fibrillation (AF) is increasing globally, and stroke prevention is the key to reduce the morbidity and mortality related to AF. Currently, direct oral anticoagulants (DOACs) are the primary options for stroke prevention, while it increases risk of bleeding. Left atrial appendage (LAA) is suspected as a vital source of cerebral emboli and may lead to ischaemic stroke, and thoracoscopic LAA clipping procedure provides an alternative option for stroke prevention in high-risk patients. However, high-quality evidence comparing LAA clipping to DOACs in terms of stroke prevention is lacking. This trial is designed to assess whether the efficacy of thoracoscopic LAA clipping is superior to DOACs for stroke prevention in AF patients at high risk of thrombosis (CHA2DS2-VASc≥2 in men and ≥3 in women)[CHA2DS2-VASc stands for "congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 and sex category (female)"]. METHODS AND ANALYSIS: This is a prospective, multicentre, open-labelled, randomised controlled study. This trial will randomly assign 290 patients with non-paroxysmal AF to thoracoscopic LAA clipping group or DOAC therapy group in a 1:1 randomisation. The primary endpoint is defined as a composite endpoint event consisting of stroke, systemic embolism, all-cause mortality, major bleeding events and clinically relevant non-major bleeding events at 24 months after randomisation. The secondary endpoints consist of the components of the primary composite endpoint, surgery-related adverse events and minor bleeding events. ETHICS AND DISSEMINATION: The central ethics committee at Fuwai Hospital approved the trial entitled "Epicardial left atrial appendage clipping versus direct oral anticoagulant to reduce stroke risk in non-paroxysmal atrial fibrillation (LAA-CLIP trial)". The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: NCT06021808.

Hybrid versus catheter ablation for Hypertrophic CardioMyopathy with Atrial Fibrillation (HCM-AF): study protocol for a randomised controlled trial.

INTRODUCTION: Atrial fibrillation (AF) is an independent predictor of adverse outcomes in patients with hypertrophic cardiomyopathy (HCM). Although catheter ablation is highly recommended for general AF populations, it is less effective in maintaining sinus rhythm in patients with HCM associated with AF. Hybrid ablation, combining a cosmetic approach with a lower rate of AF relapse, lacks comparative studies to verify its efficacy against CA in HCM. This study aims to assess the rhythm control effectiveness of hybrid versus CA in non-obstructive HCM (non-oHCM) patients with AF. METHODS/ANALYSIS: This prospective, multicentre, randomised trial involves a blinded assessment of outcomes in non-oHCM patients with non-paroxysmal AF. Sixty-six candidates from three centres will be randomised 1:1 to either hybrid or CA, including isthmus addressed lesion sets. Participants will be stratified by left atrial (LA) size (LA diameter ≤50 mm or >50 mm). Follow-ups at the 3rd, 6th and 12th months will evaluate the primary endpoint of freedom from documented atrial tachycardia lasting over 30 s within 12 months post-procedure without antiarrhythmic drugs, along with secondary endpoints of all-cause mortality, cardiovascular-related mortality, cerebral stroke, peripheral vascular embolism, heart failure-related rehospitalisation, all-cause rehospitalisation and quality of life assessments. ETHICS AND DISSEMINATIONAPPROVAL: The central ethics committee at Fuwai Hospital has approved the Hypertrophic CardioMyopathy with Atrial Fibrillation trial (approval number: 2022-1736). Results will be disseminated through publications in peer-reviewed journals and presentations at conferences. TRIAL REGISTRATION NUMBER: NCT05610215.

Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study.

BACKGROUND: With 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. METHODS: We 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. RESULTS: Among 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. CONCLUSIONS: For a technically challenging surgical procedure like off-pump CABG, prior workload adversely affected patient outcomes.

Bi-atrial versus left atrial ablation for patients with rheumatic mitral valve disease and non-paroxysmal atrial fibrillation (ABLATION): rationale, design and study protocol for a multicentre randomised controlled trial.

INTRODUCTION: Atrial fibrillation (AF) is common in patients with rheumatic mitral valve disease (RMVD) and increase the risk of stroke and death. Bi-atrial or left atrial ablation remains controversial for treatment of AF during mitral valve surgery. The study aims to compare the efficacy and safety of bi-atrial ablation with those of left atrial ablation among patients with RMVD and persistent or long-standing persistent AF. METHODS AND ANALYSIS: The ABLATION trial (Bi-atrial vs Left Atrial Ablation for Patients with RMVD and Non-paroxysmal AF) is a prospective, multicentre, randomised controlled study. The trial will randomly assign 320 patients with RMVD and persistent or long-standing persistent AF to bi-atrial ablation procedure or left atrial ablation procedure in a 1:1 randomisation. The primary end point is freedom from documented AF, atrial flutter or atrial tachycardia of >30 s at 12 months after surgery off antiarrhythmic drugs. Key secondary end point is the probability of freedom from permanent pacemaker implantation at 12 months after surgery. Secondary outcomes include the probability of freedom from any recurrence of atrial tachyarrhythmias with antiarrhythmic drugs, AF burden, incidence of adverse events and cardiac function documented by echocardiography at 12 months after operation. ETHICS AND DISSEMINATION: The central ethics committee at Fuwai Hospital approved the ABLATION trial. The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: NCT05021601.

Transformation mechanism of polycyclic aromatic hydrocarbons and hydrogen production during the gasification of coking sludge in supercritical water.

In this study, the characteristic of hydrogen production and polycyclic aromatic hydrocarbons (PAHs) transformation during supercritical water gasification (SCWG) of coking sludge (400 °C - 450 °C, 1 min-30 min) were explored. The total gas yield was between 0.62 mol/kg OM and 1.05 mol/kg OM (on dry basis), and the proportion of CH4 and H2 was only between 5.41% and 6.44%. PAH content were increased from 194.92 mg/kg to 326.04 mg/kg, and mainly high molecular weight PAHs, which were formed from the Diels-Adler reaction of single aromatic hydrocarbon and the addition reaction of low molecular weight PAHs. High reaction temperature favored more active PAH formation than reaction time. The possible control methods for PAH formation during SCWG of coking sludge was proposed. H2O2 and KOH addition effectively reduce PAHs amount in solid residues by 46.67% and 38.33%, and KOH performed positive effect on hydrogen production. The work revealed that the inhibition of PAHs and hydrogen production were achieved from SCWG of coking sludge with KOH addition.