Clinical Outcomes of Surgical Revascularization Strategies Guided by Quantitative Flow Ratio in Primary Noncoronary Cardiac Surgery.

PURPOSE: Information regarding quantitative flow ratio (QFR) usage in coronary artery bypass grafting (CABG) is lacking. We compared the incidence of postoperative long-term adverse cardiovascular and cerebrovascular events after QFR-guided or coronary angiography-guided adult cardiac surgery with concurrent bypass surgery. MATERIALS AND METHODS: This study included 432 patients who underwent cardiopulmonary bypass (CPB) at our institution with at least 1 angiographical coronary artery lesion (diameter stenosis: 30% to 90%) between January 2015 and January 2016. The QFR of each patient was calculated. Patients who only underwent intraoperative coronary revascularization following the principles of optimal revascularization strategy were assigned to group A. Patients with coronary lesions not meeting the above criteria were placed in group B. RESULTS: The average number of distal anastomoses of patients with combined CABG in group B was similar to that in Group A (1.9±1.0 vs. 1.7±0.9; P=0.081). Group A had a shorter CPB duration (114.4±49.2 vs 135.8±55.2 minutes; P<0.001) and shorter aortic cross-clamping time (83.6±36.2 vs 101.1±40.6 minutes; P<0.001). The rates of perioperative mortality and major complications did not differ between groups. Long-term major adverse cardiovascular and cerebrovascular events (MACCEs) were less common in group A than in group B (14.7% vs 29.5%; P<0.001). CONCLUSIONS: In primary noncoronary cardiac surgery, despite the similar average numbers of distal anastomoses, the group with target vessels treated using an optimal coronary revascularization strategy presented shorter CPB time and aortic cross-clamping time than the other group. Multivariate analyses also showed a lower incidence of long-term MACCEs.

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.

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.

Impact of High Lipoprotein(a) on Long-Term Survival Following Coronary Artery Bypass Grafting.

BACKGROUND: Lipoprotein(a) is a possible causal risk factor for atherosclerosis and related complications. The distribution and prognostic implication of lipoprotein(a) in patients undergoing coronary artery bypass grafting remain unknown. This study aimed to assess the impact of high lipoprotein(a) on the long-term prognosis of patients undergoing coronary artery bypass grafting. METHODS AND RESULTS: Consecutive patients with stable coronary artery disease who underwent isolated coronary artery bypass grafting from January 2013 to December 2018 from a single-center cohort were included. The primary outcome was all-cause death. The secondary outcome was a composite of major adverse cardiovascular and cerebrovascular events. Of the 18 544 patients, 4072 (22.0%) were identified as the high-lipoprotein(a) group (≥50 mg/dL). During a median follow-up of 3.2 years, primary outcomes occurred in 587 patients. High lipoprotein(a) was associated with increased risk of all-cause death (high lipoprotein(a) versus low lipoprotein(a): adjusted hazard ratio [aHR], 1.31 [95% CI, 1.09-1.59]; P=0.005; lipoprotein(a) per 1-mg/dL increase: aHR, 1.003 [95% CI, 1.001-1.006]; P=0.011) and major adverse cardiovascular and cerebrovascular events (high lipoprotein(a) versus low lipoprotein(a): aHR, 1.18 [95% CI, 1.06-1.33]; P=0.004; lipoprotein(a) per 1-mg/dL increase: aHR, 1.002 [95% CI, 1.001-1.004]; P=0.002). The lipoprotein(a)-related risk was greater in patients with European System for Cardiac Operative Risk Evaluation <3, and tended to attenuate in patients receiving arterial grafts. CONCLUSIONS: More than 1 in 5 patients with stable coronary artery disease who underwent coronary artery bypass grafting were exposed to high lipoprotein(a), which is associated with higher risks of death and major adverse cardiovascular and cerebrovascular events. The adverse effects of lipoprotein(a) were more pronounced in patients with clinically low-risk profiles or not receiving arterial grafts.

Current treatment outcomes of congenital heart disease and future perspectives.

China has the largest number of individuals with congenital heart disease (CHD) in the world and a heavy burden of CHD. Therefore, understanding current CHD treatment outcomes and patterns in China will contribute to global progress in CHD treatment and be a valuable experience. Generally, CHD treatment in China has satisfactory outcomes owing to the joint efforts by all relevant stakeholders across the country. However, efforts are needed to overcome the remaining challenges: management of mitral valve disease and paediatric end-stage heart failure needs to be improved; cohesive paediatric cardiology teams should be established and collaboration between hospitals enhanced; CHD-related medical resources need to be more accessible and equitable; and nationwide CHD databases should be enhanced. In the second paper of this Series, we aim to systematically summarise the current CHD treatment outcomes in China, discuss potential solutions, and provide future perspectives.

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.

Preoperative clopidogrel and outcomes in patients with acute coronary syndrome undergoing coronary artery bypass surgery.

OBJECTIVE: The optimal preoperative antiplatelet strategy for patients with acute coronary syndrome (ACS) requiring surgical revascularization remains unclear because of competing risks of bleeding and ischemic events. We evaluated the effect of clopidogrel within 5 days before coronary artery bypass grafting (CABG) on outcomes in patients with ACS. METHODS: Consecutive patients with ACS who underwent isolated CABG at a single center were included in this retrospective study. The primary outcome was a composite of death, myocardial infarction, and stroke within 30 days after surgery. Secondary outcomes were CABG-related major bleeding and perioperative transfusion. Inverse probability weighting using propensity score was performed to evaluate the risk-adjusted effect of preoperative clopidogrel on outcomes. RESULTS: Of 5543 patients with ACS, 820 (14.8%) patients continued clopidogrel within 5 days before CABG. After adjustment for differences in baseline factors, clopidogrel use ≤5 days before CABG was associated with significantly increased odds of the primary composite outcome (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.16-2.29; P = .005), stroke (OR, 3.13; 95% CI, 1.82-5.39; P < .001), major bleeding (OR, 2.01; 95% CI, 1.56-2.58; P < .001), and transfusion (OR, 2.05; 95% CI, 1.82-2.30; P < .001). The effects of preoperative clopidogrel use ≤5 days on primary outcome and major bleeding were greater in patients older than 65 years. CONCLUSIONS: Among patients with ACS undergoing CABG, clopidogrel therapy within 5 days before surgery was associated with increased odds of major cardiac and cerebrovascular events and bleeding complications than discontinuing clopidogrel for >5 days.

Impact of coronary total occlusion on graft failure and outcomes of coronary artery bypass grafting.

OBJECTIVE: The study objective was to assess the impact of chronic total occlusion on long-term graft failure and outcomes in patients who underwent coronary artery bypass grafting. METHODS: We conducted an observational study involving a single-center subgroup of the CORONARY trial. At 6 to 9 years after coronary artery bypass grafting, all alive patients were invited for coronary computed tomography angiography and clinical follow-up. We assessed the association between chronic total occlusion graft and failing graft showing Fitzgibbon type B or O. Risk factors associated with chronic total occlusion graft failure were assessed. The impact of chronic total occlusion on clinical outcomes was analyzed, including death, myocardial infarction, and repeated revascularization. RESULTS: A total of 349 patients undergoing coronary artery bypass grafting were enrolled between May 2007 and October 2011. Of 301 alive patients at follow-up time (median, 6.8 years; interquartile range, 6.0-8.0 years), repeat coronary computed tomography angiography was performed in 206 patients (68.4%) with 723 grafts (154 chronic total occlusion grafts and 569 nonchronic total occlusion grafts). Chronic total occlusion graft was significantly associated with an increased risk of long-term graft failure after adjustment for patient- and graft-level characteristics (adjusted odds ratio, 2.27; 95% confidence interval, 1.42-3.62; P < .001). Arterial graft, side-to-side anastomosis, higher graft flow, and antiplatelet therapy at discharge were associated with chronic total occlusion graft patency. The presence of 1 or more chronic total occlusions was not significantly associated with long-term composite of death, myocardial infarction, or repeat revascularization (adjusted hazard ratio, 0.91; 95% confidence interval, 0.54-1.51; P = .707). CONCLUSIONS: Chronic total occlusion graft was associated with an increased risk of graft failure. Surgical technique and guideline-directed medical therapy should be noted to improve chronic total occlusion graft patency.

Dual Antiplatelet Therapy with Clopidogrel and Aspirin Versus Aspirin Monotherapy in Patients Undergoing Coronary Artery Bypass Graft Surgery.

Background The optimal antiplatelet therapy after coronary artery bypass grafting remains unclear. We evaluated the association of dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin and clinical outcomes among patients undergoing coronary artery bypass grafting. Methods and Results A total of 18 069 consecutive patients who underwent primary isolated coronary artery bypass grafting between 2013 and 2017 were identified from a contemporary registry, and 10 854 (60.1%) received DAPT with clopidogrel plus aspirin as determined by claimed prescriptions after surgery. Cox regression models with inverse probability of treatment weighting were used to examine the associations between DAPT and outcomes. Patients who received DAPT, compared with those who received aspirin monotherapy, had a lower incidence of a composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at 6 months (2.9% versus 4.2%; inverse probability of treatment weighting-adjusted hazard ratio [HR], 0.65; 95% CI, 0.55-0.77; P<0.001) as well as death (HR, 0.61; 95% CI, 0.41-0.90), myocardial infarction (HR, 0.55; 95% CI, 0.40-0.74), and stroke (HR, 0.58; 95% CI, 0.46-0.74). The incidence of major bleeding did not differ significantly between the 2 groups (HR, 1.11; 95% CI, 0.69-1.78). Similar results were noted across multiple subgroups as well as when using different analytic methods. Conclusions Among patients undergoing coronary artery bypass grafting, DAPT with clopidogrel plus aspirin as secondary prevention was associated with reduced risk of major adverse cardiovascular and cerebrovascular events within 6 months as compared with aspirin monotherapy, and there was no significant increase in major 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.

Influence of operator volume on early outcomes of septal myectomy for isolated hypertrophic obstructive cardiomyopathy.

BACKGROUND: Guidelines on the diagnosis and management of hypertrophic cardiomyopathy (HCM) recommend that septal myectomy be performed by experienced operators. However, the impact of operator volume on surgical treatment outcomes for isolated HCM has been poorly investigated. METHODS: From 2002 to 2014, 435 consecutive patients with isolated HCM undergoing myectomy at the Fuwai Hospital were retrospectively enrolled. All 29 surgeons were divided into beginner surgeons (operator volume ≤20) and experienced surgeons (operator volume >20) according to the guidelines for the diagnosis and treatment of HCM. Propensity score matching of patients in the two groups was performed. RESULTS: Baseline differences included advanced New York Heart Association classification and older age in the experienced surgeon group. After matching, in the beginner surgeon group (107 cases), residual obstruction (18.7% vs. 0.9%, P<0.001) was more common, and the postoperative left ventricular outflow tract pressure gradient (20.7±15.1 vs. 14.3±7.4 mmHg, P<0.001) was higher than that of the experienced surgeon group. In the experienced surgeon group (107 cases), the incidence of mitral valve replacement (1.9% vs. 11.2%, P<0.001) and permanent pacemaker implantation (1.9% vs. 3.7%, P<0.001) was significantly lower than that in the beginner surgeon group. However, there was no difference in procedural mortality (1.9% vs. 1.9%) between the two groups. CONCLUSIONS: Operator volume is an important factor in achieving better obstruction obliteration after septal myectomy in patients with isolated HCM.

Sinoatrial nodal artery injury in thoracoscopic epicardial ablation for atrial fibrillation.

OBJECTIVES: This study aimed to clarify the incidence of sinoatrial nodal artery (SANa) injury in thoracoscopic epicardial surgical ablation for atrial fibrillation (AF) and its impact on postoperative outcomes, which have not been previously elucidated. METHODS: We enrolled 103 consecutively patients with AF who underwent thoracoscopic epicardial ablation at our institution. In these patients, we evaluated the postoperative incidence of SANa injury by using enhanced cardiac computed tomography. For patients with confirmed SANa injury, 3-day continuous electrocardiographic monitoring and exercise stress tests were performed to assess the sinus rhythm maintenance and sinus node function. RESULTS: Thirteen patients (12.6%) had a confirmed SANa injury (left anterior type in 6 patients, left posterior type in 2 patients and double-branch type in 5 patients). After a median follow-up of 24 months, the patients with SANa injury were not found to be associated with lower sinus rhythm maintenance (hazard ratio 1.09, 95% confidential interval 0.36-3.31) as compared with those without SANa injury after adjustment for patient characteristics. Sinus node function was evaluated in 7 patients with SANa injury who remained in sinus rhythm after the procedure, and no sinus node dysfunction was confirmed in the 3-day electrocardiographic monitoring and exercise stress tests at a median follow-up of 12 months. CONCLUSIONS: The prevalence of SANa injury in the patients who underwent thoracoscopic epicardial ablation for AF was relatively low, and the incidence of SANa injury was not associated with postoperative restoration of sinus rhythm and sinoatrial node dysfunction. More studies are required to better understand SANa injury.

Surgical left atrial appendage occlusion in patients with atrial fibrillation undergoing mechanical heart valve replacement.

BACKGROUND: Surgical left atrial appendage occlusion (SLAAO) may be associated with a lower risk of thromboembolism in patients with atrial fibrillation undergoing cardiac surgery. However, evidence regarding the effectiveness of SLAAO in patients undergoing mechanical heart valve replacement (MHVR) is lacking. Therefore, we aimed to evaluate the association between SLAAO and the cardiovascular outcomes in patients with atrial fibrillation undergoing MHVR. METHODS: We retrospectively analyzed data for 497 patients with atrial fibrillation; 27.6% of the patients underwent SLAAO, and the remainder of the patients did not (No-SLAAO group). The primary outcome was a composite of ischemic stroke, systemic embolism, and all-cause mortality. Cumulative event-free survival rates were estimated using Kaplan-Meier curves, and we performed multivariate Cox analyses to evaluate the association between SLAAO and outcomes. We used one-to-one propensity score matching to balance patients' baseline characteristics, and analyzed 120 matching pairs. RESULTS: Five patients died within 30 days postoperatively, and there were no significant differences between the two groups regarding in-hospital complications (all P > 0.05). After a median follow-up of 14 months, 14 primary events occurred. Kaplan-Meier curves showed no difference in the cumulative incidence of freedom from the primary outcome (log-rank P = 0.830), hemorrhagic events (log-rank P = 0.870), and the secondary outcome (log-rank P = 0.730), between the two groups. Multivariable Cox proportional hazards regression analysis showed no association between SLAAO and any outcome (all P > 0.05). After propensity score matching, cardiopulmonary bypass time and aortic cross-clamp time, and the postoperative length of stay were significantly longer in the SLAAO group (all P < 0.05); results were similar to the unadjusted analyses. CONCLUSIONS: Concomitant SLAAO and MHVR was associated with longer length of stay, and cardiopulmonary bypass time and aortic cross-clamp time, but was not associated with additional protective effects against thromboembolic events and mortality during the 14-month follow-up.

Smartphone-based application to improve medication adherence in patients after surgical coronary revascularization.

BACKGROUND: Secondary preventive therapies play a key role in the prevention of adverse events after coronary artery bypass grafting (CABG). However, adherence to secondary preventive drugs after CABG is often poor. With the increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve medication adherence. We aimed to evaluate the effectiveness and feasibility of using a smartphone-based application to improve medication adherence in patients after CABG. METHODS: The Measurement and Improvement Studies of Surgical coronary revascularizatION: medication adherence (MISSION-2) study is a multicenter randomized controlled trial that planned to enroll over 1000 patients who underwent isolated CABG at one of four large teaching hospitals in China; all enrolled participants had access to a smartphone and were able to operate at least three smartphone applications. The investigators randomly assigned the participants to one of two groups: (1) the intervention group with an advanced smartphone application for 6 months which was designed specifically for this trial and did not exist before. Participants could receive medication reminders and cardiac health education by the smartphone application or (2) the control group with usual care. The primary outcome was CABG secondary preventive medication adherence as measured by the translated Chinese version of the 8-item Morisky Medication Adherence Scale (MMAS-8) at 6 months after randomization. The secondary outcomes were mortality, major adverse cardiovascular and cerebrovascular events (MACCE), cardiovascular rehospitalization, self-reported secondary preventive medication use after 6 months of follow-up, blood pressure (BP), body mass index (BMI), and self-reported smoking status. All analyses were conducted using the intention-to-treat principle. RESULTS: A total of 1000 patients (mean age, 57.28 [SD, 9.09] years; 85.5% male) with coronary heart disease after CABG were enrolled between September 2015 and September 2016 and were randomly assigned to the intervention (n = 501) or control group (n = 499). At 6 months, the proportion of low-adherence participants, categorized by MMAS-8 scores, was 11.8% in the intervention group and 11.7% in the control group (RR = 1.005, 95% CI 0.682 to 1.480, P = 1.000). Similar results were found in sensitivity analyses that considered participants who withdrew from the study, or were lost to follow-up as nonadherent. There were no significant differences in the secondary clinical outcome measures, and there were no significant differences in the primary outcome across the subgroups tested. In the intervention group, the proportion of participants who used and operated the application during the first month after CABG was 88.1%; however, the use rate decreased sharply from 42.5% in the second month to 9.2% by the end of the study (6 months). CONCLUSIONS: A smartphone-based application supporting secondary prevention among patients after CABG did not lead to a greater adherence to secondary preventive medications. The limited room for improvement in medication adherence and the low participants' engagement with the smartphone applications might account for these non-significant outcomes.

Mis-estimation of coronary lesions and rectification by SYNTAX score feedback for coronary revascularization appropriateness.

BACKGROUND: Imprecise interpretation of coronary angiograms was reported and resulted in inappropriate revascularization. Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score is a comprehensive system to evaluate the complexity of the overall lesions. We hypothesized that a real-time SYNTAX score feedback from image analysts may rectify the mis-estimation and improve revascularization appropriateness in patients with stable coronary artery disease (CAD). METHODS: In this single-center, historical control study, patients with stable CAD with coronary lesion stenosis ≥50% were consecutively recruited. During the control period, SYNTAX scores were calculated by treating cardiologists. During the intervention period, SYNTAX scores were calculated by image analysts immediately after coronary angiography and were provided to cardiologists in real-time to aid decision-making. The primary outcome was revascularization deemed inappropriate by Chinese appropriate use criteria for coronary revascularization. RESULTS: A total of 3245 patients were enrolled and assigned to the control group (08/2016-03/2017, n = 1525) or the intervention group (03/2017-09/2017, n = 1720). For SYNTAX score tertiles, 17.9% patients were overestimated and 4.3% were underestimated by cardiologists in the control group. After adjustment, inappropriate revascularization significantly decreased in the intervention group compared with the control group (adjusted odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.73-0.95; P = 0.007). Both inappropriate percutaneous coronary intervention (adjusted OR: 0.82; 95% CI: 0.74-0.92; P < 0.001) and percutaneous coronary intervention utilization (adjusted OR: 0.88; 95% CI: 0.79-0.98; P = 0.016) decreased significantly in the intervention group. There was no significant difference in 1-year adverse cardiac events between the control group and the intervention group. CONCLUSIONS: Real-time SYNTAX score feedback significantly reduced inappropriate coronary revascularization in stable patients with CAD. CLINICAL TRIAL REGISTRATION: Nos. NCT03068858 and NCT02880605; https://www.clinicaltrials.gov.

Assessing the association of appropriateness of coronary revascularization and 1-year clinical outcomes for patients with stable coronary artery disease in China.

BACKGROUND: The Chinese appropriate use criteria (AUC) for coronary revascularization was released in 2016 to improve the use of coronary revascularization. This study aimed to evaluate the association between the appropriateness of coronary revascularization based on the Chinese AUC and 1-year outcomes in stable coronary artery disease (CAD) patients. METHODS: We conducted a prospective, multi-center cohort study of stable CAD patients with coronary lesion stenosis ≥50%. After the classification of appropriateness based on Chinese AUC, patients were categorized into the coronary revascularization group or the medical therapy group based on treatment received. The primary outcome was a composite of death, myocardial infarction, stroke, repeated revascularization, and ischemic symptoms with hospital admission. RESULTS: From August 2016 to August 2017, 6085 patients were consecutively enrolled. Coronary revascularization was associated with a lower adjusted hazard of 1-year major adverse cardiovascular and cerebrovascular events (MACCEs; hazard ratio [HR]: 0.62; 95% confidence interval [CI]: 0.45-0.86; P = 0.004) than medical therapy in patients with appropriate indications (n = 1617). No significant benefit in 1-year MACCEs was found after revascularization compared to after medical therapy in patients with uncertain indications (n = 2658, HR: 0.81; 95% CI: 0.52-1.25; P = 0.338) and inappropriate indications (n = 1810, HR: 0.80; 95% CI: 0.51-1.23; P = 0.308). CONCLUSIONS: In patients with appropriate indications according to Chinese AUC, coronary revascularization was associated with significantly lower risk of MACCEs at 1 year. No benefit was found in coronary revascularization in patients with inappropriate indications. Our findings provide evidence for using Chinese AUC to guide clinical decision-making. CLINICAL TRIAL REGISTRATION: NCT02880605. https://www.clinicaltrials.gov.

Quality Measurement and Improvement Study of Surgical Coronary Revascularization: Medication Adherence (MISSION-2).

BACKGROUND: Secondary preventive therapies play a key role in the prevention of adverse outcomes after coronary artery bypass grafting (CABG). However, medication adherence after CABG is often poor, and conventional interventions for improving adherence have limited success. With increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve adherence. Carefully designed trials are needed to provide reliable evidence for the use of these applications in patients after CABG. METHODS: The Measurement and Improvement Studies of Surgical Coronary Revascularization: Medication Adherence (MISSION-2) study is a multicenter randomized controlled trial, aiming to randomize 1000 CABG patients to the intervention or control groups in a 1:1 ratio. We developed the multifaceted, patient-centered, smartphone-based Heart Health Application to encourage medication adherence in the intervention group through a health self-management program initiated during hospital admission for CABG. The application integrated daily scheduled reminders to take the discharge medications, cardiac educational materials, a dynamic dashboard to review cardiovascular risk factors and secondary prevention targets, and weekly questionnaires with interactive feedback. The primary outcome was secondary preventive medication adherence measured by the Chinese version of the 8-item Morisky Medication Adherence Scale at 6 months after randomization. Secondary outcomes included all-cause death, cardiovascular rehospitalization, and a composite of death, myocardial infarction, stroke, and repeat revascularization. DISCUSSION: Findings will not only provide evidence regarding the feasibility and effectiveness of the described intervention for improving adherence to CABG secondary preventive therapies but also explore a model for outpatient health self-management that could be translated to various chronic diseases and widely disseminated across resource-limited settings. TRIAL REGISTRATION: https://clinicaltrials.gov (NCT02432469).

Trends in mortality and major complications for patients undergoing coronary artery bypass grafting among Urban Teaching Hospitals in China: 2004 to 2013.

Aims: Although the number of hospitals performing cardiac surgery has increased rapidly in China, information regarding the trends in coronary artery bypass grafting (CABG) outcomes remains unknown. Methods and results: We used data from the Chinese Cardiac Surgery Registry, the largest registry system that accounts for nearly 50% of total annual CABG volume in China, to assess trends of in-hospital mortality and major complication rates for patients receiving isolated CABG in 102 urban teaching hospitals in China from 25 January 2004 through 31 December 2013 (except 2006 and 2009). Using a mixed effects model, we estimated annual trends in each of these two outcomes overall and by age groups (18-64 and 65 years or older), adjusted for patient characteristics. We also assessed the trends in pre-operative, post-operative, and total length of stay (LOS). The study included 40 652 patients across 102 hospitals. Between 2004 and 2013, patients' mean age decreased from 62.7 to 61.4 years, in-hospital mortality decreased from 2.8% to 1.6% (difference, 1.3%, 95% CI: 0.70-1.85), and major complication rates decreased from 7.8% to 3.8% (difference, 4.0%; 95% CI: 3.05-4.90). The reduction in mortality and major complication rates were consistent across age groups. Between 2004 and 2013, the median (inter-quartile range) pre-operative LOS remained unchanged, post-operative LOS declined from 12.0 (8.0) to 10.0 (7.0) days, and total LOS declined from 22.0 (13.0) to 20.0 (12.0) days. Conclusion: Isolated CABG-related in-hospital mortality, major complication rates, and LOS have improved in urban teaching hospitals in China over the last decade.

Comparing Outcomes of Coronary Artery Bypass Grafting Among Large Teaching and Urban Hospitals in China and the United States.

BACKGROUND: Coronary artery disease is prevalent in China, with concomitant increases in the volume of coronary artery bypass grafting (CABG). The present study aims to compare CABG-related outcomes between China and the United States among large teaching and urban hospitals. METHODS AND RESULTS: Observational analysis of patients aged ≥18 years, discharged from acute-care, large teaching and urban hospitals in China and the United States after hospitalization for an isolated CABG surgery. Data were obtained from the Chinese Cardiac Surgery Registry in China and the National Inpatient Sample in the United States. Analysis was stratified by 2 periods: 2007, 2008, and 2010; and 2011 to 2013 periods. The primary outcome was in-hospital mortality, and the secondary outcome was length of stay. The sample included 51 408 patients: 32 040 from 77 hospitals in the China-CABG group and 19 368 from 303 hospitals in the US-CABG group. In the 2007 to 2008, 2010 period and for all-age and aged ≥65 years, the China-CABG group had higher mortality than the US-CABG group (1.91% versus 1.58%, P=0.059; and 3.12% versus 2.20%, P=0.004) and significantly higher age-, sex-, and comorbidity-adjusted odds of death (odds ratio, 1.58; 95% confidential interval, 1.22-2.04; and odds ratio, 1.73; 95% confidential interval, 1.24-2.40). There were no significant mortality differences in the 2011 to 2013 period. For preoperative, postoperative, and total hospital stay, respectively, the median (interquartile range) length of stay across the entire study period between China-CABG and US-CABG groups were 9 (8) versus 1 (3), 9 (6) versus 6 (3), and 20 (12) versus 7 (5) days (all P<0.001). This difference did not change significantly over time. CONCLUSIONS: In 2011 to 2013, there was no significant difference in in-hospital mortality among patients who underwent an isolated CABG surgery in large teaching and urban hospitals in China and the United States. The longer length of stay in China may represent an opportunity for improvement.

Rationale and design of a randomized cluster trial to improve guideline-adherence of secondary preventive drugs prescription after coronary artery bypass grafting in China: Measurement and Improvement Studies of Surgical Coronary Revascularization: Secondary Prevention (MISSION-1) Study.

OBJECTIVES: The benefits of secondary preventive drugs after coronary artery bypass grafting have been thoroughly established. However, the prescription rates of these drugs are low at discharge in China. We sought to evaluate the effectiveness of continuous quality improvement with mobile-based interventions for clinicians on improving the guideline-adherence of secondary preventive drugs prescription. METHODS AND RESULTS: The quality MISSION-1 study is a cluster-randomized controlled trial. We enrolled 60 hospitals with a bypass surgery volume of more than 30 a year and randomly assigned them into the intervention group or the control group in a 1:1 ratio using minimized random grouping. The intervention group undertakes a series of mobile-based interventions, while the control group maintains a routine practice pattern. All sites consecutively register patients who underwent isolated coronary artery bypass grafting and submit in-hospital data. We require supporting documents regarding prescription information at discharge to adjudicate the outcome measures. The estimated sample size of enrolled patients is 9,600. The primary outcome measure is the prescription rate of statins for eligible patients at discharge. The secondary outcome measures are ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and optimal medical therapy. MISSION-1 study is now recruiting patients. CONCLUSIONS: The MISSION-1 study has the potential to identify the effectiveness of interventions on improving secondary prevention adherence at discharge after bypass surgery in China and further disseminate findings to other settings to improve the quality of care.