顾大川
中国医学科学院阜外医院 成人外科
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.
Journal of the American Heart Association 2024
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.
Journal of the American Heart Association 2024
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.
BMJ quality & safety 2023
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.
Circulation. Cardiovascular quality and outcomes 2021
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.
American heart journal 2021
Coronary revascularization is the most important strategy for coronary artery disease. This review summarizes the current most prevalent approaches for coronary revascularization and discusses the evidence on the mechanisms, indications, techniques, and outcomes of these approaches. Targeting coronary thrombus, fibrinolysis is indicated for patients with diagnosed myocardial infarction and without high risk of severe hemorrhage. The development of fibrinolytic agents has improved the outcomes of ST-elevation myocardial infarction. Percutaneous coronary intervention has become the most frequently performed procedure for coronary artery disease. The evolution of stents plays an important role in the result of the procedure. Coronary artery bypass grafting is the most effective revascularization approach for stenotic coronary arteries. The choice of conduits and surgical techniques are important determinants of patient outcomes. Multidisciplinary decision-making should analyze current evidence, considering the clinical condition of patients, and determine the safety and necessity for coronary revascularization with either PCI or CABG. For coronary artery disease with more complex lesions like left main disease and multivessel disease, CABG results in more complete revascularization than PCI. Furthermore, comorbidities, such as heart failure and diabetes, are always correlated with adverse clinical events, and a routine invasive strategy should be recommended. For patients under revascularization, secondary prevention therapies are also of important value for the prevention of subsequent adverse events.
Advances in experimental medicine and biology 2020
BACKGROUND:To meet the demand of increasing surgical volume and changing of patient's risk profiles of coronary artery bypass grafting in China, we developed a new risk model that predicts in-hospital mortality.METHODS:The analysis included patients who underwent coronary artery bypass grafting between January 2013 and December 2016 at 87 hospitals in the Chinese Cardiac Surgery Registry. Patients in years 2013 to 2015 were randomly divided into training (n = 31,297 [75%]) and test (n = 10,432 [25%]) samples; 2016 patients (n = 15047) comprised the validation sample. Demographic and clinical risk factors were identified. The Harrell C statistic was used to evaluate model discrimination, and the Hosmer-Lemeshow goodness-of-fit test was used to assess calibration.RESULTS:The 56,776 patients were a mean age of 61.8 (SD, 8.8) years, and 24.6% were women. Overall, in-hospital mortality was 2.1%. The final model included 21 risk factors represented by 16 unique variables. The model achieved good discrimination, with a C statistic of 0.79 (95% confidence interval [CI], 0.77-0.80) in the training sample, 0.79 (95% CI, 0.76-0.82) in the test sample, and 0.78 (95% CI, 0.76-0.81) in the validation sample. Model calibration was good according to the Hosmer-Lemeshow test (P > .05 in the 3 samples). Compared with the European System for Cardiac Operative Risk Evaluation 2011 revision (EuroSCORE II) and the Sino(Chinese) System for Coronary artery bypass grafting Operative Risk Evaluation (SinoSCORE), the model had better discrimination and calibration.CONCLUSIONS:We developed and evaluated a model with 16 risk factors that predicted in-hospital mortality risk after coronary artery bypass grafting in China. This updated model may help surgeons and hospitals better identify high-risk patient.
The Annals of thoracic surgery 2020
BACKGROUND:Randomized controlled trials have compared the early and midterm prognosis of on-pump coronary artery bypass grafting (CABG) and off-pump CABG. However the results are controversial, and there is limited information on graft patency and long-term outcomes.METHODS:Between May 2007 and October 2011, 349 patients were randomized to off-pump or on-pump CABG as part of the CORONARY trial at Fuwai Hospital. The primary outcome was coronary bypass graft patency, which was assessed at a mean of 6.7 ± 1.7 years after surgery by multidetector computed tomography. A secondary endpoint was a composite outcome of death, nonfatal myocardial infarction, repeat coronary revascularization, or stroke; mean follow-up was 6.5 ± 1.7 years. Graft patency was compared between the off-pump and on-pump CABG treatment arms in 206 patients with follow-up computed tomography.RESULTS:During the follow-up period 107 patients were in the off-pump CABG group and 99 in the on-pump group. These patients underwent a total of 723 grafts, and the overall rate of graft patency did not differ significantly between the off-pump and on-pump groups (87.4% vs 88.9%, P = .527). The patency rate of the posterior descending branch was lower than average. Higher incidences of mortality, nonfatal myocardial infarction, and repeat revascularization were found in the off-pump patients; however it did not reach significance.CONCLUSIONS:There were no statistical differences in graft patency rates in off-pump versus on-pump CABG patients during long-term follow-up. The on-pump CABG group appeared to have a better long-term prognosis even with no statistical differences for the limited study population.
The Annals of thoracic surgery 2020
BACKGROUND:We developed a multidimensional quality monitoring system using an electronic health care records-derived database, and mobile-based reports for individual cardiovascular surgeons.METHODS:This study included surgeons who performed coronary artery bypass graft surgery at a single center in China from January to December 2015. Patient data were automatically derived from structured electronic health records. Surgeon-specific quality measures included inhospital mortality and morbidity, transfusion-free procedure, use of internal mammary artery, postoperative length of stay, and hospitalization cost. The "technique for order of preference by similarity to ideal solution" method was used to create a composite quality measure and rank surgeons on performance. Surgeons were rated into three categories: the top 20%, middle 20% to 80%, and the bottom 20%. Quality data were delivered to surgeons through mobile-based reports.RESULTS:Forty surgeons performed 4,288 coronary artery bypass graft surgeries in 2015. For surgeons in the top, middle, and bottom performance categories, there was a trend of increase in risk adjusted inhospital morbidity rate (2.66%, 2.89%, and 3.07%, respectively; p = 0.5101). There were significant differences in the use of internal mammary artery (94.65%, 95.8%, 90.14%, respectively; p < 0.0001), risk-adjusted postoperative length of stay (7.01 days, 7.99 days, and 8.69 days, respectively; p < 0.0001), and hospitalization cost (81.27 thousand yuan, 88.36 thousand yuan, and 102.77 thousand yuan, respectively; p < 0.0001).CONCLUSIONS:We developed a surgeon-specific quality monitoring system using structured electronic health records-derived database, multidimensional measures, and mobile-based reporting. This system will facilitate quality reporting and peer comparison, and strengthen the effect of quality improvement.
The Annals of thoracic surgery 2019
Neurogenic airway inflammation in chronic cough and bronchial asthma related to gastroesophageal reflux (GER) is involved in the esophageal-bronchial reflex, but it is unclear whether this reflex is mediated by central neurons. This study aimed to investigate the regulatory effects of the dorsal vagal complex (DVC) on airway inflammation induced by the esophageal perfusion of hydrochloric acid (HCl) following the microinjection of nuclei in the DVC in guinea pigs. Airway inflammation was evaluated by measuring the extravasation of Evans blue dye (EBD) and substance P (SP) expression in the airway. Neuronal activity was indicated by Fos expression in the DVC. The neural pathways from the lower esophagus to the DVC and the DVC to the airway were identified using DiI tracing and pseudorabies virus Bartha (PRV-Bartha) retrograde tracing, respectively. HCl perfusion significantly increased plasma extravasation, SP expression in the trachea, and the expression of SP and Fos in the medulla oblongata nuclei, including the nucleus of the solitary tract (NTS) and the dorsal motor nucleus of the vagus (DMV). The microinjection of glutamic acid (Glu) or exogenous SP to enhance neuronal activity in the DVC significantly potentiated plasma extravasation and SP release induced by intra-esophageal perfusion. The microinjection of γ-aminobutyric acid (GABA), lidocaine to inhibit neuronal activity or anti-SP serum in the DVC alleviated plasma extravasation and SP release. In conclusion, airway inflammation induced by the esophageal perfusion of HCl is regulated by DVC. This study provides new insight for the mechanism of airway neurogenic inflammation related to GER.
Frontiers in physiology 2018
