Left atrial appendage occlusion for patients with valvular diseases without atrial fibrillation (the OPINION Study): study protocol for a multicentre, randomised controlled trial.

INTRODUCTION:Atrial fibrillation (AF) is a significant cause of perioperative stroke in aortic and mitral valve surgeries. Although several large studies have evaluated surgical left atrial appendage occlusion (SLAAO) during cardiac surgeries, their retrospective nature and an uncontrolled broad spectrum of conditions leave them subject to potential residual confounding. This trial aims to test the hypothesis that opportunistic SLAAO can prevent long-term stroke after cardiac surgery in patients receiving mitral or aortic valve surgeries without a history of AF and with a CHA2DS2-VASc score of 2 or higher.METHODS AND DESIGN:This study is a single-blinded, multicentre, randomised controlled trial. A total of 2118 patients planning to undergo aortic or mitral surgery without AF will be recruited and equally randomised into intervention or control arms at a 1:1 ratio. In the intervention arm, suture excision of the left atrial appendage (LAA) will be performed during the operation in addition to the original surgery plan. In the control arm, the operation will be performed according to the surgery plan without any intervention on the LAA. The primary outcome is a composite of newly occurred ischaemic stroke or transient ischaemic attack and cardiovascular mortality during a 1-year follow-up. Secondary outcomes include postoperative AF, cardiovascular mortality, newly occurred ischaemic stroke, newly occurred transient ischaemic attack, newly occurred haemorrhagic stroke, bleeding events, and AF-associated health utilisation.ETHICS AND DISSEMINATION:The Ethics Committee in Fuwai Hospital approved this study. Patients will give informed consent to the study. An information leaflet will be provided to participating patients to introduce the SLAAO procedure. Patients and the public will not get involved in developing the research hypothesis, study design or any other part of this protocol. We plan to publish several papers in peer-reviewed journals about the current research and these will include a description of the study's development and the main findings of the study.TRIAL REGISTRATION NUMBER:ChiCTR2100042238.

Association between stress hyperglycaemia and in-hospital cardiac events after coronary artery bypass grafting in patients without diabetes: A retrospective observational study of 5450 patients.

AIMS:To investigate the impact of stress hyperglycaemia (SH) on in-hospital adverse cardiac events after coronary artery bypass grafting (CABG) in patients without diabetes.MATERIALS AND METHODS:In total, 5450 patients without diabetes who underwent CABG were analysed. SH was defined as any two instances in which the random blood glucose level was >7.8 mmol/L after CABG in the intensive care unit (ICU). The primary outcome was major adverse cardiac events (MACEs), including in-hospital mortality, acute myocardial infarction, stroke and acute renal failure. Secondary outcomes included surgical site infection (SSI) and length of ICU stay.RESULTS:Patients with SH had higher rates of MACEs (5.7% vs. 2.3%, p < .0001) and higher SSI (3.3% vs. 1.4%, p = .0003) and longer ICU stays (2.6 ± 2.0 vs. 1.3 ± 1.3 days, p < .0001) than those without SH. Furthermore, SH was associated with a higher risk of MACEs [odds ratio (OR): 2.32, 95% confidence interval (CI): 1.38-3.90], SSI (OR: 2.21, 95% CI: 1.20-3.95) and longer ICU stay (OR: 12.27, 95% CI: 9.41-16.92) after adjusting for confounders. Subgroup analysis showed that patients with SH >10 mmol/L or SH that occurred in the ICU and lasted more than 48 h had increased risks of postoperative complications (p < .05).CONCLUSIONS:SH was significantly associated with an increased risk of MACEs, SSI and longer ICU stay after CABG in patients without diabetes. In addition, SH >10 mmol/L or that occurred in the ICU and lasted more than 48 h increased the risk of adverse outcomes.

Effect of glycemic control and glucose fluctuation on in-hospital adverse outcomes after on-pump coronary artery bypass grafting in patients with diabetes: a retrospective study.

BACKGROUND:The optimal glycemic control level in diabetic patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (On-Pump) remains unclear. Therefore, this study aimed to investigate the effect of different blood glucose control levels and glucose fluctuations on in-hospital adverse outcomes in diabetic patients undergoing on-pump CABG.METHOD:A total of 3918 patients with diabetes undergoing CABG were reviewed in this study. A total of 1638 patients were eligible for inclusion and were categorized into strict, moderate and liberal glucose control groups based on post-operative mean blood glucose control levels of  < 7.8 mmol/L, from 7.8 to 9.9 mmol/L and ≥ 10.0 mmoL/L, respectively. The primary endpoint was defined as a composite endpoint including in-hospital all-cause mortality and major cardiovascular complications. The secondary endpoint was defined as major cardiovascular complications including acute myocardial infarction, strokes and acute kidney injuries. To determine the associations between blood glucose fluctuations and adverse outcomes, patients with different glycemic control levels were further divided into subgroups according to whether the largest amplitude of glycemic excursion (LAGE) was ≥ 4.4 mmol/L or not.RESULTS:A total of 126 (7.7%) patients had a composite endpoint. Compared with moderate control, strict glucose control was associated with an increased risk of the primary endpoint (adjusted OR = 2.22, 95% CI 1.18-4.15, p = 0.01) and the secondary endpoint (adjusted OR = 1.95, 95% CI 1.01-3.77, p = 0.049). Furthermore, LAGE ≥ 4.4 mmol/L was significantly associated with the primary endpoint (adjusted OR = 1.67, 95% CI 1.12-2.50, p = 0.01) and the secondary endpoint (adjusted OR = 1.75, 95% CI 1.17-2.62, p = 0.01),respectively. Patients with LAGE ≥ 4.4 mmol/L had significantly higher rates of the composite endpoint and major vascular complications in both the strict-control (the primary endpoint, 66.7% vs 12.4%, p = 0.034, the secondary endpoint, 66.7% vs 10.3%, p = 0.03) and moderate-control groups (the primary endpoint, 10.2% vs 6.0%, p = 0.03, the secondary endpoint, 10.2% vs 5.8%, p = 0.02).CONCLUSIONS:After On-Pump CABG patients with diabetes, strict glucose control (< 7.8 mmol/L) and relatively large glucose fluctuations (LAGE ≥ 4.4 mmol/L) were independently associated with in-hospital adverse outcomes.

Evaluation of the effectiveness and safety of a multi-faceted computerized antimicrobial stewardship intervention in surgical settings: A single-centre cluster-randomized controlled trial.

BACKGROUND:Inappropriate antimicrobial use is common among patients undergoing surgery. It remains unclear whether a multi-faceted computerized antimicrobial stewardship programme is effective and safe in reducing inappropriate antimicrobial use in surgical settings.METHODS:A multi-faceted computerized antimicrobial stewardship intervention system was developed, and an open-label, cluster-randomized, controlled trial was conducted among 18 surgical teams that enrolled 2470 patients for open chest cardiovascular surgery. The surgical teams were divided at random into intervention and control groups at a ratio of 1:1. The primary endpoints were days of therapy (DOT)/1000 patient-days, defined daily dose (DDD)/1000 patient-days and length of therapy (LOT)/1000 patient-days.RESULTS:Mean DOT, DDD and LOT per 1000 patient-days were significantly lower in the intervention group compared with the control group (472.2 vs 539.8, 459.5 vs 553.8, and 438.4 vs 488.7; P<0.05), with reductions of 14.2% [95% confidence interval (CI) 11.8-16.7%], 18.7% (95% CI 15.9-21.4%) and 11.9% (95% CI 9.6-14.1%), respectively. The daily risk of inappropriate antimicrobial use after discharge from the intensive care unit decreased by 23.9% [95% CI 15.5-31.5% (incidence risk ratio 0.76, 95% CI 0.69-0.85)] in the intervention group. There was no significant difference in rates of infection or surgical-related complications between the groups. Median antimicrobial costs were significantly lower in the intervention group {873.4 [interquartile range (IQR) 684.5-1255.4] RMB vs 1178.7 (IQR 869.1-1814.5) RMB; P<0.001} (1 RMB approximately equivalent to 0.16 US$ in 2022).CONCLUSIONS:The multi-faceted computerized antimicrobial stewardship interventions reduced inappropriate antimicrobial use safely.CLINICAL TRIAL REGISTRATION:Clinicaltrials.gov: NCT04328090.

Causal effect of hypertension and blood pressure on aortic diseases: evidence from Mendelian randomization.

Hypertension or elevated blood pressure was documented to be an important risk factor for aortic diseases in observational studies, yet the causality remains to be determined. By applying a two-sample Mendelian randomization (MR) approach, we aim to determine whether hypertension or elevated blood pressure (systolic blood pressure [SBP] or diastolic blood pressure [DBP]) is linked causally to aortic aneurysm or aortic dissection. Genetic instruments and summary statistics for hypertension and aortic diseases were obtained from large genome-wide association studies. The traditional inverse variance weighted (IVW) method was used to obtain the causal estimates. Sensitivity analyses including MR-Egger, weighted median and multivariable MR were also performed. Our results suggested that genetic liability to hypertension was associated with aortic dissection (odds ratio [OR]: 1.81; 95% confidence interval [CI]: 1.27-2.58; P = 1.13 × 10-3) and aortic aneurysm (OR: 1.43; 95% CI: 1.22-1.66; P = 7.79 × 10-6). Per standard deviation increase in genetically-determined DBP was significantly associated with increased aortic dissection (OR: 1.14; 95% CI: 1.09-1.19; P = 1.58 × 10-9) and aortic aneurysm (OR: 1.07; 95% CI: 1.05-1.09; P = 8.37 × 10-14). There was a null association between SBP and aortic dissection (OR: 1.01; 95% CI: 0.99-1.94; P = 0.38) or aortic aneurysm (OR: 1.00; 95% CI: 0.99-1.01; P = 0.92). Sensitivity analyses documented similar results. Therefore, hypertension and elevated DBP are causally associated with higher risks of aortic aneurysm and aortic dissection. Preventive interventions for aortic diseases may consider individuals with hypertension, especially those with higher DBP. Meanwhile, further research is required to determine the mechanisms underlying the significantly greater correlation between DBP and aortic diseases than SBP.

Clinical implication of coronary artery bypass grafting with surgical ventricular reconstruction in clinical practice.

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.

Long-term outcomes after coronary artery bypass graft with or without surgical ventricular reconstruction in patients with severe left ventricular dysfunction.

Background:Patients with chronic myocardial infarction (MI) and severe left ventricular (LV) dysfunction have poor clinical outcomes. This study aimed to determine whether coronary artery bypass graft (CABG) with surgical ventricular reconstruction (SVR) leads to further improvement in long-term patient outcomes compared with isolated CABG (I-CABG).Methods:From April 2010 to June 2013, 140 consecutive patients with chronic MI and severe LV dysfunction who received contrast-enhanced cardiovascular magnetic resonance imaging (CE-CMR) within 1 month before surgery were enrolled in this study. The cardiovascular events (CVEs) and long-term survival of patients who underwent CABG and SVR were compared with those who met the criteria for SVR but received I-CABG.Results:A total of 140 patients were included in the final analysis, including 70 patients who underwent CABG and SVR and 70 patients who underwent I-CABG. No differences were observed in the baseline characteristics, LV function, and late gadolinium enhancement (LGE) between the two groups. CABG+SVR patients experienced a longer cardiopulmonary bypass (CPB) time (116.0±35.0 vs. 100.2±23.8 minutes, P=0.002) and ventilation time [median (interquartile range): 22.0 (17.0, 37.0) vs. 20.0 (15.0, 24.0) hours, P=0.019] than I-CABG patients. During a mean follow-up of 123.1±12.7 months (range, 102-140 months), the CABG+SVR group had fewer rehospitalizations for congestive heart failure (CHF) (4.3% vs. 19.1%, P=0.007), but no statistical difference in the mortality rate was observed (2.9% vs. 4.4%, P=0.987). The cumulative CVE-free survival rate was significantly higher in CABG+SVR patients (87.0% vs. 67.6%, P=0.007).Conclusions:Our findings indicated that patients with chronic MI and severe LV dysfunction experienced similar perioperative outcomes after CABG+SVR or I-CABG. However, the CABG+SVR group resulted in fewer rehospitalizations for CHF and a higher cumulative CVE-free survival rate.

Effect of early hypoglycaemia on hospitalization outcomes in patients undergoing coronary artery bypass grafting.

OBJECTIVE:To investigate the effect of early postoperative hypoglycaemia on hospitalization outcomes including major cardiovascular complications and in-hospital mortality among patients undergoing coronary artery bypass grafting (CABG).METHODS:Data from an observational study of 9583 patients in the intensive care unit (ICU) who underwent CABG were analyzed. Hypoglycaemia was defined as a nadir blood glucose level <70 mg/dL (3.9 mmol/L). One-to-one propensity score matching (PSM) was used to identify 251-balanced pairs of patients to compare outcomes.RESULTS:A total of 306 (3.2%) patients experienced hypoglycaemia, of whom, 133 had diabetes, 173 hadn't diabetes. Patients who were hypoglycaemia had higher incidences of compositeoutcomes than those without hypoglycaemia (12.1% versus 6.0%, P < 0.0001). Postoperative length of ICU stay was longer in patients with hypoglycaemia [2.8 (0.8-21.0) versus 2.0 (0.25-36.0) days, P < 0.0001]. After PSM, the compositeoutcomes and length of ICU stay remained significantly increased for the patients with hypoglycaemia [compositeoutcomes: odd ratio (OR) 2.78, 95% CI, 1.30-5.88, P = 0.01; length of ICU stay: OR 1.60, 95% CI, 1.14-2.26, P = 0.007].CONCLUSION:Postoperative hypoglycaemia was an independent associated factor of adverse composite outcomes and a lengthened ICU stay after CABG. Hypoglycaemia should be avoided for both postoperative patients with and without diabetes.

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.

Left atrial appendage occlusion for patients with valvular diseases without atrial fibrillation (the OPINION Study): study protocol for a multicentre, randomised controlled trial.

INTRODUCTION:Atrial fibrillation (AF) is a significant cause of perioperative stroke in aortic and mitral valve surgeries. Although several large studies have evaluated surgical left atrial appendage occlusion (SLAAO) during cardiac surgeries, their retrospective nature and an uncontrolled broad spectrum of conditions leave them subject to potential residual confounding. This trial aims to test the hypothesis that opportunistic SLAAO can prevent long-term stroke after cardiac surgery in patients receiving mitral or aortic valve surgeries without a history of AF and with a CHA2DS2-VASc score of 2 or higher.METHODS AND DESIGN:This study is a single-blinded, multicentre, randomised controlled trial. A total of 2118 patients planning to undergo aortic or mitral surgery without AF will be recruited and equally randomised into intervention or control arms at a 1:1 ratio. In the intervention arm, suture excision of the left atrial appendage (LAA) will be performed during the operation in addition to the original surgery plan. In the control arm, the operation will be performed according to the surgery plan without any intervention on the LAA. The primary outcome is a composite of newly occurred ischaemic stroke or transient ischaemic attack and cardiovascular mortality during a 1-year follow-up. Secondary outcomes include postoperative AF, cardiovascular mortality, newly occurred ischaemic stroke, newly occurred transient ischaemic attack, newly occurred haemorrhagic stroke, bleeding events, and AF-associated health utilisation.ETHICS AND DISSEMINATION:The Ethics Committee in Fuwai Hospital approved this study. Patients will give informed consent to the study. An information leaflet will be provided to participating patients to introduce the SLAAO procedure. Patients and the public will not get involved in developing the research hypothesis, study design or any other part of this protocol. We plan to publish several papers in peer-reviewed journals about the current research and these will include a description of the study's development and the main findings of the study.TRIAL REGISTRATION NUMBER:ChiCTR2100042238.

Association between stress hyperglycaemia and in-hospital cardiac events after coronary artery bypass grafting in patients without diabetes: A retrospective observational study of 5450 patients.

AIMS:To investigate the impact of stress hyperglycaemia (SH) on in-hospital adverse cardiac events after coronary artery bypass grafting (CABG) in patients without diabetes.MATERIALS AND METHODS:In total, 5450 patients without diabetes who underwent CABG were analysed. SH was defined as any two instances in which the random blood glucose level was >7.8 mmol/L after CABG in the intensive care unit (ICU). The primary outcome was major adverse cardiac events (MACEs), including in-hospital mortality, acute myocardial infarction, stroke and acute renal failure. Secondary outcomes included surgical site infection (SSI) and length of ICU stay.RESULTS:Patients with SH had higher rates of MACEs (5.7% vs. 2.3%, p < .0001) and higher SSI (3.3% vs. 1.4%, p = .0003) and longer ICU stays (2.6 ± 2.0 vs. 1.3 ± 1.3 days, p < .0001) than those without SH. Furthermore, SH was associated with a higher risk of MACEs [odds ratio (OR): 2.32, 95% confidence interval (CI): 1.38-3.90], SSI (OR: 2.21, 95% CI: 1.20-3.95) and longer ICU stay (OR: 12.27, 95% CI: 9.41-16.92) after adjusting for confounders. Subgroup analysis showed that patients with SH >10 mmol/L or SH that occurred in the ICU and lasted more than 48 h had increased risks of postoperative complications (p < .05).CONCLUSIONS:SH was significantly associated with an increased risk of MACEs, SSI and longer ICU stay after CABG in patients without diabetes. In addition, SH >10 mmol/L or that occurred in the ICU and lasted more than 48 h increased the risk of adverse outcomes.

Effect of glycemic control and glucose fluctuation on in-hospital adverse outcomes after on-pump coronary artery bypass grafting in patients with diabetes: a retrospective study.

BACKGROUND:The optimal glycemic control level in diabetic patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (On-Pump) remains unclear. Therefore, this study aimed to investigate the effect of different blood glucose control levels and glucose fluctuations on in-hospital adverse outcomes in diabetic patients undergoing on-pump CABG.METHOD:A total of 3918 patients with diabetes undergoing CABG were reviewed in this study. A total of 1638 patients were eligible for inclusion and were categorized into strict, moderate and liberal glucose control groups based on post-operative mean blood glucose control levels of  < 7.8 mmol/L, from 7.8 to 9.9 mmol/L and ≥ 10.0 mmoL/L, respectively. The primary endpoint was defined as a composite endpoint including in-hospital all-cause mortality and major cardiovascular complications. The secondary endpoint was defined as major cardiovascular complications including acute myocardial infarction, strokes and acute kidney injuries. To determine the associations between blood glucose fluctuations and adverse outcomes, patients with different glycemic control levels were further divided into subgroups according to whether the largest amplitude of glycemic excursion (LAGE) was ≥ 4.4 mmol/L or not.RESULTS:A total of 126 (7.7%) patients had a composite endpoint. Compared with moderate control, strict glucose control was associated with an increased risk of the primary endpoint (adjusted OR = 2.22, 95% CI 1.18-4.15, p = 0.01) and the secondary endpoint (adjusted OR = 1.95, 95% CI 1.01-3.77, p = 0.049). Furthermore, LAGE ≥ 4.4 mmol/L was significantly associated with the primary endpoint (adjusted OR = 1.67, 95% CI 1.12-2.50, p = 0.01) and the secondary endpoint (adjusted OR = 1.75, 95% CI 1.17-2.62, p = 0.01),respectively. Patients with LAGE ≥ 4.4 mmol/L had significantly higher rates of the composite endpoint and major vascular complications in both the strict-control (the primary endpoint, 66.7% vs 12.4%, p = 0.034, the secondary endpoint, 66.7% vs 10.3%, p = 0.03) and moderate-control groups (the primary endpoint, 10.2% vs 6.0%, p = 0.03, the secondary endpoint, 10.2% vs 5.8%, p = 0.02).CONCLUSIONS:After On-Pump CABG patients with diabetes, strict glucose control (< 7.8 mmol/L) and relatively large glucose fluctuations (LAGE ≥ 4.4 mmol/L) were independently associated with in-hospital adverse outcomes.

Evaluation of the effectiveness and safety of a multi-faceted computerized antimicrobial stewardship intervention in surgical settings: A single-centre cluster-randomized controlled trial.

BACKGROUND:Inappropriate antimicrobial use is common among patients undergoing surgery. It remains unclear whether a multi-faceted computerized antimicrobial stewardship programme is effective and safe in reducing inappropriate antimicrobial use in surgical settings.METHODS:A multi-faceted computerized antimicrobial stewardship intervention system was developed, and an open-label, cluster-randomized, controlled trial was conducted among 18 surgical teams that enrolled 2470 patients for open chest cardiovascular surgery. The surgical teams were divided at random into intervention and control groups at a ratio of 1:1. The primary endpoints were days of therapy (DOT)/1000 patient-days, defined daily dose (DDD)/1000 patient-days and length of therapy (LOT)/1000 patient-days.RESULTS:Mean DOT, DDD and LOT per 1000 patient-days were significantly lower in the intervention group compared with the control group (472.2 vs 539.8, 459.5 vs 553.8, and 438.4 vs 488.7; P<0.05), with reductions of 14.2% [95% confidence interval (CI) 11.8-16.7%], 18.7% (95% CI 15.9-21.4%) and 11.9% (95% CI 9.6-14.1%), respectively. The daily risk of inappropriate antimicrobial use after discharge from the intensive care unit decreased by 23.9% [95% CI 15.5-31.5% (incidence risk ratio 0.76, 95% CI 0.69-0.85)] in the intervention group. There was no significant difference in rates of infection or surgical-related complications between the groups. Median antimicrobial costs were significantly lower in the intervention group {873.4 [interquartile range (IQR) 684.5-1255.4] RMB vs 1178.7 (IQR 869.1-1814.5) RMB; P<0.001} (1 RMB approximately equivalent to 0.16 US$ in 2022).CONCLUSIONS:The multi-faceted computerized antimicrobial stewardship interventions reduced inappropriate antimicrobial use safely.CLINICAL TRIAL REGISTRATION:Clinicaltrials.gov: NCT04328090.

Causal effect of hypertension and blood pressure on aortic diseases: evidence from Mendelian randomization.

Hypertension or elevated blood pressure was documented to be an important risk factor for aortic diseases in observational studies, yet the causality remains to be determined. By applying a two-sample Mendelian randomization (MR) approach, we aim to determine whether hypertension or elevated blood pressure (systolic blood pressure [SBP] or diastolic blood pressure [DBP]) is linked causally to aortic aneurysm or aortic dissection. Genetic instruments and summary statistics for hypertension and aortic diseases were obtained from large genome-wide association studies. The traditional inverse variance weighted (IVW) method was used to obtain the causal estimates. Sensitivity analyses including MR-Egger, weighted median and multivariable MR were also performed. Our results suggested that genetic liability to hypertension was associated with aortic dissection (odds ratio [OR]: 1.81; 95% confidence interval [CI]: 1.27-2.58; P = 1.13 × 10-3) and aortic aneurysm (OR: 1.43; 95% CI: 1.22-1.66; P = 7.79 × 10-6). Per standard deviation increase in genetically-determined DBP was significantly associated with increased aortic dissection (OR: 1.14; 95% CI: 1.09-1.19; P = 1.58 × 10-9) and aortic aneurysm (OR: 1.07; 95% CI: 1.05-1.09; P = 8.37 × 10-14). There was a null association between SBP and aortic dissection (OR: 1.01; 95% CI: 0.99-1.94; P = 0.38) or aortic aneurysm (OR: 1.00; 95% CI: 0.99-1.01; P = 0.92). Sensitivity analyses documented similar results. Therefore, hypertension and elevated DBP are causally associated with higher risks of aortic aneurysm and aortic dissection. Preventive interventions for aortic diseases may consider individuals with hypertension, especially those with higher DBP. Meanwhile, further research is required to determine the mechanisms underlying the significantly greater correlation between DBP and aortic diseases than SBP.

Clinical implication of coronary artery bypass grafting with surgical ventricular reconstruction in clinical practice.

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.

Long-term outcomes after coronary artery bypass graft with or without surgical ventricular reconstruction in patients with severe left ventricular dysfunction.

Background:Patients with chronic myocardial infarction (MI) and severe left ventricular (LV) dysfunction have poor clinical outcomes. This study aimed to determine whether coronary artery bypass graft (CABG) with surgical ventricular reconstruction (SVR) leads to further improvement in long-term patient outcomes compared with isolated CABG (I-CABG).Methods:From April 2010 to June 2013, 140 consecutive patients with chronic MI and severe LV dysfunction who received contrast-enhanced cardiovascular magnetic resonance imaging (CE-CMR) within 1 month before surgery were enrolled in this study. The cardiovascular events (CVEs) and long-term survival of patients who underwent CABG and SVR were compared with those who met the criteria for SVR but received I-CABG.Results:A total of 140 patients were included in the final analysis, including 70 patients who underwent CABG and SVR and 70 patients who underwent I-CABG. No differences were observed in the baseline characteristics, LV function, and late gadolinium enhancement (LGE) between the two groups. CABG+SVR patients experienced a longer cardiopulmonary bypass (CPB) time (116.0±35.0 vs. 100.2±23.8 minutes, P=0.002) and ventilation time [median (interquartile range): 22.0 (17.0, 37.0) vs. 20.0 (15.0, 24.0) hours, P=0.019] than I-CABG patients. During a mean follow-up of 123.1±12.7 months (range, 102-140 months), the CABG+SVR group had fewer rehospitalizations for congestive heart failure (CHF) (4.3% vs. 19.1%, P=0.007), but no statistical difference in the mortality rate was observed (2.9% vs. 4.4%, P=0.987). The cumulative CVE-free survival rate was significantly higher in CABG+SVR patients (87.0% vs. 67.6%, P=0.007).Conclusions:Our findings indicated that patients with chronic MI and severe LV dysfunction experienced similar perioperative outcomes after CABG+SVR or I-CABG. However, the CABG+SVR group resulted in fewer rehospitalizations for CHF and a higher cumulative CVE-free survival rate.

Effect of early hypoglycaemia on hospitalization outcomes in patients undergoing coronary artery bypass grafting.

OBJECTIVE:To investigate the effect of early postoperative hypoglycaemia on hospitalization outcomes including major cardiovascular complications and in-hospital mortality among patients undergoing coronary artery bypass grafting (CABG).METHODS:Data from an observational study of 9583 patients in the intensive care unit (ICU) who underwent CABG were analyzed. Hypoglycaemia was defined as a nadir blood glucose level <70 mg/dL (3.9 mmol/L). One-to-one propensity score matching (PSM) was used to identify 251-balanced pairs of patients to compare outcomes.RESULTS:A total of 306 (3.2%) patients experienced hypoglycaemia, of whom, 133 had diabetes, 173 hadn't diabetes. Patients who were hypoglycaemia had higher incidences of compositeoutcomes than those without hypoglycaemia (12.1% versus 6.0%, P < 0.0001). Postoperative length of ICU stay was longer in patients with hypoglycaemia [2.8 (0.8-21.0) versus 2.0 (0.25-36.0) days, P < 0.0001]. After PSM, the compositeoutcomes and length of ICU stay remained significantly increased for the patients with hypoglycaemia [compositeoutcomes: odd ratio (OR) 2.78, 95% CI, 1.30-5.88, P = 0.01; length of ICU stay: OR 1.60, 95% CI, 1.14-2.26, P = 0.007].CONCLUSION:Postoperative hypoglycaemia was an independent associated factor of adverse composite outcomes and a lengthened ICU stay after CABG. Hypoglycaemia should be avoided for both postoperative patients with and without diabetes.

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.