Advances in cancer therapy have markedly expanded the population of survivors at risk for cardiovascular disease; however, evidence regarding the safety and outcomes of coronary artery bypass grafting (CABG) in patients...Advances in cancer therapy have markedly expanded the population of survivors at risk for cardiovascular disease; however, evidence regarding the safety and outcomes of coronary artery bypass grafting (CABG) in patients with malignancy remains scarce. This study aimed to investigate the prognostic impact of cancer on early postoperative outcomes after CABG, including mortality, bleeding, infection, stroke, and acute kidney injury (AKI). We conducted a systematic review and meta-analysis according to the PRISMA and Cochrane guidelines. PubMed, Embase, and Cochrane Library were searched through August 2025 for studies comparing CABG outcomes in patients with and without cancer. Random-effects models generated pooled odds ratios (OR) and 95% confidence intervals (CI). Five studies were included, comprising 99,866 patients (30,818 with cancer). Early mortality was higher in cancer patients (OR 1.88; 95% CI [1.004 to 3.520]; p = 0.049) as well as bleeding (OR 1.47; 95% CI [1.018 to 2.138]; p = 0.044). Infection (OR 1.66; 95% CI [0.142 to 19.477]; p = 0.467), stroke (OR 0.85; 95% CI [0.463 to 1.563]; p = 0.370), and AKI (OR 1.08; 95% CI [0.755 to 1.545]; p = 0.545) did not significantly differ between groups. Sensitivity analysis excluding the only study restricted to non-metastatic solid tumors reduced heterogeneity (I² from 87.6% to 0%) and strengthened the mortality association (OR 2.65; 95% CI [1.94 to 3.61]; p = 0.002). In conclusion, cancer was associated with increased early mortality and bleeding after CABG, whereas infection, stroke, and AKI rates were not, and CABG prognosis may depend on cancer activity and stage, underscoring the need for individualized risk assessment and prospective validation.
This sub-analysis of SEQUOIA-HCM (NCT05186818) evaluated the efficacy and safety of aficamten in obstructive hypertrophic cardiomyopathy (oHCM) and very-high Valsalva left ventricular outflow tract gradients (LVOT-G). Pa...This sub-analysis of SEQUOIA-HCM (NCT05186818) evaluated the efficacy and safety of aficamten in obstructive hypertrophic cardiomyopathy (oHCM) and very-high Valsalva left ventricular outflow tract gradients (LVOT-G). Patients with oHCM and Valsalva LVOT-G ≥100 mm Hg (n = 73) were randomized to aficamten (n = 33) or placebo (n = 40) for 24 weeks. The primary endpoint was proportional change in Valsalva LVOT-G from baseline to Week 24. Secondary endpoints included the proportion of patients achieving Valsalva LVOT-G < 30 mm Hg, absolute change in Valsalva LVOT-G, Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CCS), New York Heart Association (NYHA) functional class, NT-proBNP, and exercise capacity (peak oxygen uptake [pVO₂], workload), and time eligible for septal reduction therapy (SRT). Over 24 weeks, aficamten significantly reduced Valsalva LVOT-G by 66% from 123 ± 28 mm Hg to 41 ± 30 mm Hg (p = 0.001), including to <30 mm Hg in 42% of aficamten patients (p <0.001). Aficamten was also associated with symptom relief: 16 patients (48%) had ≥1 improvement in NYHA class, including 9 with both class I and ≥5-point increase in KCCQ-CSS. Compared with placebo, aficamten substantially decreased NT-proBNP concentration (‒85%; p = 0.001) and increased pVO₂ (+1.8 ml/kg/min; p = 0.003). Aficamten also reduced time eligible for SRT (p = 0.002) without any clinically relevant decrease in systolic function (ejection fraction <50%). Aficamten effectively reduced gradients in patients with oHCM and very-high Valsalva LVOT-G. Hemodynamic changes were associated with enhanced exercise capacity and symptom relief, underscoring aficamten treatment benefit across the spectrum of LVOT-G.
Risk factors (RF) for permanent pacemaker (PPM) placement in cardiac surgery include valvular operations and redo operations. We aim to identify RF for PPM placement prior to discharge (DC) specifically among redo mitral...Risk factors (RF) for permanent pacemaker (PPM) placement in cardiac surgery include valvular operations and redo operations. We aim to identify RF for PPM placement prior to discharge (DC) specifically among redo mitral valvular operations, and to analyze outcomes in this population. Our retrospective review considered 943 patients undergoing redo MV operations between 01/2002 and 12/2021, excluding patients experiencing in-hospital death within 48 hours of their operation and patients with existing PPM or implanted cardiac defibrillator (ICD). Patients (n = 742) were categorized based on whether they received a PPM before DC or not. Of the 742 patients analyzed, 47 (6%) had a PPM placed before DC. Logistic regression analysis identified increasing age, increasing severity of MR (OR: 1.9, p < 0.01), bioprosthetic and mechanical valve implantation (OR: 1.9, p = 0.045), sternotomy incision (OR: 0.12, p = 0.04), and simultaneous tricuspid procedure (OR: 1.9, p = 0.06) as predictors of PPM placement. Cox hazards analysis showed advanced age (HR 1.03, p < 0.01), higher NYHA class (HR 1.45, p < 0.01), DM (HR 1.51, p = 0.01), and prior valve replacement (HR 1.43, p < 0.01) are predictors of mortality, while PPM placement before DC was not. In redo MV surgery, RF for PPM include procedural risks that prolong operative time and increase risk of conduction system injury, including simultaneous tricuspid valve procedures, maximally invasive approaches, and valve replacement, as well as poorer preoperative functional status, advanced age, and medical comorbidities. PPM placement before DC was not predictive of mortality, and did not negatively impact survival in long term follow-up.
Fragmented QRS (fQRS) on electrocardiography (ECG) is a known marker of myocardial fibrosis and electrical instability. However, its prognostic role in patients undergoing transcatheter aortic valve implantation (TAVI) r...Fragmented QRS (fQRS) on electrocardiography (ECG) is a known marker of myocardial fibrosis and electrical instability. However, its prognostic role in patients undergoing transcatheter aortic valve implantation (TAVI) remains uncertain. This study aimed to evaluate whether the presence of fQRS on preprocedural ECG is associated with increased risk of in-hospital major adverse cardiovascular events (MACE) in patients undergoing TAVI for severe aortic stenosis. A total of 149 patients undergoing TAVI between 2018 and 2025 were retrospectively analyzed. Patients were divided into 2 groups based on the presence of fQRS. Clinical, laboratory, and echocardiographic parameters were compared, and multivariate logistic regression was used to identify independent predictors of in-hospital MACE. fQRS was present in 54 patients (36.2%) and was significantly associated with higher incidence of in-hospital MACE (48.1% vs 18.9%, p < 0.001). Patients with fQRS also had lower glomerular filtration rates (p = 0.009) and higher rates of contrast-induced acute kidney injury (p = 0.002). Multivariate analysis confirmed that fQRS (odds ratio [OR] 3.773, p = 0.002), low hemoglobin levels (OR: 0.721, p = 0.003), and smaller valve size (OR: 0.858, p = 0.024) were independent predictors of MACE. In conclusion, the presence of fQRS on preprocedural ECG is independently associated with a higher risk of in-hospital MACE in patients undergoing TAVI. fQRS may serve as a simple, non-invasive marker to improve perioperative risk stratification and clinical decision-making in this high-risk population.
Patients' length of stay (LOS) during admission for myocardial infarction (MI) represents a closely tracked outcome metric for Cardiology services, which has declined over time. Charlson Comorbidity Index (CCI) is a vali...Patients' length of stay (LOS) during admission for myocardial infarction (MI) represents a closely tracked outcome metric for Cardiology services, which has declined over time. Charlson Comorbidity Index (CCI) is a validated tool for assessing overall disease burden, but its abstraction is laborious. Large language models (LLMs) have emerged as an attractive option for chart abstraction, with limited uptake so far. We studied n = 6,129 MI admissions at a tertiary cardiac hospital from May 2018 to August 2024. An LLM was used to derive CCI from clinical case notes with manual validation by expert auditors in 10% of patients (R-squared 0.81). Fine and Gray survival analysis was performed to study time-to-discharge in mixed survival models with clustering on individual patients and in-hospital death as competing outcome, adjusting for covariates not already included in CCI (e.g., age, race, smoking, MI type, atrial fibrillation, revascularization). We found an increase in CCI over time (0.09 (CI: 0.06 to 0.12) points per year) due to more diabetes, hypertension, renal failure, lymphomas and metastatic solid tumors) and a concomitant rise in mean LOS by 6.5 (CI: 3.9 to 9.1) hours annually. CCI emerged as the strongest predictor of LOS (p < 2e-16), with no significant effect by calendar year to suggest a residual secular trend after full adjustment (p = 0.17). These results validate the use of an LLM for chart abstraction and indicate that rising patient complexity is reversing the earlier downtrend in LOS in MI patients.
The evidence for optimal antithrombotic therapy after isolated surgical mitral valve repair (MVr) is limited resulting in variable use of antithrombotic regimens in practice. This study aimed to characterize what antithr...The evidence for optimal antithrombotic therapy after isolated surgical mitral valve repair (MVr) is limited resulting in variable use of antithrombotic regimens in practice. This study aimed to characterize what antithrombotic regimens are being used and elucidate rationale. We conducted a retrospective descriptive study of adult patients after isolated surgical MVr at two cardiac surgery centers to characterize the type of antithrombotics used, timing of initiation, and duration. We then conducted semi-structured interviews of cardiac surgeons across Canada to elucidate post-MVr antithrombotic prescribing practices along with their rationale. Of 365 MVr patient screened, 89 had isolated MVr without a concomitant indication for anticoagulation and majority were prescribed dual antiplatelet therapy (DAPT) (40%) or warfarin (36%). Other regimens included antiplatelet (13%), warfarin plus acetylsalicylic acid (ASA) (6%), or apixaban (5%). The intended duration of therapy was 3 months in 85% of cases, and after completion of initial antithrombotic therapy most cases (80%) were followed by indefinite ASA thereafter. Of the 15 surgeons interviewed, preferred regimens included ASA (47%), warfarin plus ASA (20%), warfarin (13%), apixaban (13%), apixaban plus ASA (13%), or DAPT (13%). Surgeons identified convention or clinical experience as rationale for choice of therapy. Those preferring anticoagulation cited high rates of post-operative atrial fibrillation and concern for preventable strokes while those preferring antiplatelets cited minimal risk of stroke and high risks of bleeds. In conclusion, this retrospective descriptive study and semi-structured interview found substantial heterogeneity in the antithrombotic regimens used and prescribing patterns following isolated mitral valve repair.
The long-term clinical impact of mitral prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) remains incompletely defined. We aimed to systematically assess the prevalence of mitral PPM and its associat...The long-term clinical impact of mitral prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) remains incompletely defined. We aimed to systematically assess the prevalence of mitral PPM and its association with long-term mortality, cardiac death, and heart failure-related hospitalizations. We conducted a systematic review and meta-analysis of observational studies reporting Kaplan-Meier time-to-event data in patients with and without mitral PPM. Sixteen studies, including 10,872 patients, were analyzed. The pooled prevalence of any mitral PPM was 43% (95% confidence interval [CI], 29% to 59%), with significant heterogeneity (I² = 100%). All-cause mortality was higher with PPM (hazard ratio [HR], 1.32; 95% CI, 1.20 to 1.45; p < 0.001; RMST difference, -3.35 years; 95% CI, -3.98 to -2.71; p < 0.001), as was cardiac mortality (HR, 1.96; 95% CI, 1.54 to 2.51; p < 0.001) and risk of heart failure hospitalization (HR, 2.82; 95% CI, 1.86 to 4.29; p < 0.001). Risk-adjusted analyses confirmed these associations for all-cause and cardiac mortality. Severity-stratified analyses demonstrated a gradient effect: moderate PPM showed a trend toward higher mortality (HR, 1.12; 95% CI, 0.98 to 1.27; p = 0.08), whereas severe PPM significantly increased mortality risk (HR, 1.36; 95% CI, 1.15 to 1.60; p < 0.001). Sensitivity analyses according to PPM quantification method (in vivo vs Doppler) and leave-one-out testing confirmed the robustness of the results. In conclusion, mitral PPM is common and independently associated with increased long-term all-cause mortality, cardiac death, and heart failure hospitalizations after MVR, with a dose-response relationship according to PPM severity. These findings highlight the importance of preventive strategies to avoid PPM when planning MVR.
As survival improves for adults with tetralogy of Fallot (TOF), long-term outcomes have taken on greater importance. We aimed to compare the long-term health, socioeconomic, and quality of life (QOL) outcomes between adu...As survival improves for adults with tetralogy of Fallot (TOF), long-term outcomes have taken on greater importance. We aimed to compare the long-term health, socioeconomic, and quality of life (QOL) outcomes between adult survivors and sibling controls. CHD PULSE is a cross-sectional survey from 2021 to 2023 across 11 Pediatric Cardiac Care Consortium centers; 3,133 adults with a history of CHD and 326 unaffected siblings completed surveys on health, socioeconomic, and QOL outcomes with the Patient-Reported Outcomes Measurement Information System (PROMIS). There were 337 TOF survivors, who were similar in age to controls (33.4 yrs vs 32.0 yrs, p = 0.076) but less likely to be female (56% vs 65%, p = 0.022). TOF survivors more frequently reported difficulty paying for medical care (31% vs 15%, p < 0.001), overnight hospitalizations (13% vs 7%, p = 0.015), and concern for future health (53% vs 38%, p < 0.001). They were less likely to have an associate's degree or higher (53% vs 74%, p < 0.001) and more likely to have health-related work limitations (43% vs 8%, p < 0.001) or be unemployed within the preceding year (20% vs 7% p < 0.001). However, PROMIS scores were favorable for both TOF survivors and the sibling comparison group. In conclusion, adults with TOF face persistent medical, education, and socioeconomic challenges relative to unaffected siblings. However, PROMIS quality of life scores demonstrate resiliency in the TOF survivors, with similar self-perceived QOL to their siblings.
Out-of-hospital cardiac arrest (OHCA) without ST-segment elevation represents a challenging diagnostic scenario, particularly in young patients with low pretest probability of atherosclerotic disease. We report the case...Out-of-hospital cardiac arrest (OHCA) without ST-segment elevation represents a challenging diagnostic scenario, particularly in young patients with low pretest probability of atherosclerotic disease. We report the case of a 25-year-old man with cystic fibrosis who presented with ventricular fibrillation during a pulmonary exacerbation complicated by hemoptysis and hypoxemia. After successful resuscitation, electrocardiography showed anterolateral T-wave inversions and high-sensitivity troponin demonstrated a marked rise and fall. Transthoracic echocardiography revealed regional wall motion abnormalities with mildly reduced left ventricular ejection fraction. In the absence of ST-segment elevation, coronary computed tomography angiography was performed and excluded obstructive coronary artery disease and congenital anomalies. Early cardiac magnetic resonance demonstrated extensive transmural late gadolinium enhancement in a coronary distribution with microvascular obstruction, consistent with acute ischemic myocardial infarction despite normal epicardial coronaries, establishing a diagnosis of myocardial infarction with nonobstructive coronary arteries (MINOCA). This case illustrates a structured, stepwise, and entirely noninvasive multimodality imaging approach to OHCA without ST-elevation and highlights the central role of early cardiac magnetic resonance in mechanism clarification and clinical decision-making in suspected MINOCA.
Atrial fibrillation/flutter (AF/AFL) and supraventricular tachycardia (SVT) are common arrhythmias in pregnancy. While known to contribute to adverse outcomes, large studies have not evaluated cardiac and perinatal outco...Atrial fibrillation/flutter (AF/AFL) and supraventricular tachycardia (SVT) are common arrhythmias in pregnancy. While known to contribute to adverse outcomes, large studies have not evaluated cardiac and perinatal outcomes in patients with arrhythmias. The objective of this study is to compare the cardiac/perinatal outcomes of pregnant patients with AF/AFL and SVT in pregnancy versus those without arrhythmias. We performed a retrospective cohort study utilizing Epic Cosmos, a dataset from 1,500 US hospitals. We identified pregnancies between October 25, 2021, and October 24, 2024, of patients with a diagnosis of AF/AFL and SVT using simultaneous diagnoses codes for each arrhythmia and pregnancy. A control group of pregnancies without arrhythmias was also identified. Descriptive statistics were calculated, and comparisons were made with ANOVA or Chi-square tests, as appropriate. During the study period, there were 8,642 pregnant patients with AF/AFL, 29,638 with SVT, and 5,372,171 healthy pregnant controls. Patients with these arrhythmias were older (AF/AFL: 33 ± 6, SVT: 32 ± 6, control: 31 ± 6, p < 0.0001) with a higher body mass index than the control group. Those with arrhythmias experienced higher rates of heart failure (AF/AFL: 11%, SVT: 4%, control: 0.3%), thromboembolism, stroke, preterm birth, and cesarean delivery (all p < 0.0001). Patients with AF/AFL had 24 times higher odds of stroke compared to the control group (95% CI 21 to 27). In conclusion, while both AF/AFL and SVT are associated with adverse outcomes, AF/AFL had a higher association with heart failure and stroke in the perinatal period, and further research is need to understand optimal perinatal AF/AFL management, especially anticoagulation therapy.
Atrial fibrillation (AF) screening is important because AF can be paroxysmal and asymptomatic. Although AF is closely linked to certain abnormal echocardiographic parameters, these parameters have never been incorporated...Atrial fibrillation (AF) screening is important because AF can be paroxysmal and asymptomatic. Although AF is closely linked to certain abnormal echocardiographic parameters, these parameters have never been incorporated as criteria for AF screening. The SAFE-ECHO study is a prospective, randomized, open-label, multicenter trial to evaluate AF detection using extended electrocardiogram (ECG) monitoring in patients without AF who meet echocardiographic criteria, including left atrial enlargement (LAE), left ventricular hypertrophy (LVH), E/e' > 14, grade II/III diastolic dysfunction, valvular heart disease (VHD), or heart failure (HF). Patients will be randomized in a 1:1 ratio to contemporary care (control arm) versus proactive staged screening (study arm). In the study arm, patients will undergo a 30-second single strip ECG and 7-day continuous ECG monitoring at enrollment and every 3 months for 1 year. The total study duration is 2 years, comprising a 1-year screening period and an additional year of follow-up. The primary endpoint is detection of new-onset AF within the 12-month screening period. The secondary endpoint is any arrhythmia of clinical significance or those requiring clinical interventions or a change of treatments. The tertiary endpoint is a composite of ischemic stroke, systemic thromboembolism, myocardial infarction, HF hospitalization, or emergent visit or mortality after the screening period, which will be evaluated for exploratory purposes only. In conclusion, the SAFE-ECHO study aims to evaluate the feasibility of specific echocardiographic parameters as criteria for AF screening and to determine the AF detection yield of scheduled extended ECG monitoring, which may help inform future AF screening strategies. Trial registration: URL: https://clinicaltrials.gov; Unique identifier: NCT07278089.
Kato N, Ito J, Kaneko T
… +12 more, Hirose N, Amano M, Okada T, Sato Y, Ohno Y, Obokata M, Sato K, Watanabe H, Morita K, Machino-Ohtsuka T, Abe Y, Kagiyama N
The left atrium (LA) size varies in patients with atrial functional mitral regurgitation (AFMR) and its clinical impact remains unclear. This study aimed to assess the distribution of LA volume index (LAVI) and the impac...The left atrium (LA) size varies in patients with atrial functional mitral regurgitation (AFMR) and its clinical impact remains unclear. This study aimed to assess the distribution of LA volume index (LAVI) and the impact of LAVI on clinical outcomes in a large cohort of patients with ≥ moderate AFMR. Patients with AFMR diagnosed by transthoracic echocardiography in 2019 were retrospectively enrolled from the REVEAL-AFMR registry. The endpoint was a composite of cardiovascular death and heart failure hospitalization, compared across the LAVI groups. Of the 877 patients (age 78 ± 9 years, 45% male, 81% with atrial fibrillation), the median LAVI was 75 ml/m. LAVIs of < 50, 50 to 99, 100 to 149, 150 to 199, and ≥ 200 ml/m were observed in 14%, 55%, 18%, 7%, and 6%, respectively. The prevalence of severe MR increased across these LAVI groups (10%, 19%, 38%, 62%, and 66%; p <0.01 for trend), and the prevalence of symptoms also worsened accordingly (56%, 61%, 62%, 82%, and 96%; p <0.01 for trend). During the median follow up of 2.9 years, LAVIs ≥ 200 and 150 to 199 ml/m were associated with lower event-free survival compared with LAVI < 50 ml/m. LAVI ≥ 150 ml/m was associated with the adverse event (adjusted hazard ratio 2.14; 95% CI, 1.30 to 3.52; p <0.01), notably independent of severe mitral regurgitation (MR) and atrial fibrillation. In conclusion, larger LA was associated with severe MR and symptoms in patients with AFMR. Extremely enlarged LA with LAVI ≥ 150 ml/m was observed in 13% and associated with worse outcomes independent of MR severity and atrial fibrillation.
Infective endocarditis (IE) in pregnancy is a rare but serious infection that increases morbidity and mortality. We aimed to assess the risk factors and outcomes in pregnant patients with IE as compared to pregnancy with...Infective endocarditis (IE) in pregnancy is a rare but serious infection that increases morbidity and mortality. We aimed to assess the risk factors and outcomes in pregnant patients with IE as compared to pregnancy without IE. The National Inpatient Sample was used to identify hospitalizations for delivery from 2011 to 2020. Propensity score matching was performed to study the association of IE with the primary outcomes of in-hospital medical and obstetric complications. A total of 37,482,206 weighted delivery hospitalizations in women ≥18 years were identified, of which 2020 patients had IE. Pregnant patients with IE had a higher incidence of complications during delivery, including in-hospital mortality, pre-eclampsia/eclampsia, peripartum cardiomyopathy, acute coronary syndrome, stroke, acute kidney injury, pulmonary edema, cardiac arrhythmias, and venous thromboembolism compared to those without IE. In propensity-matched analysis, IE was significantly associated with a higher risk of in-hospital mortality (odds ratio 16.50 [95% confidence interval 3.65 to 74.60], p <0.001), acute kidney injury (30.70 [11.00 to 86.00], p <0.001), stroke (18.00 [4.02 to 80.60], p <0.001), cardiac arrhythmias (4.67 [3.19 to 6.83], p <0.001), and venous thromboembolism (7.50 [2.35 to 23.90], p <0.001) compared to patients without IE. In conclusion, delivery hospitalizations in patients with IE are associated with a high risk of mortality and complications.
Valvular heart disease (VHD) is increasingly prevalent and associated with substantial morbidity and mortality. However, severe multivalvular heart disease (MVHD) remains poorly characterized; therefore, we sought to elu...Valvular heart disease (VHD) is increasingly prevalent and associated with substantial morbidity and mortality. However, severe multivalvular heart disease (MVHD) remains poorly characterized; therefore, we sought to elucidate its prevalence, phenotypes, and clinical correlates. A single center study including all individuals with echocardiographic diagnosis of native VHD between 2010 and 2019 were included and grouped by the presence of severe MVHD. Multivariable logistic regression was used to determine the association between clinical and echocardiographic factors and presence of severe MVHD. A total of 95,588 patients (age 67 ± 16.4; female 57.1%) comprised the study cohort. Severe VHD was diagnosed in 7,499 (7.8%) patients: 87.7% with severe single VHD and 12.3% with severe MVHD. Among those with severe MVHD, mitral-tricuspid was the most prevalent valve combination (68.4%), followed by aortic-mitral (13.7%), and aortic-tricuspid (11.9%). According to MVHD type, mitral regurgitation, and tricuspid regurgitation was the most prevalent combination (70.6%), followed by aortic stenosis and tricuspid regurgitation (11.1%), and aortic stenosis and mitral regurgitation (7.6%). Severe MVHD was associated with older age (odds ratio [OR] 1.04 [1.03 to 1.05]), lower body surface area (OR 0.18 [0.08 to 0.41]), atrial fibrillation (1.92 [1.31 to 2.81]), chronic kidney disease (OR 2.08 [1.40 to 3.09]), rheumatic heart disease (OR 2.06 [1.23 to 3.45]), absence of hyperlipidemia (OR 0.41 [0.27 to 0.62]), larger left ventricular (LV) end-diastolic dimension (OR1.60 [1.26 to 2.03]), lateral E/e' (OR 1.03 [1.02 to 1.05]), and lower LV ejection fraction (OR 0.95 [0.94 to 0.96]). In conclusion, approximately 12% of patients with severe VHD had MVHD, most commonly involving the mitral and tricuspid valves, followed by aortic-mitral, and then aortic-tricuspid.