Objective:To evaluate the cost-effectiveness of implantable cardioverter defibrillator (ICD) and drug administration in primary prevention of sudden cardiac death (SCD) from the perspective of Chinese health system, and to provide reference for clinical and policy decision making.Methods:This was a cross-sectional study. A Markov model was developed to describe different health states of patients after treatment with ICD and drug therapy, and predict the cost of ICD and drug administration. The patient characteristics, efficacy, treatment complications and utilities were obtained from the literature. The costs were based on the tender price listed by government and the results of cost surveys of fifteen local clinicians from different demographic parts of China. For each therapy, the total lifetime costs and quality-adjusted life-years (QALY) were modelled, and the incremental cost-effectiveness ratio (ICER) was calculated. Deterministic and probabilistic sensitivity analyses were performed to assess the uncertainty of the model parameters.Results:The incremental cost-effectiveness ratio of ICD compared to drug administration was 182 618 yuan/QALY, about 2.1 times of Chinese gross domestic product (GDP) per capita. Referring to three times of Chinese GDP per capita (257 100 yuan) in 2022, ICD therapy was more cost-effective in preventing SCD among primary prevention patients than traditional drug administration. Probability sensitivity analysis showed that ICD was 86.3%, more cost effective than drug administration in preventing SCD.Conclusion:In the prevention of SCD in China, the economic value of ICD therapy is superior to drug administration, and it can be used as the preferred plan for the primary prevention of SCD.
Left bundle branch area pacing (LBBAP) has emerged as an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). We aimed to compare the morbidity and mortality associated with LBBAP versus BVP in patients undergoing CRT implantation. Consecutive patients who received CRT from two high-volume implantation centers were retrospectively recruited. The primary endpoint was a composite of all-cause death and heart failure hospitalization, and the secondary endpoint was all-cause death. A total of 491 patients receiving CRT (154 via LBBAP and 337 via BVP) were included, with a median follow-up of 31 months. The primary endpoint was reached by 21 (13.6
全皮下植入型心律转复除颤器（S-ICD）是心脏性猝死的有效防治手段之一，其术前筛选、植入术式等与经静脉植入型心律转复除颤器不同。为规范与推广S-ICD的临床应用，中华医学会心电生理和起搏分会（CSPE）和中国医师协会心律学专业委员会（CSA）共同组织了多名国内该领域知名专家，就S-ICD的发展历程、适应证、术前筛选及准备、植入流程、并发症及处理、程控和随访等多方面进行了深入解析。
Objective:To explore the feasibility of tricuspid valve annulus (TVA) angiography in guiding conduction system pacing (CSP) in Beagles.Methods:Six adult beagles (12-15 kg, male or female animals) underwent TVA angiography using dual dual pacing lead (3830) under the right anterior oblique (RAO) 30°.The His sheath with pacing lead was moved nearby the tricuspid septal to map HB potential for distal His-bundle pacing (DHBP) .A "triangle zone" was drawn from the TVA summit, right and left midpoints of the right ventricular free-wall.For 3 beagles, the "triangle-center" was intended as the target lead screwing position for left septal fascicle pacing (LSFP) .For another 3 beagles, move the sheath parallel to the bottom of the "triangle-center" to the left line of this triangle to perform left posterior fascicle pacing (LPFP). Twelve-lead electrocardiogram, intra-cardiac electrogram, Purkinje potential, pacing threshold and R-wave amplitude etc.were collected. Five percent Lugo iodine staining method was used for determining whether the final position of the pacing lead matches the imaging position during the procedure.Results:All beagles successfully underwent CSP, and the electrocardiogram met the guideline criteria for CSP capture.Subgroup analysis showed that there were no significant difference in P-V interval [ (11.33±0.58) ms vs. (11.00±1.00) ms, P=0.643], V 6 R-wave peak time [ (36.67±1.53) ms vs. (34.67±4.04) ms, P=0.468] and paced QRS duration [ (68.33±3.21) ms vs. (63.00±4.58) ms, P=0.174] between LSFP and LPFP.There were also no significant difference in pacing parameters between the two pacing modality.Transient right bundle branch injury occurred in 5 dogs during the implementation of DHBP.Two dogs eventually developed permanent right bundle branch block.No lead-related complications were observed during the follow-up.Purkinje conduction system components in left ventricular endocardium were dyed using 5% Lugol iodine, indicating that the final position of the lead was consistent with the imaging position during the procedure. Conclusion:The TVA angiography approach was useful for implement DHBP, LSFP and LPFP, demonstrating its safety, effective and easiness to promote.
Objective:To evaluate the clinical value of cardiovascular magnetic resonance-feature tracking technique (CMR-FT) -based left ventricle strain for predicting echocardiographic response after cardiac resynchronization therapy (CRT) .Methods:This study retrospectively enrolled heart failure patients who underwent biventricular pacing CRT between January 2017 and December 2019, with QRS duration (QRSd) >120 ms but whose electrocardiogram morphology did not meet the true left bundle branch block (LBBB) criteria. All patients underwent plain cardiovascular magnetic resonance (CMR) scan within 3 months prior to the procedure. CMR-FT was used to quantify the left ventricle (LV) global, lateral and septal (Sep) strain in longitudinal (LS), circumferential (CS) and radial (RS) dimensions. CRT response was defined as a≥5% absolute increase in left ventricular ejection fraction (LVEF) evaluated by echocardiography 6 months after the procedure.Results:Seventy-three patients were included [age (55.6±11.6) years old, male 79.45% (58/73) ], among whom 60.3% (44/73) were CRT responders, and only 8.2% (6/73) were super-responders. Compared with non-responders, the responders had significantly impaired Sep-LS [-3.98% (-6.05%--1.44%) vs. -7.08% (-8.75%--3.14%), P=0.038], Sep-CS [-2.75% (-4.60%--0.98%) vs. -5.71% (-7.12%--4.09%), P<0.001] and Sep-RS [4.17% (1.77%-6.68%) vs. 7.55% (5.72%-9.77%), P<0.001]. Sep-RS and Sep-CS significantly correlated with LVEF improvement (Sep-RS: r=-0.42, P<0.001; Sep-CS: r=0.43, P<0.001). Univariate logistic regression indicated that baseline QRSd, LVEF, QRSd reduction, cardiac output, Sep-CS and Sep-RS were predictors of CRT response. After adjusting other significant factors, Sep-CS was also independently associated with CRT response [ OR=1.201 95% CI 1.010-1.428, P=0.039]. With cut-off values of -4.72% and 5.71% respectively, Sep-CS and Sep-RS yielded area under the receiver operating characteristic curve of 0.756 and 0.752 respectively for predicting CRT response. Conclusion:In heart failure patients without true LBBB, CMR-FT-evaluated impaired septal circumferential and radial strain were associated with CRT response. These might be promising imaging biomarkers for providing favorable predictive value to identify who might benefit from CRT.
传统心脏起搏器通常通过锁骨下静脉入路植入。由于对导线的长度需求、递送系统长度限制以及髂静脉穿刺和囊袋制作流程顾虑，甚少选择髂静脉入路。本文拟介绍本中心经髂外静脉途径分别植入双腔起搏器和三腔起搏器的2个病例及其随访结果。
心房颤动（房颤）是临床常见的心律失常疾病，导管消融是房颤节律控制的有效治疗方式。消融形成连续透壁的损伤是手术成功的基础，目前消融指数（AI）作为消融损伤的综合评价指标已得到广泛应用。但研究显示，相同AI下组织消融损伤程度与阻抗大小显著相关，阻抗作为反映组织本身性质的指标逐渐受到关注。本文将对阻抗的影响因素、与损伤大小的关系和目前应用进展加以综述。
临床上对于窄QRS波的心脏性猝死高风险心力衰竭患者，植入型心律转复除颤器（ICD）可降低其心脏性猝死风险，但不能改善其心功能；同时植入心肌收缩力调节器（CCM）能够提高心脏功能，有效改善患者的临床症状。本文拟报道1例CCM联合ICD一站式植入在扩张型心肌病患者中应用。
Objective:To analyze and summarize the clinical and imaging features of lead perforation.Methods:The medical records of patients with lead perforation who were discharged from Peking University People′s Hospital from January 1, 2008 to April 1, 2023 were reviewed. The demographic data, medical history, laboratory and imaging examination data, lead related parameters were collected.Results:A total of 106 patients were enrolled, 64.1% (68/106) were female, and the mean age was (67±15) years. Ninety-four (88.5%, 94/106) patients had perforation-related symptoms, and chest pain was the most common (65.1%, 69/106). A total of 106 perforated leads were included, 98 (92.5%, 98/106) were pacing leads, and 8 (7.5%, 8/106) were implantable cardioverter defibrillator (ICD) leads. There were 85 active fixed leads (80.2%, 85/106), and 21 passive fixed electrodes (19.8%, 21/106). Eighty-four (79.2%, 84/106) patients had at least one parameter abnormality. Eighty-six cases (81.1%, 86/106) were diagnosed by imaging examination, and 20 cases (18.9%, 20/106) were diagnosed by symptoms, signs, and lead parameters. In terms of the detection rate of lead perforation, the positive rates of CT (88.2%, 53/60) and X-ray multi-position fluoroscopy (90.3%, 84/93) were statistically higher than that of echocardiography (35.2%, 37/106) and chest X-ray (32.1%, 34/106) ( P < 0.001) . Conclusion:The diagnosis of lead perforation should be combined with imaging examination, symptoms/signs and lead parameters. X-ray multi-position fluoroscopy and chest CT examination have a higher detection rate and can be used as the preferred examination methods.
电风暴是短时间内发生室性心律失常的心脏电不稳定状态，最为广泛接受的定义是24 h内室性心动过速或心室颤动发作≥3次。电风暴严重影响患者的生活质量，甚至危及其生命。心脏交感神经过度激活在电风暴的发生中扮演重要角色，因此干预交感神经活性是治疗电风暴的潜在手段。目前干预交感神经活性的主要方式包括镇静、去肾交感神经、硬膜外麻醉、星状神经节干预等。本文综述了电风暴和干预交感神经的相关概念及研究进展。
Objective:To evaluate the effects of unipolar and bipolar left bundle branch pacing (LBBP) on cardiac electrical and mechanical synchrony.Methods:A retrospective study of patients undergoing LBBP from January 2018 to August 2019 in Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, cardiac electrical and mechanical synchrony were evaluated in three different pacing modes: atrial pacing with atrioventricular node (SR Group), unipolar left bundle branch pacing (ULBBP group) at 1.0 V/0.5 ms and bipolar left bundle branch pacing (BLBBP group) at 7.5 V/0.5 ms, respectively.From June 2018 to October 2020, 10 normal patients with complete right bundle branch block (CRBBB) with normal cardiac structure and function were selected as the control group.The cardiac electrical and mechanical synchrony were also compared between LBBP and CRBBB patients.Results:The median age of the patients was 64.8 years old, age ranging from 44 to 83 years, and 5 patients were male (5/15, 33.3%) .There was no significant difference in baseline characteristics between LBBP group and CRBBB group.The QRS duration (QRSd) during pacing and the interventricular mechanical delay (IVMD) in LBBP group were significantly shorter than those in CRBBB group [QRSd: (135.0±16.2) ms vs. (157.1±16.4) ms, P=0.003; IVMD: (19.7±19.0) ms vs. (52.5±15.5) ms, P<0.001] .During LBBP, the QRSd of BLBBP was significantly shorter than that of ULBBP [ (120.3±14.2) ms vs. (135.0±16.2) ms, P<0.001] .However, there was no significant difference in IVMD, standard deviation of time-to-peak contraction velocity in the 12 segments of left ventricle (Tmsv12-SD) and global longitudinal strain (GLS) between BLBBP and ULBBP groups [IVMD: (14.0±13.1) ms vs. (19.7±19.0) ms, P=0.221; Tmsv12-SD: (37.3±17.4) ms vs. (39.9±14.2) ms, P=0.492; GLS: (-16.6±3.1) %vs. (-15.6±3.5) %, P=0.116] . Conclusion:During LBBP, compared with ULBBP, BLBBP corrected right bundle branch block (RBBB) morphology and improved cardiac electrical synchrony, but didn’t significantly improved cardiac mechanical synchrony.
血栓栓塞性疾病已严重威胁人类健康。口服抗凝药是防治该类疾病的有效方法。目前临床常用的口服抗凝药主要分为传统的维生素K拮抗剂及非维生素K拮抗剂口服抗凝药（NOAC）。尽管NOAC相对维生素K拮抗剂更加安全，但临床实践中仍发现其伴有一定程度的出血风险。Asundexian（BAY 2433334）是以Ⅺa因子为靶点开发的全新的口服抗凝药，现正处于Ⅲ期临床研究阶段。前期研究结果显示，该药在有效预防血栓形成的同时几乎不增加出血风险，表现出较好的上市潜力。本文综述了Asundexian的药理作用、临床前研究及临床研究，拟为该药后期可能的临床应用提供参考。
Objective:To investigate the safety and efficacy of percutaneous left atrial appendage closure (LAAC) guided by intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) periprocedurally and after 2-year follow-up.Methods:This study was a retrospective study. Patients with nonvalvular atrial fibrillation (NVAF) who underwent LAAC from January 2018 to June 2021 in Arrhythmia Center, The First Affiliated Hospital of Ningbo University were continuously enrolled. ICE was used to replace TEE to guide LAAC if patients could not tolerate or refusal to intraoperative TEE guidance. The implantation success rate, periprocedural adverse events and follow-up outcome were compared between the two groups.Results:A total of 109 patients who received ICE-guided LAAC were included (ICE group). The median age was 74 (67, 80) years, including 42 (38.5%, 42/109) females. Propensity score match (1∶3) was performed to select patients who underwent TEE-guided LAAC during the same period (TEE group). The median age of TEE group was 72 (68, 76) years, including 131 (40.1%, 131/327) females. In ICE group, X-ray exposure dose [ (136.8±134.4) mGy vs. (204.7±252.9) mGy, P=0.008], X-ray exposure time [ (6.4±4.3) min vs. (7.5±4.6) min, P=0.027] and contrast dose [ (28.0±31.0) ml vs. (75.2±29.8) ml, P<0.001] were significantly lower than those in TEE group.The hospital stay was also shorter in ICE group [ (3.9±0.9) d vs. (4.9±0.9) d, P<0.001] .There was no death in both groups periprocedurally. No statistical significance was observed for thromboembolic events and bleeding events between ICE group and TEE group. The rates of peridevice leakage, device-related thrombus, thromboembolic events and bleeding events were similar between the two groups at 45-day and 2-year follow-up after LAAC. Conclusion:ICE can significantly reduce the X-ray exposure dose, X-ray exposure time, contrast dose and hospital stay duration. Long-term safety and efficacy after LAAC are comparable between ICE group and TEE group.
Objective:To investigate the effect of ventricular septal scar on left bundle branch pacing (LBBP) implantation by analyzing the results of cardiac magnetic scan.Methods:Patients who intended to receive LBBP in the Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University from August 2019 to February 2023 were enrolled, and cardiac MRI scan was completed before surgery.Receiver operating characteristic curve (ROC) was used to evaluate the sensitivity and specificity of ventricular septal late-gadolinium-enhancement (LGE) and ventricular septal scar score (SSS) to diagnose the success of LBBP.With ventricular septal LGE load and SSS as independent variables and LBBP success as dependent variables, univariate binary Logistic regression analysis was performed.Spearman correlation coefficient was used to examine the correlation between ventricular septal LGE load, SSS and LBBP parameters.Results:Fifty-two patients were included in the study, including 18 females, aged (63±13) years.LBBP was successfully achieved in 44 patients (84.6%, 44/52) .The LGE load [4.00 (1.25, 8.00) % vs. 13.00 (5.00, 26.00) %, P=0.015] and SSS [ (0.80±0.41) scores vs. (1.13±0.24) scores, P=0.034] of interventricular septum were smaller in patients with LBBP.Using 7.50% as the cut-off value of LGE load in the interventricular septum, the sensitivity, specificity and positive predictive value of the successful of LBBP were 75.0%, 72.7% and 94.1%, respectively.Using 1.10 as the cut-off value of SSS, the sensitivity, specificity and positive predictive value of successful of LBBP were 62.5%, 88.6% and 92.9%, respectively.High ventricular septal LGE load was associated with lower LBBP success rate ( Wald=5.535, OR=0.125, P=0.019) .High SSS was associated with lower LBBP success rates ( Wald=8.668, OR=0.077, P=0.003) . Conclusion:Ventricular septal scar can effectively predict the success rate of LBBP, and the success rate of implantation is higher in patients with less scar load.
本文报道1例心电图表现为宽QRS波和窄QRS波两种形式心动过速的病例，通过详细的病史询问及完善相关检查后诊断为普罗帕酮导致心房扑动1∶1下传伴宽QRS波心动过速，为宽QRS波心动过速的鉴别诊断以及抗心律失常药物合理应用提供一定的经验。
心脏性猝死（SCD）是心血管病患者死亡的主要原因。大多数SCD发生在缺血性心肌病（ICM）患者中，小部分发生在非缺血性心肌病（NICM）患者中，而这些患者往往更年轻，其死亡风险不如ICM患者明确。SCD风险分层的传统评估方法是超声心动图测定左心室射血分数（LVEF），也是目前确定SCD患者一级预防植入心律转复除颤器（ICD）的主要筛选指标。先进的心脏成像方法，如斑点跟踪超声心动图、计算机断层扫描（CT）、单光子发射计算机断层扫描（SPECT）、正电子发射断层扫描（PET）、心脏磁共振成像（CMR），通过描述易发心律失常的潜在心肌基质的特征，已经成为一系列非侵入性的、有应用前景的心律失常风险评估手段。PET和SPECT是确定心肌活力、神经支配及炎症的核医学检查手段。CMR的晚期钆增强（LGE）检测心肌瘢痕，可以为ICD植入决策提供重要信息；总体瘢痕负荷、节段特异性瘢痕和瘢痕异质性都可以作为风险分层参数。CT可用于评估心肌脂肪及其与折返形成的关系。应用先进的成像技术优化心律失常发生的风险分层越来越成熟，将在临床决策中发挥更大的作用。
Objective:To observe changes in the visiting patterns of patients with atrial fibrillation (AF) during COVID-19 epidemic.Methods:This was a cross-sectional study. The patients diagnosed with "atrial fibrillation" in Huashan Hospital of Fudan University from January 2018 to December 2021 were selected using AF comprehensive management platform database. And the patients from January 2018 to December 2019 were recorded as the pre-epidemic group (group A) , while the patients from January 2020 to December 2021 were named as the post-epidemic group (group B) . Information on age, gender, CHA 2DS 2-VASc score, department of consultation, and comorbidities were collected and compared between two groups. And the distribution of visits, the percentage of comorbidities, the regularity of visits and their influencing factors were analyzed. Results:① All of 10 077 AF patients with a mean age of 74.1 years, including 5 030 males were selected. There were 3 420 patients in group A (number of visits 11 804) and 6 657 patients in group B (number of visits 21 268) . The average age of group B was lower than group A (74.62 years old vs.73.81 years old, P<0.001) . The proportion of female patients of group B was higher than group A [50.3% (5 936/11 804) vs.52.7% (11 214/21 268) , P<0.001] . And the median CHA 2DS 2-VASc score of group B was higher than group A (2 vs.3, P<0.001) . For group B, the proportion of outpatient and emergency visits increased, while the proportion of inpatients decreased. ②The percentage of strokes in group B patients increased [10.0% (1 175/11 804) vs.12.0% (2 545/21 268) , P<0.001] , and the percentage of heart failure decreased [5.8% (679/11 804) vs.9.4% (1 996/21 268) , P<0.001] . ③Factors of regular visits of outpatient and emergency patients: City household registration ( OR=5.624, 95% CI 4.173-7.579) , age>65 years old ( OR=1.676, 95% CI 1.351-2.079) were positively associated with regularity of visits. The COVID-19 epidemic ( OR=0.746, 95% CI 0.623-0.892) , heart failure ( OR=0.568, 95% CI 0.365-0.883) , and hypertension ( OR=0.807, 95% CI 0.663-0.982) were negatively associated with regularity of visits. ④The percentage of cardiology visits decreased in group B patients [70.5% (6 893/9 777) vs.63.6% (12 095/19 004) , and the percentage of neurology visits increased [6.1% (599/9 777) vs.9.8% (1 853/19 004) , P<0.001] .In group B, the average number of visits decreased for patients with cardiology visits (3.16 visits/year vs. 2.24 visits/year, P<0.001) and increased for patients with neurology visits (1.51 visits/year vs. 2.72 visits/year, P<0.001) . Conclusion:After the outbreak of COVID-19, the visiting patterns of patients with AF have also changed. The total number of patients with AF in our hospital increased, with more complications. The proportion of regular visit patients has decreased, which was closely related to the COVID-19 epidemic, and the number of patients of in the Emergency and Neurology increased.
右旋心是一种罕见的心脏畸形，心脏解剖结构复杂，常规X线透视下经静脉行起搏器植入较为困难。本文报道了1例病态窦房结综合征合并右旋心的患者，起搏器植入术前行心脏CT三维重建，较为直观地显示了心腔内各结构及其与血管连接关系，在三维影像的指导下顺利植入双腔起搏器。并结合既往经验及相关文献，总结了右旋心患者行起搏器植入的相关操作要点，探讨了CT三维重建技术在这一领域的应用前景。
Objective:To assess the concerns about oral anticoagulants (OAC) in patients with nonvalvular atrial fibrillation (NAF) receiving anticoagulant therapy and find the education target in the use of OAC.Methods:It was a cross-sectional study. From December 2018 to October 2019, patients with NAF receiving OAC treatment in Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University were included. The questionnaire survey containing 10 questions was conducted to evaluate each patient's degree of concerns about OAC. A score of 0-10 indicated a level of concern ranging from none to very serious, with 0-3 considered as mild concern, 4-7 considered as moderate concern, and 8-10 considered as serious concern.Results:A total of 115 patients [mean age (65.9±12.5) years and 71 males] were selected in this study. The mean CHA 2DS 2-VASc score was 2.87±1.80. Fifty-six patients (48.7%, 56/115) took warfarin, 36 patients (31.3%, 36/115) took rivaroxaban, and 23 patients (20.0%, 23/115) took dabigatran. There were 89 (77.4%, 89/115) urban residents (urban group) and 26 (22.6%, 26/115) rural residents (rural group) . It had no significant difference in the types of OAC between urban and rural groups ( P=0.828) . Compared to urban patients, rural patients were more concerned about the risk of bleeding (4.1±3.6 vs.6.9±3.0, P=0.003) and the absence of antagonist after OAC overdose (3.6±3.8 vs.5.8±3.7, P=0.039) . There was no significant difference in drug cost between rural and urban population ( P=0.349) . Both of the two groups showed little concern about OAC's interaction with other drugs (66.1%, 76/115) or food (42.6%, 49/115) , while much concern about the potential impairment of liver and kidney functions by OAC (36.5%, 42/115) . Conclusion:Patients with NAF who received OAC treatment had little economic concerns. However, their knowledge of OAC remained lacking. Proper scientific education and optimized out-patient management of OAC should be further strengthened to improve the adherence to OAC.
慢性心力衰竭（心衰）是一种复杂的临床综合征，也是多种心脏疾病的严重阶段或终末期表现。优化药物治疗（OMT）一直被视为慢性心衰患者治疗的基石。近20年以来心脏再同步治疗（CRT）逐渐成为心衰器械治疗的选择，但只适用于左心室射血分数降低、合并完全左束支传导阻滞或宽QRS波的患者，并且在已植入CRT的患者中约30%对治疗无反应。心肌收缩力调节器（CCM）的出现为药物治疗效果不佳、不适合CRT或对CRT无反应的患者提供了新的选择。本文将综述CCM的作用机制和最新的临床试验，为临床应用提供参考。
