心血管植入型电子器械（CIED）经过半个多世纪的发展，对其相关的病理学改变的认识越来越深入。早年主要关注起搏器和植入型心律转复除颤器（ICD）的急性和慢性阈值改变及其病理学基础，而当前认识到其慢性病理学改变更加复杂而严重，这包括导致静脉入路的狭窄或阻塞、三尖瓣关闭不全、血栓形成或栓塞及CIED相关的感染、导线拔除。废弃、失功及感染导线拔除遇到的困难超出了想象，这反过来促使研究CIED相关的病理学改变，以揭示这些问题的病理学机制，以便在临床上更好地处理这些患者和相关的问题。
结构性心脏病是近十几年来提出来的介入心脏病学的一个亚专科。本文旨在对2022年结构性心脏病领域相关的主动脉瓣置换技术、二尖瓣缘对缘修复、三尖瓣修复技术、肺动脉反流介入技术及左心耳封堵等技术的最新发展做一总结报告，以期成为该领域的风向标。
经导管主动脉瓣置换（TAVR）已经成为治疗主动脉瓣狭窄（AS）的常规术式，但使用自膨胀式主动脉瓣经股动脉入路TAVR治疗单纯主动脉瓣反流（PAR）尚未获得指南推荐。PAR患者TAVR手术成功率较低，术中瓣中瓣、瓣周漏、房室传导阻滞，甚至转外科开胸的比例相对较高。总结我中心既往TAVR治疗PAR成功的案例发现：主动脉瓣环尺寸、升主动脉和窦管交界宽度、主动脉瓣水平成角、二尖瓣幕帘长度、流出道情况（包括有无室间隔突出点）及瓣叶情况（有无增厚、交界区黏连）是术前解剖学评估的重要参数；手术中的一般技巧和特殊技巧：无冠窦支撑法、推动测试、室间隔突出点锚定法、“三明治”植入法、第二瓣拖拽及球囊拖拽法，是提高PAR患者TAVR成功率的有效手段。
Objective:To survey the treatment options of cardiac electrophysiologists if they suffered from non-paroxysmal atrial fibrillation, including the selection of catheter ablation methods and the application of related drugs, in order to find the most reasonable treatment method approved by cardiac electrophysiologists themselves.Methods:A network questionnaire was designed, which mainly included the general situation of the physicians participating in the survey (such as gender, age, education, etc.), the treatment strategy of non paroxysmal atrial fibrillation, the choice of catheter ablation, and the choice of treatment strategy after catheter ablation. From June 2021 to July 2021, the questionnaire was shared with many large-scale WeChat groups of cardiac electrophysiologists across the country for investigation and analysis. The respondents are first-line cardiac electrophysiologists engaged in catheter ablation.Results:A total of 387 questionnaires were recovered,and 195 were valid. 54.9% (107/195) cardiac electrophysiologists chose catheter ablation, 35.9% (70/195) chose catheter ablation strategy after drug therapy failed. 90.9% (161/177) of the interviewees chose radiofrequency ablation. Individual catheter ablation strategies during index ablation procedure included: pulmonary vein electrical isolation 24.9% (44/177); pulmonary vein electrical isolation plus substrate modification under sinus rhythm 22% (39/177); pulmonary vein electrical isolation plus posterior wall box ablation 11.9% (21/177); 2C3L ablation strategy 9.6%(17/177); pulmonary vein electrical isolation plus roof line ablation 7.9% (14/177); pulmonary vein electrical isolation plus rotor ablation 6.8% (12/177). More than 90% respondents (92.8%, 181/195) would take non-vitamin K antagonist oral anticoagulants (NOAC), 6.7% (13/195) warfarin, and only 0.5% (1/195) antiplatelet drug if the anticoagulation indications were determined.Conclusion:Most of the respondents will choose catheter ablation and NOAC as their treatment strategy if they suffer from non-paroxysmal atrial fibrillation.
右心声学造影被认为是卵圆孔未闭诊断的“金标准”，虽然有众多流程指导临床诊断，但在实践过程中依然有假阳性及假阴性的可能性。本文通过阐述1例卵圆孔未闭患者诊断过程中的诸多陷阱及应对策略，以期为临床提供参考。
Objective:To investigate the effects of aerobic exercise and resistance exercise on heart rate variability in patients with heart failure.Methods:Patients with heart failure admitted to Xiaolan People's Hospital of Zhongshan from February 2021 to April 2022 were selected, and randomly divided into aerobic exercise group, resistance exercise group and control group by random number table method. All patients were given conventional drug therapy. Aerobic exercise group and resistance exercise group participated in exercise rehabilitation therapy for 12 weeks, while the control group did not receive exercise rehabilitation therapy.The changes of heart rate variability indexes were compared before and after treatment in each group. The evaluation indexes were the sequential five-minute R-R interval means(SDANN) and the root mean square of the successive differences(RMSSD).Results:A total of 90 patients were included, aged (65±8) years, including 48 males (53.3%, 48/90).Thirty patients in aerobic exercise group, resistance exercise group and control group respectively. The RMSSD of the aerobic exercise group and the resistance exercise group increased after the test, and the RMSSD of the aerobic exercise group increased significantly, and the difference was statistically significant (t=-4.70, P=0.001).The SDANN values of the control group and the aerobic exercise group decreased significantly after the test, and the difference was statistically significant (t=2.82, P=0.009; t=3.81, P=0.001), while the SDANN value of the resistance exercise group was significantly higher than that before the test (t=-4.85, P=0.001).Conclusion:Aerobic exercise can increase vagus nerve activity and increase RMSSD value.Resistance exercise can decrease sympathetic nerve activity and increase SDANN value.Exercise rehabilitation can improve the regulation of autonomic nervous system on the basis of drug therapy.
左心室血栓在人群中发生率较低。其最常发生于缺血性心肌病，尤以急性心肌梗死最为多见。左心室血栓是血栓栓塞并发症的独立危险因素，可引起较高的致残率和死亡率。临床上主要借助影像学检查来明确左心室血栓的存在，并采用抗凝治疗来降低栓塞风险。本综述对近年来左心室血栓方面的研究进展进行了总结。
Objective:To construct a nursing quality evaluation index system of volume management in patients with chronic heart failure (CHF), and to provide references for evaluating the quality of system volume management in patients with CHF objectively.Methods:A pool of nursing quality indicators was established by integrating results of literature inquiry, semi-structured interviews and group discussion. The importance and weight of the indicators were evaluated after 2 rounds of Delphi expert consultation.Results:According to the index screening criteria, 15 items were finally deleted, 17 items were modified, and 2 indicators were added. The recovery rate of 2 rounds of expert consultation questionnaire was 100% (25/25) and 95.65% (24/25)respectively. The expert authority coefficient of two rounds of expert consultation was 0.822 and 0.834 respectively, and the harmony coefficient of Kendall of two rounds was 0.234 and 0.166 respectively. The nursing quality evaluation index system of the volume management care of CHF patients constructed in this study includes 3 first-level indicators, 9 second-level indicators and 61 third-level indicators.Conclusion:The nursing quality index system of volume management in patients with CHF constructed in this study is highly scientific and effective, with guiding significance for evaluating the quality of volume management in patients with CHF.
Objective:To investigate the mastery of knowledge about atrial fibrillation (AF) among grass-roots general practitioners in Fengxian District, Shanghai, and analyze related influencing factors.Methods:A cross-sectional study was conducted, and an self-designed electronic questionnaire including four modules: general information, basic knowledge of AF, knowledge of anticoagulation treatment and heart rate/heart rate control. Electronic questionnaires were distributed to 21 community health service centers in Fengxian District and general practitioners in each community through systematic sampling.The awareness rate of primary general practitioners for each module was counted, and Logistic regression was used to analyze the influencing factors of primary general practitioners' awareness of AF.Results:A total of 526 general practitioners in Fengxian District were included in this study, and 524 valid questionnaires were recovered, with an effective recovery rate of 99.6%.The correct rates of general practitioners in the three modules of basic knowledge of AF knowledge of anticoagulation therapy and knowledge of heart rhythm/heart rate control were 60.9%(1 596/2 620), 23.5%(738/3 144) and 47.1% (1 235/2 620)respectively.Logistic regression analysis showed that,Standardized training(OR=2.192, 95%CI 1.079-4.454),professional title (OR=0.073, 95%CI 0.023-0.232 for no professional title; OR=0.153, 95%CI 0.061-0.384 for primary level; OR=0.405, 95%CI 0.198-0.830 for intermediate level) and study on line (OR=2.186) were the related influencing factors of AF cognition among general practitioners.Conclusion:General practitioners in Fengxian District, Shanghai's overall awareness of AF knowledge needs to be improved. In particular, general practitioners with untrained and low professional titles have low scores on AF knowledge, and need to strengthen relevant learning and training.
Objective:To investigate whether exercise blood pressure (BP) was associated with cardiac structure and function independent of BP at rest.Methods:In the outpatients who underwent non-invasive cardiac exercising test and echocardiography at The First Affiliated Hospital of Sun Yat-Sen University between January 2019 and October 2020, collected the clinical data and retrospectively assessed the association of cardiac structure (i.e., left atrial internal diameter, interventricular septal wall thickness, left ventricular posterior wall thickness), diastolic function [i.e., the peak early-diastolic (E) and peak end-diastolic (A) transmission velocity, the mean early-diastolic myocardial velocity (e')], and systolic function (left ventricular ejection fraction) with 1-SD increment in BP during exercise and at rest, using multivariable regression analyses.Results:Among the 323 participants, age averaged (46.2±15.1) years. 40.2% (130/323) were men, and 13.6% (44/132) had coronary heart disease. With adjustments applied for gender, age, body mass index, coronary heart disease, and BP at rest, the association sizes with 1-SD increase in exercise systolic, and diastolic BP were 0.33 mm (P<0.001) / 0.33 mm (P<0.001) for interventricular septal wall thickness, and 0.32 mm (P<0.001) / 0.24 mm (P=0.004) for left ventricular posterior wall thickness, while the association sizes were non significant for the associations between indices of cardiac function and exercise systolic BP. After adjusted for gender, age, body mass index, coronary heart disease, and exercise BP, the association sizes with 1-SD increase in systolic BP at rest were 3.93 mm/s (P<0.001) for A peak and 0.46 (P=0.002) for E/e'. The association sizes with 1-SD increase in diastolic BP at rest were 2.91 mm/s (P=0.005) for A peak and -0.08 (P=0.002) for E/A, and 1-SD increase in systonic BP at rest were 0.26 mm for IVST (P=0.007), while there were no associations between indices of cardiac structure and systolic BP at rest with exception for interventricular septal wall thickness. After accounted for potential confounders, there was no association of left ventricular ejection fraction with BP during exercise and at rest.Conclusion:Exercise BP was mainly associated with cardiac structure independent of BP at rest, while BP at rest was mainly correlated with cardiac diastolic function independently of exercise BP.
Objective:To observe the safety of transcatheter aortic valve replacement (TAVR) for symptomatic aortic valve stenosis patients infected with Corona Virus Disease 2019 (COVID-19) and with negative antigen.Methods:Ninteen patients with symptomatic severe aortic valve stenosis were performed TAVR in 7 hospitals in Shanghai from December 9th, 2022 to January 13th, 2023. The patients were infected with COVID-19 and the antigen turned negative within 15 days. The general conditions, disease history, preoperative examinations, procedures, postoperative examinations, complications and discharge conditions of the patients were summarized and analyzed.Results:Two of the patients were ordinary COVID-19 pneumonia, and the rest were mild. All patients successfully completed the operation, including 1 case of valve-in-valve implantation. Three patients had pacemaker implantation due to complete atrioventricular block, and 1 patient had stroke after operation. There was no mild to moderate or above perivalvular leakage, coronary occlusion or death happened.Conclusion:It is safe for symptomatic aortic valve stenosis patients to perform TAVR within 15 days after antigen negative conversion after infection with mild or common COVID-19 pneumonia.
Takotsubo综合征（TTS）以其左心室造影表现为收缩期窄颈、心尖球形膨出，类似于“章鱼壶”样改变而得名。TTS的心电图4个不同阶段的变化具有连续性：ST段抬高、T波倒置、T波倒置进行性加深以及QT间期逐渐延长。TTS心电图的标志特征对临床诊断及结局预测有一定敏感性和特异性。本文旨在简要回顾与TTS相关的重要心电图发现及其临床指导意义。
Objective:To report the 5-year clinical outcomes of transcatheter aortic valve replacement with VitaFlow? system in the treatment of severe aortic stenosis and to analyze the influence factors.Methods:From September 2014 to November 2016, 110 patients in 11 centers in China, who were not appropriate for surgical operation were consequently enrolled and underwent transcatheter aortic valve replacement with VitaFlow? system.After excluding three patients who underwent transcatheter aortic valve replacement (TAVR) surgery but experienced complications, 107 patients remained. The primary endpoints were all-cause death and disabling stroke, and the secondary endpoints were new permanent pacemaker implantation and so on. The Kaplan-Meier method was used to create survival curves, Cox analysis was employed to pinpoint risk factors related to the endpoint events.Results:The age of the 107 patients [men 53.3% (57/107)] was (77.2±4.8) years old and the Society of Thoracic Surgeons (STS)score was (8.63 ±4.2) %. The 5-year survival rate at follow-up was 83.2%(89/107), the composite incidence of death and disabling stroke was 19.6%(19/107), the rate of new permanent pacemaker implantation was 20.0%(22/107). Multivariate Cox regression showed that diabetes mellitus (HR=2.63,95% CI 1.04-6.69,P=0.042) were independent predictors of all-cause death and disabling stroke occurrence.Conclusion:Clinical follow-up at 5 years postoperatively demonstrates the good long-term prognosis of the VitaFlow? in the treatment of patients with severe aortic stenosis who are inappropriate for surgery or at high risk. Diabetes mellitus were independent predictors of long-term prognosis.
Objective:To investigate the effectiveness and safety of "one-stop" combining trial septal defect (ASD) and left atria appendage (LAA) closure(LAAC).Methods:Patients with atrial fibrillation (AF) combined with ASD who underwent one-stop surgery for LAAC combined with ASD occlusion at Zhongshan Hospital of Fudan University from June 2018 to September 2022 were retrospectively analyzed, and demographic data such as age and gender; intraoperative imaging data such as pulmonary artery pressure, LAA pressure, and ASD size of atrial septal defect were collected.And left atrial septal defect was followed up at 6 and 12 months after surgery echocardiographic information such as left atrial internal diameter (LAD), left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), pulmonary artery systolic pressure (PASP), degree of tricuspid regurgitation (TR) and electrocardiogram (ECG) information were followed up at 6 months and 12 months after surgery. Postoperative complications such as blocker thrombosis, residual shunt at blocker, blocker malfunction, pericardial effusion and new arrhythmias were recorded.Results:A total of 32 patients [(68.2±9.3) years ], including 11 males (34.3%,11/32) were included in this study, and all patients successfully underwent a combined "one-stop" procedure for LAAC and ASD occlusion. Intraoperatively, the blocker was properly positioned and well fixed, and no complications such as residual shunt were found. One patient was found to have a minor residual shunt, and one patient developed novel right bundle branch block at the 6-month postoperative follow-up, but no adverse events were found at the 12-month postoperative follow-up.Conclusion:The combined "one-stop" procedure of LAA and ASD occlusion is safe and effective for patients with ASD combined with AF, with satisfactory follow-up results.
2023年5月19日至21日，第44届美国心律学会年会在美国新奥尔良市举行。本次年会上公布了众多心律失常领域的最新研究进展，现将其重点内容归纳为射频消融新技术相关研究进展、心房颤动的综合治疗与管理及创新器械与疗法相关研究3个方面进行介绍。
心脏起搏器（PM）和植入型心律转复除颤器（ICD）的临床应用已多年，但植入手术操作本身尚无全面系统的指导性文件。本共识由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）共同组织了多位国内该领域知名专家，查阅了大量的参考文献并结合丰富的临床经验及国内医院的实际情况编撰而成，就植入PM和ICD的手术流程，包括基本要求、详细的手术步骤、出院前管理、围术期并发症及处理、ICD植入特殊要点和脉冲发生器更换注意事项等多个方面通过详尽的文字和图片的形式对涉及手术的每个细节都进行了深入地解析。
Objective:To evaluate the association between resting heart rate and ten-year risk of cardiovascular disease, and provide evidence for the prevention and treatment of cardiovascular disease.Methods:This cross-sectional study was from the baseline survey of the Prediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR), including 117 309 participants aged 18 years and above in 15 provinces in China. Participants were categorized into five groups (＜60, 60-69, 70-79, 80-89, ≥90 beats/min) based on resting heart rates. The ten-year cardiovascular disease risks were estimated using the China-PAR equations, and those with ten-year risk ≥10% were identified as high-risk individuals. Odds ratios (OR) and 95% confidence intervals (CI) of high-risk for cardiovascular disease associated with resting heart rates were estimated using multivariate Logistic regression.Results:Sex- and age-adjusted levels of ten-year cardiovascular disease risk increased with elevated resting heart rate, which increased from 2.31% among participants at resting heart rates <60 beats/min to 2.67% among those at ≥90 beats/min. Similar trend was observed for prevalence of high-risk, which climbed from 5.15% among individuals at <60 beats/min to 7.09% among those at ≥90 beats/min. After adjustment for sex, age, education, marital status, occupation, work-related physical activity, and household income per capita, an increment of 10 beats/min in resting heart rate was associated with a 9% increment in prevalence of high-risk for cardiovascular disease (OR=1.09, 95% CI 1.06-1.11). Compared with participants at resting heart rate 70-79 beats/min, those at 80-89 and ≥90 beats/min had ORs of 1.21 (95% CI 1.14-1.29) and 1.24 (95% CI 1.14-1.35), respectively. The association between resting heart rate and ten-year risk of cardiovascular disease was stronger in women, participants lived in urban and with higher monthly household income per capita, but weaker in farmers and population with moderate-heavy work-related physical activity.Conclusion:Resting heart rate was independently associated with ten-year risk of cardiovascular disease. It could be used as a simple and auxiliary clinical indicator in pre-screening for high-risk population and evaluation for the effectiveness of cardiovascular disease interventions, particularly in women, population lived in urban, with higher income or with physical inactivity.
Objective:To explore the application of artificial intelligence-assisted electrocardiograms (ECG) to identify patients without coronary heart disease (coronary artery stenosis < 50%).Methods:Patients with suspected coronary heart disease and who underwent coronary angiography during hospitalization were enrolled. The ECG data set was established based on standard 12-lead ECG. The ECG was labeled as a group without coronary disease and a control group according to whether the main coronary artery or its main branches were narrowed by less than 50% in diameter. A deep neural network model was established by training ECG to identify patients without coronary heart disease.Results:A total of 4 489 ECG medical records were included, of which 4 187 were used for model construction and 302 were used for external verification of the model. The area under curve (AUC) value, sensitivity, and specificity of the model were 0.70, 0.701, 0.630, and 0.469 respectively. The AUC value of external validation was 0.55, sensitivity 0.359, specificity 0.784, and F1 score 0.373.Conclusion:The artificial intelligence model based on ECG can identify patients without coronary heart disease in patients with suspected coronary heart disease, which has certain clinical application value.
