Background:The integration of large language models (LLMs) into cardio-oncology patient education holds promise for addressing the critical gap in accessible, accurate, and patient-friendly information. However, the performance of publicly available LLMs in this specialized domain remains underexplored. Objectives:This study evaluates the performance of three LLMs (ChatGPT-4, Kimi, DouBao) act as assistants for physicians in cardio-oncology patient education and examines the impact of prompt engineering on response quality. Methods:Twenty standardized questions spanning cardio-oncology topics were posed twice to three LLMs (ChatGPT-4, Kimi, DouBao): once without prompts and once with a directive to simplify language, generating 240 responses. These responses were evaluated by four cardio-oncology specialists for accuracy, comprehensiveness, helpfulness, and practicality. Readability and complexity were assessed using a Chinese text analysis framework. Results:Among 240 responses, 63.3% were rated "correct," 35.0% "partially correct," and 1.7% "incorrect." No significant differences in accuracy were observed between models (p = 0.26). Kimi demonstrated no incorrect responses. Significant declines in comprehensiveness (p = 0.03) and helpfulness (p < 0.01) occurred post-prompt, particularly for DouBao (accuracy: 57.5% vs. 7.5%, p < 0.01). Readability metrics (readability age, difficulty score, total word count, sentence length) showed no inter-model differences, but prompts reduced complexity (e.g., DouBao's readability age decreased from 12.9 ± 0.8 to 10.1 ± 1.2 years, p < 0.01). Conclusion:Publicly available LLMs provide largely accurate responses to cardio-oncology questions, yet their utility is constrained by inconsistent comprehensiveness and sensitivity to prompt design. While simplifying language improves readability, it risks compromising clinical relevance. Tailored fine-tuning and specialized evaluation frameworks are essential to optimize LLMs for patient education in cardio-oncology.

Abstract Background The coexistence of cardiac arrhythmias in patients with acute myocardial infarction (AMI) usually exhibits poor prognosis. However, there are few contemporary data available on the burden of cardiac arrhythmias in AMI patients and their impact on in-hospital outcomes. Methods The present study analyzed data from the China Acute Myocardial Infarction (CAMI) registry involving 23,825 consecutive AMI patients admitted to 108 hospitals from January 2013 to February 2018. Cardiac arrhythmias were defined as the presence of bradyarrhythmias, sustained atrial tachyarrhythmias, and sustained ventricular tachyarrhythmias that occurred during hospitalization. In-hospital outcome was defined as a composite of all-cause mortality, cardiogenic shock, re-infarction, stroke, or heart failure. Results Cardiac arrhythmia was presented in 1991 (8.35%) AMI patients, including 3.4% ventricular tachyarrhythmias, 2.44% bradyarrhythmias, 1.78% atrial tachyarrhythmias, and 0.73% ≥2 kinds of arrhythmias. Patients with arrhythmias were more common with ST-segment elevation myocardial infarction (83.3% vs. 75.5%, P < 0.001), fibrinolysis (12.8% vs. 8.0%, P < 0.001), and previous heart failure (3.7% vs. 1.5%, P < 0.001). The incidences of in-hospital outcomes were 77.0%, 50.7%, 43.5%, and 41.4%, respectively, in patients with ≥ 2 kinds of arrhythmias, ventricular tachyarrhythmias, bradyarrhythmias, and atrial tachyarrhythmias, and were significantly higher in all patients with arrhythmias than those without arrhythmias (48.9% vs. 12.5%, P < 0.001). The presence of any kinds of arrhythmia was independently associated with an increased risk of hospitalization outcome (≥ 2 kinds of arrhythmias, OR 26.83, 95%CI 18.51–38.90; ventricular tachyarrhythmias, OR 8.56, 95%CI 7.34–9.98; bradyarrhythmias, OR 5.82, 95%CI 4.87–6.95; atrial tachyarrhythmias, OR4.15, 95%CI 3.38–5.10), and in-hospital mortality (≥ 2 kinds of arrhythmias, OR 24.44, 95%CI 17.03–35.07; ventricular tachyarrhythmias, OR 13.61, 95%CI 10.87–17.05; bradyarrhythmias, OR 7.85, 95%CI 6.0-10.26; atrial tachyarrhythmias, OR 4.28, 95%CI 2.98–6.16). Conclusion Cardiac arrhythmia commonly occurred in patients with AMI might be ventricular tachyarrhythmias, followed by bradyarrhythmias, atrial tachyarrhythmias, and ≥ 2 kinds of arrhythmias. The presence of any arrhythmias could impact poor hospitalization outcomes. Registration Clinical Trial Registration: Identifier: NCT01874691.

心动过缓是心脏外科手术后的常见并发症,心脏外科的手术类型及其与心脏传导系统的解剖毗邻关系导致术后心动过缓发生率和需要植入永久起搏器的比例不同,多见于瓣膜外科手术和肥厚型心肌病手术术后.目前心脏外科术后房室传导阻滞的患者多在5～7 d行永久起搏器植入治疗,部分中心在早期(＜72 h)或者晚期(＞14 d)行起搏器植入术.窦房结功能障碍的患者植入起搏器的时机需要结合临床症状观察一定时间后进行判断.本文就目前文献中不同种类心脏外科手术后心动过缓植入起搏器治疗患者的发生率及植入时机进行了汇总分析,有助于了解心脏外科术后发生心动过缓的危险预测和治疗措施.

Abstract Aims To investigate whether left bundle branch area pacing (LBBAP) can reduce the risk of new-onset atrial fibrillation (AF) compared with right ventricular pacing (RVP). Methods and results Patients with indications for dual-chamber pacemaker implant and no history of AF were prospectively enrolled if they underwent successful LBBAP or RVP. The primary endpoint was time to the first occurrence of AF detected by pacemaker programming or surface electrocardiogram. Follow-up at clinic visit was performed and multivariate Cox regression models were applied to evaluate the effect of LBBAP on new-onset AF. The final analysis included 527 patients (mean age 65.3 ± 12.6, male 47.3%), with 257 in the LBBAP and 270 in the RVP groups. During a mean follow-up of 11.1 months, LBBAP resulted in significantly lower incidence of new-onset AF (7.4 vs. 17.0%, P < 0.001) and AF burden (3.7 ± 1.9 vs. 9.3 ± 2.2%, P < 0.001) than RVP. After adjusting for confounding factors, LBBAP demonstrated a lower hazard ratio for new-onset AF compared with RVP {hazard ratio (HR) [95% confidence interval (CI)]: 0.278 (0.156, 0.496), P < 0.001}. A significant interaction existed between pacing modalities and the percentage of ventricular pacing (VP%) (P for interaction = 0.020). In patients with VP ≥ 20%, LBBAP was associated with decreased risk of new-onset AF compared with RVP [HR (95% CI): 0.199 (0.105, 0.378), P < 0.001]. The effect of pacing modalities was not pronounced in patients with VP < 20% [HR (95% CI): 0.751 (0.309, 1.823), P = 0.316]. Conclusion Left bundle branch area pacing demonstrated a reduced risk of new-onset AF compared with RVP. Patients with a high ventricular pacing burden might benefit from LBBAP.

To the Editor: Tricuspid regurgitation (TR) is a known complication of cardiac implantable electrical device (CIED) implantation with a prevalence of up to 10–30%. Due to the detrimental effects of right ventricular pacing (RVP) on cardiac function, His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) have been increasingly used as physiological pacing modalities. This observational study aimed to assess the lead-related significant TR (moderate and severe) in patients with HBP, LBBAP, right ventricular apical pacing (RVAP), and right ventricular septal pacing (RVSP) in bradycardia patients during the two-year follow-up. All consecutive patients with left ventricular ejection fraction (LVEF) over 40% who received pacemaker implantation due to bradycardia were enrolled if they underwent successful HBP or LBBAP or RVP from October 2018 to December 2020 in Fuwai Hospital. The pacing modality was decided by the two physicians who performed the implantation procedures. Patients were excluded for the final analysis if they received implantable cardioverter-defibrillator or biventricular pacing, or if they had a history of tricuspid annuloplasty. All patients signed written informed consent for an agreement of the implantation procedure and analysis of clinical data, and this study was approved by the Review Board of Fuwai Hospital (No. 2019-1223). Venous access was obtained via the left or right axillary or subclavian vein. LBBAP or HBP was performed using the 3830 lead (Select Secure system, Medtronic, Inc., Minneapolis, MN, USA). The procedure of HBP and LBBAP followed the previous descriptions.[1,2] The procedure of RVP followed a standard fashion by placing the ventricular lead at the RV apex or septum, and stylet-driven pacing leads were routinely used. All patients were followed every 6 months after pacemaker implantation. We collected the pacing parameters at the latest device follow up. Lead-related complications were routinely tracked. All patients underwent transthoracic echocardiography at baseline (1 or 2 days before the procedure) and during follow up by using Vivid E9 systems (GE Vingmed Ultrasound AS, Horten, Norway). Multiple echocardiographic views were evaluated to quantify TR and to assess if there was any limitation of tricuspid leaflet motion induced by the septal electrode. Grading of TR was identified based on the 2017 American Society of Echocardiography recommendations for valvular regurgitation.[3] In patients with LBBAP, the distance from the septal leaflet of the tricuspid valve (TV) to the electrode screwing site (electrode–tricuspid valve distance, E–T distance) was measured from a standard 4-chamber view. TR grade was interpreted by two experienced echocardiographers. In cases of disagreement, an invited echocardiographer examined the echocardiogram and reached an agreement on the grade. The primary endpoint for this study was the first occurrence of worsening of TR during follow up, which was defined as an increase in TR of at least one grade and the TR grade up to moderate or severe as compared with that at pre-implantation. Statistical analyses were performed with SPSS version 24.0 (SPSS, Inc., Chicago, IL, USA). Continuous variables were presented as the mean ± standard deviation (SD) and compared with analysis of variance (ANOVA) analysis. Nominal data were presented as numbers and percentages and were compared by chi-squared test. Kaplan–Meier survival methods were used to compare significant TR risk. Cox regression models for significant TR were used to assess the association between pacing strategies and risk of TR. Receiver operating characteristics (ROC) curves were used to determine the cut-off point of the best E–T distance. Two-tailed P-value of <0.05 was considered significant. During the study period, 608 consecutive patients who underwent permanent pacemaker implantation were finally enrolled (HBP, n = 44, LBBAP, n = 269, RVSP, n = 203, and RVAP, n = 92). Most clinical characteristics were comparable among the four groups, except for age, the prevalence of AVB, previous atrial fibrillation (AF), and percutaneous coronary intervention or coronary artery bypass grafting history. The prevalence of moderate TR at baseline was comparable among the four pacing groups. During the mean follow-up of 23.7 ± 4.8 months, significant TR progression differed significantly among four pacing groups (LBBAP 14.5% [39/269] vs. HBP 2.3% [1/44] vs. RVSP 5.9% [12/203] vs. RVAP 13.0% [12/92],χ2 = 12.898, P = 0.004). LBBAP demonstrated the highest risk of significant TR worsening as compared with other pacing modalities, while HBP had the lowest risk of significant TR progression. During the follow-up period, 4.3% (26/608) of the cohort's patients suffered heart failure hospitalization events (HBP 0% [0/44], LBBAP 1.9% [5/269], RVSP 5.9% [12/203], RVAP 9.8% [9/92], χ2 = 13.946,P = 0.003), and no all-cause death events occurred. Two patients who received LBBAP suffered from perioperative septal perforation and received acute lead revision, and two patients in HBP experienced increased pacing threshold (increment of pacing threshold ≥1.0 V/0.4 ms) during the follow up and the pulse width of 1.0 ms was programmed. One of the patients in the RVAP group suffered chronic perforation and received late lead adjustment at a 3-month follow up. The univariate and multivariate analyses of risk factors of post-procedure significant TR worsening are shown in Table 1. When compared with RVP (including RVAP and RVSP), LBBAP conferred a 2.59-fold increased risk of significant TR worsening after adjustment for multiple clinical factors. HBP did not demonstrate a statistically significant decrease in the significant TR worsening risk. VP >40% was also an independent risk factor of significant TR worsening after pacemaker implantation in the whole study population. Table 1 - Univariate and multivariate analyses for the progression of TR in the overall cohort and LBBAP cohort. Variables Univariate analysis Multivariate analysis Hazard ratio (95% CI) P-value Hazard ratio (95% CI) P-value Overall cohort Pacing strategies HBP vs. RVP 0.25 (0.04–1.90) 0.183 0.24 (0.03–1.80) 0.164 LBBAP vs. RVP 3.06 (1.83–5.13) <0.001 2.59 (1.51–4.44) 0.001 Age (years) 1.02 (1.00–1.04) 0.049 1.12 (0.99–1.04) 0.156 Female 1.64 (1.00–2.69) 0.048 1.63 (0.98–2.69) 0.058 Atrial fibrillation 1.66 (1.01–2.73) 0.045 1.60 (0.96–2.67) 0.072 Ventricular pacing >40% 2.06 (1.18–3.58) 0.011 2.06 (1.15–3.70) 0.016 MI or coronary intervention 2.24 (1.22–4.13) 0.008 1.91 (0.99–3.68) 0.053 Operator 0.82 (0.60–1.11) 0.202 Baseline tricuspid regurgitation 0.80 (0.49–1.32) 0.380 LBBAP cohort Age (years) 1.02 (0.99–1.06) 0.196 1.00 (0.97–1.04) 0.948 Female 1.78 (0.79–3.97) 0.152 1.23 (0.52–2.91) 0.630 Atrial fibrillation 4.68 (2.12–10.33) <0.001 6.04 (2.50–14.60) <0.001 Ventricular pacing >40% 0.51 (0.23–1.10) 0.091 0.53 (0.21–1.39) 0.197 Previous MI or coronary intervention 1.64 (0.48–5.53) 0.457 Operator 0.75 (0.41–1.40) 0.336 Baseline tricuspid regurgitation 0.67 (0.36–1.25) 0.203 Distance from the base of TV leaflet 0.86 (0.76–0.97) 0.009 0.77 (0.68–0.91) 0.002 AF: Atrial fibrillation; CI: Confidence interval; HBP: His bundle pacing; LBBAP: Left bundle branch area pacing; MI: Myocardial infarction; RVP: Right ventricular pacing; TR: Tricuspid regurgitation; TV: Tricuspid valve. Compared with patients without significant worsening of TR, those with significant worsening of TR had a higher predicted prevalence of AF (50.0% vs. 24.9%, log-rank χ² = 9.952, P = 0.002) and a shorter E–T distance (20.2 ± 2.6 mm vs. 22.3 ± 2.6 mm, t value = 2.463, P = 0.010). Other clinical characteristics were comparable between patients with and without significantly worsening TR. As shown in Table 1, after adjustment of age, gender, VP >40%, and previous myocardial infarction or coronary disease history, the increased risk of significant TR progression was independently associated with AF (hazard ratio [HR] 6.04, 95% confidence interval [CI]: 2.50–14.60, P <0.001) and the E–T distance (HR 0.77, 95% CI: 0.68–0.91, P = 0.002) in patients received LBBAP implantation. However, VP >40% was no longer the independent risk factor of significant TR worsening after pacemaker implantation in patients who received LBBAP. ROC curve analysis was used to find the best cut-off value of the E–T distance influencing the risk of significant post-procedure TR progression. According to the cut-off value of 20 mm E–T distance, patients with LBBAP were divided into proximal LBBAP (E–T distance <20 mm) and distal LBBAP groups (E–T distance ≥20 mm). Kaplan–Meier analysis showed that distal LBBAP was related to significantly decreased risk of significant post-procedure TR progression (18.6% vs. 61.4%; χ² = 7.713, P = 0.006 by Log-rank test) when compared with proximal LBBAP. Pacing parameters and paced QRS duration were comparable between proximal and distal LBBAP. The present study demonstrated the risk of significant TR progression in bradycardia patients with LBBAP and comparison among four pacing modalities: HBP, LBBAP, RVSP, and RVAP. Our study found that LBBAP was associated with an increased risk of significant TR as compared with RVP. The risk of LBBAP-related significant TR progression was negatively associated with the E–T distance in the RV septum. AF was the other factor associated with an increased risk of LBBAP-related significant TR progression. Four pacing approaches demonstrated a different association between pacing lead and TV. HBP-related TR progression is very rare due to the location of His bundle. In some patients with HBP, the pacing lead may be positioned on the atrial side. Therefore, the TV function mostly remains stable after the HBP procedure. In this study, the lowest TR progression was observed in the HBP group (2.3%) during follow up. The prevalence of significant TR progression in patients with RVP in our study was consistent with the previous results,[4] and RVSP demonstrated less prevalence of post-procedure significant TR worsening than RVAP in our study. The less TR progression risk in patients with RVSP may be caused by mild mechanical and electrical dyssynchrony and less lead-related interference as compared with RVAP. The association of LBBAP with significant TR progression has been focused on in this study. In previous studies, Vijayaraman et al[1] reported 7% (4/55) of TR progression in patients with LBBAP. In their study, the E–T distance was 22.0 mm on average, and they reported a moderate TR due to the impingement of the septal leaflet by the LBBAP lead (E–T distance 11 mm). Our results observed a negative association between E–T distance and TR progression. Therefore, we surmised that the short E–T distance might contribute to the occurrence of LBBAP-related significant TR progression. The higher risk of significant TR progression in patients with short E–T distance might be due to the mechanical TV interference. Recently, Su et al[5] reported the occurrence of TR worsening of 12.3% in their single-center experience of 560 patients with LBBAP after 1-year follow up. Our study identified a cut-off point of 20 mm of E–T distance and found that distal LBBAP (E–T distance ≥20 mm) was associated with decreased risk of significant TR progression. In patients with LBBAP, AF was a risk factor associated with LBBAP-related significant TR progression. AF can cause the enlarged right atrium and tricuspid annular dilation and diastolic dysfunction of LV. Our study observed the association between AF and significant TR progression in patients with LBBAP but not in the whole study population with four pacing forms. In contrast, high VP percentage was another risk factor of post-CIED TR progression in the whole study population but not in patients with LBBAP. We speculated that the impact of dyssynchrony on TR progression due to high VP percentage in patients with non-physiological RVP was reduced in patients with LBBAP, and then the impact of AF on TR progression appeared obviously. Several limitations in this study need to be mentioned. First, the non-randomized study design was the major limitation and our findings might be overstated due to the unrecognized confounders. Second, the sample size was not comparable among the four pacing modality groups, and HBP or RVAP group had a relatively small sample size. However, the incidence of significant TR worsening was consistent with previous studies. Third, the postoperative TR outcomes could be impacted by the pacing electrode selection and lead reserve length. Additionally, RV function was not routinely evaluated in this study, which will be focused in the future study. Overall, LBBAP might be associated with an increased risk of lead-related significant TR as compared with other pacing strategies based on the two-year follow-up results, and the E–T distance might influence the risk of LBBAP-related significant TR progression. The distal LBBAP (with E–T distance ≥20 mm) may achieve equal pacing efficacy to proximal LBBAP and confer a comparable risk of significant TR progression with RVP. Funding This work was supported by grants from the National Natural Science Foundation of China to Xiaohan Fan (No. 81970284), and the project for the Distinguishing Academic Discipline of Fuwai Hospital (No. 2022-FWQN16) to Xiaofei Li. Conflicts of interest None.

目的:回顾性分析大动脉转位患者合并房室传导阻滞(AVB)的类型、特征及其他心律失常合并情况.方法:收集2003年1月至2020年1月我院45例合并AVB的大动脉转位患者(男性26例,女性19例)的临床资料,分析大动脉转位类型、超声Van Praagh分型、外科术前/术后发生AVB情况,其他心律失常的分布、治疗及随访情况.结果:45例患者平均入院年龄(30.6±18.7)岁,发现AVB时的年龄为(26.3±17.9)岁.发生AVB的大动脉转位患者以矫正型大动脉转位为主,占75.6％(34例),24.4％(11例)为右位心;超声Van Praagh分型多为SLL型占75.6％(34例),13.3％(6例)合并窦性心动过缓,11.1％(5例)合并房性心动过速,合并心房颤动、心房扑动和非持续性室性心动过速(NSVT)者均占6.7％(各3例),2.2％(1例)合并持续性室性心动过速/心室颤动.外科术前/术后出现AVB者为24/21例.35例植入起搏器患者中随访30例,平均随访时间(5.8±6.5)年,死亡7例,其中6例(6/30,20.0％)患者因心力衰竭加重死亡,1例患者在起搏器导线断裂后猝死.10例未植入起搏器患者中随访9例,患者平均随访时间(9.7±6.6)年.1例三度AVB患者拒绝植入起搏器,出院6年后猝死,3例三度AVB和3例一度AVB的患者无变化,2例二度AVB的患者进展为高度或三度AVB.结论:发生AVB的大动脉转位患者以矫正型大动脉转位为主,少数为右位心,可合并多种心律失常.外科术前、术后出现AVB的患者大致各占一半,起搏器治疗可预防猝死,但心力衰竭死亡率达20.0％.

Background: The present study aimed to clarify the impact of the 2020 COVID-19 pandemic on emergency management of acute type A aortic dissection. Methods: We consecutively enrolled 337 acute type A aortic dissection (ATAAD) patients at emergency room in Fuwai Hospital (Beijing, China) from January to June during the 2020 COVID-19 epidemic (n = 148) and the same period in 2019 as the historical control (n = 189). The primary outcome was defined as in-hospital death. Other outcomes included automatic discharge during emergency admission. The factors with significant differences before and after the epidemic were compared and analyzed by stages with the study endpoint to clarify their changes in different stages of the epidemic. Results: There was no significant difference in inhospital mortality (35 (20.5%) vs. 23 (17.4%), p = 0.472). Compared with year 2019, proportion of patients receiving surgical treatment decreased significantly (74 (50.0%) vs. 129 (68.25%), p < 0.001). The surgery time of ATAAD patients in 2020 was significantly shorter (6.46 [5.52, 7.51] vs. 7.33 [6.00, 8.85] hours, p = 0.01). The length of stay in the emergency department significantly differed at each stage. Conclusions: Our study demonstrated a significant reduction in the number of ATAAD patients and surgical treatment during COVID-19 outbreak. The surgical strategy of patients changed, but the overall mortality was largely the same. Patients undergoing surgery had a trend toward longer interval from the onset to the operating room, but they tended to be normal at the end of the epidemic. Proper epidemic prevention policies may avoid COVID-19 hitting patients who are not infected with the virus to the greatest extent.

目的 探讨左束支区域起搏(LBBAP)在持续性心房颤动(简称房颤)合并心动过缓患者中治疗的临床效果.方法 连续纳入自2019年10月至2020年4月的持续房颤合并心动过缓需要起搏治疗且超声评估左室射血分数≤0.35并接受LBBAP的患者.术中记录导线参数,术后3个月、6个月及1年随访起搏器程控参数和起搏相关并发症,以及术后1年超声心动图评估,对比基线、术后1年各项参数的变化.结果 连续入选共41例患者,年龄为(68.9±11.0)岁,其中男性占比73.2％(30/41).LBBAP的手术成功率为97.6％(40/41).术后起搏QRS波时限较术前基线心电图QRS波时限无明显变化[(115.2±9.6)ms vs(110.8±20.3)ms,P=0.145].LBBAP的心室电极中位植入时间为12(6.0,25.0)min,中位X线暴露时间为4.6(3.0,7.8)min.心室起搏平均阈值为(0.7±0.2)V.随访(13.3±7.0)个月,起搏比例达83.3％(48.3％,96.5％),随访心室起搏阈值(0.8±0.3)V.围手术期有2例在电极拧入过程中出现室间隔穿孔,经回撤起搏电极调整植入位点后均成功施行LBBAP且患者无临床症状,余患者在围手术期和随访期间均未出现任何起搏相关并发症.术后1年随访与基线对比左室射血分数(0.60±0.07vs0.60±0.06,P=0.243)和左室舒张末直径[(51.6±6.7)mmvs(52.1±6.6)mm,P=0.449]均无明显变化,但左房前后径较术前显著缩小[(50.1±10.9)mm vs(47.6±1.4)mm,P=0.013].结论 持续性房颤心动过缓患者接受LBBAP治疗1年随访起搏参数稳定,维持窄QRS波时限,且可能有助于逆转左房重构.

目的:探讨埋藏式心律转复除颤器(ICD)的除颤电极在右心室不同植入位置与三尖瓣反流进展的相关性.方法:回顾性纳入2016年1月至2019年12月于中国医学科学院阜外医院心律失常中心植入ICD或心脏再同步治疗除颤器(CRT-D)患者198例.所有患者在术前及术后均完善超声心动图,根据三尖瓣反流面积分为无、轻、中、重度四级.术后三尖瓣反流进展定义为:随访超声心动图评估的三尖瓣反流程度较术前基线提高至少一个等级.按除颤电极植入部位分为间隔部电极组和心尖部电极组.采用Kaplan-Meier曲线生存分析及Cox比例风险模型评估除颤电极植入部位对于三尖瓣反流进展是否存在影响.结果:198例患者平均年龄(57.1±12.1)岁,其中125例患者植入ICD,73例患者植入CRT-D.间隔部电极组115例(58.1％),心尖部电极组83例(41.9％),基线存在中-重度三尖瓣反流的患者共28例(14.1％).中位随访12(9,16)个月,共有48例(24.2％)患者出现三尖瓣反流进展,其中间隔部电极组28例(24.3％),心尖部电极组20例(24.1％),两组发生率差异无统计学意义(P=0.97).进一步分析显示,24例(12.1％)患者在随访期间进展为中-重度三尖瓣反流,其中间隔部电极组16例(13.9％),心尖部电极组8例(9.6％),两组发生率差异无统计学意义(P=0.36).同时,两组患者随访时的三尖瓣舒张期流速和三尖瓣舒张期跨瓣压差的差异均无统计学意义(P均>0.05).Kaplan-Meier曲线生存分析显示两组三尖瓣反流进展发生率差异无统计学意义(log-rank P=0.141).多因素Cox回归分析提示,除颤电极植入间隔部并未增加三尖瓣反流进展的发生风险(HR=0.55,95％CI:0.29～1.02,P=0.07).结论:ICD除颤电极的植入位置与术后三尖瓣反流进展可能并不相关.

BACKGROUND Left bundle branch pacing (LBBP) is the most rapidly growing conduction system pacing technique that is capable of correcting intrinsic left bundle branch block (LBBB). As such, it is potentially an optimal alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BiVP).OBJECTIVES The authors sought to compare the efficacy of LBBP-CRT with BiVP-CRT in patients with heart failure and reduced left ventricular ejection fraction (LVEF).METHODS This is a prospective, randomized trial of patients with nonischemic cardiomyopathy and LBBB with 6-month preplanned follow-up. Crossovers were allowed if LBBP or BiVP were unsuccessful. The primary endpoint was the dif-ference in LVEF improvement between 2 groups. The secondary endpoints included changes in echocardiographic measurements, N-terminal pro-B-type natriuretic peptide (NT-proBNP), New York Heart Association functional class, 6-minute walk distance, QRS duration, and CRT response.RESULTS The study included 40 consecutive patients (20 males, mean age 63.7 years, LVEF 29.7% +/- 5.6%). Cross-overs occurred in 10% of LBBP-CRT and 20% of BiVP-CRT. All patients completed follow-up. Intention-to-treat analysis showed significantly higher LVEF improvement at 6 months after LBBP-CRT than BiVP-CRT (mean difference: 5.6%; 95% CI: 0.3-10.9; P = 0.039). LBBP-CRT also appeared to have greater reductions in left ventricular end-systolic volume (-24.97 mL; 95% CI: -49.58 to -0.36 mL) and NT-proBNP (-1,071.80 pg/mL; 95% CI: -2,099.40 to -44.20 pg/mL), and comparable changes in New York Heart Association functional class, 6-minute walk distance, QRS duration, and rates of CRT response compared with BiVP-CRT.CONCLUSIONS LBBP-CRT demonstrated greater LVEF improvement than BiVP-CRT in heart failure patients with nonischemic cardiomyopathy and LBBB. (Left Bundle Branch Pacing Versus Biventricular Pacing for Cardiac Resynchro-nization Therapy [LBBP-RESYNC]; NCT04110431) (J Am Coll Cardiol 2022;80:1205-1216) (c) 2022 by the American College of Cardiology Foundation.

Tricuspid regurgitation (TR) is a known complication of cardiac implantable electrical devices. Theoretically, lead-related TR risk in patients with left bundle branch area pacing (LBBAP) should be lower than in patients with right ventricular (RV) septal pacing because of the thinner pacing lead and physiological pacing effect. This study aimed to assess lead-related TR outcomes of LBBAP and compare LBBAP and RV septal pacing in patients with bradycardia.

Whether left bundle branch area pacing (LBBAP) could be achieved in patients with hypertrophic cardiomyopathy (HCM) requiring ventricular pacing remains unknown. The present study aimed to investigate the feasibility and effect of LBBAP in HCM.

Purpose This study aims to assess whether left bundle branch area pacing (LBBAP) can result in favorable clinical and echocardiographic outcomes among patients with persistent atrial fibrillation (PeAF). Methods We prospectively enrolled consecutive patients with PeAF if they required ventricular pacing and had left ventricular ejection fraction (LVEF) > 35%. During the same period, two experienced operators performed LBBAP and right ventricular pacing (RVP). All-cause death and heart failure hospitalization (HFH) were routinely followed after procedure. The primary outcome was the composite endpoints of all-cause death or HFH. Results LBBAP was successful in 49 of 52 patients (94.2%), whereas 44 patients received RVP. During a mean follow-up of 13.9 +/- 7.0 months, LBBAP group presented with higher ventricular pacing percentage (80% vs. 50.9%, p = .04) and narrower paced QRS duration (117.2 +/- 18.8 ms vs. 151.8 +/- 13.7 ms, p < .001) than RVP group. The primary endpoint was slightly reduced in LBBAP group than RVP without reaching statistical significance (7.7% vs. 11.4%, p = .48). Compared with baseline, we observed significant changes in LVEF (+0.7% vs. -2.2%, p = .007) and left atrial diameter (-1.63 mm vs. +1.23 mm, p = .011) between LBBAP and RVP. Conclusion Our results indicate possible effect of LBBAP on reverse remodeling of left atrium and a trend towards favorable clinical outcomes in patients with PeAF requiring high burden of ventricular pacing when compared with RVP.

目的:对比有无合并糖尿病的急性主动脉夹层(AAD)患者的临床特征,探讨糖尿病对AAD患者短期和中期预后的影响.方法:入选2008年1月至2010年12月就诊于中国医学科学院阜外医院急诊科,经CT确诊为AAD的患者.采集患者的基线资料,记录患者的治疗方案和住院期间预后,并对患者进行中期随访.结果:本研究共纳入994例AAD患者,其中Stanford A型AAD 520例,Stanford B型AAD 474例.Stanford A型AAD患者中有16例(3.1％)患者合并糖尿病,Stanford B型患者中有24例(5.1％)患者合并糖尿病.合并糖尿病的AAD患者平均年龄、合并高血压、冠心病和高脂血症的比例均高于未合并糖尿病的AAD患者(P<0.05).合并和未合并糖尿病的AAD患者30 d死亡率分别为2.5％和8.2％,两者之间差异无统计学意义(P>0.05).多因素Cox回归显示糖尿病不是影响AAD患者短期预后(HR=0.251,95％CI:0.027～2.372,P>0.05)或中期预后(HR=0.233,95％CI:0.030～1.819,P>0.05)的独立因素.结论:合并糖尿病的AAD患者的平均年龄较大,合并高血压、冠心病和高脂血症的比例高,但糖尿病不是AAD患者短期或中期预后的影响因素.

目的:旨在观察左束支区域起搏(LBBAP)纠正右束支阻滞(RBBB)的临床效果及心电图特点.方法:本研究为单中心、前瞻性观察性研究,纳入2018年4月至2019年12月间入院有心室起搏指征,存在基线RBBB图形且QRS波群时限≥120 ms、左心室射血分数>50％并接受LBBAP的患者,分析LBBAP纠正RBBB的临床效果及心电图特点.结果:共纳入33例患者,平均年龄(63.6±10.5)岁.LBBAP成功者共30例(90.9％),其余3例患者为左心室间隔部起搏.通过调整起搏极性与输出电压,多数患者QRS波群时限较治疗前得以缩窄[(118.2±10.3)ms vs.(142.9±12.1)ms,P<0.001],其中20例(60.6％)实现RBBB完全纠正(QRS波群时限<120 ms),11例(33.3％)实现RBBB部分纠正(QRS波群时限较基线缩窄,但QRS波群时限≥120 ms).根据V1导联的QRS波群形态,可将RBBB纠正后的心电图图形大致分为4种类型,包括Qr型、QR型、qR型与QS型,其中以Qr型最为常见(n=15,48.4％).而基线呈现qR型的RBBB患者LBBAP纠正成功率更高(n=5,62.5％).结论:LBBAP可有效纠正RBBB,显著缩短QRS波群时限,心电图V1导联QRS波群图形以Qr型最为多见,术前V1导联呈现qR型的RBBB患者LBBAP纠正成功率更高.

The long-term lead stability and echocardiographic outcomes of left bundle branch area pacing (LBBAP) are not fully understood. This study aimed to observe the mid-long-term clinical impact of LBBAP compared to right ventricular pacing (RVP). Consecutive bradycardia patients undergoing LBBAP or RVP were enrolled. Pacing and electrophysiological characteristics, echocardiographic measurements, and procedural complications were prospectively recorded at baseline and follow-up. LBBAP was successful in 376 of 406 patients (92.6%), while 313 patients received RVP. During a mean follow-up of 13.6 ± 7.8 months, LBBAP presented with similar pacing parameters and complications to RVP, except a significantly narrower paced QRS duration (115.7 ± 12.3 ms vs. 148.0 ± 18.0 ms, p < 0.001). In 228 patients with ventricular pacing burden >40%, LBBAP at last follow-up resulted in decreased left atrial diameter (LAD) (40.1 ± 8.5 mm vs. 38.5 ± 8.0 mm, p < 0.001) while RVP produced decreased left ventricular ejection fraction (62.7 ± 4.8% vs. 60.5 ± 6.9%, p < 0.001) when compared to baseline. After adjusting for age, the presence of atrial fibrillation, and other clinical factors, LBBAP was still associated with a decrease in LAD (−1.601, 95% CI −3.094–−0.109, p = 0.036). We conclude that LBBAP might result in more preserved echocardiographic outcomes than RVP.

Background: Left bundle branch area pacing (LBBAP) is a novel physiological pacing approach. Objective: To assess learning curve for LBBAP and compare the procedure and fluoroscopy time between LBBAP and right ventricular pacing (RVP). Methods: Consecutive bradycardia patients who underwent LBBAP or RVP were prospectively recruited from June 2018 to June 2020. The procedure and fluoroscopy time for ventricular lead placement, pacing parameters, and periprocedural complications were recorded. Restricted cubic splines were used to fit learning curves for LBBAP. Results: Left bundle branch area pacing was successful in 376 of 406 (92.6%) patients while 313 patients received RVP. Learning curve for LBBAP illustrated initial (1–50 cases), improved (51–150 cases), and stable stages (151–406 cases) with gradually increased success rates (88.0 vs. 90.0 vs. 94.5%, P = 0.106), steeply decreased median procedure (26.5 vs. 14.0 vs. 9.0min, P < 0.001) and fluoroscopy time (16.0 vs. 6.0 vs. 4.0min, P < 0.001), and shortened stimulus to left ventricular activation time (Sti-LVAT; 78.7 vs. 78.1 vs. 71.2 ms, P < 0.001). LBBAP at the stable stage showed longer but close median procedure (9.0 vs. 6.9min, P < 0.001) and fluoroscopy time (4.0 vs. 2.8min, P < 0.001) compared with RVP. Conclusion: The procedure and fluoroscopy time of LBBAP could be reduced significantly with increasing procedure volume and close to that of RVP for an experienced operator.

目的:探讨左束支区域起搏(LBBAP)对三尖瓣反流(TR)的影响.方法:前瞻性入选2019年9月至2020年12月在中国医学科学院阜外医院本团队行LBBAP的缓慢性心律失常患者,术后定期随访超声心动图.按反流束面积/右心房面积比值的半定量法评估TR级别为无、轻、中、重度TR.TR进展定义为随访超声心动图评估的TR程度较术前进展至少一个等级.TR改善定义为随访超声心动图评估的TR程度较术前改善至少一个等级,中度或重度TR判断为有临床意义TR.结果:入选331例患者,303例患者完成随访,平均随访时间(6.63±4.57)个月.303例完成随访患者平均年龄(62.5±14.3)岁,男性167例(55.1％).术前轻度以上TR患者137例(45.2％),包括102例轻度TR、26例中度TR和9例重度TR;术后随访发生TR患者126例(41.6％),包括97例轻度TR、24例中度TR和5例重度TR.术后TR无进展患者260例(85.8％),术后TR改善患者57例(41.6％),TR进展患者43例(14.2％),包括TR进展1级42例(13.9％)、进展2级1例(0.3％).术后14例(4.6％)患者进展为有临床意义TR,术后出现新发TR患者29例(9.6％).Logistic回归分析发现心房颤动是LBBAP后TR进展的危险因素(OR=2.749,95％CI:1.404～5.380,P=0.003);持续性心房颤动是导致术后出现有临床意义TR的危险因素(OR=7.212,95％CI:1.928～26.969,P=0.003).结论:LBBAP可改善部分患者术前TR,少部分患者LBBAP后发生TR进展.心房颤动可能是LBBAP术后TR进展的影响因素.

Background It is well established that postoperative atrial fibrillation (POAF) is associated with adverse postoperative outcomes after major cardiac operations. The purpose of this study was to investigate the incidence of new‐onset POAF after successful total arch repair surgery and the association between POAF and in‐hospital mortality. Methods and Results All consecutive patients undergoing total arch repair from September 2012 to December 2019 in Fuwai hospital were enrolled (n=1280). Patients diagnosed with preoperative atrial fibrillation were excluded. POAF was diagnosed as the new‐onset atrial fibrillation or flutter for more than 5 minutes based on continuous electrocardiogram monitoring. A logistic regression model was used to determine predictors of in‐hospital mortality. Multivariable adjustment, inverse probability of treatment weighting, and propensity score matching were used to adjust for confounders. POAF was diagnosed in 32.3% (411/1271) of this cohort population. The occurrence of new‐onset POAF was associated with age (odds ratio [OR], 1.05; 95% CI, 1.04–1.06; P<0.001), male sex (OR, 0.72; 95% CI, 0.52–0.98; P=0.035), and surgery duration (OR, 1.2; 95% CI, 1.12–1.28; P<0.001). The in‐hospital mortality was significantly higher in patients with POAF than those without POAF (10.7% versus 2.4%, P<0.001). Inverse probability of treatment weighting and propensity score matching analyses confirmed the results. The increased in‐hospital mortality in POAF group still existed among subgroup analysis based on different age, sex, hypertension, smoking, and hypokalemia, combined with cardiac surgery, and deep hypothermic circulatory arrest. Conclusions More careful attention should be given to POAF after total arch repair surgery. The incidence of POAF after total arch repair surgery was 32.3% and associated with increased in‐hospital mortality. The elderly female patient who experienced longer operation duration was at highest risk for POAF.

Background: Left bundle branch area pacing (LBBAP) is a novel pacing modality with stable pacing parameters and a narrow-paced QRS duration. We compared heart failure (HF) hospitalization events and echocardiographic measures between LBBAP and right ventricular pacing (RVP) in patients with atrioventricular block (AVB). Methods and Results: This multicenter observational study prospectively recruited consecutive AVB patients requiring ventricular pacing in five centers if they received LBBAP or RVP and had left ventricular ejection fraction (LVEF) >50%. Data on electrocardiogram, pacing parameters, echocardiographic measurements, device complications, and clinical outcomes were collected at baseline and during follow-up. The primary outcome was first episode hospitalization for HF or upgrade to biventricular pacing. LBBAP was successful in 235 of 246 patients (95.5%), while 120 patients received RVP. During a mean of 11.4 ± 2.7 months of follow-up, the ventricular pacing burden was comparable (83.9 ± 35.1 vs. 85.7 ± 30.0%), while the mean LVEF differed significantly (62.6 ± 4.6 vs. 57.8 ± 11.4%) between the LBBAP and RVP groups. Patients with LBBAP had significantly lower occurrences of HF hospitalization and upgrading to biventricular pacing than patients with RVP (2.6 vs. 10.8%, P <0.001), and differences in primary outcome between LBBAP and RVP were mainly observed in patients with ventricular pacing >40% or with baseline LVEF <60%. The primary outcome was independently associated with LBBAP (adjusted HR 0.14, 95% CI: 0.04–0.55), previous myocardial infarction (adjusted HR 6.82, 95% CI: 1.23–37.5), and baseline LVEF (adjusted HR 0.91, 95% CI: 0.86–0.96). Conclusion: Permanent LBBAP might reduce the risk of HF hospitalization or upgrade to biventricular pacing compared with RVP in AVB patients requiring a high burden of ventricular pacing. Clinical Trial Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03851315; URL: http://www.chictr.org.cn ; Unique Identifier: ChiCTR2100043296.