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。

心血管疾病是我国居民健康的“头号杀手”。近年来，睡眠与心血管疾病的关系越来越受到重视。研究表明，睡眠可能通过自主神经活动影响心血管系统健康。心率变异性是衡量心脏自主神经功能的可靠、无创指标，且与心血管疾病的发病与死亡风险紧密相关。因此，睡眠与心率变异性的关系也得到较广泛的研究。本文重点论述睡眠与心率变异性关系的研究新进展。

To investigate the stability, safety and efficacy of a new domestic portable nitric oxide (NO) generator in children with pulmonary hypertension after surgery for congenital heart disease.

Children with refractory pulmonary hypertension after congenital heart disease from October 2022 to September 2023 were continuously enrolled in Heart Center of Shanghai Children's Medical Center. Basic information, diagnosis, ventilator parameters, concentration and duration of NO treatment, hemodynamic indexes and biochemical indexes were collected. The stability of the gas concentration of the portable NO generator in the early 24 hours after surgery were evaluated. The concentrations of related gases including nitrogen dioxide and methemoglobin were tested to evaluate the safety. Pulmonary artery pressure, oxygenation index, central venous pressure (CVP), N-terminal pro-B-type natriuretic(NT-proBNP), urine output, serum creatinine before and after NO inhalation therapy were compared to evaluate the effectiveness.

Among the 18 children, 8 were males,and 10 were females, with a median,weight of 11.0 (3.4,22.3) kg, a median age of 422.5 (44.0,2 327.3) d, a preoperative percutaneous arterial oxygen saturation (SPO₂) of (84.3±11.7)%, 12 cases with biventricular correction, and 6 cases with single ventricular correction. The inhalation treatment time of NO was (95±11.2) h, the concentration of inhaled NO ranged from 3-80 (19±3.5)ppm. The tidal volume on the ventilator was 25-290 ml. The mortality rate was 16.7% in 3 children, and the causes of death were sepsis, right heart failure and multiorgan insufficiency. After inhalation, the mean pulmonary artery pressure decreased significantly [(50.2±20.6) mmHg vs. (28.6±10.5) mmHg, P=0.01), CVP decreased significantly [(15.3±2.1) mmHg vs. (13.8±1.3) mmHg, P<0.01], NT-proBNP decreased significantly [(10 583.9±7 938.4) pg/ml vs. 9 (866.0±7 802.5) pg/ml, P=0.02], and oxygenation index was significantly increased. [(91.4±35.9)% vs. (103.4±39.9)%, P<0.01] The concentration of nitrogen dioxide was (0.1±0.02) ppm, the content of methemoglobin was 0.9±0.6%, and the maximum content was 2.8%. All within the safe range.

The NO concentration produced by this domestic portable NO generator is stable, which can significantly reduce the pulmonary artery pressure and central venous pressure in children with pulmonary hypertension refractory to congenital heart disease surgery, significantly improve the oxygenation index with the related products including nitrogen dioxide and methemoglobin within the safe range, which is safe and effective.

经皮左心耳封堵（LAAC）作为口服抗凝治疗的替代，已在众多非瓣膜性房颤患者中广泛开展。术中影像指导是手术成功的关键因素之一。经食管超声心动图（TEE）是当前指导LAAC最常用的术中超声影像工具，但应用有一定局限性。心腔内超声心动图（ICE）做为替代TEE的较为成熟的术中超声影像学工具，已被越来越多地应用于LAAC术。本文结合目前临床较为常用的三轴六向评估技术，为临床提供ICE指导LAAC手术的规范化标准流程。

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。

To evaluate the electrophysiological and histological characteristics of the atrioventricular node (AVN) and His bundle (His) post the temporal and spatial change of pulse field ablation (PFA) in canine.

A stable biphasic square wave pulse width (100 ms) was delivered with output 2 000 V (± 1 000) V from a novel contact-force sensing focal PFA catheter in a bipolar electrode arrangement. After mapping the site with the highest his potential navigated by a 3-dimensional electroanatomical mapping system in 6 canines. Sites 1 was defined as those 0~2 mm away from the highest His potential. Then the PFA catheter was moved to map the sites 2 which with his potential were ≥6 mm far from the highest His potential, and the sites 3 were without His. The one and consecutive 3 pulse train deliveries were applied in sites 1, 2 and 3 in sequence, and were named in sequence as 1PFA-1 site, 3PFA-1 site, 1PFA-2 site, 3PFA-2 site, 1PFA-3 site and 3PFA-3 site. The safe distance in vivo was defined as the shortest width between the sites 3, without high-degree atrioventricular block (AVB) or complete bundle brunch block post PFA, to the sites 1. Estimated the range of estimated lesion was confirmed after simulation of focal ablation catheter placed on the surface of atrial musculature tissue in vitro in a computational model. The cardiac specimens were sectioned for histopathological analysis such as depth and width of ablation in 24 h post the PFA procedure.

①The transient Ⅲ-degree AVB reproducibly occurred in 6 1PFA-1 sites, 6 3PFA-1 sites and 2 3PFA-2 sites. Right bundle branch block (RBBB) occurred in 6 1PFA-1 sites, 6 1PFA-2 sites, 2 1PFA-3 sites, 6 3PFA-1 sites, 4 3PFA-2 sites and 3 3PFA-3 sites. ②The duration of transient Ⅲ-degree AVB and RBBB were sorted as follows: 3PFA-1 sites>1PFA-1 sites>3PFA-2 sites [(4.15±0.58) min vs. (2.97±0.46) min vs. (1.35±0.21) min, P<0.01]. The transient duration of RBBB in 1PFA-1 sites was longer than that in 1PFA-2 sites followed by 1PFA-3 sites, and it was reoccurred in 1PFA-3 sites [1PFA: (2.01±0.81) min vs. (1.07±0.63) min vs. (0.40±0.14) min; 3PFA: [(4.53±0.80) min vs. (3.27±0.17) min vs. (0.43±0.12)] min, P<0.05]. The duration of RBBB either in 3PFA-1 sites or 3PFA-2 sites was longer than that in 1PFA-1 sites [(4.53±0.80) min vs. (2.01±0.81) min, P<0.01] and 1PFA-2 sites [(3.27±0.17) min vs. (1.07±0.63) min, P<0.01]. The safe distance in vivo was 10.0-14.1 mm. A maximal transmural lesion producing a width of 14 mm by histology was comparable to irreversible damage width in a computational model in vitro.

PFA can produce transmural lesions near AVN- His region, and PFA-related Ⅲ-degree AVB or RBBB was site and dose dependent.

心力衰竭（心衰）是各类心血管疾病发展的终末阶段，国内外指南根据患者左心室射血分数将心力衰竭分为四类，分别为射血分数减少型心衰（HFrEF）、射血分数中间值心衰（HFmEF）、射血分数保留型心衰（HFpEF）及最新提出的射血分数改善型心衰。虽然针对HFrEF治疗已取得巨大进展，但对其他类型心衰治疗手段仍有限。研究发现HFpEF主要病理生理机制与左心室舒张功能不全致左心房压升高及肺循环淤血有关，因此心房分流术通过降低HFpEF患者左心房压，或许可改善患者肺淤血症状，提高活动耐受力，降低患者心衰再住院率。本文综述近年来心房分流术治疗的最新研究进展及争议情况，以期为后期心房分流术标准化诊疗流程提供思路。

结构性心脏病的介入治疗是近年来心血管介入诊疗中发展最快速的领域。国内外多种用于结构性心脏病介入治疗的新器械和新技术正呈现百花齐放、蓬勃发展的态势。本文旨在综述结构性心脏病介入治疗的现状和进展，能让更多的结构性心脏病患者受益。

先天性心脏病（先心病）是我国最主要的出生缺陷疾病。本文围绕内外科治疗过程中护理的重点（导管穿刺后的血管并发症及围手术期的心肺护理管理）进行阐述，并提出先心病患儿开展全生命周期的康复护理必要性、重要性及存在的难点与挑战。

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。

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.

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.

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.

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.

心腔内超声心动图（ICE）指导下的左心耳封堵术（LAAC）不仅能清晰地展示左心耳及邻近组织解剖结构，还能实现“零射线”“绿色封堵”。本视频为ICE指导下的LAAC标准流程解析，供广大术者交流、借鉴与参考。

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。

To explore the level of ruminant meditation and its influencing factors in patients with coronary heart disease (CHD) after secondary percutaneous coronary intervention.

From September 2019 to June 2021, patients with CHD who were hospitalized in The First Affiliated Hospital of Nanjing Medical University for reintervention were selected. A cross-sectional survey of target patients was conducted using the Social Demographic Questionnaire, the Connor-Davidson Resilience Scale and the Rumination Questionnaire. Multiple linear regression analysis was used to analyze the influencing factors of rumination.

A total of 106 patients with CHD who underwent reintervention were included. The age was (53.55±9.61) years old, and 56.60% (60/106) were males. The score of purposive rumination was (13.18±6.65), and the score of invasive rumination was (16.67±5.75). Multiple linear regression analysis showed that the patients' interests and psychological resilience explained 19.6% of intrusive rumination, and personal monthly income and psychological resilience explained 38.2% of purposeful rumination.

The level of rumination in patients with CHD after reintervention is at a medium level and more inclined to invasive rumination. We should pay attention to the negative psychological impact of reintervention on patients with CHD, formulate corresponding measures to improve the psychological resilience level of patients with CHD after reintervention and adjust their coping style.

目前，二尖瓣反流的分型主要是Carpentier分型，该分型最初用于指导外科二尖瓣修复手术。经导管缘对缘修复（TEER）是二尖瓣反流的新兴治疗技术，已经逐渐广泛应用于临床，但目前缺少指导该手术的二尖瓣反流分型。本文基于目前一些研究提供的基本结论，结合自身300例（经心尖或经股）TEER手术经验，提出了新的二尖瓣反流分型，该分型体系可为TEER手术提供更好手术策略指导。然而，该分型未经过严谨的研究数据证实，仍需开展相关临床研究，对这些分型的实践意义进行严谨论证。

报道1例高血栓风险及高出血风险的心房颤动伴缓慢心室率合并R-R长间歇患者在心腔内超声心动图指导下行经皮左心耳封堵与无导线起搏器植入一站式手术。手术安全、有效，患者体验感好，整体缩短了住院时间和减少住院费用。

To investigate the mastery of knowledge about atrial fibrillation (AF) among grass-roots general practitioners in Fengxian District, Shanghai, and analyze related influencing factors.

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.

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.

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.

To investigate whether exercise blood pressure (BP) was associated with cardiac structure and function independent of BP at rest.

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.

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.

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.

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。