We sought to assess the risk of sudden death (SD) in both male and female athletes age 12 to 35 years.
Little is known about the risk of SD in adolescents and young adults engaged in sports.
We did a ...21-year prospective cohort study of all young people of the Veneto Region of Italy. From 1979 to 1999, the total population of adolescents and young adults averaged 1,386,600 (692,100 males and 694,500 females), of which 112,790 (90,690 males and 22,100 females) were competitive athletes. An analysis by gender of risk of SD and underlying pathologic substrates was performed in the athletic and non-athletic populations.
There were 300 cases of SD, producing an overall cohort incidence rate of 1 in 100,000 persons per year. Fifty-five SDs occurred among athletes (2.3 in 100,000 per year) and 245 among non-athletes (0.9 in 100,000 per year), with an estimated relative risk (RR) of 2.5 (95% confidence interval CI 1.8 to 3.4; p < 0.0001). The RR of SD among athletes versus non-athletes was 1.95 (CI 1.3 to 2.6; p = 0.0001) for males and 2.00 (CI 0.6 to 4.9; p = 0.15) for females. The higher risk of SD in athletes was strongly related to underlying cardiovascular diseases such as congenital coronary artery anomaly (RR 79, CI 10 to 3,564; p < 0.0001), arrhythmogenic right ventricular cardiomyopathy (RR 5.4, CI 2.5 to 11.2; p < 0.0001), and premature coronary artery disease (RR 2.6, CI 1.2 to 5.1; p = 0.008).
Sports activity in adolescents and young adults was associated with an increased risk of SD, both in males and females. Sports, per se, was not a cause of the enhanced mortality, but it triggered SD in those athletes who were affected by cardiovascular conditions predisposing to life-threatening ventricular arrhythmias during physical exercise.
This single-center retrospective study assessed the variation of left ventricular ejection fraction (LVEF) after transapical transcatheter aortic valve implantation and its effect on survival. We ...also evaluated the effect of sheath diameter on LVEF.
We analyzed data of all consecutive patients who underwent transapical transcatheter aortic valve implantation with the Sapien (Edwards Lifesciences, Irvine, CA) device (and its evolutions) between 2009 and 2015. We analyzed the difference between preoperative LVEF and LVEF at discharge (ΔEF = LVEFpost-op - LVEFpre-op) and considered its interquartile range (±5%) as the cutoff. Patients were divided in three groups: (1) improved LVEF (ΔEF ≥ +5%); (2) unchanged LVEF (ΔEF -5% to +5%), and (3) worsened LVEF (ΔEF ≤ -5%). Survival was evaluated with Kaplan-Meier analysis, and logistic regression multivariable analysis was used to determine independent predictors of LVEF improvement.
Data of 122 patients were analyzed. Patients in the three groups were distributed as follows: (group 1) 27 patients (22.1%), (group 2) 69 (56.6%), and (group 3) 26 (21.3%). The mean ΔEF was 12.7% ± 4.7% in group 1 and -10.8% ± 3.9% in group 3. The ΔEF was more likely to improve in patients with preoperative LVEF of less than 0.35 (p = 0.014). There were no significant differences in survival (p = 0.41), rehospitalization (p = 0.472), and New York Heart Association Functional Classification (p = 0.307) among the groups. The use of the smallest available sheath (18F) was not associated with a significant change of ΔEF.
LVEF worsened in a small number of patients after transapical transcatheter aortic valve implantation, but this change was not associated with worse postoperative outcomes. Patients with a low LVEF showed better improvement. The progressive reduction of sheath diameter does not have a significant effect on LVEF changes.
Objective Although surgical aortic valve replacement (SAVR) is the treatment of choice for patients with aortic valve stenosis, transcatheter aortic valve replacement (TAVR) and sutureless aortic ...valve replacement (SU-AVR) have shown good results. The aim of our multicenter, propensity-matched study was to compare the clinical and hemodynamic outcomes of surgical SAVR, transapical TAVR (TA-TAVR), and SU-AVR. Methods We analyzed data from 566 TA-TAVR, 349 SAVR, and 38 SU-AVR patients treated from January 2009 to March 2012. We used a propensity-matching strategy to compare on-pump (SAVR, SU-AVR) and off-pump (TA-TAVR) surgical techniques. The outcomes were analyzed using multivariate weighted logistic regression or multinomial logistic analysis. Results In the matched cohorts, the 30-day overall mortality was significantly lower after SAVR than TA-TAVR (7% vs 1.8%, P = .026), with no differences in mortality between SU-AVR and TA-TAVR. Multivariate analysis showed SU-AVR to have a protective effect, although not statistically significant, against aortic regurgitation, pacemaker implantation, and renal replacement therapy compared with TA-TAVR. Compared with TA-TAVR, SAVR demonstrated significant protection against aortic regurgitation (odds ratio, 0.04; P < .001) and a trend toward protection against death, pacemaker implantation, and myocardial infarction. The mean transaortic gradient was 10.3 ± 4.4 mm Hg, 11 ± 3.4 mm Hg, and 16.5 ± 5.8 mm Hg in the TA-TAVR, SU-AVR, and SAVR patients, respectively. Conclusions SAVR was associated with lower 30-day mortality than TA-TAVR. SAVR was also associated with a lower risk of postoperative aortic regurgitation compared with TA-TAVR. We did not find other significant differences in outcomes among matched patients treated with SAVR, SU-AVR, and TA-TAVR.
Tricuspid valve replacement (TVR) is an uncommon procedure. The use of biological vs mechanical prostheses in TVR has pros and cons. Therefore, we debate the choice between the different types of ...valves by means of a meta-analysis of studies of the last decade.
The heading “tricuspid valve replacement and (bio* or mec*)” was used to retrieve studies from Medline, Current Contents, and Embase. Eight out of 11 studies met the preset strict criteria: intra-institutional comparison of results of biological or mechanical TVR. Survival of hospital-discharged patients was recalculated to reduce the effect of unbalanced perioperative risk factors on overall survival. Hazard ratio was obtained from actuarial survival graphics comparison and at-risk groups, according to the method described by Parmar . If missing, the number of patients at risk was approximated assuming constant and noninformative censoring. Hazard pooling was done according to study heterogeneity. Bioprostheses were assumed as the gold standard and mechanical prostheses assumed as the challenging device. Therefore, a hazard more than 1 pointed to a higher risk of mechanical prostheses. Our 1998 study was updated for this analysis.
In this study, 1,160 prostheses and 6,046 follow-up years were analyzed. The pooled survival hazard ratio of mechanical prostheses versus bioprostheses was 1.07 (0.84 to 1.35,
p = 0.60). The pooled freedom from reoperation hazard ratio was 1.24 (0.67 to 2.31,
p = 0.67). Pooled survival differences were trivial, favoring mechanical prostheses at 1 (−0.04%) and 15 years (−1.1%) and favoring bioprostheses (+1.8%) at 10 years.
There is not a gold standard in tricuspid prostheses replacement. Prosthetic choice is left to the surgeon's clinical judgment, taking into consideration each patient's characteristics and needs.
This study was undertaken to quantify the relationship between prosthesis size adjusted for patient size (prosthesis-patient size) and long-term survival after aortic valve replacement.
Data from ...nine representative sources on 13,258 aortic valve replacements provided 69,780 patient-years of follow-up (mean 5.3 ± 4.7 years), with reliable survival estimates to 15 years. Prostheses included 5757 stented porcine xenografts, 3198 stented bovine pericardial xenografts, 3583 mechanical valves, and 720 allografts. Manufacturers’ labeled prosthesis size was 19 mm or smaller in 1109 patients. Expressions of prosthesis-patient size assessed were indexed internal prosthesis orifice area (in centimeters squared per square meter of body surface area) and standardized internal prosthesis orifice size (Z, the number of SDs from mean normal native aortic valve size). Multivariable hazard domain analysis with balancing score and risk factor adjustment quantified the association of prosthesis-patient size with survival.
Prosthesis-patient size down to at least 1.1 cm2/m2 or −3 Z did not adversely affect intermediate- or long-term survival (P > .2). However, 30-day mortality increased 1% to 2% when indexed orifice area fell below 1.2 cm2/m2 (P = .002) or standardized orifice size fell below −2.5 Z (P = .0003). The increased early risk affected fewer than 1% of patients receiving bioprostheses but about 25% of those receiving mechanical devices.
Aortic prosthesis-patient size down to 1.1 cm2/m2 or −3 Z did not reduce intermediate- or long-term survival after aortic valve replacement. However, patient-prosthesis size under 1.2 cm2/m2 or −2.5 Z was associated with a 1% to 2% increase in 30-day mortality. Prosthesis-patient sizes this small or smaller were rarely implanted in patients receiving bioprostheses.
The aim of this study was to describe gender differences in patients operated on for TOF and to define the impact of pregnancy in late post-surgical follow-up in women.
In this research, we studied ...145 patients after correction of TOF: 66 male, 79 women, 41 of which reported history of 68 pregnancies, means age 37±10 years, age at operation 7±8 years, mean duration of post-surgical follow-up 30±7 years. Selected variables were compared according to sex and according to history of pregnancy with statistical tests.
Men had more severe hemodynamic impairment and a higher number of cardiac reoperations than females. 41% of patients had at least one complication during pregnancy; there were 16 (67%) abortions and 39 (74%) Caesarian delivers; the recurrence of congenital heart defect was 10%. After pregnancy, there was a shift from first to second functional class: unique pregnancy determined no differences in term of morpho-functional ventricular features compared to nulliparous, but they complained fatigue and palpitation and echocardiographyc dysfunction. Left ventricular dysfunction and QRS duration at ECG were independent predictors of ventricular arrhythmias in all patients.
There were no gender-specific differences in patients operated on for TOF using ventriculotomy. Pregnancy is an event in these patients at risk for the newborn, in terms of miscarriage, prematurity, and recurrence of birth defects, and for the mother in terms of ventricular dysfunction and electrical instability. At least a single pregnancy does not appear to significantly modify the natural history of post-surgical patients operated on for TOF.
Objective We have analyzed, in a clinical multicenter study, the effect of cardiac surgery in adults with congenital heart disease in Italy. Methods We collected clinical data from 856 patients aged ...19 years or older who underwent surgical intervention from January 1, 2000, to December 31, 2004. Patients were divided into 3 surgical groups: group 1, palliation (3.1%); group 2, repair (69.7%); and group 3, reoperation (27.4%). Results Preoperatively, 34.6% of patients were in New York Heart Association class I, 48.4% were in class II, 14.2% were in class III, and 2.8% were in class IV. Sinus rhythm was present in 83%. There were 1179 procedures performed in 856 patients (1.37 procedures per patient), with a hospital mortality of 3.1%. Overall mean intensive care unit stay was 2.3 days (range, 1–102 days). Major complications were reported in 247 (28.8%) patients, and postoperative arrhythmias were the most frequent. At a mean follow-up of 22 months (range, 1 month–5.5 years; completeness, 87%), late death occurred in 5 (0.5%) patients. New York Heart Association class was I in 79.3%, II in 17.6%, and III in 2.9%, and only 1 (0.11%) patient was in class IV. Overall survival estimates are 82.6%, 98.9%, and 91.8% at 5 years for groups 1, 2, and 3, respectively. Freedom from adverse events at 5 years is 91% for acyanotic patients versus 63.9% for preoperative cyanotic patients ( P < .0001). Conclusions Surgical intervention for congenital heart disease in adults is a safe and low-risk treatment. However, patients presenting with preoperative cyanosis show a higher incidence of late adverse events and complications.
Objective The aim of the present study was to compare the hydrodynamics of 4 different mechanical prostheses fitting the atrioventricular annulus in children. Methods We tested different inverted ...aortic prostheses with a prosthesis–annulus relationship in the mitral chamber of the Sheffield pulse duplicator (Department of Medical Physics and Clinical Engineering, Royal Hallamshire Hospital, Sheffield, UK), analyzed by comparing the prosthetic housing diameter and the predicted annulus diameter based on body surface area (0.8 and 1 m2 corresponding to an annulus diameter of 18.8–20.2 mm). The On-X 19 (On-X Life Technologies, Inc, Austin, Tex), SJM Regent 19 (St Jude Medical Inc, St Paul, Minn), Sorin Overline 18 (Sorin Biomedica, Saluggia, Italy), and Medtronic Advantage Supra 19 (Medtronic Inc, Minneapolis, Minn) valves with a housing diameter of 19 to 20 mm were hydrodynamically compared. The tests were carried out at increasing pulse rate of 72, 80, 100, and 120 beats/min for a stroke volume of 20 and 30 mL. Therefore, cardiac output ranged from 1.44 to 3.6 L/min. Results Regardless of the pulse rate and stroke volume, the Medtronic Advantage Supra valve showed the highest mean diastolic pressure difference at each cardiac output ( P < .05). The mean gradients were significantly lower for the Sorin Overline valve regardless of the cardiac output, stroke volume, and pulse rate ( P < .05). The effective orifice areas observed followed exactly the same behavior: the lowest for the Medtronic Advantage Supra valve and the highest for the Sorin Overline valve. The Sorin Overline valve showed the highest closure volumes ( P < .05), and the On-X prosthesis showed the highest leakage volumes ( P < .05). The Sorin Overline valve had the highest total regurgitant volume ( P < .05), and the Medtronic Advantage Supra valve had the lowest total regurgitant volume ( P < .05). The On-X valve showed the highest total energy loss regardless of the pulse rate at 20 mL of stroke volume, which was comparable to the SJM Regent and Sorin Overline valves at increased stroke volume. The Medtronic Advantage Supra valve showed the lowest total energy loss regardless of cardiac outputs ( P < .05). Conclusions This hydrodynamic evaluation model allowed us to compare the efficiency of currently available valve prostheses suitable for atrioventricular replacement in children. Among these prostheses, the Sorin Overline valve showed the best diastolic performance. On the other hand, for total energy loss, the Medtronic Advantage Supra valve demonstrated excellent performance.
Survival and prosthetic complications of patients receiving the Hancock II second-generation bioprosthesis (Medtronic, Inc, Minneapolis, Minn) in the aortic, mitral, mitral-aortic, and tricuspid ...positions were analyzed at 15 years’ follow-up.
Between May 1983 and December 1993, 212 patients (104 men and 108 women; mean age, 63 ± 9 years; age range, 29-81 years) received 66 aortic, 114 mitral, 26 mitral-aortic, and 6 tricuspid Hancock II valves. Thirty-one percent of patients had previous valve operations, 15% had concomitant cardiac procedures, and 87% were in New York Heart Association class III or IV. Follow-up included 1704 patient-years and was 98% complete, with a median of 9 patient-years (range, 0.013-17.4 years). Forty-six patients were at risk at 14 to 15 years, and 30 were at risk after 15 years.
One hundred twenty-two (57%) of 212 patients died, 20 of them perioperatively. Fifteen-year actuarial Kaplan-Meier survival was 35.2% ± 3.8%, and freedom from valve-related mortality was 84% ± 3.5%, with no difference on the basis of position or age (<65 or ≥65 years). Percentages for freedom from thromboembolism, anticoagulant-related hemorrhage, endocarditis, and paravalvular leak were, respectively, 78.2% ± 4%, 83.5% ± 3.6%, 95.7% ± 2%, and 97.3% ± 1.4%, with no significant difference between the aortic and mitral positions. Freedom from structural valve deterioration was 71.8% ± 5.6%: 88.9% ± 6.2% in the aortic position versus 59.5% ± 3.9% in the mitral position (
P = .01) and 64.3% ± 3% in the mitral-aortic position. In patients younger than 65 years, actual freedom from structural valve deterioration was less than that seen in older patients (84.5% ± 3.5% vs 95% ± 3.0%) and was better in the aortic versus the mitral position (92% ± 4.5% vs 82% ± 4.2%).
The Hancock II porcine valve showed excellent 15-year durability. We recommend its use in patients 65 years of age, as well as in younger patients undergoing aortic replacement.
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The Hancock II bioprosthesis is a second-generation porcine valve xenograft treated with the detergent sodium dodecyl sulphate (T6) to retard calcification. The aim of this investigation was to study ...the gross and microscopic features in Hancock II explants to assess the structural changes occurring with time.
Among 1382 Hancock II bioprostheses (701 isolated aortic, 421 isolated mitral, 130 double) implanted from 1983 to 1997 in 1252 patients, 22 (16 mitral, 6 aortic) were removed at reoperation until 1999 and were available for pathological investigation
: infective endocarditis occurred in 5 and structural deterioration in 8, whereas in the remaining 9 xenografts reoperation was performed for nonstructural valve deterioration (paravalvular leak in 4 and prophylactic replacement in 5). Morphological investigation consisted of gross examination and x-ray, histologic, immunohistochemistry, electron microscopic, and atomic absorption spectroscopic examination.
The cause of structural valve deterioration was dystrophic calcification in 4 cases (1 aortic, 3 mitral; range of time graft was in place, 101 to 144 months), non-calcium–related tears in 3 cases (all mitral, range 121 to 163 months), and commissural dehiscence in 1 (aortic, range 156 months). Five of the nonstructural valve deterioration explants (range 42 to 122 months) showed only pinpoint mineralization at the commissures. Mean calcium content in nonstructural deterioration explants was 14.70 ± 22.33 versus 99.11 ± 81.52 mg/g in explants with structural valve deterioration. Electron microscopic examination showed early nuclei of mineralization mostly consisting of calcospherulae upon cell debris. Local or diffuse lipid insudation was observed in all but 2 explants and consisted of cholesterol clefts, lipid droplets, and lipid-laden macrophages featuring foam cells. The lipid insudation was the most plausible cause of tearing in 2 explants.
These pathologic findings support the clinical results of a delayed occurrence of structural failure of Hancock II bioprostheses and a mitigation of mineralization by the anti-calcification treatment. However, other factors such as lipid insudation may come into play in the long term.
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