ΑΘΛΗΣΗ ΚΑΙ ΣΥΓΓΕΝΕΙΣ ΚΑΡΔΙΟΠΑΘΕΙΕΣ. Διευθυντής Καρδιολογικό Τμήμα, ΤΖΑΝΕΙΟ Νοσοκομείο Πειραιά

Transcript

1 ΑΘΛΗΣΗ ΚΑΙ ΣΥΓΓΕΝΕΙΣ ΚΑΡΔΙΟΠΑΘΕΙΕΣ Χ. Ντέλλος Διευθυντής Καρδιολογικό Τμήμα, ΤΖΑΝΕΙΟ Νοσοκομείο Πειραιά Υπεύθυνος Παιδοκαρδιολογικού και Συγγενών Καρδιοπαθειών Ενηλίκων

2 Disclosures : No conflicts of interest

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4 ΠΡΟΑΘΛΗΤΙΚΟΣ ΕΛΕΓΧΟΣ 1. Πρόληψη αιφνίδιου θανάτου (1: /έτος) 2. Διάγνωση παθήσεων που απαιτούν περιορισμό της αθλητικής δραστηριότητας 3. Διάγνωση παθολογικών καταστάσεων που δεν περιορίζουν την αθλητική δραστηριότητα, αλλά απαιτούν παρακολούθηση

5 Sudden Death Among Athletes The incidence of sudden death from cardiovascular causes: 0.6/ person years. 66 deaths from cardiovascular causes per year. At present, the AHA does not believe it is practical or financially feasible to support a large scale preparticipation screening involving standard 12- lead ECG in competitive athletes. Maron BJ et al: Sudden deaths in young compititive athletes. Circulation 2009.

6 Top Health Risks for Young Adults Us Healths statistics on young adults Febr Top cause of death: Accidents: 40 per Smoking: 29% of men and 21% of women Obesity: 24% of young adults are obese 28% more are overweight. Obesity rates for young adults tripled from 1970s Inactivity: only 36% of young adults get regular physical activity No health insurance: About a third of young adults are uninsured

7 «Αιφνίδιος» θάνατος σε νέους Σε 1 θάνατο στην άθληση αντιστοιχούν περισσότεροι από 100 θάνατοι νέων από τροχαία, ναρκωτικά και αυτοκτονίες

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9 OI ΚΥΡΙΟΤΕΡΕΣ ΠΑΘΗΣΕΙΣ ΣΤΟΝ ΑΙΦΝΙΔΙΟ ΚΑΡΔΙΑΚΟ ΘΑΝΑΤΟ ΣΕ ΑΘΛΗΤΕΣ (I) Υπερτροφική μυοκαρδιοπάθεια Συγγενείς παθήσεις στεφανιαίων (ανώμαλη εκβολή) Σύνδρομο Marfan CoA- δίπτυχη αορτική βαλβίδα(cystic media necrosis) «Αρρυθμιογόνος» δεξιά κοιλία Μυοκαρδίτιδα, διατατική μυοκαρδιοπάθεια «Ιδιοπαθής» υπερτροφία της αριστερής κοιλίας Στένωση αορτικής βαλβίδας Πρόπτωση μιτροειδούς

10 ΚΥΡΙΟΤΕΡΕΣ ΠΑΘΗΣΕΙΣ ΣΤΟΝ ΑΙΦΝΙΔΙΟ ΚΑΡΔΙΑΚΟ ΘΑΝΑΤΟ ΣΕ ΑΘΛΗΤΕΣ (II) Ισχαιμική καρδιοπάθεια Σύνδρομο WPW Σύνδρομο μακρού Q-T «Iδιοπαθής» κοιλιακή μαρμαρυγή Καρδιακό τραύμα Cardiac concussion or commotio cordis Drug abuse (cocaine, anabolics)

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12 European Society of Cardiology Recommendations for competitive sports participation in athletes with cardiovascular disease Pelliccia et al Eur Heart J 2005;26,

13 J Am Coll Cardiol 2008

14 Atrial septal defect (ASD) - untreated Recommentations: 1. Athletes with small defects, normal right heart volume, and no pulmonary hypertension can participate in all sports. 2. Athletes with a large ASD and normal pulmonary artery pressure can participate in all competitive sports. 3. Athletes with an ASD and mild pulmonary hypertension can participate in lowintensity competitive sports (class IA).

15 ASD closed at operation or by interventional catheterization Recommentations: Three to six months after the operation or intervention, patients can participate in all sports unless the following are present: a) evidence of pulmonary hypertension b) symptomatic atrial or ventricular tachyarrhythmias or second or third-degree heart block c) evidence of myocardial dysfunction.

16 Ventricular septal defect (VSD) - untreated Recommentations: 1. Athletes with a VSD and normal pulmonary artery pressure can participate in all sports. 2. Athletes with a large VSD who do not have marked elevation of pulmonary resistance resistance are candidates for repair, and full participation in all sports would normally occur after a successful VSD closure.

17 VSD closed at operation or by interventional catheterization Recommentations: At three to six months after repair, asymptomatic athletes with no defect or only a small residual defect can participate in all competitive sports if they have no evidence of evidence of pulmonary artery hypertension, ventricular or atrial tachyarrhythmia, or myocardial dysfunction.

18 Patent ductus arteriosus (PDA) - untreated Recommentations: 1. Athletes with a small PDA and normal left heart chamber dimension can participate in all competitive sports. 2. Athletes with a moderate or large PDA, causing left ventricular (LV) enlargement, should undergo surgical or interventional catheterization closure before unrestricted competition.

19 PDA, closed at operation or by interventional catheterization Recommentations: Three months after PDA closure, patients with no symptoms, with normal cardiac examination, and with no evidence of pulmonary hypertension or LV enlargement can participate in all competitive sports.

20 Pulmonary valve stenosis (PS) - untreated Recommentations: Athletes with a peak systolic gradient less than 40 mmhg and normal right ventricular function can participate in all competitive sports if no symptoms are present. Annual re-evaluation is recommended.

21 PS treated by operation or balloon valvuloplasty Recommentations: Athletes with no or only residual mild PS and normal ventricular function without symptoms can participate in all competitive sports. Participation in sports can begin two to four weeks after balloon valvuloplasty. After operation, an interval of approximately three months is suggested before resuming sports participation.

22 Aortic valve stenosis (AS) - untreated Recommentations: Athletes with mild AS can participate in all competitive sports if they have a normal ECG, normal exercise tolerance, and no history of exercise-related chest pain, syncope, or atrial or ventricular tachyarrhythmia associated with symptoms.

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25 Aortic stenosis treated by operation or balloon valvuloplasty Recommentations: Athletes with residual mild, moderate, or severe stenosis should follow the same recommendations as previously defined for untreated patients.

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27 Coarctation of the aorta - untreated Recommentations: Athletes with mild coarctation and the absence of large collateral vessels or significant aortic root dilation with a normal exercise test and a small pressure gradient at rest (usually 20 mmhg or less between upper and lower limbs), and a peak systolic blood pressure 230 mmhg or less with exercise can engage in all competitive sports.

28 Coarctation of the aorta treated by surgery or balloon angioplasty Recommentations: Participation in sports, three or more months after surgical or balloon angioplasty for coarctation of the aorta, is permitted for athletes with a 20 mmhg or less arm/leg blood pressure gradient at rest and a normal peak systolic blood pressure during rest and exercise.

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31 Postoperative tetralogy of Fallot (T/F) Recommentations: 1. Athletes with an excellent repair should be allowed to participate in all sports, provideng that the following criteria are met: Normal or near-normal right heart pressure No or only mild right ventricular volume overload No evidence of a significant residual shunt No atrial or ventricular tachyarrhythmia abnormality on ambulatory ECG monitoring or exercise testing 2. Patients with marked pulmonary regurgitation and right ventricular volume overload, residual right ventricular hypertension (peak systolic right ventricular pressure greater than or equal to 50% systemic pressure), or atrial or ventricular tachyarrhythmias, should participate in low-intensity competitive sports only

32 Transposition of the great arteries (TGA) postoperative Mustard or Senning operation Recommentations: 1. Selected patients can engage in low and moderate static/low dynamic competitive sports provided there is: Mild or no cardiac chamber enlargement on chest radiograph, echocardiography, or CMR No history of atrial flutter, supraventricular tachycardia, or ventricular tachyarrhythmia No history of syncope or other cardiac symptoms A normal exercise test defined as normal duration, workload, heart rate, ECG, and blood pressure response for age and gender 2. Patients not in this category require an individualized exercise prescription

33 Postoperative arterial switch for TGA Recommentations: Athletes with normal ventricular function, normal exercise test, and no atrial or ventricular tachyarrhythmias can participate in all sports

34 Postoperative Fontan operation Recommentations: 1. Athletes can participate in low-intensity competitive sports 2. Athletes can engage in class IB sports if they have normal ventricular function and oxygen saturation

35 Ebstein s anomaly Recommentations: 1. Athletes with a mild expression of Ebstein s anomaly without cyanosis, with normal right ventricular size, and with no evidence of atrial or ventricular tachyarrhythmias can participate in all sports. 2. Athletes with tricuspid regurgitation of moderate severity can participate in low-intensity competitive sports if there is no evidence of arrhythmia on ambulatory ECG Holter monitoring other than isolated premature contractions.

36 Congenital coronary artery anomalies Recommentations: 1. Detection of coronary anomalies of wrong sinus origin in which a coronary artery passes between great arteries should results in exclusion from all participation in competitive sports. 2. Participation in all sports three months after successful operation would be permitted for an athlete without ischemia, ventricular or tachyarrhythmia, or dysfunction during maximal exercise testing

37 Kawasaki disease Recommentations: 1. Patients with no coronary artery abnormalities or transient coronary artery ectasia resolving during the convalescent phase of the disease are encouraged to participate in all sports after six to eight weeks. 2. Patients with regressed aneurysms can participate in all competitive sports if they have no evidence of exercise induced ischemia by stress testing with myocardial perfusion imaging.

38 Mitral Regurgitation Recommentations: Athletes with mild to moderate MR who are in sinus rhythm with normal LV size and function and with normal pulmonary artery pressures can participate in all competitive sports

39 Aortic Regurgitation Recommentations: Athletes with mild or moderate AR, but with LV enddiastolic size that is normal or only mildly increased, consistent with that which may result solely from athletic training, can participate in all competitive sports.

40 Bicuspid Aortic Valves with Aortic Root Dilatation Recommentations: 1. Patients with bicuspid aortic valves with no aortic root dilatation (less than 40 mm or the equivalent according to body surface area in children and adolescents) and no significant AS or AR may participate in all competitive sports. 2. Patients with bicuspid aortic valves and dilated aortic roots between 40 and 45 mm may participate in low and moderate static or low and moderate dynamic competitive sports, but should avoid any sports in these categories that involve the potential for bodily collision or trauma. 3. Patients with bicuspid aortic valves and dilated aortic roots greater than 45 mm can participate in only lowintensity competitive sports.

41 Tricuspid Regurgitation Recommentations: Athletes with primary TR, regardless of severity, with normal RV function in the absence of right atrial pressure greater than 20 mm Hg or elevation of RV systolic pressure can engage in all competitive sports.

42 Gray zone of L.V. wall thickness HCM Athlete s heart (+) (+) (-) (+) (+) (+) (+) (-) (+) Unusual patterns of LVH LV cavity < 45 mm LV cavity > 55 mm LA enlargement Bizarre ECG patterns Abnormal LV filling Female gender Thickness with deconditioning Family history HCM (-) (-) (+) (-) (-) (-) (-) (+) (-)

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44 Hyperthrophic Cardiomyopathy Recommentations: Athletes with a probable or unequivical clinical diagnosis of HCM should be excluded from most competitive sports, with the possible exception of those of low intensity. This recommendation is independent of age, gender, and phenotypic appearance, and does not differ for those athletes with or without symptoms, LV outflow obstruction, or prior treatment with drugs or major interventions with surgery, alcohol septal ablation, pacemaker, or implantable defibrillator.

45 Mitral Valve Prolapse (MVP) Recommentations: 1. Athletes with MVP but without any of the following features can engage in all competitive sports: a. Prior syncope, judged probably to be arrhythmogenic in origin b. Sustained or repetitive and monsustained supraventricular tachycardia or frequent and/or complex ventricular tachyarrhythmias on ambulatory Holter monitoring c. Severe mitral regurgitation assessed with color-flow imaging d. LV systolic dysfunction (ejection fraction less than 50%) e. Prior embolic event f. Family history of MVP-related sudden death 2. Athletes with MVP and any of the aforementioned disease features can participate in low-intensity competitive sports only.

46 Myocarditis Recommentations: Athletes with probable or definite evidence of myocarditis should be withdrawn from all competitive sports and undergo a prudent convalescent period of about six months following the onset of clinical manifestations.

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48 Marfan Syndrom Recommentations: Athletes with Marfan syndrome can participate in low and moderate static/low dynamic competitive sports if they do not have one or more of the following: a.aortic root dilatation (i.e., transverse dimension 40 mm or greater in adults, or more than 2 standard deviations from the mean for body surface area in children and adolescents. b.moderate-to-severe mitral regurgitation c.family history of dissection or sudden death in a Marfan relative It is recommended however, that these athletes have an echocardiographic measurement of aortic root dimension repeated every six months, for close surveillance of aortic enlargement.

49 Arrythmogenic Right Ventricular Cardiomyopathy (ARVC) Recommentations: Athletes with probable or definite diagnosis of ARVC should be excluded from most competitive sports, with the possible exception of those of low intensity.

50 Ο ΕΝΗΛΙΚΑΣ ΜΕ ΧΕΙΡΟΥΡΓΗΘΕΙΣΑ ΤΕΤΡΑΛΟΓΙΑ FALLOT ΜΕΤΑ ΤΗΝ ΗΛΙΚΙΑ ΤΩΝ 40 ΕΤΩΝ Μακροχρόνια χειρουργικά αποτελέσματα Χ. Ντέλλος, Μ. Κανάκης, Ε. Μπιλιανού, Κ. Κατσάρος, Ι. Καραντζής, Φ. Αναστασιάδης, Ε. Χαλλή, Φ. Μητρόπουλος, Σ. Φούσας Καρδιολογικό Τμήμα Κέντρο Συγγενών Καρδιοπαθειών Ενηλίκων «Τζάνειο» Γενικό Νοσοκομείο Πειραιά

51 ΑΡΡΥΘΜΙΕΣ Υπερκοιλιακές ταχυκαρδίες 5 ασθενείς (18%) Κοιλιακή Ταχυκαρδία 4 (14%) Βηματοδότης DDD 3 (11%) Εμφυτεύσιμος Απινιδωτής 2 (7%) Φλεβοκομβικός ρυθμός : 16 ασθενείς (57%)

52 ΒΑΘΜΟΣ ΑΝΕΠΑΡΚΕΙΑΣ ΠΝΕΥΜΟΝΙΚΗΣ, ΔΙΑΡΚΕΙΑ QRS ΚΑΙ ΑΝΑΠΤΥΞΗ ΑΡΡΥΘΜΙΩΝ PR+++/++++ και QRS 160ms (8 ασθενείς) : 87,5% αρρυθμίες Οι ασθενείς με QRS 180ms (4) : 100% αρρυθμίες. Στους ασθενείς με σοβαρού βαθμού PR παρατηρήθηκε μείωση του QRS μετά από επανεγχείρηση.

53 ΠΡΟΑΘΛΗΤΙΚΟΣ ΚΑΡΔΙΟΛΟΓΙΚΟΣ ΕΛΕΓΧΟΣ Οικογενειακό ιστορικό Συμπτώματα (κυρίως στην άθληση) Φυσική εξέταση ΗΚΓ ECHO Συγκοπτικό επεισόδιο, Έντονη ζάλη, Προκάρδιο άλγος Holter Δοκιμασία κόπωσης Ειδικές εξετάσεις (MRI, ΗΦΕ, κ.α.)

54 ΠΡΟΣΟΧΗ! Η «ΝΟΣΟΣ ΤΩΝ ΥΠΕΡΗΧΩΝ» ΧΤΥΠΑ ΚΥΡΙΩΣ ΤΟΥΣ ΝΕΟΥΣ!

55 «ΣΥΜΠΕΡΑΣΜΑ» ΥΠΕΡΗΧΟΚΑΡΔΙΟΓΡΑΦΗΜΑΤΩΝ ΠΡΟΑΘΛΗΤΙΚΩΝ ΕΛΕΓΧΩΝ ΣΕ ΓΕΝΙΚΟ ΠΛΗΘΥΣΜΟ Στο 97% περίπου των περιπτώσεων: «Μελέτη με φυσιολογικά ευρήματα» ή «Μελέτη χωρίς παθολογικά ευρήματα».

56 ΚΙΝΔΥΝΟΣ «ΥΠΕΡΔΙΑΓΝΩΣΗΣ» ΣΕ ΠΑΙΔΙΑ ΚΑΙ ΝΕΟΥΣ Πρόπτωση μιτροειδούς Ανεπάρκεια μιτροειδούς Ανεπάρκεια τριγλώχινας Ανεπάρκεια πνευμονικής Ανοικτό ωοειδές τρήμα

57 Επίπτωση της ΠΜΒ στο γενικό πληθυσμό. 18% (σε νέες γυναίκες) Μarkiewitz W,Stoner J. et al, Circulation 53:464, % Devereux RB, Hawking J, et al. Am J Med 81:751, % Freed LA, Levy D, et al. N Engl J med 341:1, 1999

58 Highlights ESC Congress 2004 The incidence and clinical significance of mitral valve prolapse in childhood and adolescence. Are we overdiagnose the syndrome? Ntellos C, et al. Tzanion Hospital, Piraeus, Greece

59 Παιδοκαρδιολογικό & Κέντρο Συγγενών Καρδιοπαθειών Ενηλίκων Καρδιολογικό Τμήμα ΤΖΑΝΕΙΟΥ Νοσοκομείου παιδιά και έφηβοι ετών

60 0-6 ετών 7-12 ετών ετών Φυσική εξέταση ΗΚΓ Υπερηχογράφημα Δοκιμασία κόπωσης Holter ρυθμού 24ώρου

61 Αποτελέσματα - ΤΖΑΝΕΙΟ 121 παιδιά και έφηβοι ( 1.5% του πληθυσμού) είχαν ΠΜΒ. 44 αγόρια και 77 κορίτσια (p<0.004) 64% ΚΟΡΙΤΣΙΑ 36% ΑΓΟΡΙΑ

62 Αποτελέσματα - ΤΖΑΝΕΙΟ Σε παρακολούθηση 3 8 χρόνων κανένας ασθενής δεν παρουσίασε επιδείνωση κλινική ή υπερηχο-γραφική, ούτε αναφέρθηκαν ενδοκαρδίτιδα, εμβολικό επεισόδιο, συγκοπή ή αρρυθμία χρήζουσα φαρμακευτικής αγωγής.

63 Συμπεράσματα Το σύνδρομο της πρόπτωσης της μιτροειδούς βαλβίδας παρουσιάζει στατιστικώς σημαντικά μικρότερη επίπτωση στα παιδιά και στους εφήβους συγκριτικά με τους ενήλικες. Η επίπτωση παρουσιάζει αύξηση με την ηλικία και συσχετίζεται θετικά με το γυναικείο φύλο

64 Συμπεράσματα Οι καρδιολόγοι θα πρέπει να είναι ιδιαίτερα προσεκτικοί στην «ελαστική» διάγνωση της ΠΜΒ, ώστε να αποφύγουμε τον αδικαιολόγητο αποκλεισμό νέων από αθλητικές δραστηριότητες και την αναίτια πρόκληση άγχους στην οικογένεια.

65 Υπερηχοκαρδιογραφικά κριτήρια Μετατόπιση των γλωχίνων της μιτροειδούς βαλβίδας > 2mm πάνω από τον δακτύλιο, εντός του αριστερού κόλπου, στην αριστερή παραστερνική λήψη, Πάχυνση των γλωχίνων >3-5mm

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69 ΠΜΒ και άθληση Επιτρέπεται κάθε αθλητική δραστηριότητα, με εξαίρεση: Ιστορικό συγκοπτικού επεισοδίου που προκλήθηκε από αρρυθμία Οικογενειακό ιστορικό αιφνίδιου θανάτου που αποδόθηκε σε ΠΜΒ Υπερκοιλιακές αρρυθμίες ή σύμπλοκες κοιλιακές αρρυθμίες Μετρίου ή σοβαρού βαθμού ανεπάρκεια της μιτροειδούς Ιστορικό εμβολικού επεισοδίου Γενικά συνιστάται Holter και δοκιμασία κόπωσης

70 CSC Congress Paris Pre-participation cardiovascular screening of 1000 children and adolescents The significance of echocardiogram C. Ntellos, V. Papaioannou, K. Katsaros, E. Bilianou, E. Challi, S. Karvounaris Tzaneio General hospital Cardiology Department, Piraeus, Greece

71 Results Abnormal results in 23 patients (2,3%) 13 (1,3%) of them, had mitral valve prolapse (with or without insufficiency of mitral valve) 7 (0,7%) of them had bicuspid aortic valve 1 of them (0,1%) atrial secundum septal defect 2 (0,2%) hypertrophic cardiomyopathy

72 Results From the 23 patients with abnormal findings in echocardiography: 11 (47%) had pathologic findings in clinical examination and only 3 (13%) appeared with electrocardiographic abnormalities The 2 patients with hypertrophic cardiomyopathy had clinical and electrocardiographic findings, indicative of the disease

73 Cardiologist must be the master, not the slave of the new powerful technology E.Braunwald

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77 Υπερηχοκαρδιογραφική Μελέτη Συνεστήθη η αποφυγή άρσης βαρών!

78 Υπερηχοκαρδιογραφική Μελέτη

79 Υπερηχοκαρδιογραφική Μελέτη

80 Υπερηχοκαρδιογραφική Μελέτη

81 Υπερηχοκαρδιογραφική Μελέτη 08/05/07

82 Υπερηχοκαρδιογραφική Μελέτη 22/05/07

83 Υπερηχοκαρδιογραφική Μελέτη 27/01/10

84 Υπερηχοκαρδιογραφική Μελέτη 16/07/10

85 I.

86 II.

87 Γιατρέ, τι είναι αυτό το ωοειδές;

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92 Amblatzer device

93 Patent Foramen Ovale: Innocent or Guilty? Evidence from a Prospective Population Based Study. SPARC (Stroke Prevention: Assesment of Risk in a Community) Conclusions PFO is not an independent risk factor for future cerebrovascular events in the general population. A larger study is required to test the putative stroke risk associated with Atrial Septal Aneurysm. Meissner et al. JACC 2006.

94 Patent foramen ovale and the risk of ischemic stroke in a multiethnic population NOMAS (Northern Manhattan Study) Conclusions PFO, alone or together with ASA (Atrial Septal Aneurysm), was not associated with an increased stroke risk in this multiethnic cohort. The independent role of ASA needs further assessment in appositely designed and powered studies. Di Toullio MR, et al. J Am Coll Cardiol 2007;49:

95 GUIDELINES for Prevention of Stroke in patients with Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals from the AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION/AMERICAN ACADEMY OF NEUROLOGY For patients with an ischemic stroke or TIA and a PFO, antiplatelet therapy is reasonable to prevent a recurrent event. Class II a, Level B Warfarin is reasonable for high-risk patients who have other indications for oral anticoagulation such as those with an underlying hypercoagulable state or evidence of venous thrombosis. Class II a, Level C Sacco R. et al. Stroke 2006;37:

96 GUIDELINES for Prevention of Stroke in patients with Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals from the AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION/AMERICAN ACADEMY OF NEUROLOGY PATENT FORAMEN OVALE Insufficient data exist to make a recommendations about PFO closure in patients with a first stroke and a PFO. PFO closure may considered for patients with recurrent cryptogenic stroke despite medical therapy. Class II b, Level C Sacco R. et al. Stroke 2006;37:577-6

97 FDA RECOMMENDATIONS 2007 Off-label closure should be discouraged. Patients and physicians should be educated about the lack of evidence of benefit of closure and the need for completion of trials. Pinto T. et al. Circulation 2007;116:

98 It might be time for other arms of government or the professional societies to take a tougher stance on off-label use of devices for PFO closure. Meeting on March 2, 2007 of the FDA s Circulatory System Devices Panel.

99 Several ongoing randomized trials for RESPECT trial over of 6 years (2007): CLOSURE 1 trial PC (Percutaneous Closure) trial Their results may clarify the affectiveness of percutaneous closure as compared with medical therapy.

100 A Prospective, Multicenter, Randomized Controlled Trial to Evaluate the Safety and Efficacy of the STARFlex Septal Closure System Versus Best Medical Therapy in Patients with a Stroke or Transient Ischemic Attack due to Presumed Paradoxical Embolism through a Patent Foramen Ovale Anthony J Furlan MD Gilbert Humphrey Professor Chairman Department of Neurology Co-Director Neurological Institute University Hospitals Case Medical Center Case Western Reserve University School of Medicine For the CLOSURE I Investigators Trial Sponsor: NMT Medical Boston

101 CONCLUSIONS CLOSURE I is the first completed, prospective, randomized, independently adjudicated PFO device closure study Superiority of PFO closure with STARFlex plus medical therapy over medical therapy alone was not demonstrated no significant benefit related to degree of initial shunt no significant benefit with atrial septal aneurysm insignificant trend (1.8%) favoring device driven by TIA 2 year stroke rate essentially identical in both arms (3%) Major vascular (procedural) complications in 3% of device arm Significantly higher rate of atrial fibrillation in device arm (5.7%) 60% periprocedural

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105 Η γενοκτονία των PFO «Το καλό PFO είναι το κλειστό PFO!» «Η συμμορία του PFO» Υπερηχογραφιστές «κυνηγοί PFO» Επεμβατικοί «βιαστές PFO» Η συμμορία των «PFOφιλων»

106 ΠΡΟΣΕΞΤΕ ΤΟ PFO ΣΑΣ! ΤΟ ΔΙΚΟ ΣΑΣ ΚΑΙ ΤΩΝ ΠΑΙΔΙΩΝ ΣΑΣ! ΚΥΚΛΟΦΟΡΟΥΝ PFOΦΙΛΟΙ! (Ελεύθερη απόδοση πρόσφατης οδηγίας του FDA)

107 Σύγκλειση Ανοικτού Ωοειδούς Τρήματος (PFO), σε Ποιους; Με τις υπάρχουσες γνώσεις Σε κανένα!

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109 Mandatory electrocardiographic screening of athletes to reduce their risk of sudden death J Am Coll Cardial 2011; 57: Screening Does Not Reduce Sudden Death in Young Athletes Too many false positive results Too high cost

110 Πόσο το Κόστος της Προαθλητικής Εξέτασης; Ιταλία 30 ανά αθλητή (ΗΚΓ) για 1 ζωή αθλητή. ΗΠΑ (Αν εφαρμοσθεί) πολύ μεγαλύτερο κόστος Ελλάδα Προαθλητικός έλεγχος σε Ιδιωτικά Κέντρα (+ECHO) Προσφορές εποχής (!) 100

111 ΣΗΜΕΡΑ Ο ΠΡΟΑΘΛΗΤΙΚΟΣ ΕΛΕΓΧΟΣ ΜΕ ΥΠΕΡΗΧΟΥΣ ΩΦΕΛΕΙ ΛΙΓΟΥΣ ΚΑΙ ΒΛΑΠΤΕΙ ΠΑΡΑ ΠΟΛΛΟΥΣ! Έλλειψη εμπειρίας και γνώσης Αμυντική ιατρική «Επαγγελματική» νοοτροπία : «Θα το πει ο άλλος»! «Ο ΆΛΛΟΣ» Ο ΜΕΓΑΛΟΣ ΣΥΝΕΝΟΧΟΣ!

112 ΥΠΕΡΒΟΛΕΣ ΣΤΗΝ ΠΡΟΛΗΠΤΙΚΗ ΙΑΤΡΙΚΗ ΤΩΝ ΝΕΩΝ Υπέρταση, Υπερχοληστερολαιμία «Είναι εύκολο ο γιατρός να γράφει συνταγές, αλλά είναι δύσκολο να συνεννοηθεί με τους αρρώστους» Franz Kafka

113 Θεραπεύουμε αρρώστους ή εργαστηριακές εξετάσεις;

114 Progress and challenges in metabolic syndrome in children and adolecents. A scientific statement from the American Heart Association. Circulation, February 2009.

115 Cholesterol, triglucerides, blood pressure, fasting glucose, in children are moving targets, there really aren t very well established criteria for what is normal or abnormal. In kids the focus in on prevention and management of obesity, smoking and increasing physical inactivity. The treatment strategy would not be improved by labeling a patient dichotomously as having the metabolic syndrome.

116 ΠΑΙΔΟΚΑΡΔΙΟΛΟΓΙΚΟ ΤΖΑΝΕΙΟΥ ΝΟΣΟΚΟΜΕΙΟΥ ΠΕΙΡΑΙΑ παιδιά και έφηβοι σε 20 χρόνια Σε κανένα δεν χρειάσθηκε φαρμακευτική αγωγή για «Ιδιοπαθή Υπέρταση»

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118 Εμείς οι γιατροί ζούμε από τις ιατρικές ανάγκες αλλά και τις φοβίες του κόσμου. Αυτό είναι φυσικό και χρήσιμο, αρκεί να μην αυξάνουμε εμείς οι ίδιοι τις τελευταίες.

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