Repositório RCAAP

ABSTRACT Introduction: Cervical Spondylotic myelopathy (CSM) is a disabling manifestation of extended cervical stenosis characterized by pronounced neurological dysfunction. Decompressive interventions contribute to significant regression of symptoms and, in some cases, complete recovery can be achieved. Objective: To explore the potential of laminoplasty in patients with extended cervical spondylotic stenoses complicated by myelopathy, and to develop approaches for surgical intervention in these patients. Methods: Fifty-six patients were included in the study. Laminoplasty was performed in 34 patients. Corpectomy was performed in 22 patients who made up the comparison group. The frequency and initial severity of concomitant non-neurological disorders in both groups were comparable. Results: Indications for laminoplasty were determined. They include: symptoms of spondylotic myelopathy, three or more levels of compression, preservation of lordosis, absence of signs of segmental instability, inability to perform anterior decompression, and age over 55 years. The presence of signs of segmental instability, kyphotic deformation, and history of mental disorders may be considered as contraindications for this surgery. Conclusions: Due to a number of advantages, laminoplasty is the treatment of choice for extended cervical spondylotic stenosis. Adequate selection of patients based on the evaluation of clinical symptoms, extension of stenosis, neurological signs and neuroimaging features enable excellent results to be achieved. Level of Evidence: II. Type of Study: Prospective comparative study.

ABSTRACT Objective: The article presents an analysis of the clinical efficacy and causes of unsatisfactory outcomes of surgical treatment in patients with degenerative diseases of the lumbosacral junction of the spine. Methods: Patients were allocated to one of three groups, depending on the method of surgical intervention on the lumbosacral junction: 1) (n=352) - operated by the method of microsurgical discectomy; 2) (n=83) - operated with the use of artificial IVD prostheses; 3) (n = 183) - operated with the use of interbody fusion and posterior rigid stabilization. To investigate the causes of unsatisfactory outcomes, a correlation analysis was conducted of long-term clinical outcomes with preoperative instrumental parameters in the operated segment, surgical tactics used, and the development of complications. Results: It is determined that long-term “good” clinical outcomes are associated with individual preoperative parameters of the lumbosacral junction of the spine - linear displacement, sagittal angulation, height of the interbody space, degree of IVD degeneration by ADC. Conclusion: In degenerative diseases of the lumbosacral junction of the spine, the detailed analysis of long-term clinical outcomes enable the identification of the causes that affect the development of unsatisfactory outcomes, which are individual morphostructural changes in the lower lumbar segment: the amplitude of the segmental angle, the angle of the lumbar lordosis, the degree of linear displacement of the vertebrae, the height of the interbody space, and ADC. Complex clinical and instrumental analysis enabled us to determine possible surgical tactics. Level of Evidence II; Prognostic Studies— Investigating the Effect of a Patient Characteristic on the Disease Outcome.

ABSTRACT Objective: To analyze the structure of degenerative lumbar stenosis surgical treatment complications and to analyze their effect on the results and indications for revision operations. Methods: Between 2009 and 2013, 513 patients with lumbar stenosis of degenerative etiology were surgically treated. There were 205 men, 308 women, aged 23 to 74 years. The main clinical manifestations were persistent compression radiculopathy, chronic pain in the back and lower limbs, and difficulty walking. The intensity of the pain was assessed by the VAS. At the time of hospitalization, VAS was 55-90 points. Results: Of the 513 operated patients, 65 (12.67%) had complications in the early postoperative period (up to three months after the operation); intraoperative complications occurred in 26 (5.1%) patients; intraoperative dura mater injury occurred in 24 (4.67%); pulmonary embolism (PE) occurred in 2 (0.39%) patients; 39 patients had early postoperative complications; acute radiculopathy occurred in 22 patients (4.28%); and 17 patients (3.31%) had surgical wound complications. Conclusions: Liquorrhea, postoperative hematomas and acute radiculopathy had no negative effect on the results of treatment in any of the cases. In the early postoperative period, 4 (0.77%) deaths were recorded intraoperatively and in 2 (0.39%) cases, intraoperative PE occurred. Two cases (0.39%) resulted in sepsis and multiple organ failure. In eight (1.55%) patients, the results of the treatment were unsatisfactory: in 4 (0.77%) cases due to death, and in a further 4 (0.77%) due to elimination of the system by the spinal column as a result of suppuration. Level of Evidence IV; Therapeutic studies - Investing the results of treatment.

ABSTRACT Objective: The aim of the study was to investigate the clinical and radiological results of using the annular closure device in patients with lumbar disc herniation (LDH). Methods: The study involved 120 patients with LDH operated on by limited discectomy and annular closure using the Barricaid device. A literature review was conducted to evaluate the effectiveness of the annuloplasty. Results: All patients showed postoperative regression of the radicular pain syndrome and were mobilized on the day of surgery. The correlation between the removed nucleus pulposus and changes in DHI was studied by linear regression. The results revealed that disc height loss is directly correlated with the volume of removed nucleus pulposus (p <0.05). Modic changes were present in 22 (22%) patients. Endplate changes (resorption and erosion) were present in 25 patients (20.7%). We found that these changes in MR and CT images have no effect on the clinical presentation of the disease. No intraoperative complications, such as severe hemorrhage requiring blood transfusion, or injury to the dura mater or nerve roots, were observed in our case series. Postoperative complications occurred in 3 (2.5%) patients. The reoperation rate was 4.2%. Conclusions: The use of the Barricaid annular closure device in 120 patients with lumbar disc herniation and high risk of recurrent herniation showed good clinical and radiographic outcomes. The reoperation rate in our study was 2.5%; disc reherniation at the operated level was observed in 1.7% of patients. This is a good outcome compared to the data reported for patients having a high risk of disc reherniation. Level of Evidence IV; Case series.

ABSTRACT Objective: Infectious complications are the most common cause of unsatisfactory results of surgical treatment and prolongation of hospitalization in patients following spinal surgery. The purpose - to assess the microbiological characteristics of SSI in patients after posterior lumbar fusion for degenerative disease, and to determine the relationship between these characteristics and surgical features of SSIs. Methods: A single-center retrospective non-randomized cohort study was performed, 1563 patients aged 37 to 59 years were included in the study. Microbiological characteristics were analyzed, and their interrelations with the surgical features of all cases of SSIs were determined. Results: The incidence of SSIs was 2.67% (41). Monomicrobial SSIs were detected in 46.3% (19) patients, polymicrobial in 36.5% (15) cases, and negative results of inoculation in 17.07% (7) patients. The most frequent pathogens of SSIs in the study group were S. aureus and S. epidermidis - 37.9% (33) and 24.1% (21), respectively. The period of development of symptoms of SSIs in patients after posterior lumbar fusion averaged 25.9±65.3 days. Methicillin-resistant S. aureus and S. epidermidis (MRSA and MRSE) were verified in 24.1% (21) cases. Conclusions: Assessment of microbiological characteristics should be carried out in all diagnosed cases of SSIs in patients after spine surgical interventions, as these are closely linked to the surgical features of the infectious process. Also, the treatment tactics for this group of patients should be determined by a medical team working in conjunction. Level of evidence IV; Descriptive study.

Abstract Background: There is a physiologic elevation of total cholesterol (TC) and triglycerides (TG) during pregnancy. Some authors define dyslipidemia (DLP) in pregnant women when TC, LDL and TG concentrations are above the 95th percentile (p95%) and HDL concentration is below the 5th percentile (P5%) for gestational age (GA). Objective: To compare the prevalence of DLP in pregnant women using percentiles criteria with the V Brazilian Guidelines on Dyslipidemia and the association with maternal and fetal outcomes. Results: Pregnant women with high-risk conditions, aged 18-50 years, and at least one lipid profile during pregnancy was classified as the presence of DLP by two diagnostic criteria. Clinical and laboratorial data of mothers and newborns were evaluated. Conclusion: 433 pregnant women aged 32.9 ± 6.5 years were studied. Most (54.6%) had lipid profile collected during third trimester. The prevalence of any lipid abnormalities according to the criteria of the National Guidelines was 83.8%: TC ≥ 200 mg/dL was found in 49.9%; LDL ≥ 160 mg/dL, in 14.3%, HDL ≤ 50 mg/dL in 44.4% and TG ≥ 150 mg/dL in 65.3%. Any changes of lipid according to percentiles criteria was found in 19.6%: elevation above the P95% for TC was found in 0.7%; for LDL, 1.7%; for TG 6.4% and HDL lower than the P5% in 13%. The frequency of comorbidity: hypertension, diabetes, smoking, obesity and preeclampsia was similar among pregnant women when DLP was compared by both criteria. Conclusion: The prevalence of DLP during pregnancy varies significantly depending on the criteria used, however none demonstrated superiority in association with comorbidities.

Abstract Background: The accuracy of zero coronary calcium score as a filter in patients with chest pain has been demonstrated at the emergency room and outpatient clinics, populations with low prevalence of coronary artery disease (CAD). Objective: To test the gatekeeping role of zero calcium score in patients with chest pain admitted to the coronary care unit (CCU), where the pretest probability of CAD is higher than that of other populations. Methods: Patients underwent computed tomography for calcium scoring, and obstructive CAD was defined by a minimum 70% stenosis on invasive angiography. Results: In 146 patients studied, the prevalence of CAD was 41%. A zero calcium score was present in 35% of the patients. The sensitivity and specificity of zero calcium score yielded a negative likelihood ratio of 0.16. After logistic regression adjustment for pretest probability, zero calcium score was independently associated with lower odds of CAD (OR = 0.12, 95%CI = 0.04-0.36), increasing the area under the ROC curve of the clinical model from 0.76 to 0.82 (p = 0.006). Zero calcium score provided a net reclassification improvement of 0.20 (p = 0.0018) over the clinical model when using a pretest probability threshold of 10% for discharging without further testing. In patients with pretest probability < 50%, zero calcium score had a negative predictive value of 95% (95%CI = 83%-99%), with a number needed to test of 2.1 for obtaining one additional discharge. Conclusion: Zero calcium score substantially reduces the pretest probability of obstructive CAD in patients admitted to the CCU with acute chest pain. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Abstract Heart failure with preserved ejection fraction (HFpEF) is now an emerging cardiovascular epidemic, being identified as the main phenotype observed in clinical practice. It is more associated with female gender, advanced age and comorbidities such as hypertension, diabetes, obesity and chronic kidney disease. Amyloidosis is a clinical disorder characterized by the deposition of aggregates of insoluble fibrils originating from proteins that exhibit anomalous folding. Recently, pictures of senile amyloidosis have been described in patients with HFpEF, demonstrating the need for clinical cardiologists to investigate this etiology in suspect cases. The clinical suspicion of amyloidosis should be increased in cases of HFPS where the cardio imaging methods are compatible with infiltrative cardiomyopathy. Advances in cardio imaging methods combined with the possibility of performing genetic tests and identification of the type of amyloid material allow the diagnosis to be made. The management of the diagnosed patients can be done in partnership with centers specialized in the study of amyloidosis, which, together with the new technologies, investigate the possibility of organ or bone marrow transplantation and also the involvement of patients in clinical studies that evaluate the action of the new emerging drugs.

Abstract Background: The dietary limitation during pregnancy influences the growth and development of the fetus and offspring and their health into adult life. The mechanisms underlying the adverse effects of gestational protein restriction (GPR) in the development of the offspring hearts are not well understood. Objectives: The aim of this study was to evaluate the effects of GPR on cardiac structure in male rat offspring at day 60 after birth (d60). Methods: Pregnant Wistar rats were fed a normal-protein (NP, 17% casein) or low-protein (LP, 6% casein) diet. Blood pressure (BP) values from 60-day-old male offspring were measured by an indirect tail-cuff method using an electro sphygmomanometer. Hearts (d60) were collected for assessment of connexin 43 (Cx43) mRNA expression and morphological and morphometric analysis. Results: LP offspring showed no difference in body weight, although they were born lighter than NP offspring. BP levels were significantly higher in the LP group. We observed a significant increase in the area occupied by collagen fibers, a decrease in the number of cardiomyocytes by 104 µm2, and an increase in cardiomyocyte area associated with an increased Cx43 expression. Conclusion: GPR changes myocardial levels of Cx43 mRNA in male young adult rats, suggesting that this mechanism aims to compensate the fibrotic process by the accumulation of collagen fibers in the heart interstitium.

Abstract Background: Cox-Maze III procedure is one of the surgical techniques used in the surgical treatment of atrial fibrillation (AF). Objectives: To determine late results of Cox-Maze III in terms of maintenance of sinus rhythm, and mortality and stroke rates. Methods: Between January 2006 and January 2013, 93 patients were submitted to the cut-and-sew Cox-Maze III procedure in combination with structural heart disease repair. Heart rhythm was determined by 24-hour Holter monitoring. Procedural success rates were determined by longitudinal methods and recurrence predictors by multivariate Cox regression models. Results: Thirteen patients that obtained hospital discharge alive were excluded due to lost follow-up. The remaining 80 patients were aged 49.9 ± 12 years and 47 (58.7%) of them were female. Involvement of mitral valve and rheumatic heart disease were found in 67 (83.7%) and 63 (78.7%) patients, respectively. Seventy patients (87.5%) had persistent or long-standing persistent AF. Mean follow-up with Holter monitoring was 27.5 months. There were no hospital deaths. Sinus rhythm maintenance rates were 88%, 85.1% and 80.6% at 6 months, 24 months and 36 months, respectively. Predictors of late recurrence of AF were female gender (HR 3.52; 95% CI 1.21-10.25; p = 0.02), coronary artery disease (HR 4.73 95% CI 1.37-16.36; p = 0.01) and greater left atrium diameter (HR 1.05; 95% CI 1.01-1.09; p = 0.02). Actuarial survival was 98.5% at 12, 24 and 48 months and actuarial freedom from stroke was 100%, 100% and 97.5% in the same time frames. Conclusions: The Cox-Maze III procedure, in our experience, is efficacious for sinus rhythm maintenance, with very low late mortality and stroke rates.

Abstract Background: Estimative of left ventricular ejection fraction (LVEF) is a major indication for echocardiography. Speckle tracking echocardiography (STE) allows analysis of LV contraction mechanics which includes global longitudinal strain (GLS) and twist/torsion, both the most widely used. Direct comparison of correlations between these novel parameters and LVEF has never been done before. Objective: This study aims to check which one has the highest correlation with LVEF. Methods: Patients with normal LVEF (> 0,55) and systolic dysfunction (LVEF <0,55) were prospectively enrolled, and underwent echocardiogram with STE analysis. Correlation of variables was performed by linear regression analysis. In addition, correlation among levels of LV systolic impairment was also tested. Results: A total of 131 patients were included (mean age, 46 ± 14y; 43%, men). LVEF and GLS showed a strong correlation (r = 0.95; r2 = 0.89; p < 0.001), more evident in groups with LV systolic dysfunction than those with preserved LVEF. Good correlation was also found with global longitudinal strain rate (r = 0.85; r2 = 0.73; p < 0.001). Comparing to GLS, correlation of LVEF and torsional mechanics was weaker: twist (r = 0.78; r2 = 0.60; p < 0.001); torsion (r = 0.75; r2 = 0.56; p < 0.001). Conclusion: GLS of the left ventricle have highly strong positive correlation with the classical parameter of ejection fraction, especially in cases with LV systolic impairment. Longitudinal strain rate also demonstrated a good correlation. GLS increments analysis of LV systolic function. On the other hand, although being a cornerstone of LV mechanics, twist and torsion have a weaker correlation with LV ejection, comparing to GLS.

Abstract Background: Crocin is reported to have a wide range of biological activities such as cardiovascular protection. Recent epidemiologic studies have shown that exercise reduces cardiovascular morbidity and mortality in the general population. Objective: The aim of this study was to evaluate the effect of crocin and voluntary exercise on miR-126 and miR-210 expression levels and angiogenesis in the heart tissue. Methods: Animals were divided into 4 groups: control, exercise, crocin, and exercise-crocin. Animals received oral administration of crocin (50 mg/kg) or performed voluntary exercise alone or together for 8 weeks. Akt, ERK1/2 protein levels, miR-126 and miR-210 expression were measured in the heart tissue. Immunohistochemical method was used to detect CD31 in the heart tissue. Results: Akt and ERK1/2 levels of the heart tissue were higher in crocin treated group and voluntary exercise trained group after 8 weeks. Combination of crocin and exercise also significantly enhanced Akt and ERK1/2 levels in the heart tissue. MiR-126, miR-210 expression and CD31 in the heart increased in both crocin and voluntary exercise groups compared with control group. In addition, combination of exercise and crocin amplified their effect on miR-126 and miR-210 expression, and angiogenesis. Conclusion: Crocin and voluntary exercise improve heart angiogenesis possibly through enhancement of miR-126 and miR-210 expression. Voluntary exercise and diet supplementation with crocin could have beneficial effects in prevention of cardiovascular disease.

Abstract Background: QRS fragmentation (fQRS) is classically defined as the presence of slurred QRS morphology in at least two contiguous leads, and its prognostic importance has been shown in ST elevation myocardial infarction (STEMI). However, no study has investigated the significance of single lead fQRS (sl-fQRS) in surface electrocardiography (ECG). Objectives: To evaluate whether sl-fQRS is as valuable as classical fQRS in patients with acute STEMI who had successful revascularization with primary percutaneous coronary intervention (pPCI). Methods: We included 330 patients with a first STEMI who had been successfully revascularized with pPCI. The patient’s electrocardiography was obtained in the first 48 hours, and the patients were divided into three groups according to the absence of fQRS (no-fQRS); fQRS presence in a single lead (sl-fQRS); and ≥2 leads with fQRS (classical fQRS). Results: In-hospital mortality was significantly higher both in patients with sl-fQRS and in patients with ≥ 2 leads with fQRS compared to patients with no-fQRS. In ROC curve analysis, ≥ 1 leads with fQRS yielded a sensitivity of 75% and specificity of 57.4% for the prediction of in-hospital mortality. Multivariate analysis showed that sl-fQRS is an independent predictor of in-hospital mortality (OR: 3.989, 95% CI: 1.237-12.869, p = 0.021). Conclusions: Although the concept of at least two derivations is mentioned for the classical definition of fQRS, our study showed that fQRS in only one lead is also associated with poor outcomes. Therefore, ≥1 leads with fQRS can be useful when describing the patients under high cardiac risk in acute STEMI.

Abstract Background: Little has been studied on heart rate and its relationship with metabolic disorders. Objective: To identify possible association between heart rate (HR) and metabolic disorders in children and adolescents. Methods: This cross-sectional study evaluated 2.098 subjects, aged between 7 and 17 years. The variables evaluated were: HR, systolic (SBP) and diastolic blood pressure (DBP), pulse pressure (PP), double-product (DP), myocardial oxygen consumption (mVO2), lipids, glucose and uric acid levels, body mass index (BMI) and waist circumference (WC). The values of HR at rest and effort were divided into quartiles. The association between continuous values of HR and cardiometabolic indicators was tested by linear regression. Results: LDL cholesterol presented a significantly higher mean (p = 0.003) in schoolchildren with resting HR greater or equal to 91 bpm, compared to students with less than 75 bpm. Compared with the quartiles of effort HR, SBP, DBP, glucose and uric acid presented high values when HR was greater or equal than 185 bpm. SBP, glucose and HDL cholesterol demonstrated a significant association with resting HR. Uric acid was observed as a predictor of increased effort HR. Conclusion: Schoolchildren with a higher resting HR have higher mean of LDL cholesterol. For effort HR, there was an increase in blood pressure, glucose and uric acid levels. Uric acid has been shown to be a predictor of elevated effort HR.

Abstract Background: Childhood obesity is an important health problem worldwide. In this context, there is a need for the development and evaluation of innovative educational interventions targeting prevention and formation of health habits. Objectives: To ascertain the impact of ludic workshops on children’s knowledge, self-care, and body weight. Methods: This was a randomized, clinical study with 79 students aged 7-11 years, conducted from March to November 2012. Anthropometric measurements were collected and two questionnaires (Typical Day of Physical Activities and Food Intake, in Portuguese, and the CARDIOKIDS, a questionnaire of knowledge about cardiovascular risk factors) were applied at baseline, at the end of intervention, and three months thereafter. The intervention consisted of eight playful workshops, which involved the presentation of a play. Results: Seventy-nine students were randomized to the intervention (n = 40) or the control group (n = 39). Mean age was 10.0 ± 1.1 years. After eight weeks, the intervention group showed significant improvement in the knowledge score (p < 0.001). There was an increase in physical activity scores in both groups, but with no difference between the groups at the end of intervention (p = 0.209). A reduction in the BMI percentile was observed in the intervention group, but there was no significant statistical difference between the two groups after the intervention. Conclusions: Playful interventions may improve knowledge and physical activity levels in children and, when combined with other strategies, may be beneficial to prevent child obesity and improve self-care.

Abstract Background: Mediastinitis is a severe surgical complication of low incidence, but high lethality. Scores used in the preoperative period to stratify the risk of postoperative mediastinitis may contribute to improve the results. Objective: To test the applicability of the MagedanzSCORE in predicting the risk factors for mediastinitis in patients undergoing coronary artery bypass grafting at a cardiology reference hospital. Methods: Historical cohort study with adult patients who underwent coronary artery bypass grafting. The analyzed variables were contemplated in the MagedanzSCORE: reoperation, chronic obstructive pulmonary disease (COPD), obesity, class IV unstable angina, polytransfusion therapy, mediastinitis and death as outcome variables. Results: Of the 1.322 patients examined, 56 (4.2%) developed mediastinitis. Of these, 26 (46.4%) were classified as high risk for mediastinitis and 15 (26.8%) at very high risk for mediastinitis. Three of the five variables of the Magendanz Score showed statistically significant differences: reoperation, COPD and obesity. Class IV unstable angina and postoperative polytransfusion were not associated with mediastinitis after coronary artery by-pass grafting. The area under the ROC curve was 0.80 (CI 95% 0.73 - 0.86), indicating the model's satisfactory ability to predict the occurrence of mediastinitis. Conclusion: The tool was useful in the preoperative assessment demonstrating the risk for mediastinitis in this population of intensive care patients. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Abstract Background: Heart failure (HF) is a major public health issue with implications on health-related quality of life (HRQL). Objective: To compare HRQL, estimated by the Short-Form Health Survey (SF-36), in patients with and without HF in the community. Methods: Cross-sectional study including 633 consecutive individuals aged 45 years or older, registered in primary care. The subjects were selected from a random sample representative of the population studied. They were divided into two groups: group I, HF patients (n = 59); and group II, patients without HF (n = 574). The HF group was divided into HF with preserved ejection fraction (HFpEF - n = 35) and HF with reduced ejection fraction (HFrEF - n = 24). Results: Patients without HF had a mean SF-36 score significantly greater than those with HF (499.8 ± 139.1 vs 445.4 ± 123.8; p = 0.008). Functional capacity - ability and difficulty to perform common activities of everyday life - was significantly worse (p < 0.0001) in patients with HF independently of sex and age. There was no difference between HFpEF and HFrEF. Conclusion: Patients with HF had low quality of life regardless of the syndrome presentation (HFpEF or HFrEF phenotype). Quality of life evaluation in primary care could help identify patients who would benefit from a proactive care program with more emphasis on multidisciplinary and social support. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Abstract Background: Exercise-based cardiac rehabilitation tends to reduce mortality. However, it requires medium/long-term adherence to regular physical exercise. It is relevant to identify the variables that affect adherence to an supervised exercise program (SEP). Objective: To evaluate the influence of pre-participation levels of aerobic and non-aerobic physical fitness components in medium-term adherence to SEP. Methods: A total of 567 SEP participants (65 ± 12 years) (68% men) were studied. Participants adherent to the program for less than 6 months (48%) (non-adherent - NAD) were compared with 52% of participants who were adherent for 6 months or more (adherents - AD). In the non-aerobic fitness, flexibility (FLX) (Flexitest) and muscle power (MPW)/body weight in standing rowing (watts/kg) were evaluated while aerobic fitness was obtained by direct measure of VO2max/body weight (VO2). These measurements were normatized for sex and age based on percentiles (P) (P-FLX/P-MPW) of reference data or percentages of predicted (P-VO2). Additionally, AD and NAD with extreme results (tertiles) were simultaneously compared for the three variables. Results: There was no difference between AD and NAD for non-aerobic results, in median [P25-P75], P-FLX: 30 [13-56] and 31 [9-52], respectively, (p = 0.69) and P-MPW: 34 [17-58] and 36 [16-62], respectively (p = 0.96), and for aerobic results (mean ± standard error) P-VO2 (75.9 ± 1.3% and 75.0 ± 1.3%, respectively) (p = 0.83). When comparing extreme tertiles, a difference was found for P-MPW in the lower tertile only, with a slight advantage of AD over NAD- 9 [5-16] versus 4 [1-11] (p = 0.04). Conclusion: Although awareness of the pre-participation levels of aerobic and non-aerobic physical fitness components is useful for individualized exercise prescription, these variables do not seem to influence medium-term adherence to SEP.

Abstract Background: Children and adolescents with congenital heart disease often have alterations in their exercise capacity that can be evaluated by various functional testing. Objective: To evaluate the functional capacity of children and adolescents with congenital heart disease (CHD) with systematic review and meta-analyses. Methods: The review included observational studies, data from the first evaluation of randomized clinical trials or observational follow-up periods after clinical trials which evaluated functional capacity by cardiopulmonary exercise test, stress testing, six-minute walk test or step test, in children and adolescents with CHD, aged between six and 18 years, and comparisons with healthy controls in the same age group. The quantitative assessment was performed by meta-analysis, by comparing the maximal oxygen consumption (VO2max) of children and adolescents with CHD and respective control groups. Results: Twenty-five of 2.683 studies identified in the search met the inclusion criteria. The VO2max measurement showed that patients with CHD have a decrease of 9.31 ml/Kg/min (95% CI. -12.48 to -6.13; I2, 94.3%, P for heterogeneity < 0.001) compared with the control group. The meta-analysis of the data of maximum heart rate (HR) reached during cardiopulmonary test and stress testing, retrieved from 18 studies, showed a HR value of -15.14 bpm (95% CI. -20.97 to -9.31; I2, 94.3%, P for heterogeneity < 0.001) compared with the control group. Conclusion: Children and adolescents with CHD have lower VO2max and HR compared to controls.

Abstract Background: Few studies have characterized the surgical outcomes following epicardial pacemaker implantation in neonates with congenital complete atrioventricular block (CCAVB). Objective: This study sought to assess the long-term outcomes of a minimally invasive epicardial approach using a subxiphoid access for pacemaker implantation in neonates. Methods: Between July 2002 and February 2015, 16 consecutive neonates underwent epicardial pacemaker implantation due to CCAVB. Among these, 12 (75.0%) had congenital heart defects associated with CCAVB. The patients had a mean age of 4.7 ± 5.3 days and nine (56.3%) were female. Bipolar steroid-eluting epicardial leads were implanted in all patients through a minimally invasive subxiphoid approach and fixed on the diaphragmatic ventricular surface. The pulse generator was placed in an epigastric submuscular position. Results: All procedures were successful, with no perioperative complications or early deaths. Mean operating time was 90.2 ± 16.8 minutes. None of the patients displayed pacing or sensing dysfunction, and all parameters remained stable throughout the follow-up period of 4.1 ± 3.9 years. Three children underwent pulse generator replacement due to normal battery depletion at 4.0, 7.2, and 9.0 years of age without the need of ventricular lead replacement. There were two deaths at 12 and 325 days after pacemaker implantation due to bleeding from thrombolytic use and progressive refractory heart failure, respectively. Conclusion: Epicardial pacemaker implantation through a subxiphoid approach in neonates with CCAVB is technically feasible and associated with excellent surgical outcomes and pacing lead longevity.