Exercise restrictions after balloon aortic valvuloplasty.

We read with interest the study of outcomes after balloon aortic valvuloplasty recently published by Brown et al. (1), and the accompanying editorial by Rome (2). The authors have valuably demonstrated the outcome of patients who have had balloon aortic valvuloplasty and shown that sudden death in this young patient population is rare. Their paper and Dr. Rome’s editorial also remind readers that any recommendations for exercise restrictions in these patients are not evidence-based and that such restrictions have risks as well as benefits. Many of us rely upon the 36th Bethesda Conference guidelines (3) when imposing restrictions on our young patients. These guidelines, however, are intended for competitive athletes and not for young children. They are stated to be “most easily applied to high school, college, and professional sports” with deference to the clinician’s individual judgment for youth sports activities, “particularly for those children less than age 12 years” (3). The authors’ choice to extend the evaluation of exercise restricion in aortic stenosis down to patients as young as 4 years of age ncreases the number of patient-years in the assessment, but erhaps not in a meaningful way. In the subgroup of 403 patients n whom an exercise recommendation could be determined, many atients were not old enough for such a recommendation to be pplicable for much of the study period. In those patients with an xercise restriction, follow-up began at a mean age of 4 years and asted for an average of 14.4 years. Those in whom there was no xercise restriction began follow-up at a mean age of 3 years for an verage duration of 12.1 years. If one limits the data to those atients old enough to participate in competitive sports, and urther to those who chose to participate, the study sample size and vailable years of follow-up would decrease significantly. To ppropriately assess the population of young athletes at highest heoretic risk for life-threatening events will likely require a larger, ulticenter study. Brown et al. (1) should be congratulated for lighting a candle in he darkness of our understanding of sudden death in the context f aortic stenosis, and they raise important questions about our ecommendations for our patients’ activity. Unfortunately, it is still retty dark out there.