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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Etiologies of valvular heart disease&#46; IE&#58; infectious endocarditis&#59; MR&#58; mitral regurgitation&#59; MVP&#58; mitral valve prolapse&#59; TR&#58; tricuspid regurgitation&#59; VHD&#58; valvular heart disease&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Valvular heart disease &#40;VHD&#41; has recently been described as &#8220;the next cardiac epidemic&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> in particular due to its increased prevalence in the elderly mainly from degenerative causes in industrialized countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;2</span></a> However&#44; rheumatic etiology is still the most frequent cause of VHD in developing countries and predominantly affects younger populations&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The epidemiology of VHD is especially difficult to study as most cases run their natural history without significant symptoms for varying periods of time&#44; and imaging studies &#40;particularly echocardiography&#41; are required for accurate diagnosis and characterization&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;3</span></a> Based on data from large population-based epidemiological studies in the USA which included individuals from the general population who had been assessed prospectively with echocardiography&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> the estimated prevalence of significant VHD in developed countries is 2&#46;5&#37;&#46; Mitral regurgitation &#40;MR&#41; was found to be the most frequent VHD&#44; especially in the elderly&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> However&#44; in the Euro Heart Survey&#44; a prospective study conducted in 25 European countries that included inpatients and outpatients with moderate to severe VHD&#44; infective endocarditis&#44; or prior valve intervention&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> the most frequent VHD &#40;43&#46;1&#37;&#41; was aortic stenosis &#40;AS&#41;&#44; predominantly of degenerative cause&#46; Rheumatic etiology was found in 22&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Published data clearly show a high prevalence of AS and MR in industrialized countries&#44; where VHD mainly affects the elderly population due to increased life expectancy&#44; and in association with functional and structural cardiac abnormalities&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;5</span></a> VHD is linked to significant cardiovascular and all-cause mortality&#44; independently of ventricular function and comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Degenerative AS&#44; a consequence of a continuous process of valve sclerosis and calcification&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a> increases significantly in prevalence with age&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;3&#44;6&#44;7</span></a> and around 40&#37; of individuals aged over 75 years are estimated to have a calcified aortic valve&#46; When intervention is indicated&#44; the decision between surgical aortic valve replacement &#40;SAVR&#41; or transcatheter aortic valve implantation &#40;TAVI&#41; should be made by the heart team according to the individual patient&#39;s characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Functional MR is the most frequent valve disease in the USA&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">3&#44;9&#44;10</span></a> as a consequence of the left ventricular &#40;LV&#41; remodeling and dilatation commonly seen in both non-ischemic cardiomyopathy &#40;mostly due to hypertensive heart disease or idiopathic dilated cardiomyopathy&#41; and ischemic heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> As the prevalence of heart failure &#40;HF&#41; is increasing&#44; functional MR is also likely to increase in the future&#46; In patients with severe primary or secondary &#40;functional&#41; MR&#44; in addition to optimal medical management of HF&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> valve repair or replacement may be necessary&#44; and the recent advent of percutaneous techniques has provided an effective and safe way of improving HF symptoms in suitable candidates&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">8&#44;11&#44;12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In developing countries rheumatic heart disease &#40;which mainly affects the mitral valve&#41; is still the major cause of VHD&#44; due to the persistently high prevalence of rheumatic fever&#44; and is associated with reduced life expectancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;13&#44;14</span></a> The prevalence of rheumatic heart disease in developed countries has decreased&#44; but as degenerative valve disease affecting the elderly is increasing&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> the burden of VHD will is likely to grow substantially in the future&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The present study aims to characterize the current profiles of patients with significant VHD admitted over a period of 22 consecutive months to the cardiology ward at a large referral tertiary hospital center in southwestern Europe &#40;Lisbon&#44; Portugal&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data sources</span><p id="par0040" class="elsevierStylePara elsevierViewall">Patient data were acquired by searching for electronic discharge notes coded with a diagnosis of valve disease according to the International Classification of Diseases&#44; Ninth Revision &#40;ICD-9&#41; of all patients admitted to the cardiology ward in the Cardiology Department of Santa Maria University Hospital between January 1&#44; 2014 and October 3&#44; 2015 &#40;see <a class="elsevierStyleCrossRef" href="#app1">Appendix 1</a> for details&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The search identified 391 patients&#44; whose discharge notes were then manually reviewed&#46; Only patients with significant VHD and those with prior heart valve interventions were selected&#46; Accordingly&#44; only patients who underwent echocardiographic assessment during the hospitalization under study &#40;index hospitalization&#41; were included&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Significant VHD was defined on the basis of clinical plus imaging criteria &#40;mainly echocardiography&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">15&#44;16</span></a> and included moderate to severe valvular stenosis and&#47;or regurgitation of any cardiac valve &#40;or multiple valves&#41; that was responsible in any way for the index hospitalization&#46; Left ventricular ejection fraction &#40;LVEF&#41; was considered to be reduced if &#60;50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study population and design</span><p id="par0055" class="elsevierStylePara elsevierViewall">In accordance with the above criteria&#44; 66 patients were excluded for presenting only mild valvular disease&#59; additionally&#44; 38 patients were also excluded because of insufficient information available in the system &#40;patients admitted electively to undergo selective examinations only or patients with hospital stay less than 24 hours&#41;&#46; The final study population included 287 patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Discharge notes of these patients were carefully manually reviewed&#46; In addition to characterization of VHD &#40;valves involved&#44; disease severity and etiology&#41; on the basis of all the available information&#44; the following data were collected and analyzed&#58; demographics &#40;gender&#44; age&#44; ethnicity&#44; place of birth&#41;&#44; admission and discharge dates&#44; type of admission to the cardiology ward &#40;elective or urgent&#41;&#44; main reason for hospital admission&#44; length of hospital stay &#40;LOS&#41;&#44; major cardiovascular risk factors &#40;systemic hypertension&#44; diabetes&#44; dyslipidemia&#44; smoking&#41;&#44; presence and type of comorbidities&#44; history of chronic HF and New York Heart Association &#40;NYHA&#41; functional class&#44; presence of advanced atrioventricular &#40;AV&#41; block&#44; bundle branch block &#40;BBB&#41; or atrial fibrillation &#40;AF&#41; &#40;chronic or new-onset&#41;&#44; presence of pulmonary hypertension &#40;assessed invasively or by echocardiography&#41;&#44; coronary artery disease &#40;CAD&#41; &#40;assessed by coronary angiography&#41;&#44; coronary artery bypass grafting &#40;CABG&#41; during the index admission&#44; implanted cardiac devices &#40;during the index hospitalization or in the past&#41;&#44; valvular intervention &#40;during the index hospitalization or in the past&#41;&#44; hospital admissions due to VHD in the 12 months preceding the index hospitalization&#44; mortality &#40;and cause of death&#41; during the index hospitalization&#44; and destination after discharge&#46; Various echocardiographic parameters and indices &#40;assessed during the index hospitalization before any new valvular intervention&#41; were also collected&#44; including cardiac chamber size and measures of systolic LV and right ventricular &#40;RV&#41; function&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In addition to the descriptive data&#44; we looked for associations between the type and etiology of VHD and demographic&#44; clinical&#44; electrocardiographic and echocardiographic features&#44; in order to improve characterization of the profiles of hospitalized patients with VHD&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">The statistical analysis was performed with Microsoft Excel 2013&#174; and IBM SPSS&#174; version 22&#46;0&#46; A descriptive analysis of the different variables was performed and possible differences between genders were assessed&#46; Quantitative variables are expressed as means &#177; standard deviation&#44; and qualitative variables as absolute or relative frequencies &#40;percentages&#41;&#46; The Student&#39;s parametric t test for independent variables was used to compare quantitative variables as a function of the presence and type of VHD &#40;mitral&#44; aortic&#44; mitral-aortic or tricuspid valve disease&#41;&#46; Categorical variables were analyzed using the chi-square test and Fisher&#39;s exact test&#44; as appropriate&#46; Possible associations between type of VHD and demographic&#44; clinical&#44; electrocardiographic and echocardiographic features were analyzed using Pearson&#39;s correlation test&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A p-value of &#60;0&#46;05 for a confidence interval of 95&#37; was considered statistically significant&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">Population characteristics and interventions are displayed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Population and hospitalization-related data</span><p id="par0085" class="elsevierStylePara elsevierViewall">The study population included 142 females &#40;49&#46;5&#37;&#41; and 145 males &#40;50&#46;5&#37;&#41;&#44; mean age 74&#46;86&#177;13&#46;39 years &#40;range 23 to 93&#41;&#44; with no difference between genders&#46; Most patients were born in Portugal and 11&#37; were originally from Portuguese-speaking African countries&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The majority of patients were admitted through the emergency room or by transfer from other departments or hospitals &#40;66&#46;9&#37;&#41;&#44; while 33&#46;1&#37; were elective admissions&#46; Fifty-six patients &#40;19&#46;51&#37;&#41; were hospitalized for causes not directly related to VHD&#44; primarily with acute coronary syndrome &#40;ACS&#41; &#40;71&#46;4&#37; of these cases and 16&#46;4&#37; of all patients with VHD&#41;&#44; and valvular disease was a secondary diagnosis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding all patients with a diagnosis of VHD&#44; decompensated HF was the most frequent reason for admission &#40;84 patients&#44; 29&#46;3&#37;&#41;&#46; This proportion was even higher in the group of 231 patients admitted for VHD &#40;35&#46;5&#37;&#41;&#46; Eighty-four &#40;36&#46;4&#37;&#41; were admitted electively for valve intervention&#44; 70 &#40;24&#46;4&#37;&#41; because of a dysrhythmia &#40;AF in 9&#46;1&#37;&#41;&#44; 15 &#40;5&#46;2&#37;&#41; in the context of a syncopal episode &#40;four of which were due to complete AV block&#41;&#44; and seven &#40;2&#46;4&#37;&#41; due to infective endocarditis&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Forty patients &#40;13&#46;9&#37;&#41; had been hospitalized for reasons related to VHD in the 12 months preceding the index hospitalization&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Etiology and type of valvular disease</span><p id="par0105" class="elsevierStylePara elsevierViewall">Etiologies and types of valvular disease are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#46; Most patients &#40;67&#46;9&#37;&#41; had degenerative aortic and&#47;or mitral valve disease&#44; followed in frequency &#40;15&#46;3&#37;&#41; by significant functional mitral and&#47;or tricuspid regurgitation &#40;TR&#41; &#40;secondary to left and&#47;or right ventricular dilatation due to ischemic heart disease or dilated cardiomyopathy&#41;&#46; Rheumatic etiology was diagnosed in 8&#46;7&#37; of patients&#46; Other etiologies included infectious endocarditis &#40;3&#46;8&#37;&#41;&#44; mitral valve prolapse &#40;2&#46;8&#37;&#41;&#44; and congenital VHD &#40;0&#46;7&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Most patients with rheumatic valve disease were women &#40;84&#37;&#44; p&#60;0&#46;001&#41;&#44; with no significant gender differences observed in other etiologies&#46; Age correlated directly with degenerative etiology &#40;r&#61;0&#46;473&#59; p&#60;0&#46;001&#41;&#44; and inversely with rheumatic disease &#40;r&#61;-0&#46;36&#59; p&#60;0&#46;001&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Aortic valve disease was documented in most cases &#40;181 patients&#44; 63&#46;1&#37;&#41;&#44; of whom 89&#37; &#40;56&#37; of all patients&#41; had AS&#44; and 27&#46;1&#37; &#40;17&#46;1&#37; of all patients&#41; had aortic valve regurgitation&#46; Mitral disease was diagnosed in 146 patients &#40;50&#46;9&#37;&#41;&#44; mostly MR &#40;90&#46;4&#37;&#44; 46&#37; of all patients&#41;&#59; mitral stenosis was observed in 15&#37; of these patients &#40;7&#46;7&#37; of all patients&#41;&#46; Concomitant aortic and mitral valve disease was present in 22&#46;3&#37; of patients&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">There were no documented cases of tricuspid valve stenosis&#44; but significant TR was diagnosed in 100 patients &#40;34&#46;8&#37;&#41;&#44; and was associated with mitral valve disease in 69 patients &#40;69&#46;7&#37; of patients with TR&#44; 24&#37; of all patients&#41;&#46; Isolated moderate to severe TR was observed in 20 cases &#40;6&#46;97&#37;&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Moderate pulmonary valve regurgitation was infrequent &#40;13 patients&#41;&#44; and was diagnosed in the context of predominant mitral valve disease and TR&#59; it did not require targeted therapeutic intervention in any patient&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Cardiovascular risk factors and other comorbidities</span><p id="par0130" class="elsevierStylePara elsevierViewall">A significant proportion of patients admitted had chronic HF &#40;39&#46;4&#37;&#41;&#44; and 47&#46;4&#37; had chronic AF&#46; Systemic hypertension was the most frequent cardiovascular risk factor observed&#44; present in 219 &#40;76&#46;3&#37;&#41; patients&#44; while 177 &#40;61&#46;7&#37;&#41; patients had more than one of the classical cardiovascular risk factors&#46; Multiple comorbidities were found in 53&#37; of patients&#46; The most common was CAD &#40;n&#61;81&#59; 28&#46;21&#37;&#41;&#44; followed by chronic kidney disease &#40;n&#61;60&#59; 20&#46;9&#37;&#41;&#44; chronic anemia &#40;n&#61;76&#59; 26&#46;5&#37;&#41;&#44; chronic pulmonary disease &#40;n&#61;43&#59; 15&#37;&#41; and malignancies &#40;n&#61;39&#59; 13&#46;6&#37;&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Coronary angiography was performed in 105 &#40;36&#46;6&#37;&#41; of patients&#44; mostly in the context of ACS&#44; but also due to a previous history of CAD or as a standard procedure before valve intervention&#46; Significant CAD was documented in 55 &#40;52&#46;4&#37;&#41; of cases&#46; Coronary revascularization was performed in 32 &#40;11&#46;1&#37;&#41; patients&#44; by a percutaneous approach in 28 and by CABG in four&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Electrocardiographic data</span><p id="par0140" class="elsevierStylePara elsevierViewall">AF was diagnosed in 136 &#40;47&#46;4&#37;&#41; patients&#44; and was significantly associated with aortic valve disease &#40;p&#61;0&#46;014&#41;&#44; mitral valve disease &#40;p&#60;0&#46;001&#41; or TR &#40;p&#60;0&#46;001&#41;&#46; Advanced AV block was also frequent&#44; with 29 patients &#40;10&#46;1&#37;&#41; having complete AV block at presentation &#40;16 patients with AS and 13 with MR&#59; AS and MR coexisted in five patients&#41;&#46; Complete AV block was the primary reason for pacemaker implantation in the index hospitalization&#46; However&#44; it was not a frequently documented cause of syncope on admission&#46; Other causes of syncope at presentation were sinus node dysfunction and ventricular tachycardia&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Echocardiographic data</span><p id="par0145" class="elsevierStylePara elsevierViewall">Reduced &#40;&#60;50&#37;&#41; LVEF was documented in 33&#46;4&#37; of patients and was associated with mitral disease &#40;p&#61;0&#46;003&#41;&#46; In 12&#46;2&#37; of patients RV longitudinal systolic function assessed by tricuspid annular plane systolic excursion &#40;TAPSE&#41; was also compromised&#44; coexisting with LV systolic dysfunction in 22 &#40;62&#46;9&#37;&#41; patients&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">LV dilatation &#40;24&#37;&#41; and LV hypertrophy &#40;54&#46;7&#37;&#41; were both associated with aortic valve disease&#44; but only the former with mitral disease&#46; The left atrium was dilated in 79&#46;4&#37; of patients&#44; but there was no significant association with aortic or mitral valve disease&#46; RV dilatation was present in 16&#46;4&#37; of cases and right atrial dilatation in 47&#37;&#59; both conditions were associated with the presence of severe TR&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Cardiac devices</span><p id="par0155" class="elsevierStylePara elsevierViewall">Forty-eight &#40;16&#46;7&#37;&#41; patients had a cardiac device in place prior to the index admission&#58; a pacemaker &#40;PM&#41; in 30 &#40;10&#46;5&#37;&#41;&#44; an implanted cardioverter-defibrillator &#40;ICD&#41; in 10 &#40;3&#46;5&#37;&#41;&#44; and a cardiac resynchronization therapy &#40;CRT&#41; device in eight &#40;2&#46;7&#37;&#41; patients&#46; Severe chronic TR was documented in 62&#46;5&#37; of these patients&#44; and was associated with mitral valve disease in 21 &#40;43&#46;8&#37;&#59; significant chronic MR in 50&#37; of these&#41; and with aortic valve disease in 10 patients &#40;20&#46;8&#37;&#59; moderate or severe AS in 41&#46;7&#37;&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In addition&#44; in 55 patients &#40;19&#46;2&#37;&#41; a device was implanted for the first time during the index hospitalization&#58; a PM in 51 &#40;17&#46;8&#37;&#41; patients&#44; an ICD in two &#40;0&#46;7&#37;&#41;&#44; and a CRT pacemaker in another two&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Associations between valvular heart disease and demographic&#44; clinical and functional data</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Aortic valve disease</span><p id="par0165" class="elsevierStylePara elsevierViewall">Disease of the aortic valve showed no gender predominance&#44; but correlated directly with age &#40;p&#60;0&#46;001&#41;&#44; degenerative etiology &#40;p&#60;0&#46;001&#41; and presence of HF &#40;p&#61;0&#46;004&#41;&#44; AF &#40;p&#61;0&#46;014&#41;&#44; LV dilatation &#40;p&#61;0&#46;003&#41;&#44; and LV hypertrophy &#40;p&#60;0&#46;001&#41;&#46; There was no significant association between aortic valve disease and rheumatic etiology&#44; reduced LVEF&#44; left atrial &#40;LA&#41; dilatation&#44; AV block or bundle branch block &#40;p&#61;NS for all&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Mitral valve disease</span><p id="par0170" class="elsevierStylePara elsevierViewall">Mitral disease was more frequent in women than in men &#40;58&#46;9&#37; vs&#46; 41&#46;1&#37;&#44; p&#61;0&#46;002&#41;&#44; and was associated directly with rheumatic etiology &#40;p&#61;0&#46;011&#41;&#44; ischemic heart disease &#40;p&#60;0&#46;001&#41;&#44; HF &#40;p&#61;0&#46;001&#41;&#44; AF &#40;p&#60;0&#46;001&#41;&#44; LV dilatation &#40;p&#60;0&#46;001&#41; and reduced LVEF &#40;p&#61;0&#46;003&#41;&#46; No significant association was found between mitral valve disease and LA dilatation&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Tricuspid valve regurgitation</span><p id="par0175" class="elsevierStylePara elsevierViewall">The presence of moderate-to-severe TR did not differ between genders &#40;p&#61;0&#46;702&#41;&#44; and correlated directly with age &#40;p&#60;0&#46;001&#41; and with the presence of previously implanted cardiac devices &#40;p&#60;0&#46;001&#41;&#46; The latter association was observed only when TR coexisted with aortic or mitral disease &#40;of any etiology&#41;&#46; A significant association was also found between TR and mitral disease &#40;p&#60;0&#46;001&#41;&#44; right chamber dilatation &#40;p&#60;0&#46;001&#41;&#44; AF &#40;p&#60;0&#46;001&#41; and pulmonary hypertension &#40;p&#60;0&#46;001&#41;&#44; but not with chronic pulmonary disease&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Valve intervention procedures</span><p id="par0180" class="elsevierStylePara elsevierViewall">Thirty-one patients &#40;10&#46;8&#37;&#41; had previously undergone valve intervention &#40;repair or replacement&#41;&#44; most frequently SAVR &#40;58&#46;1&#37;&#41;&#44; followed by mitral valve repair &#40;38&#46;7&#37;&#41; and TAVI &#40;12&#46;9&#37;&#41;&#46; No patient had been previously submitted to percutaneous mitral valve intervention&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">During the index hospitalization&#44; 118 patients &#40;41&#46;1&#37;&#41; underwent valve intervention&#46; Percutaneous procedures were the most frequently performed &#40;74&#46;6&#37;&#41;&#44; mainly TAVI &#40;65&#46;3&#37;&#41;&#59; surgical replacement was performed in 12&#46;7&#37; of patients &#40;aortic valve in 12 patients&#44; mitral valve in four&#41;&#44; and surgical repair in 5&#46;9&#37; of cases &#40;mitral valve in four patients and aortic valve in three&#41;&#46; Percutaneous mitral valve interventions were performed in 11 &#40;9&#46;3&#37;&#41; patients&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Regarding the 31 patients who had previously undergone valve intervention&#44; most were admitted with decompensated HF &#40;48&#46;4&#37;&#41;&#44; 16&#46;1&#37; were admitted electively for another valve procedure&#44; and 6&#46;5&#37; presented with infectious endocarditis&#46; Furthermore&#44; 35&#46;5&#37; of this population underwent valve intervention again&#44; 25&#46;8&#37; on the same valve&#46; In-hospital mortality was 12&#46;9&#37; in this high-risk population&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Of note&#44; 4 patients underwent CABG during the index hospitalization&#44; and 2 also underwent SAVR&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Discharge and post-discharge data</span><p id="par0200" class="elsevierStylePara elsevierViewall">Overall&#44; mean LOS was 11&#46;98&#177;14&#46;33 days&#46; Most patients were discharged home from hospital &#40;84&#46;3&#37;&#41; and 5&#46;2&#37; were transferred to another hospital &#40;in their area of residence&#41; for continued care&#46; Overall in-hospital mortality was 9&#46;8&#37; and cardiovascular mortality was 8&#46;7&#37;&#46; Most deaths &#40;33&#46;3&#37;&#41; occurred in the context of ACS&#44; followed by advanced refractory HF and cardiogenic shock due to VHD &#40;29&#46;6&#37;&#41;&#44; and to severe refractory pulmonary hypertension &#40;related to valve disease and&#47;or pulmonary embolism&#41; in 7&#46;4&#37;&#46; Other causes of death were infectious endocarditis of prosthetic valves &#40;7&#46;4&#37;&#41; or devices &#40;3&#46;7&#37;&#41;&#44; acute complications after prosthetic valve implantation &#40;surgical or percutaneous&#41; &#40;7&#46;4&#37;&#41;&#44; and pericardial effusion &#40;3&#46;7&#37;&#41;&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Discussion</span><p id="par0205" class="elsevierStylePara elsevierViewall">From an overall analysis of the data on this population&#44; the first point to highlight is that significant VHD has no gender predominance&#44; a finding consistent with the results of large population studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#8211;4</span></a> The second point is the median age of the population&#44; almost 10 years older than those included in the Euro Heart Survey&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> According to Eurostat 2015 data&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> the proportion of people aged 65 years or more in Portugal was 20&#46;5&#37;&#44; compared to the overall median percentage of 19&#37; in Europe&#44; but this small difference does not appear to account for the discrepancy&#46; The most likely explanation is that the Euro Heart Survey included both inpatients and outpatients&#44; whereas the cohort presented here included only inpatients&#44; a population with more advanced and severe disease&#44; and probably also an older one compared to VHD patients in an outpatient setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;4</span></a> This difference would also explain the 56&#37; of patients with AS found in our hospitalized population compared to the 43&#37; reported in the Euro Heart Survey&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> Of note&#44; we found a predominance of females in patients with rheumatic valve disease and consequently in patients with mitral disease &#40;which was significantly associated with the latter&#41;&#44; and rheumatic etiology mainly affected younger patients&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Although about 11&#37; of included patients were born in Portuguese-speaking African countries&#44; most of them had been living in Portugal for decades&#44; and it was thus impossible to compare the epidemiology of valve disease in Africa and Portugal&#46; In the VALVAFRIC study&#44; a prospective hospital registry of patients with rheumatic valve disease in west and central sub-Saharan Africa&#44; 40&#46;2&#37; presented with moderate to severe disease&#44; the median age of the population was 29&#46;3&#177;15&#46;6 years&#44; and female gender predominated &#40;60&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Decompensated HF was the main reason for admission in our cohort&#44; reflecting the long-term evolution of valve disease&#44; the advanced age of the population&#44; and the severity of the clinical condition of patients with VHD needing hospitalization&#46; Additionally&#44; AF and pulmonary hypertension related to valve disease were both frequent conditions with significant hemodynamic consequences&#46; Underlying the clinical impact of VHD&#44; a significant proportion of patients also presented with echocardiographic evidence of LV hypertrophy and&#47;or dilatation&#44; features linked to an unfavorable prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> Contrary to expectations&#44; neither aortic nor mitral valve disease was significantly associated with LA dilatation&#44; highlighting the multiplicity of conditions that can contribute to alterations in atrial architecture and function&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Aging is associated with degenerative changes that affect not only the aortic annulus but also the conduction system&#44; and complete AV block was another frequent reason for hospital admission&#44; particularly in patients with degenerative AS&#44; and was a common indication for PM implantation&#46; Advanced AV block was also present in many patients with MR&#44; albeit less frequently&#44; as it may occur as a consequence of CAD and fibrosis&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The majority of patients with VHD had several cardiovascular risk factors and multiple comorbidities&#44; mostly significant CAD&#44; another frequent cause for hospital admission&#46; In a recent retrospective study&#44; Emren et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> assessed the prevalence of concurrent CAD in 241 patients &#40;51&#37; female&#41; who underwent surgery due to severe VHD&#46; CAD was detected in 57&#46;7&#37; of patients with AS and in 41&#46;9&#37; of those with MR&#46; CAD and severe AS frequently coexist&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">20&#8211;22</span></a> although the significance and severity of CAD in AS may be particularly difficult to assess&#46; Concomitant CAD had a clinical negative impact in our cohort&#44; being responsible for 33&#37; of all-cause in-hospital mortality&#44; highlighting the need for CAD to be managed concurrently during hospitalization for VHD&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Coronary revascularization at the time of aortic valve replacement may be associated with improved long-term survival without affecting operative risk in some patient subsets&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> However&#44; this is an open-ended issue and most studies looking at the outcomes of CAD and PCI in patients undergoing TAVI reveal no benefit in terms of mortality or major cardiovascular events&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">22&#8211;27</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">A significant proportion of patients &#40;35&#37;&#41; presented with TR associated with other valve disease&#44; mostly mitral disease&#44; thus showing a significant association with rheumatic disease and with secondary MR&#46; Dilated cardiomyopathy was particularly observed&#44; in agreement with the current literature&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> Besides&#44; cardiac devices previously implanted in the right heart were associated with development of TR&#44; as previously described&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> with most patients also having MR&#46; Decision for intervention in moderate-to-severe secondary TR is frequently a matter of debate&#44; being recommended when left-sided valve surgery is indicated&#44; or when right HF is manifest&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">In the index hospitalization 40&#37; of patients underwent valve intervention&#44; primarily TAVI&#44; reflecting recent changes in the paradigm regarding valve disease management&#46; Calcified AS is associated with a higher risk of myocardial infarction&#44; stroke and death&#44; independently of traditional cardiovascular risk factors&#44; and since there is no effective medical approach and five-year survival without intervention ranges from 15&#37; to 50&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> percutaneous valve interventions are increasingly important in the setting of the old&#44; frail patient with multiple comorbidities&#44; who frequently is not considered suitable for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">In summary&#44; the findings in the cohort presented herein may be considered a real-world picture of current VHD in developed countries&#46; Globally&#44; VHD is most commonly degenerative&#44; mainly affects the elderly with multiple comorbidities&#44; is severe and has already run a long course&#46; It is frequently associated with CAD&#44; HF&#44; AF and advanced conduction disease&#44; and has an unfavorable impact on prognosis&#46; This includes quality of life &#40;particularly symptoms and long LOS&#41; and in-hospital mortality&#46; Valve intervention is often necessary&#44; and the percutaneous approach is a therapeutic option in many of these high-risk patients&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Limitations</span><p id="par0250" class="elsevierStylePara elsevierViewall">The data presented are derived from a single center and may not reflect the circumstances of other centers specializing in the management of patients with VHD&#46; Furthermore&#44; the information was not acquired in the setting of a prospective registry&#44; but consists of retrospective data collected from clinical files and echocardiographic reports&#44; which in some cases may not be as detailed as would be desirable&#46; However&#44; the data collected reflect the actual profiles of patients hospitalized with VHD in the cardiology ward of a tertiary hospital&#44; and the thorough manual analysis and multiple revisions performed provide a precise and objective set of real-world information&#44; similar in general respects to previous work published in this field&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The influence of the different variables on mortality was not studied&#44; as this was beyond the scope of this study&#46; Our aim was to characterize the profiles of patients with VHD currently admitted to a tertiary hospital in contemporary Europe&#44; in which the new therapeutic options for patients with VHD are available&#44; and where the European guidelines for the treatment of heart disease are applied&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conclusion</span><p id="par0260" class="elsevierStylePara elsevierViewall">On the basis of the data presented&#44; two main profiles can be delineated for patients currently hospitalized with VHD&#58; a dominant one&#44; characterized by the elderly patient&#44; male or female&#44; with multiple comorbidities&#44; admitted with decompensated HF in the setting of degenerative AS&#44; presenting with LV hypertrophy and&#47;or dilatation but with preserved LVEF&#44; frequently with AF&#44; who is preferably treated by TAVI&#59; and a second&#44; less prevalent profile&#44; that of a younger patient&#44; predominantly female&#44; also admitted with decompensated HF but in the setting of functional mitral regurgitation &#40;secondary to ischemic heart disease or dilated cardiomyopathy&#41;&#44; also presenting with AF and LV dilatation but with reduced LVEF&#44; who less often undergoes valve intervention&#44; but is treated medically for HF&#46; Of note&#44; common denominators of both profiles were HF and AF&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Author contributions</span><p id="par0265" class="elsevierStylePara elsevierViewall">AFE and DB conceived and designed the research&#44; and drafted the first version of the manuscript&#59; JR&#44; IR&#44; MMP&#44; and FV contributed to the research and data analysis&#59; AFE and RP performed the statistical analysis&#46; All authors critically reviewed the manuscript for drafting and key intellectual content&#44; helped revise the paper and gave final approval for the version to be published&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Conflicts of interests</span><p id="par0270" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Valvular heart disease &#40;VHD&#41; is increasing worldwide&#44; mostly because of aging&#46; Percutaneous valve intervention is the preferred therapeutic option in high-risk patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To characterize the profiles of patients with VHD admitted to the cardiology ward at a tertiary referral center&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">On the basis of ICD-9 codes for VHD&#44; the discharge notes of 287 patients hospitalized over a 22-month period were reviewed and analyzed&#46; One hundred characteristics were considered&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Median age was 74 &#40;23-93&#41; years&#44; and 145 &#40;51&#37;&#41; were male&#46; The admissions were elective &#40;for valve intervention&#41; in 36&#37;&#46; Heart failure &#40;HF&#41; was the reason for urgent admissions in 29&#46;3&#37;&#46; Multiple comorbidities were observed in 53&#37; of patients&#46; Etiology of VHD was degenerative in 68&#37;&#44; functional in 15&#46;3&#37; and rheumatic &#40;predominantly in women and younger patients&#41; in 8&#46;7&#37;&#46; Aortic valve disease was present in 63&#37; &#40;aortic stenosis in 56&#37;&#41;&#44; and was associated with HF &#40;p&#61;0&#46;004&#41;&#44; atrial fibrillation &#40;AF&#41; &#40;p&#61;0&#46;01&#41;&#44; and left ventricular &#40;LV&#41; dilatation &#40;p&#61;0&#46;003&#41; or hypertrophy &#40;p&#60;0&#46;001&#41;&#46; Mitral valve disease &#40;51&#37;&#41;&#44; mostly mitral regurgitation &#40;degenerative or functional&#41;&#44; predominated in women&#44; and was associated with HF&#44; AF&#44; LV dilatation &#40;p&#60;0&#46;001&#41; and reduced LV ejection fraction &#40;p&#61;0&#46;003&#41;&#46; Significant tricuspid regurgitation &#40;34&#46;8&#37;&#41; associated with the presence of previously implanted cardiac devices &#40;p&#60;0&#46;001&#41;&#46; Valve intervention &#40;mostly transcatheter aortic valve implantation&#41; was performed in 41&#37; of patients&#46; Mean length of hospital stay was 12&#177;14&#46;3 days and overall in-hospital mortality was 9&#46;8&#37;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Nowadays&#44; the profiles of hospitalized patients with VHD are dominated by the elderly&#44; with degenerative disease and multiple comorbidities&#44; presenting with HF&#44; AF and LV remodeling&#44; who frequently undergo valve intervention&#44; usually via a percutaneous approach&#46; Mortality remains significant in this high-risk population&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A doen&#231;a card&#237;aca valvular &#40;DCV&#41; &#233; problema crescente&#44; relacionando-se com o envelhecimento populacional&#46; A interven&#231;&#227;o valvular por via percut&#226;nea &#233; op&#231;&#227;o preferencial em alguns contextos&#44; inclusive em doentes de elevado risco&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Caracteriza&#231;&#227;o do perfil dominante do doente com DCV admitido em enfermaria de cardiologia &#40;centro terci&#225;rio de refer&#234;ncia&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Revis&#227;o de processos cl&#237;nicos de 287 doentes &#40;c&#243;digos ICD-9 para DCV&#41; internados num per&#237;odo de 22 meses&#46; Foram consideradas para an&#225;lise 100 caracter&#237;sticas&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Idade - 74 &#40;23-93&#41; anos&#59; 145 &#40;51&#37;&#41; homens&#46; Admiss&#245;es eletivas &#40;interven&#231;&#227;o valvular&#41;&#58; 36&#37;&#46; Insufici&#234;ncia card&#237;aca &#40;IC&#41;&#58; causa de admiss&#227;o urgente em 29&#44;3&#37;&#46; Comorbilidades m&#250;ltiplas&#58; 53&#37; dos doentes&#46; Etiologias&#58; degenerativa &#40;68&#37;&#41;&#59; funcional &#40;15&#44;3&#37;&#41;&#59; reum&#225;tica &#40;8&#44;7&#37;&#41; &#8211; predominantemente em mulheres e em doentes mais jovens&#46; Doen&#231;a valvular a&#243;rtica - 63&#37; &#40;estenose em 56&#37;&#41;&#44; associou-se &#224; presen&#231;a de IC &#40;p &#61; 0&#44;004&#41;&#44; fibrilha&#231;&#227;o auricular &#40;FA&#41;- p &#61; 0&#44;014 &#8211; e hipertrofia &#40;p &#60; 0&#44;001&#41; ou dilata&#231;&#227;o ventricular esquerda &#40;VE&#41; &#8211; p &#61; 0&#44;003&#46; Doen&#231;a valvular mitral &#40;51&#37;&#41; - predominantemente regurgita&#231;&#227;o - degenerativa ou funcional&#44; mais frequente em mulheres&#59; associou-se &#224; presen&#231;a de IC&#44; FA&#44; dilata&#231;&#227;o VE &#8211; p &#60; 0&#44;001 - e fra&#231;&#227;o de eje&#231;&#227;o VE diminu&#237;da &#40;p &#61; 0&#44;003&#41;&#46; Insufici&#234;ncia tric&#250;spide &#40;34&#44;8&#37;&#41;&#44; associou-se &#224; presen&#231;a de eletrocat&#233;teres previamente implantados &#40;p &#60; 0&#44;001&#41;&#46; Interven&#231;&#245;es valvulares&#58; 41&#37; dos doentes&#44; predominantemente TAVI&#46; Dura&#231;&#227;o de internamento&#58; 12 &#177; 14&#44;3 dias&#59; mortalidade global intra-hospitalar&#58; 9&#44;8&#37;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclus&#245;es</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">O perfil atual do doente hospitalizado com DCV &#233; dominado pelo idoso com doen&#231;a degenerativa e m&#250;ltiplas comorbidades&#44; apresentando remodelagem VE&#44; IC e FA&#44; e sendo frequentemente submetido a interven&#231;&#227;o valvular &#40;predominantemente por via percut&#226;nea&#41;&#46; A mortalidade &#233; significativa nessa popula&#231;&#227;o de risco elevado&#46;</p></span>"
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            "apendice" => "<p id="par0275" class="elsevierStylePara elsevierViewall">ICD-9 &#40;International Classification of Diseases&#41; diagnosis of valve diseases used&#58;</p> <p id="par0280" class="elsevierStylePara elsevierViewall">394&#46;0 &#40;rheumatic mitral stenosis&#41;&#44; 394&#46;1 &#40;rheumatic mitral regurgitation&#41;&#44; 394&#46;2 &#40;rheumatic mitral stenosis with insufficiency&#41;&#44; 394&#46;9 &#40;other and unspecified mitral valve diseases&#41;&#44; 395&#46;0 &#40;rheumatic aortic stenosis&#41;&#44; 395&#46;1 &#40;rheumatic aortic insufficiency&#41;&#44; 395&#46;2 &#40;rheumatic aortic stenosis with insufficiency&#41;&#44; 395&#46;9 &#40;other and unspecified rheumatic aortic diseases&#41;&#44; 396&#46;0 &#40;mitral valve stenosis and aortic valve stenosis&#41;&#44; 396&#46;1 &#40;mitral valve stenosis and aortic valve insufficiency&#41;&#44; 396&#46;2 &#40;mitral valve insufficiency and aortic valve stenosis&#41;&#44; 396&#46;3 &#40;mitral valve insufficiency and aortic valve insufficiency&#41;&#44; 396&#46;8 &#40;multiple involvement of mitral and aortic valves&#41;&#44; 396&#46;9 &#40;mitral and aortic valve diseases&#44; unspecified&#41;&#44; 397&#46;0 &#40;diseases of tricuspid valve&#41;&#44; 397&#46;1 &#40;rheumatic diseases of pulmonary valve&#41;&#44; 397&#46;9 &#40;rheumatic diseases of endocardium&#44; valve unspecified&#41;&#44; 424&#46;0 &#40;mitral valve disorders&#41;&#44; 424&#46;1 &#40;aortic valve disorders&#41;&#44; 424&#46;2 &#40;tricuspid valve disorders&#44; specified as nonrheumatic&#41;&#44; 424&#46;3 &#40;pulmonary valve disorders&#41; and&#47;or 424&#46;9 &#40;endocarditis&#44; valve unspecified&#41;&#46;</p>"
            "etiqueta" => "Appendix 1"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Etiologies of valvular heart disease&#46; IE&#58; infectious endocarditis&#59; MR&#58; mitral regurgitation&#59; MVP&#58; mitral valve prolapse&#59; TR&#58; tricuspid regurgitation&#59; VHD&#58; valvular heart disease&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LV hypertrophy plus dilatation&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;6&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>RV dilatation&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;16&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>RV hypertrophy&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>RV hypertrophy plus dilatation&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Reduced TAPSE&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;12&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LA dilatation&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">228 &#40;79&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>RA dilatation&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">135 &#40;47&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LA plus RA dilatation&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">129 &#40;44&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Cardiac devices</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Previously implanted&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;16&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PM&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;10&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>ICD&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;3&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>CRT-P&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>CRT-D&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;2&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Implanted during index hospitalization&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55 &#40;19&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PM&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51 &#40;17&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>ICD&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>CRT-P&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>CRT-D&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Procedures and interventions related to CAD</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Coronary angiography performed&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">105 &#40;36&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PCI&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;9&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CABG&#44; n &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;1&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Valve interventions</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Prior to index hospitalization&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;10&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Aortic valve&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;58&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Mitral valve&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;51&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Tricuspid valve&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;3&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Surgery with prosthesis implantation&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;58&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Surgery with valve repair&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12 &#40;38&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;12&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">77 &#40;65&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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