Monday, February 1, 2016

Normann Stadler, Heart Surgery, and You

by Larry Creswell, M.D.

Editor's note: This article originally appeared in July 2011

We learned recently from news reports that two-time Ironman World Champion Normann Stadler underwent heart surgery on July 4 because of a “failing heart valve and aortic aneurysm.” On Twitter, I re-tweeted a link to one of these news reports and I was surprised to see that more than 1,200 of my Twitter followers clicked on that link to read about Stadler. In the past few days, I’ve received a bunch of inquiries about his situation and I thought I’d share some of my initial thoughts with the readers here at Endurance Corner.

In truth, very little information has been provided in the various news reports, but we’ve learned that the surgery was performed by Professor Matthias Karck at Heidelberg University Hospital and that, a couple weeks now after operation, Stadler is making a good recovery. Needless to say, it’s great news that his operation was deemed to be successful. Heart surgery to repair or replace a heart valve, combined with repair of an aortic aneurysm, is major surgery by any standard, and even in the best of circumstances, there are patients who don’t survive. So I wish Stadler the very best as he continues to recover from his operation.

The questions that I’ve received from friends and readers have included:

  1. What was Stadler’s specific heart condition?
    I don’t know any more specific information than the reports in the popular press have provided. We know that one of the heart valves was described as “failing” and he had aneurysm (enlargement) of the aorta, the large blood vessel that carries bloodflow away from the heart.

    I’m confident that we’ll eventually learn more about Stadler’s condition, but one potential cause of this combination of problems is congenital bicuspid aortic valve and accompanying aortic aneurysm. I’ve written about this topic at my blog and it’s one of the most popular topics researched by visitors. When individuals are born with an aortic valve with only two leaflets (bicuspid) instead of the normal three (tricuspid), the valve tends to become narrowed at an early age. Moreover, the bicuspid aortic valve is associated with weakness of the walls of the aorta and these individuals are predisposed to have enlargement (that we call an aneurysm) of the aorta. As you may know, this condition sidelined professional triathlete, Torbjorn Sindballe, who elected to retire when these problems were discovered at a relatively early stage, rather than risk any further damage because of continued participation in triathlon.

  2. How could a professional triathlete have such serious heart disease?
    The readers here at Endurance Corner will know that triathletes as a group are healthy, fit people. But this doesn’t exempt them from heart disease. Although serious heart disease is relatively uncommon among triathletes, we shouldn’t be surprised that it occurs. Thinking broadly, high blood pressure is present in more than one third of American adults and congenital heart disease (such as bicuspid aortic valve) is present in approximately 2%. Arrhythmias (such as premature beats or atrial fibrillation) are common in the general population and perhaps even more so among long-term endurance athletes.

    From reports in the popular press in the past couple years -- and largely from information provided from the athletes themselves—we know that more than a few professional triathletes have noteworthy heart conditions. Just off the top of my head, the group includes Gina Ferguson (bicuspid aortic valve), Justin Park (atrial arrhythmias), Torbjorn Sindballe (bicuspid aortic valve and aortic aneurysm), Greg Welch (ventricular arrhythmias), and Samantha Warriner (atrial arrhythmias), among others. We should be thankful that they’ve shared their stories.

    In the years since I started my blog and my column here at Endurance Corner, I’ve heard from many age-group endurance athletes with heart problems of all sorts. I’ve learned that there’s no age group, no particular sport, and no particular ability level of athlete that is spared.

    It’s important to remember that many important forms of heart disease can remain silent until the problem has caused some sort of lasting harm.

  3. Can triathlon (or any endurance sport) cause heart disease... and should I be worried?
    This is a common concern among athletes, but worrying is probably the wrong response. I wrote about the many health benefits from exercise in a previous column here at Endurance Corner and you should take comfort in knowing that the beneficial effects of exercise are well established.

    That said, it is possible to have unrecognized heart disease. And it is possible for continued athletic activity to pose some risk. As just one example, unrecognized and untreated high blood pressure over many years can lead to heart disease, peripheral vascular disease, and stroke.

  4. What can I do to protect myself from a situation similar to Stadler’s?
    Some forms of heart disease are silent, but most produce some sort of sign or symptom such as chest pain/discomfort, unusual shortness of breath, palpitations, or light-headedness. My best advice is to get a doctor, have an annual physical examination, get screened for silent forms of heart disease, and then work closely with your doctor when worrisome symptoms do occur.

    It’s probably unrealistic to think that we can recognize all instances of heart disease before there is an emergency or irreparable harm, but I suspect that we could come very close to that goal for the typical endurance athlete.

  5. What’s the prognosis after heart surgery such as Stadler’s?
    I’m not yet familiar with all of the details surrounding Stadler’s operation, but I can offer some general thoughts about participating in sports after major heart surgery. Patients who have had valve repair/replacement and aortic aneurysm repair will require close follow-up with physical exams and various imaging tests (such as echocardiogram) on a periodic basis for the rest of their lives.

    I know firsthand of many athletes who’ve returned to running and triathlon after having had operations such as coronary artery bypass surgery or heart valve repair or replacement. Many have returned to become (or once again be) competitive age groupers at their sport. If you’re an athlete in that situation, check out the Ironheart Racing Team, a Seattle-based team whose membership consists primarily of athletes with heart disease of all sorts. Many of the team members have had heart surgery and have returned successfully to racing.

    One consideration for athlete patients who have had heart valve replacement is that the artificial heart valves are not quite as efficient as our own, native heart valves. These valve substitutes produce some small resistance to bloodflow and require extra effort from the heart to eject the blood through the artificial valve. Although that situation may not even be recognizable to patients when they are at rest, even a slight loss of efficiency becomes noticeable at the higher workloads that accompany exercise. For that reason, I’ve seen most such athletes lose some degree of top-end performance. So although I know a bunch of age group athletes who’ve returned to training and competition, I’m not aware of any elite level endurance athlete who has returned to his or her sport at the top level after heart valve replacement.

    In practical terms, it takes a couple months after heart surgery for the sternum (which is divided during most open heart operations) to regain its strength and for those first couple months, we recommend avoiding activities that place any stress on the sternum (such as lifting, reaching, pulling, pushing). At the same time, we encourage activities such as walking or spinning on the stationary bike. After those first couple months, athlete patients can return to most any activity, sometimes with close monitoring depending upon the exact type of operation that was performed.

From the reactions I’ve seen and heard these past few days, Stadler’s story will be an eye-opener for many triathletes. As I say, I hope that Stadler will eventually share the details of his story so that we might all learn something more about heart disease and endurance athletes. In his case, it should be interesting to learn how his problem manifested and how he went about getting the problem sorted out.

My best advice is to use Stadler’s situation as a call to action, of sort. Instead of worrying about the potential cardiac risks of our sport, take charge of your own cardiovascular health. Today!


Larry Creswell, M.D., is a cardiac surgeon and Associate Professor of Surgery at the University of Mississippi Medical Center in Jackson, Mississippi. In addition to his regular column on Endurance Corner, he maintains The Athlete's Heart blog and Twitter account (@athletesheart)to offer information about athletes and heart disease in an informal way and to encourage exchange and discussion that will help athletes build a heart-healthier lifestyle. You can contact him at lcreswell@umc.edu.
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