ClinicalImaging/mappingConcealed cardiomyopathies in competitive athletes with ventricular arrhythmias and an apparently normal heart: role of cardiac electroanatomical mapping and biopsy
Introduction
The clinical assessment of ventricular arrhythmias (VAs) in the setting of an apparently normal heart is a challenging issue,1 particularly in competitive athletes, in whom a clear association between some forms of structural heart disease and sudden cardiac death has been consistently reported,2 thus representing a clinical dilemma regarding their eligibility for sports.3 Distinguishing truly idiopathic VAs from those related to undetected subclinical cardiomyopathies may be difficult4, 5, 6 but is critically important because it implies different prognosis and management strategies.7, 8 The clinically subtle abnormalities of early-stage cardiomyopathies, however, may remain undetected by currently available noninvasive diagnostic techniques, including echocardiography and even cardiac magnetic resonance imaging (cMRI).4, 9, 10 Three-dimensional electroanatomical mapping (EAM) has been demonstrated to reliably identify the pathological substrate underlying VAs in different clinical settings by the detection of myocardial areas with abnormally low voltages,11 which reflect the presence of different cardiomyopathic substrates at endomyocardial biopsy.9, 10, 11
In this study on a consecutive series of competitive athletes with recent-onset VAs and an apparently normal heart, we tested the hypothesis that EAM may help in the differential diagnosis between truly idiopathic and cardiomyopathy-related VAs by the identification of otherwise concealed cardiomyopathic substrates.
Section snippets
Methods
From January 2008 to February 2009 we examined 1,644 athletes at our institution, a national-level referral center for Sports Cardiology. Repetitive VAs (nonsustained and sustained ventricular tachycardia [VT]) were present in 27 (1.6%) subjects, while frequent ventricular premature beats (VPBs) (>1,000/24 hours) were found in 30 (2.1%) subjects. All these subjects underwent a full noninvasive evaluation as reported below, and 17 were judged normal and were considered eligible for invasive
Clinical characteristics
Clinical characteristics and electrophysiological data are summarized in Table 1, Table 2. All patients were actively involved in competitive sports (see Table 1). Two patients (15%) had a family history of premature sudden death (age <40 years) due to ARVC. Spontaneous VAs were documented in all patients, on 12-lead ECG (n = 4), or on 24-hour Holter monitoring (n = 5), or on ECG exercise testing (n = 4). Sustained VT was documented in three (23%) patients, nonsustained VT in seven (54%)
Discussion
The granting of sports eligibility in athletes with VAs with no visible cardiac structural anomalies is a challenging problem, since even subtle structural heart disease in these patients increases the risk of sudden cardiac death by a factor of 2.5 compared with nonathletes.24 Therefore, an early diagnosis of concealed cardiomyopathy in athletes is crucial to promptly ban these subjects from competitive sports.2, 3, 7 In this study, we demonstrate that EAM allows the early recognition of
Conclusions
Our results demonstrate that EAM allows the unmasking of subtle structural heart disease in athletes with VAs and an apparently normal heart, despite a thorough noninvasive evaluation, including cMRI. Further studies are warranted to explore the prognostic implications of such subtle myocardial abnormalities and to assess the optimal management strategies for these patients.
Acknowledgments
The authors thank Gianluca Cionci, MD, for his help in data collection.
References (31)
- et al.
Ventricular arrhythmias in normal hearts
Cardiol Clin
(2008) - et al.
Preparticipation screening of young competitive athletes for prevention of sudden cardiac death
J Am Coll Cardiol
(2008) Saving athletes' lives a reason to find common ground?
J Am Coll Cardiol
(2008)- et al.
Results of biventricular endomyocardial biopsy in survivors of cardiac arrest with apparently normal hearts
Am J Cardiol
(1994) - et al.
Task Force 7: arrhythmias
J Am Coll Cardiol
(2005) - et al.
Three-dimensional electroanatomical voltage mapping and histologic evaluation of myocardial substrate in right ventricular outflow tract tachycardia
J Am Coll Cardiol
(2008) - et al.
High prevalence of myocarditis mimicking arrhythmogenic right ventricular cardiomyopathy differential diagnosis by electroanatomic mapping-guided endomyocardial biopsy
J Am Coll Cardiol
(2009) - et al.
Right ventricular substrate mapping using the Ensite Navx system: accuracy of high-density voltage map obtained by automatic point acquisition during geometry reconstruction
Heart Rhythm
(2009) - et al.
Guidelines for clinical intracardiac electrophysiological and catheter ablation proceduresA report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Intracardiac Electrophysiologic and Catheter Ablation Procedures), developed in collaboration with the North American Society of Pacing and Electrophysiology
J Am Coll Cardiol
(1995) - et al.
Real-time integration of 2D intracardiac echocardiography and 3D electroanatomical mapping to guide ventricular tachycardia ablation
Heart Rhythm
(2008)
Long-term clinical significance of frequent and complex ventricular tachyarrhythmias in trained athletes
J Am Coll Cardiol
Impact of physical deconditioning on ventricular tachyarrhythmias in trained athletes
J Am Coll Cardiol
Endomyocardial biopsy in arrhythmogenic right ventricular cardiomyopathy
Am Heart J
Does sports activity enhance the risk of sudden death in adolescents and young adults?
J Am Coll Cardiol
Sudden death in young competitive athletes: clinicopathologic correlations in 22 cases
Am J Med
Cited by (68)
Interpretation and management of premature ventricular beats in athletes: An expert opinion document of the Italian Society of Sports Cardiology (SICSPORT)
2023, International Journal of CardiologyElectroanatomic mapping in athletes: Why and when. An expert opinion paper from the Italian Society of Sports Cardiology
2023, International Journal of CardiologyVentricular arrhythmias in athletes: Role of a comprehensive diagnostic workup
2022, Heart RhythmCitation Excerpt :Invasive evaluation included 3-dimensional EAM, electrophysiological study (EPS), and EAM- or cardiac magnetic resonance imaging (cMRI)-guided EMB (Figure 1). The decision to perform invasive diagnostic evaluations was prespecified by institutional protocol as follows: 3-dimensional EAM and EPS were performed in case of diagnostic doubts after noninvasive tests or, in case of diagnostic certainty after noninvasive tests, as a preliminary step to catheter ablation (CA) procedures.1,3–6 EMB was performed in case of persistent diagnostic uncertainty after noninvasive evaluations, EPS, and EAM.6
Special Article - Exercise-induced right ventricular injury or arrhythmogenic cardiomyopathy (ACM): The bright side and the dark side of the moon
2020, Progress in Cardiovascular DiseasesVentricular Arrhythmias in Myocarditis: Prognostic Role of Electroanatomic Voltage Mapping
2020, JACC: Clinical ElectrophysiologyRole of extensive diagnostic workup in young athletes and nonathletes with complex ventricular arrhythmias
2020, Heart RhythmCitation Excerpt :LV or biventricular EMB through the right femoral vein and femoral artery for access to the RV and LV, respectively, was preferred.15 EMB was guided by low-voltage areas detected by 3D-EAM, as described previously,16 and the local site of EMB as well as possible early complications were monitored by intracardiac echocardiography. Samples for histology and immunohistochemical analysis were promptly fixed in 10% formalin or snap-frozen in liquid nitrogen depending on the antibody to be used.15
The first two authors contributed equally to this work and should be both considered as first authors. C.T. has served as a member of the advisory board of Biosense Webster and has been a consultant for and received lecture fees from St. Jude Medical. A.N. has received consultant fees or honoraria from Biosense Webster, Boston Scientific, Medtronic, Biotronik, and LifeWatch. The other authors declare no significant relationships with industry.