Laurie G. Futterman

Sudden death in athletes: an update

The athlete projects the ultimate image of well-being in the health status spectrum. Nevertheless, exercise-related sudden cardiac death (SCD) is an uncommon, yet tragic, occurrence. Exercise-related SCD is defined by symptoms that arise within 1 hour of participation in sport. The major mechanisms involved in exercise-related SCD are related to haemodynamic and electrophysiological changes brought about by exercise in the susceptible individual. Fatal arrhythmia seems to be the most common mechanism of death. Between 1 and 5 cases of SCD per 1 million athletes occur annually. In young athletes (<35 years old), the majority of these cases are caused by defined and hereditary cardiovascular disorders. Among other aetiologies, hypertrophic cardiomyopathy and coronary artery anomalies are most common in this group. In older athletes (>35 years old), sudden death is usually associated with atherosclerotic cardiac disease.A problem for identifying athletes at risk for SCD is that the athlete’s heart undergoes adaptive changes in response to regular physical exercise. Alterations in cardiac function influence the physical examination, the electrocardiogram and the echocardiogram. Because of these characteristic ‘abnormalities’ of the athlete’s heart, it is often difficult to distinguish physiological adaptations from pathophysiological processes.Although studies and observations have helped to clarify the cardiovascular pathology responsible for SCD in young, apparently healthy individuals, effective methods for preventing SCD and identifying and screening athletes at risk remain elusive. Problems with routine comprehensive screening of athletes include the limitations inherent in the predictive value of available diagnostic procedures and the cost of testing large populations. The variation from normal cardiac physiology found within the athletic population and the rarity of SCD in athletes means that elaborate screening to determine individuals at risk is neither practical nor cost effective. A thorough assessment of pertinent family and medical histories, cardiac auscultation of young athletes, evaluation of exercise-induced symptoms and education of older athletes to the symptoms of cardiac ischaemia are all essential to primary prevention of SCD in the athletic population.Until reliable methods can accurately identify those athletes at risk for SCD, broad recommendations are available to help guide the management and participation in sports of athletes with cardiovascular disease.

Ambulatory electrocardiographic monitoring: use of the implantable loop recorder in the evaluation of syncope.

Syncope may be related to a large spectrum of medical and psychologic disorders, yet the precise etiology is often difficult to determine. Although the evaluation of syncope involves extensive testing, nearly 50% of these individuals remain without definitive diagnosis. Because of the infrequent and unpredictable nature of syncope, many ambulatory screening techniques are not suited to diagnose syncope. The use of an implantable loop recording device provides continuous monitoring of heart rate and rhythm during syncopal events and may help clinicians arrive at a more precise diagnosis in a more timely manner. The Reveal Plus implantable loop recorder (ILR) (Medtronic USA, Minneapolis, Minn) has demonstrated its clinical utility in evaluating syncope and drug-refractory seizure disorders.

Orthotopic Cardiac Transplant and Straight-Back Syndrome: A Case Report

Straight-back syndrome is a common malformation of the thoracic spine that is associated with a marked decrease in the anterior-posterior intrathoracic cavitary space. The authors describe their experience with a patient with straight-back syndrome who required orthotopic cardiac transplantation. Mi nor modification of the procurement and surgical procedure was required to facilitate graft implantation without cardiac compression.