Massimiliano Bianco

Concealed cardiomyopathies in competitive athletes with ventricular arrhythmias and an apparently normal heart: role of cardiac electroanatomical mapping and biopsy.

BACKGROUND The diagnosis of subtle structural heart disease in competitive athletes with ventricular arrhythmias (VAs) and an apparently normal heart is challenging. Three-dimensional electroanatomic mapping (EAM) has been demonstrated to reliably identify low-voltage areas that correspond to different cardiomyopathic substrates. OBJECTIVE The purpose of this study was to test whether EAM may help in the diagnosis of concealed cardiomyopathies in athletes with VAs and an apparently normal heart. METHODS We studied 13 consecutive competitive athletes (12 males, age 30 ± 13 years) who had documentation of VAs within the previous 6 months on 12-lead electrocardiogram (ECG), 24-hour Holter ECG, or ECG exercise testing and who were judged as having a structurally normal heart after a thorough noninvasive evaluation, including signal-averaged ECG, transthoracic echocardiogram, and cardiac magnetic resonance imaging. Depending on the presumed site of VA origin according to 12-lead ECG criteria, patients underwent right or left ventricular EAM and EAM-guided endomyocardial biopsy. RESULTS Presenting arrhythmias included sustained ventricular tachycardia (n = 3), multiple episodes of nonsustained ventricular tachycardia (n = 7), and frequent ventricular ectopic beats (>1,000 during 24 hours; n = 3). Three patients had a history of syncope. Twelve (92%) patients had at least one low-voltage region at EAM, which corresponded at EAM-guided endomyocardial biopsy to the histological diagnosis of active myocarditis in seven patients and of arrhythmogenic right ventricular cardiomyopathy in five. In one patient the histological evidence of contraction band necrosis allowed the unmasking of caffeine and ephedrine abuse. CONCLUSIONS Electroanatomical substrate mapping may help diagnose concealed myocardial diseases in competitive athletes presenting with recent-onset VAs and an apparently normal heart. Further studies are warranted to assess the prognostic implications of such subtle myocardial abnormalities.

Medical survey of female boxing in Italy in 2002–2003

Background: Female boxing has been permitted in Italy since 2001. According to the latest Italian laws, athletes applying to become boxers have to pass a pre-participation medical examination. Objective: To collect novel medical information from the pre-participation visits and mandatory pre-competition and post-competition examinations for all fights involving Italian female boxers in 2002–2003. Methods: A retrospective study on all official female boxing competitions in Italy from January 2002 to October 2003 was conducted. A prospective study on 28 amateur female boxers was also carried out. Results: Retrospective study: data from 664 examinations were collected. Pre-match examinations were negative. After competitions, 19/645 visits showed some injuries, with mild, soft tissue facial lesions, epistaxis, and hand-wrist problems being the most common. Prospective study: no major lesions were found during the study. One fibroadenoma, one ovarian cyst, and one intramural uterine myoma were found. One boxer was referred to a neurologist because of non-specific electroencephalographic (EEG) abnormalities, which persisted six months later. On a re-admission examination, which was needed because of a contest that was stopped because the referee judged that she was receiving blows to the head that were dangerous, one boxer showed non-specific EEG alterations and nystagmus. A cerebral magnetic resonance imaging scan was normal. She was allowed to participate in competitions again when her EEG returned to normal and clinical signs disappeared. Deviation of the nasal septum was quite common (68%). No major eye injuries were reported. Conclusion: Probably because of the correct preventive medical approach, female boxing is much safer than expected, and no major lesions (requiring hospital admission) were reported. Any lesions to the breast and reproductive system could not be considered to be boxing related.

Bicuspid aortic valve: an innocent finding or a potentially life-threatening anomaly whose complications may be elicited by sports activity?

The bicuspid aortic valve is the most frequent congenital anomaly of the heart in adults. Since the 1970s, with the advent of two-dimensional echocardiography, the in-vivo diagnosis of bicuspid aortic valve has become easier and greater attention has been paid to this anomaly in normal young people, particularly in sportsmen because, from a theoretical point of view, physical exercise may stress the abnormal aortic valve, favouring an early deterioration of the valve itself, as well as a dilation of the ascending aorta. Although the bicuspid aortic valve may remain without clinical consequences for a lifetime, it may be responsible for severe complications such as aortic stenosis, aortic insufficiency, endocarditis and aortic dilation/dissection, sometimes requiring surgery. Moreover, the bicuspid aortic valve may be associated with other cardiovascular anomalies, mainly aortic coarctation. At present there are no prospective studies dealing with effect of physical training and competitive sports on the natural course of the bicuspid aortic valve. However, in order to take any decision about sports eligibility, sports physicians should perform an initial accurate staging of the bicuspid aortic valve, taking into account haemodynamic factors, aortic complications and associated significant cardiovascular anomalies. A strict follow-up, with serial cardiological controls, is mandatory as well as antibiotic prophylaxis for endocarditis, particularly in subjects engaged in contact sports.

Early repolarization in the athlete

An “abnormal” resting electrocardiogram is common in top-ranking, endurance-trained athletes ([1][1]). These abnormalities belong to physiological changes induced by training, as sinus bradycardia, high QRS and T-wave voltages, and early repolarization (ER), consisting of an elevation of QRS–

Aborted sudden death in a young football player due to anomalous origin of the left coronary artery: successful surgical correction

Congenital anomalies of coronary arteries may precipitate sudden death in young athletes. We describe the case of a 14-year-old soccer player who developed chest pain and syncope during physical exertion, as the first manifestation of an abnormal aortic origin of the left coronary artery from the right coronary sinus. Correct identification by transthoracic echocardiography and confirmation by coronary angiography were made. Two years after the successful surgical correction, the boy had no recurrence of symptoms.

Left-Dominant arrhythmogenic cardiomyopathy

A 50-year-old recreational futsal player was referred to our sports cardiology outpatient clinic for palpitations and detection of frequent (>5000) ventricular premature beats with bigeminy and runs of nonsustained ventricular tachycardia at 24-hour Holter monitoring. Rest ECG showed normal QRS morphology with negative T waves in precordial lateral (V4 to V6) and inferior leads (Figure 1A). Less-prominent negative T waves in lateral but not inferior leads also were present in previous ECGs obtained during routine sports preparticipation evaluation at age 26 years (Figure 1B) but in the absence of symptoms and arrhythmias at Holter monitoring; no other diagnostic test was performed at that time. Figure 1. Rest ECGs. A , Rest ECG obtained in 1984 showing negative T waves in lateral precordial leads (V4 to V6). B , Rest ECG obtained in 2010 showing more-prominent negative T waves in lateral precordial leads. A stress ECG failed to reveal ST-segment changes diagnostic for myocardial ischemia, whereas frequent polymorphic ventricular premature beats with right bundle branch block morphology and a short run of nonsustained ventricular tachycardia were observed during the recovery phase. Two-dimensional echocardiography showed a mild reduction of ejection fraction with a diffuse apical a-dyskinesia of the left ventricle (LV), whereas the right ventricle (RV) presented normal dimensions and global function but hypokinesia of the apex and …

Anomalous origin of coronary arteries from the “wrong” sinus in athletes: Diagnosis and management strategies

AIMS Although anomalous origin of left (AOLCA) and right coronary artery (AORCA) from the wrong sinus may cause sudden death (SD) in athletes, early diagnosis and management of these anomalies are still challenging. We analysed clinical/instrumental profiles of athletes identified with AOLCA/AORCA focusing our attention on diagnosis, management and follow-up. METHODS AND RESULTS We report 23 athletes (17 males, mean age 27±17yrs.), 6 with AOLCA and 17 with AORCA. Diagnosis was made by trans-thoracic echocardiography (TTE) in 21/23(91%). Symptoms were present only in 10(41%). Only 3 had an abnormal rest-ECG and 9(39%) an abnormal stress test ECG (3 ST-depression, 4 ventricular arrhythmias, 1 supraventricular arrhythmias, 1 rate-dependent left-bundle-branch-block). Anatomy of the anomalous coronary artery showed no significant correlation with clinical presentation, except for a tendency to higher occurrence of proximal hypoplasia in symptomatic athletes (83% vs 40%, p=0.09). All athletes were disqualified from competitive-sports and advised to avoid strenuous effort. Surgery was recommended to all athletes with AOLCA and 6 with AORCA, but only 6 underwent surgery. No major cardiac events or ischemic symptoms/signs occurred during a mean follow-up of 65±70months. CONCLUSIONS Early diagnosis of AOLCA/AORCA in athletes is feasible by TTE. Typical symptoms/signs of myocardial ischemia are present only in one third of cases thus underlying the need of a high index of clinical suspicion to achieve the diagnosis. After exercise restriction, none had major cardiac events or ischemia symptoms/signs recurrence. There was no correlation between anatomical characteristics and clinical presentation with the possible exception of coronary hypoplasia.

The Preparticipation Examination: Evaluation of the Pediatric and Adolescent Athlete

Health care of healthy pediatric–adolescent population is an item of great concern, due to social, economic, and emotional burden of adverse, sometime dramatic events in young subjects. The only systematic medical screening of apparently healthy young population appears to be, nowadays, the pre-participation physical examination (PPE). A fundamental part of this examination is to take an accurate medical history, not rarely able to suspect several diseases, sometimes at risk of sudden death. History taking should start from the family history, going on investigating all the organs and systems. This chapter, moreover, deals with the medical examination of the main apparatuses with particular emphasis to the heart (the leading cause of sports related sudden death), chest and lungs, musculoskeletal, and neurological systems. Special care, finally, has been paid to concussion, especially when examining athletes involved in contact/collision sports. Concussion, actually, is a clinical entity often underestimated by athletes, coaches and doctors, which can lead to impairing physical/psychological symptoms and, although rarely, may predispose to life-threatening conditions.