Athletes and Risk of SCD

Clinical Vignette

Stefano Caselli

MD, PhD, FASE, FESC

490 B.C:. The Battle of Marathon

Historical Perspectives

The first episode of Sudden Cardiac Death

Athletes per Year

Sudden Cardiac Death in Athletes

Who are the athletes at risk?

HCM

CAD

Anomalous

origin of CA

Ao rupture

ARVC

DCM

Myocarditis

MVP

LAD Bridge

Ao. Aneur.

Maron BJ et al, J Am Coll Cardiol 2014

Corrado D et al JAMA 2006

Italian Pre-participation Screening

Screening with Clinical History, Physical Examination and ECG.

Other examination by clinical suspicion

45 yo female triathlete

Negative Family Hx;

low CV risk profile

Palpitations.

Systolic murmur 2/6 +

mid-systolic click

Clinical case

Clinical case

12 – leads ECG

Echo

Relevant measurements

LV diameter 47mm

LV wall thickness 10mm

LA size 35mm

EF 74%

PASP 34mmHg

Clinical case

Clinical case

Clinical case

Clinical case

Exercise Test

Relevant measurements

Max Load 195Watts

145% Predicted

Max HR 141bpm

Max BP 191/92mmHg

ST Changes None

Arrhythmias Frequent PVCs

Clinical case

48h Holter ECG

Results

PVC 19166

Vent Coupl. 149

VT 1 (3 beats)

Clinical case

Cardiac MRI

Prognostic Stratification?

• 45 yo female Triathlete

• Palpitations, No Family Hx of SCD

• Bileaflet MVP

• Mild to Moderate MR

• Complex VAs, 2 Morphologies

• No LV Fibrosis, mild MAD

Common valvular abnormality

2-3% of general population.

Associated with

arrhythmias in 1/3 of pts

Myxomatous degeneration of

mitral leaflets

Mitral Valve Prolapse

MVP as a cause of Sudden Cardiac Death

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2

4

6

8

10

12

14

Anderson1994

Van Camp1995

Maron1996

Wisten2002

Corrado2003

Puranik2005

Di Gioia2006

Maron2009

Eckart2011

Winkel2011

Pilmer2013

Risgaard2014

Basso 2015

Studies that include young individuals < 40years

Studies on Athletes

Symptoms:

Synkope / Presynkope

Bileaflet Prolapse

Myoxomatous Leaflets

MAD

No significant MR.

ECG:

Fequent PVCs

MVP as a cause of Sudden Cardiac Death

42 Resuscitated patients with SCA

in whom MVP was the only

detectable cause.

Mean Age at event: 45+15

Women: 67%

Hourdain J et al Circulation 2018

Basso et al. Circulation 2015

MVP as a cause of Sudden Cardiac Death

Perazzolo Marra M et al Circ Img 2016

LV Fibrosis MAD

Qualifying athletes with MVP

Ok Doctor, but…

Can I do something

to reduce the risk?

Can I do something to reduce the risk?

Beta-Blockers:

- May Reduce Symptoms and

Arrhythmias in some patients

- No Randomized trials on

Outcome

- Doping in some sporting

disciplines

Can I do something to reduce the risk?

Catheter Ablation

Can I do something to reduce the risk?

ICD Implantation:

No specific recommendation

for Mitral valve prolapse.

Usually not indicated in

primary prevention if there is

no LV systolic dysfunction.

Can I do something to reduce the risk?

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5

10

15

20

25

30

VentricularArrhythmias

Frequent PVCs NSVT VT ICD Schock

Arrhythmic Events

Before Surgery After Surgery

Herzgefässzentrum, unpublished Data.

93 patients with MV

Surgery due to MVP

and severe MR

2 SCD and 1 ICD

Shock in 3 years FU

Surgery

Arrhythmias after MV Surgery

Qualifying athletes with MVP

Ok Doctor, but…

Can I participate in

a Triathlon Race?

MVP n=215

2.9% athletes

MVP in Athletes

Caselli S et al. Circulation 2018

7449 consecutive athletes

evaluated from 2000 to 2010

One third with significant

arrhythmias defined as:

- More than 1000 PVC / 24

hours

- Couplets or NSVT on

Holter or Exercise Testing.

Caselli S et al. Circulation 2018

Qualifying athletes with MVP

215 MVP (2.9%)

188 MVP athletes with

8 years follow-up

27 lost to follow-up,

no deaths

VA - / MR -

n=130

No events

VA - / MR +

n=2

VA + / MR –

n=48

No events

3 Events (6%)Ischemic stroke n= 1

Atrial fibrillation n=1

Mitral surgery n=1

VA + / MR +

n=8

5 events (62%)Mitral surgery = 5

Further evaluation

Family history of SCD

Disproportionate dilation of the LV(>35mm/m2 in male and >40mm/m2 in female)

High blood pressure

Caselli S et al. Circulation 2018Basso C et al. Circulation 2015Bonow RO et al. ACC / AHA recommendations Athletes with VHD. JACC 2015Pelliccia A, Caselli S, Sharma S; EAPC / EACVI recommendations for imaging in athletes Eur Heart J 2017

Qualifying athletes with MVP

Borderline cases

Qualifying athletes with MVP

Borderline cases

When VA are present, CMR is

useful to detect areas of LGE

Mitral annulus disjunction appear

to be a novel risk factor for SCD

Caselli S et al. Circulation 2018Basso C et al. Circulation 2015Bonow RO et al. ACC / AHA recommendations Athletes with VHD. JACC 2015Pelliccia A, Caselli S, Sharma S; EAPC / EACVI recommendations for imaging in athletes Eur Heart J 2017

Qualifying athletes with MVP

Athlete with

MVP

Risk Stratification

Low RiskIntermediate

Risk ProfileHigh Risk

- Bileaflet Prolapse- Female Gender- Frequent PVC- Mild Moderate MR- MAD

Eligibility or Disqualification

Echonomic

What is the athlete’s perspective?

Hey STOP you have

a Mitral Valve

Prolapse!

No, I must go!

Panathinaikon Stadium, Athens, Greece.

Thank You!