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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
0
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?
0
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!
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