SARS-CoV-2 infection and return to play in junior competitive athletes: is systematic cardiac screening needed?

BACKGROUND: SARS-CoV-2 infection might be associated with cardiac complications in low-risk populations, such as in competitive athletes. However, data obtained in adults cannot be directly transferred to preadolescents and adolescents who are less susceptible to adverse clinical outcomes and are often asymptomatic. OBJECTIVES: We conducted this prospective multicentre study to describe the incidence of cardiovascular complications following SARS-CoV-2 infection in a large cohort of junior athletes and to examine the effectiveness of a screening protocol for a safe return to play. METHODS: Junior competitive athletes suffering from asymptomatic or mildly symptomatic SARS-CoV-2 infection underwent cardiac screening, including physical examination, 12-lead resting ECG, echocardiogram and exercise ECG testing. Further investigations were performed in cases of abnormal findings. RESULTS: A total of 571 competitive junior athletes (14.3±2.5 years) were evaluated. About half of the population (50.3%) was mildly symptomatic during SARS-CoV-2 infection, and the average duration of symptoms was 4±1 days. Pericardial involvement was found in 3.2% of junior athletes: small pericardial effusion (2.6%), moderate pericardial effusion (0.2%) and pericarditis (0.4%). No relevant arrhythmias or myocardial inflammation was found in subjects with pericardial involvement. Athletes with pericarditis or moderate pericardial effusion were temporarily disqualified, and a gradual return to play was achieved after complete clinical resolution. CONCLUSIONS: The prevalence of cardiac involvement was low in junior athletes after asymptomatic or mild SARS-CoV-2 infection. A screening strategy primarily driven by cardiac symptoms should detect cardiac involvement from SARS-CoV-2 infection in most junior athletes. Systematic echocardiographic screening is not recommended in junior athletes.

Clinical management of young competitive athletes with premature ventricular beats: A prospective cohort study.

BACKGROUND: Premature ventricular beats (PVBs) are not an unusual finding and their interpretation is sometimes challenging. Unfortunately, few data on the characteristics of PVBs that correlate with the risk of an underlying heart disease are available in athletes. OBJECTIVES: The aim of this prospective study was to investigate the diagnostic and prognostic value of PVBs characteristics in competitive athletes. METHODS: From a cohort of 1751 athletes evaluated at our sports cardiology centre, we enrolled 112 competitive athletes <40 years of age (mean age 21 ± 10 years) and with no known heart disease referred for PVBs. All athletes underwent physical examination, ECG, 12­lead ambulatory ECG monitoring, exercise testing, and echocardiography. Further investigations including cardiac magnetic resonance were performed for abnormal findings at first-line evaluation or for specific PVBs characteristics. RESULTS: The majority (79%) of athletes exhibited monomorphic PVBs with a fascicular or infundibular pattern (common morphologies). A definitive diagnosis of cardiac disease was reached in 26 athletes (23% of the entire population) and correlated with uncommon PVBs morphology (p < 0.001) and arrhythmia complexity (p < 0.001). The number of PVBs/24-h was lower in athletes with cardiac disease than in those with normal heart (p < 0.05). During the follow-up a spontaneous reduction of PVBs and no adverse events were observed. CONCLUSIONS: Infundibular and fascicular PVBs were the most common morphologies observed in athletes with ventricular arrhythmias referred for cardiological evaluation. Morphology and complexity of PVBs, but not their number, predicted the probability of an underlying disease. Athletes with PVBs and negative investigation showed a good prognosis.

The determinants of positivization of anterior T-wave inversion in children.

BACKGROUND: Anterior T-wave inversion (aTWI) can be a common electrical sign in cardiomyopathies but also a benign feature regressing with age in healthy children. Unfortunately, little is known about the age of positivization of aTWI and its determinants in children and longitudinal data are not available. The aim of this longitudinal study was to identify the age and determinants of positivization of aTWI in healthy children. METHODS: ATWI was observed in 331 healthy children. They were evaluated yearly until positivization for a maximum period of 4 years. Positivization of aTWI was observed in 312 children (94%). The weight, height/length and their respective percentiles at birth and at the time of positivization of aTWI and weeks of gestation at birth were collected. RESULTS: Positivization of aTWI occurred at a mean age of 13.0±2.0 years. When aTWI became positive, most children had a height between 51° and 75° or over the 75° percentile. At the multivariate logistic regression analysis height, weight, percentiles of height and weight at the time of positivization were identified as the strongest independent predictors of the positivization of aTWI. No correlation was found for prematurity and anthropometrics characteristics at birth. CONCLUSIONS: ATWI is a common feature of pediatric ECG, usually regressing with age. Height, weight, percentiles of height and weight at the time of positivization were identified as determinants of TWI positivization. These simple anthropometric characteristics should be used in addition to chronological age in order to interpret aTWI in children.

Normal and abnormal QT interval duration and its changes in preadolescents and adolescents practicing sport.

AIMS: Twelve-lead electrocardiogram (ECG) is an established tool in the evaluation of athletes, providing information about life-threatening cardiovascular diseases, such as long QT syndrome. However, the interpretation of ECG is sometimes challenging in children, particularly for the repolarization phase. The aim of this prospective, longitudinal study was to determinate the distribution of QT interval in children practicing sport and to evaluate changes in QT duration overtime. METHODS AND RESULTS: A population of 1473 preadolescents practising sport (12.0 ± 1.8 years, 7-15 years) was analysed. Each athlete was evaluated at baseline, mid-term, and end of the study (mean follow-up: 3 ± 1 years). QT interval was corrected with Bazett (B) and Fridericia (F) formulae. At baseline QT interval corrected with the Bazett formula (QTcB) was 412 ± 25 ms and QT interval corrected with the Fridericia formula (QTcF) 387 ± 21 ms, with no changes during follow-up. Ten children (0.68%) had an abnormal QTc. In those with QTcB and QTcF ≥480 ms, QTc duration persisted abnormal during the follow-up and they were disqualified. Conversely, children with 460 ms < (QTcB) <480 ms had a normal QTc interval at the end of the study. These children had also a normal QTcF. Mean difference in the calculation of QT between the two formulae was 25 ± 11 ms (P < 0.0001). For resting heart rate (HR) ≥82 b.p.m., QTcF was independent from HR contrary to QTcB. CONCLUSION: Normal QTc interval does not change over time in preadolescents. A minority of them has a QTc ≥480 ms; in these subjects, QTc interval remains prolonged. The use of Bazett and Fridericia correction formulae is not interchangeable and the Fridericia correction should be preferred in preadolescents with a resting HR ≥82 b.p.m.

Prevalence and significance of T-wave inversion in children practicing sport: A prospective, 4-year follow-up study.

BACKGROUND: T-wave inversion (TWI) is rare in athlete's heart but is a common manifestation in cardiomyopathies. Although TWI has been extensively investigated in adult athletes, the ability of this ECG pattern to distinguish between a physiological variant and a developing heart muscle disease in children is controversial. The aim of this longitudinal study was to establish the prevalence, changes and clinical significance of TWI in a large cohort of pre-adolescent athletes. METHODS: 2227 children (mean age 12.3 ±â€¯2.0 years) undergoing sports preparticipation screening were included. Children with TWI underwent yearly follow-up until the positivisation of TWI for a maximum follow-up of 4 years. RESULTS: Among 2227 children, 358 (16%) had TWI. Children with TWI were younger (11.4 ±â€¯2.1 vs. 12.5 ±â€¯2.0 years, p < 0.0001) and had a lower BSA than children without TWI (p < 0.0001). 97% of children showed anterior TWI while only 3% had infero-lateral TWI. Anterior TWI became positive in 94% of children during the 4-year follow-up (p < 0.0001 vs. baseline) and the remaining 6% did not show abnormal clinical findings. Conversely, in the group of 9 children with infero-lateral TWI, only 1 showed normalisation during follow-up (p = 0.81) and 1 was found to have a cardiomyopathy. CONCLUSIONS: Anterior TWI is common in children and generally becomes positive by the age of 14 years. Conversely, infero-lateral TWI is rare, persistent and may be associated with structural heart disease. Therefore, infero-lateral TWI should not be interpreted as physiologically related to age, development or training and children with infero-lateral TWI should remain under strict clinical surveillance.