The intriguing problem of atrial fibrillation in competitive athletes.

Atrial fibrillation (AF) is the most frequent cause of prolonged palpitations in young competitive athletes, even including those performing elite sport activity. This arrhythmia may occasionally affect impair athletes' ability to compete thus leading to non-eligibility at prequalification screening. Competitive sport has a significant impact on the autonomous nervous system. In fact, long-term regular intense physical training determines an increase in vagal tone leading to resting bradycardia. During physical activity, particularly in the setting of competition, a marked release of catecholamines occurs as a result of both the intense physical effort and emotional stress. Both of these adaptive phenomena may precipitate AF. Furthermore, in several athletes with AF an association with sick sinus syndrome has been found, even though the pathophysiological basis of this finding is not clear. This picture is further complicated by the increasingly intake of illicit substances, whose arrhythmogenic effect has been shown both at the ventricular and atrial levels. Moreover, the use of recreational drugs, such as amphetamines, ecstasy, alcohol, cannabinoids, cocaine and so called new drugs in clubs has dramatically increased, with several cases of drug-induced arrhythmic events. These effects are often exacerbated by the combined use of different drugs, especially in situations such as sports competitions, in which the adrenergic system is already hyperactivated. No data have been published on the efficacy of antiarrhythmic therapy in athletes with AF, but it has been reported that athletes are more predisposed to the development of pro-arrhythmic effects induced by antiarrhythmic drugs when compared to general population. Most recently, radiofrequency catheter ablation involving electrical disconnection of the pulmonary veins in athletes with AF limiting their normal training activity and participation in sports competitions has proven highly effective to restore stable sinus rhythm and enable subsequent re-eligibility.

Catheter ablation of Wolff-Parkinson-White syndrome associated with congenital absence of inferior vena cava.

In the present report we describe a patient (a 36-year-old woman with 15 year history of supraventricular tachyarrhythmias) with congenital absence of inferior vena cava (IVC) revealed during radiofrequency (RF) catheter ablation procedure for right postero-septal Wolff-Parkinson-White syndrome (WPW). For the absence of IVC, the ablation procedure was more difficult, because we had to perform the ablation with the catheters (the ablator catheter and the coronary sinus catheter) introduced both through the superior vena cava. The application of RF energy (35 Watt for 60 seconds) at successful site abolished accessory pathway conduction. The following day was performed the venous angiography, showing the absence of the IVC and a venous return via paravertebral venous plexus to the azygous vein and superior vena cava into the right atrium. Computer tomography confirmed the absence of the IVC with azygous continuation. The drainage via the azygous system modified the radiological image on chest roentgenogram of the right mediastinal silhouette. During cardiogenesis fusion of the IVC and organisation of the heart occur between the 33rd to 40th embryonic days. It is therefore possible that some unknown teratogenic mechanism at this critical period might have caused, in the patient, both the developmental arrest of IVC and failure of regression of atrio-ventricular anatomical and electrical continuity in the right postero-septal region.

Atrial fibrillation in elite athletes.

INTRODUCTION: Atrial fibrillation (AF) is a rare event in people younger than 25 years of age, but is probably more frequent in competitive athletes. We analyzed the presence of AF, paroxysmal or chronic, in a population of young elite athletes, including previous Olympic and World champions, who were studied for arrhythmias that endangered their athletic careers. METHODS AND RESULTS: From 1974 to June 1977, 1,772 athletes identified with arrhythmias (1,464 males and 308 females; mean age 21 years) underwent individualized work-ups. Among these, 146 (122 males and 24 females; mean age 24 years) were young elite athletes. They were studied from 1985 to 1997, with a mean follow-up of 62 months. Of the 146 young elite athletes, 13 (9%) had AF (paroxysmal in 11 and chronic in 2); all were male. The paroxysmal AF occurred during effort (n = 7), after effort (n = 1), or at rest (n = 3) and was reinduced by transesophageal pacing or endocavitary electrophysiologic testing under the same clinical circumstances. AF was the cause of symptoms in 13 (40%) of 22 young elite athletes with long-lasting palpitations. Five young elite athletes had a substrate for AF: Wolff-Parkinson-White syndrome (WPW) in 3, arrhythmogenic right ventricular dysplasia (ARVD) in 1, healed myocarditis in 1, and was considered idiopathic in 8. All elite athletes are alive with a mean follow-up of 62 months and 7 continue in their sports: 3 after radiofrequency catheter ablation (of WPW in 2 and AF with maze-type nonfluoroscopic approach in 1) and 4 after a period of de-training. CONCLUSIONS: AF, occurring in young elite athletes and affecting only males, is one of the most frequent causes of prolonged palpitations and is reproduced easily by transesophageal atrial pacing or electrophysiologic testing. AF may be a cause of disqualification from sports eligibility, but may disappear if the athletic activity is stopped for an adequate period of time, if trigger mechanisms are corrected (i.e., WPW), or if the substrate is modified.

Cardiac arrest and sudden death in competitive athletes with arrhythmogenic right ventricular dysplasia.

Arrhythmogenic right ventricular dysplasia (ARVD) is a predisposing factor for sport-related cardiac arrest (CA), sudden cardiac death (SD), and life-threatening ventricular tachyarrhythmias (VT). The aim of this study was the assessment of athletes with ARVD, particularly the CA survivors. From 1974 to January 1996, 1642 competitive athletes (aver. 25.5 yr.), 136 of whom were top level athletes (TLA), were studied for important arrhythmic manifestations. All athletes underwent an individualised study protocol including a series of non invasive and invasive diagnostic techniques. One hundred and one athletes (90 males, 11 females, aver. 25.9 yr.) were diagnosed as being affected by ARVD on the basis of the WHO/ISFC criteria. The same percentage (about 6%) of ARVD is present in both the general arrhythmic athletes population and in the subgroup of TLA. Prevalence of ARVD among athletes with CA or SD is high (respectively 23% and 25%), confirming the observation that ARVD is one of the major causes of SD in Italian athletes. All CA were athletic activity related, indicating the potentiality of exercise as a cause of electrical destabilisation in subjects with ARVD. In athletes with documented ARVD intense sport activity has to be proscribed. In athletes at risk of CA or SD an aggressive treatment, ICD implantation and RF catheter ablation must be taken into consideration.

Catheter ablation in competitive athletes: indication.

Some supraventricular tachyarrhythmias (SVT), particularly if paroxysmal and/or related to Wolff-Parkinson-White syndrome (WPW), may in some cases endanger an athlete's professional career due to hemodynamic consequences during athletic activity, which in some instances may be life-threatening. One must also take into account that in Italy the law makes antiarrhythmic drug treatment (AAD) incompatible with sport eligibility. For these reasons, the utilization of radiofrequency ablation (RFA) in athletes has different indications as opposed to the normal population, since the primary goal is "the eligibility of the athlete." In our study, we discuss the criteria for indication of RFA in athletes with SVT on the basis of the data obtained from our population of athletes, studied over a 20-year period, from 1974 to the 31st of December 1993. These athletes were evaluated for arrhythmic events, utilizing a standardized cardioarrhythmological protocol: 1,325 athletes (1,125 men, 200 women, mean age 20.7 years). One subgroup included 380 athletes with WPW (28.7%), 22 athletes with aborted sudden death (1.6%), 6 of whom had WPW, 13 athletes with sudden death (0.98%), and 2 of whom had WPW. Another subgroup was formed by 116 top level elite professional athletes (TLA) (mean age 22.9 years), of which 10 of 116 (8.6%) had WPW and 12 of 116 (10.3%) had paroxysmal SVT. The most important indications for RFA in athletes are represented by: WPW asymptomatic at risk, symptomatic during athletic activity, and/or requiring AAD treatment: paroxysmal junctional reentrant tachycardia: when this condition is disabling and related to exercise and therefore compromising an athlete's performance and sports career. Paroxysmal junctional reentrant tachycardia is easily reproduced via transesophageal atrial pacing (TAP) during exercise (bicycle ergometer), common in athletes but normally the recurrences are concentrated only during the period in which the athlete is engaged in sport. Rare indications for RFA are focal or reentry, permanent SVT, and particularly junctional reentrant tachycardia. For each individual athlete, we have to consider the possible side-effects of RFA, the possible recurrences with psychobiological traumatic consequences, the effective recovery period, and the natural history of the tachyarrhythmias, which frequently disappear after interruption of the sports career.

Improved late potential analysis in frequency domain.

This work presents a technique to improve the identification of late potentials (LP) in patients affected by greater arrhythmogenic right ventricular disease (GARVD). Several authors have documented the correlation between GARVD and LP by means of time domain analysis. Moreover, the high incidence of bundle branch block in patients affected by GARVD suggests LP analysis in the frequency domain be performed. The method of spectral mapping of the ECG with Fourier transform was adopted. This consists in dividing the ST segment into 25 subsegments and estimating their frequency components by means of the fast Fourier transform. Recently, it was documented that this technique suffers from poor reproducibility of results. Low reproducibility is the consequence of an improper localization of the analysed QRS segments. An algorithm to increase the QRS end point identification reproducibility is proposed. An optimal QRS filter was adopted as well as a technique based on the Hilbert transform. This technique allowed the reliability of the normality factor estimates to be improved. The computed normality factors on the XYZ leads and on the vector magnitude were used to classify patients and healthy subjects; 28 patients affected by greater arrhythmogenic right ventricular disease and 35 healthy subjects were analysed in the study. High sensitivity was obtained with respect to GARVD and clinical sustained ventricular tachycardia by means of a cluster analysis technique. By applying the technique proposed in this paper the identification of LP in GARVD was increased from 47% to 88%, when clinical sustained ventricular tachycardia was documented, whereas in patients affected by GARVD but not prone to sustained ventricular tachycardia LP identification increases from 18% to 64%.

[Psychological status of patients with implantable cardioverter-defibrillators]. / Risvolti psicologici nei pazienti con cardioverter defibrillatore impiantabile.

BACKGROUND: We assessed the psychological status of 20 patients (19 male, 1 female; mean age 61 +/- 9.3) with implantable cardioverter-defibrillator (ICD). Each patient underwent the Cognitive Behavioral Assessment adapted for Hospital use (CBA-H), and completed an ad hoc 20 item questionnaire designed to measure patients' perceptions of their health. METHODS: Psychological variables were treated as dependent variables and cardiac variables were considered independent variables in the one-way analysis of variance; when psychological and cardiac variables were discrete variables, Chi-square was used; correlations were performed by rank Spearman test. RESULTS: Indicated maladaptive behaviours in on 35% of the sample. Patients with pre-ICD Ventricular Fibrillation (VF) or Sustained Ventricular Tachycardia (SVT) and VF were the most psycho-physically distressed (p < .02). These were also the patients who reported feeling most stressed in the last three months (p < .03). I-E causal attribution is a psychological dimension related to the way of codify an event; I = internal means that subject attributes to itself the cause of what happens; E = external means that subject attributes to others, fate and environment what happens. The treatment received and the I-E causal attribution were found to correlate: Internal in patients who underwent both pacing and shock treatment (who were also those with the highest number of recurrent VT/VF episodes), External in patients who underwent one treatment or none (F3, 16 = 3.28; p < .04; I-E mean = 1 +/- .63 in pacing/shock treatment group; I-E mean = 2.5 +/- .57 in shock treatment group; I-E mean = 1.8 +/- .5 in pacing treatment group; I-E mean = 2 +/- .1 in no treatment group. The time since implantation (5-9, 10-18, 19-32 months) seemed to have an important effect, even if it reached statistical significance in only two areas, namely: family relationships which were better in patients who had the ICD for > 9 months, and adjustment to the physical condition, which was better in patients who had the ICD for 10-18 months. CONCLUSION: In the present study most of the patients with ICD proved to be fairly well-adjusted to their physical condition. The preimplantation cardiac condition, the treatment received, the number of recurrent VT/VF episodes, and the length of follow-up turned out to be the variables which most influenced the psychological status of patients with ICD.

Life-threatening tachyarrhythmias in athletes.

The arrhythmias in competitive athletes may be classified as "benign," "paraphysiological" due to prolonged athletic training, or "pathological" due to hemodynamic effects on the athletic performance-risk-arrhythmogenic substratum. Pathological arrhythmias include life-threatening forms that are severe enough to produce symptoms (presyncope, syncope, cardiac arrest) during athletic activity. These forms are in particular rapid VT, VF, torsades de pointes, preexcited atrial fibrillation, sinus atrial and AV block. Our study population includes 766 competitive athletes, mean age 21.1 years (74 top international level), investigated with a cardioarrhythmological work-up for symptoms and for arrhythmias from 1974 to June 30, 1991. Three leading categories, represented by 16 aborted sudden death, 8 sudden death, and 7 induced VF (by EES or TAP) athletes, are described. All athletes with life-threatening arrhythmias, previously as asymptomatic or with minor symptoms had an arrhythmogenic substratum due to underlying silent cardiopathy or primary arrhythmic disorders. Athletic activity can be regarded as a trigger of electrical destabilization.

Long-term follow-up of patients with inducible supraventricular tachycardia treated with flecainide or propafenone: therapy guided by transesophageal electropharmacologic testing.

We report our experience with flecainide and propafenone therapy for inducible supraventricular tachycardias and paroxysmal supraventricular tachycardias due to atrioventricular (AV) nodal reentry or the Wolff-Parkinson-White syndrome. We performed an electropharmacologic test (ET) that consisted of first inducing a clinical arrhythmia by transesophageal atrial pacing (TAP) protocol. This was followed by intravenous drug administration and TAP reevaluation, either after acute intravenous administration or in oral steady-state. We used ET with flecainide and/or propafenone to study 2 groups of patients at least 3 years before the long-term clinical observation period. The first group was comprised of 58 patients with reciprocating tachycardias--due to AV node reentry in 17 (29.3%) and anomalous pathway in 41 (70.7%). Twelve (29.3%) of the latter had reciprocating tachycardias, 15 (36.6%) had atrial fibrillation, and 14 (34.2%) had both arrhythmias. During ET, flecainide was administered to 42 patients, and the ET was considered positive in 28 (66.7%). Propafenone was administered to 32 patients, with positive results in 15 (46.9%). In 15 patients, both flecainide and propafenone were tested, 8 receiving flecainide after a negative ET with propafenone, and 7 receiving propafenone after a negative ET with flecainide. In the first group, the ET was positive in 7 (87.5%), and in the second group, it was positive in 3 (42.9%). In a follow-up of 40.1 +/- 11 months, 38 (65.5%) patients had positive outcomes, 5 (8.6%) had to stop receiving the drugs because of side effects, 3 (5.2%) stopped because of inefficacy, and 12 (20.7%) dropped out.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sotalol in the Wolff-Parkinson-White syndrome: an electrophysiological and clinical study]. / Il sotalolo nella sindrome di Wolff-Parkinson-White: studio elettrofisiologico e clinico.

Distinctly different from the other beta-blocking agents, sotalol prolongs action potential duration in myocardial and Purkinje fibers, and increases atrial as well as ventricular effective refractory periods. Similarly, antegrade and retrograde accessory pathway refractory periods are increased by sotalol. The electrophysiologic and clinical effects of sotalol were studied in 40 patients (31 male and 9 female, mean age 32 +/- 14 years) with Wolff-Parkinson-White Syndrome (WPW). All patients had disabling episodes of supraventricular tachyarrhythmias (ST). Of the 40 patients, 15 (37%) had spontaneous recurrence of paroxysmal supraventricular reciprocating tachycardia (PSRT), 14 (35%) of atrial fibrillation (AF) and 11 (28%) of both PSRT and AF. All of the patients were non responders to serial transesophageal electropharmacological tests using I C class drugs. Sotalol 252 +/- 73 mg daily was administered, and, in steady-state, a new transesophageal study (TS) was performed to observe the re-induction of PSRT and/or AF. 34 patients (85%) were responders to TS (noninducibility of ST, or nonsustained ST or AF inducibility with an increase of 30% in the minimum R-R interval between pre-excitated beats during AF) and the results were confirmed during a follow-up of 17 +/- 9 months. In the non-responder group (5 patients), a I C class drug was associated with sotalol. One patient, who was a "non responder" to sotalol, sotalol + I C class drug, and to amiodarone, underwent surgical therapy. In the 26 patients (65%) who had episodes of PSRT (37%) or episodes of PSRT and AF (28%), it was impossible to reinduce PSRT in 85% of the cases. AF was induced at baseline in all of the studied patients, but after sotalol administration in 15 patients, it was impossible to reinduce AF. The rate of induced AF decreased from 208 +/- 39 beats/min to 156 +/- 36 beats/min (p < 0.001). The mean shortest R-R interval between pre-excitated beats increased from 214 +/- 35 (baseline) to 293 +/- 97 msec (sotalol steady state) (p < 0.001). No side effects were observed. A significant prolongation (p < 0.001) of the QTc interval was observed in all the patients after sotalol administration (from 0.39 +/- 0.2 to 0.42 +/- 0.02 sec.). On the basis of our results, we may conclude that sotalol has a potent effect on the antegrade refractoriness of the anomalous pathway and, in WPW syndrome at risk, is also effective in patients who don't respond to I C class drugs.

Electropharmacological testing by transoesophageal atrial pacing in inducible supraventricular tachyarrhythmias. A good approach for selection of long-term anti-arrhythmic therapy.

Sixty-eight patients with disabling episodes of inducible supraventricular tachyarrhythmia were tested electropharmacologically by transoesophageal atrial pacing. Using this technique we induced clinical arrhythmia in 67 (98.5%); 26 (38.8%) had a reciprocating tachycardia due to AV node reentry and 41 (61.2%) a by-pass tract. In the latter we induced a reciprocating tachycardia in 12 (29.3%), atrial fibrillation in 25 (36.5%) and both in 14 (34.2%). We then performed an anti-arrhythmic drug test and a transoesophageal reevaluation either after acute intravenous drug administration or during oral steady state. Altogether we tested 111 drugs or a combination of drugs before the results were considered positive; all patients tolerated the procedure well and were discharged with the drug or combination of drugs judged effective. At follow-up of 16.6 +/- 8.5 months, 42 patients (62.7%) were symptom-free, 17 (25.3%) had minor and non-disabling relapses, six (9%) stopped the drug because of inefficacy (1-1.5%) or side effects (5-7.5%); two (3%) dropped out. We conclude that electropharmacological testing with transoesophageal pacing constitutes a very good approach for inducible supraventricular tachyarrhythmias: it permits selection of optimal long-term anti-arrhythmic treatment and is well tolerated, only slightly invasive and without adverse effects.

[Supraventricular reentry tachycardia and athletic fitness]. / Tachicardia da rientro sopraventricolare ed idoneità sportiva.

Paroxysmal supraventricular reciprocating tachycardias (PSRT) which are due to a different type of reentry including the atrioventricular reentry circuit of Wolff-Parkinson-White (WPW) syndrome, may disturb the professional career of an athlete. Moreover even severe episodes of preexcited atrial fibrillation of WPW may occur. PSRT in athletes may present various clinical consequences: unimportant symptoms, or severe hemodynamic effects on the athletic performance particularly during sports activity at intrinsic high risk. The athletes are evaluated by clinical protocol which includes Holter monitoring ergometric test, echocardiography study, thyroid check and transesophageal electrophysiologic study at rest and during exercise. The arrhythmological study should be carefully performed in order to exclude an underlying heart disease, to study electrophysiological mechanisms and possible hemodynamic effect sports activity relate of the inducible and clinical tachyarrhythmias. Sometimes, these PSRT may disappear after interruption of athletic activity because of modifications of electrophysiological conditions related to the sports activity.

[Role of antitachycardia pacemakers in the treatment of supraventricular hyperkinetic arrhythmias]. / Ruolo dei pacemaker antitachicardici nel trattamento delle aritmie ipercinetiche sopraventricolari.

The use of an antitachycardia pacemaker in the treatment of hyperkinetic supraventricular arrhythmias is founded on a reliable electrophysiological ground and on an high technology. Nevertheless the clinical impact of this approach is not considerable since the 5% to 7% of the potential candidates are in effect treated with an antitachycardia device. The success of new therapeutical procedures (i.e. catheter ablation) together with the shifting of the clinical, technical and commercial interest towards the electrical treatment of the malignant ventricular tachyarrhythmias are the main causes of the minor role that now the antitachycardia pacemakers play in the management of the patients with hyperkinetic supraventricular arrhythmias.

[Electropharmacological test with class-I C drugs in paroxysmal supraventricular re-entrant tachycardia: is a negative result with a drug predictive of the ineffectiveness of other drugs of the same class?]. / Test elettrofarmacologici con farmaci della classe I C nella tachicardia parossistica sopraventricolare reciprocante: il risultato negativo di un farmaco è predittivo di inefficacia per altri farmaci della stessa classe?

UNLABELLED: Propafenone and flecainide, both I C class drugs, are first choice in the treatment of paroxysmal supraventricular reciprocating tachycardia. The aim of this study was to check whether a negative or paradoxical electropharmacological test with one of the two drugs was predictive of an equally negative or paradoxical test with the other drug. Thirty patients with disabling paroxysmal supraventricular reciprocating tachycardia, 16 M, 14 F, mean age 30.6 +/- 16 years, were studied with serial electropharmacological tests using esophageal approach. The reentry circuit was sustained by an anomalous pathway in 25 patients (83.5%) whereas it was idionodal in the other 5 (16.5%). Propafenone was tested in 13 patients (43.5%, group A) after flecainide had resulted negative or paradoxical in the first test. In 17 patients (56.5%, group B) flecainide was tested after propafenone had resulted negative or paradoxical. The second drug tested was also ineffective in 14 of the 30 patients (group A + group B) while it had positive results in 16 patients. Specifically, propafenone was positive in 6 of the 13 patients (group A) in whom flecainide had been negative, and flecainide was positive in 10 of the 17 patients (group B) with acute negative or paradoxical propafenone test. These "acute" results were confirmed in steady-state with esophageal study and in the follow-up (21.9 +/- 9.3 months). CONCLUSIONS: 53.5% of the patients who are "non responders" to the electropharmacological test with one of the two drugs (propafenone or flecainide) may be "responders" to the other drug. Thus the ineffectiveness of one of the two drugs is not predictive of ineffectiveness of the other.