The Risk of Sudden Death Associated with Symptomatic and Asymptomatic Ventricular Pre-excitation in Athletes

Negru, Alina Gabriela; Vintilă, Ana-Maria; Crișan, Simina; Ana Luca, Silvia; Ivănică, Adrian Emil; Mihăicuță, Ștefan; Cismaru, Gabriel; Popescu, Florina; Iovanovici, Diana-Carina; Luca, Constantin Tudor

doi:10.2478/rjc-2022-0016

Abstract

Sudden death (SD) in athletes is a potential avoidable dramatic scenario. When done regularly, cardiological evaluation increases the chances of diagnosing ventricular pre-excitation. Consequently, the following question arises: what is the real incidence of SD risk in athletes with Wolff-Parkinson-White (WPW) syndrome/pattern? This study included 84 consecutive patients diagnosed with WPW and was designed as a retrospective analysis of data acquired between 2011 and 2021 to answer this question. The patients were evaluated using a 12-lead electrocardiogram (ECG), echocardiography, stress test, and electrophysiological study (EPS). The SD risk linked to WPW was defined as ≥ 1 of the following: the anterograde effective refractory period (AERP) of the accessory pathway (AP) ≤ 250 ms, atrial fibrillation (AF) with the shortest RR pre-excited interval ≤ 250 ms, syncope during AF or atrioventricular reentry tachycardia. The athletes with WPW pattern (n=25) or syndrome (n=59) at risk of SD were identified and treated with radiofrequency ablation (RFA). The mean age was 19.83 (10–29) years; 66.6% were men. Seventeen athletes (n=17; 20.23%) were found with SD risk: 15 (n=15; 17.85%) in the WPW syndrome group and 2 (n=2; 2.38%) in the WPW pattern group. During the EPS, n=4 developed syncope: 1 during antidromic tachycardia and 3 during pre-excited AF. RFA was curative in 96.42% of cases. The EPS is mandatory to identify athletes with short AERP APs linked to an increased risk of SD. RFA is the intervention that settles the patients into a risk-free area, allowing resumption of sports shortly afterward.

References

Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. J Am Med Assoc 2006;296:1593–1601. doi:10.1001/jama.296.13.1593.
Open DOI Search in Google Scholar Back to article
Futterman LG, Myerburg R. Sudden death in athletes. An update. Sport Med 1998;26:335–50.
Search in Google Scholar Back to article
Rao AL, Salerno JC, Asif IM, Drezner JA. Evaluation and management of Wolff-Parkinson-White in athletes. Sport health 2014;6:326–32. doi:10.1177/1941738113509059.
Open DOI Search in Google Scholar Back to article
Ferreira M, Santos-Silva PR, de Abreu LC, Valenti VE, Crispim V, Imaizumi C, Filho CF, Murad N, Meneghini A, Riera ARP, et al. Sudden cardiac death athletes: a systematic review. Sports Med, Arthrosc, Rehab, Ther Technol 2010;2:19.
Search in Google Scholar Back to article
Endres BD, Kerr ZY, Stearns RL, Adams WM, Hosokawa Y, Huggins RA, Kucera KL, Casa DJ. Epidemiology of sudden death in organized youth sports in the United States, 2007–2015. J Athlet Train 2019;54:349–55. doi:10.4085/1062-6050-358-18.
Open DOI Search in Google Scholar Back to article
Iurciuc S, Avram C, Turi V, Militaru A, Avram A, Cimpean AM, Iurciuc M. Physical training, hemodynamic parameters, and arterial stiffness: friends or foes of the hypertensive patient? In vivo (Athens, Greece) 2016;30.
Search in Google Scholar Back to article
Crimi E, Ignarro LJ, Cacciatore F, Napoli C. Mechanisms by which exercise training benefits patients with heart failure. Nat Rev Cardiol 2009;6:292–300.
Search in Google Scholar Back to article
Silverman MN, Deuster PA. Biological mechanisms underlying the role of physical fitness in health and resilience. Interface Focus 2014;4.
Search in Google Scholar Back to article
Mihl C, Dassen WRM, Kuipers H. Cardiac remodelling: concentric versus eccentric hypertrophy in strength and endurance athletes. Neth Heart J 2008;16:129–33.
Search in Google Scholar Back to article
Morganroth J, Maron BJ, Henry WL, Epstein SE. Comparative left ventricular dimensions in trained athletes. Ann Int Med 1975;82:521–24. doi:10.7326/0003-4819-82-4-521.
Open DOI Search in Google Scholar Back to article
Pelliccia A, Maron MS, Maron BJ. Assessment of left ventricular hypertrophy in a trained athlete: differential diagnosis of physiologic athlete's heart from pathologic hypertrophy. Prog Cardiovasc Dis 2012;54:387–96. doi:10.1016/j.pcad.2012.01.003.
Open DOI Search in Google Scholar Back to article
Crişan S, Tint D, PL. Therapeutic advances in emergency cardiology: a focus on acute myocarditis. Am J Ther 2019;26. doi:10.1097/MJT.0000000000000921.
Open DOI Search in Google Scholar Back to article
Fujita S, Fujii E, Sugiura S, Ito M. Atrioventricular accessory pathway with anterograde decremental conduction property. BMJ Case Reports 2013;2013. doi:10.1136/bcr-2013-009814.
Open DOI Search in Google Scholar Back to article
Gupta A, Al-Ahmad A. Wolff-Parkinson-White syndrome. In Cardiac Electrophysiology: Clinical Case Review. Springer International Publishing, 2020, 267–69. ISBN 9783030285333.
Search in Google Scholar Back to article
Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan G-A, Dilaveris PE, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Euro Heart J 2020;1–126. doi:10.1093/eurheartj/ehaa612.
Open DOI Search in Google Scholar Back to article
Patel DA, Lavie CJ, Milani RV, Shah S, Gilliland Y. Clinical implications of left atrial enlargement: a review. Ochsner J 2009;9:191–96.
Search in Google Scholar Back to article
Zachariah JP, Walsh EP, Triedman JK, Berul CI, Cecchin F, Alexander ME, Bevilacqua LM. Multiple accessory pathways in the young: the impact of structural heart disease. Am Heart J 2013;165:87–92. doi:10.1016/j.ahj.2012.10.025.
Open DOI Search in Google Scholar Back to article
Brugada J, Keegan R. Asymptomatic ventricular pre-excitation: between sudden cardiac death and catheter ablation. Arrhyth Electrophysiol Rev 2018;7:32–38. doi:10.15420/aer.2017.51.2.
Open DOI Search in Google Scholar Back to article
Grazioli G, Sanz M, Montserrat S, Vidal B, Sitges M. Echocardiography in the evaluation of athletes. F1000 Research 2015;4:151.
Search in Google Scholar Back to article
Wackel P, Irving C, Webber S, Beerman L, Arora G. Risk stratification in Wolff-Parkinson-White syndrome: the correlation between noninvasive and invasive testing in pediatric patients. PACE—Pacing Clin Electrophysiol 2012;35:1451–57. doi:10.1111/j.1540-8159.2012.03518.x.
Open DOI Search in Google Scholar Back to article
Negru AG, Alzahrani T. Electrophysiologic Testing. StatPearls Publishing, 2020.
Search in Google Scholar Back to article
World Medical Association Declaration of Helsinki. Recommendations guiding physicians in biomedical research involving human subjects. JAMA: J Am Med Assoc 1997;277:925–26. doi:10.1001/jama.1997.03540350075038.
Open DOI Search in Google Scholar Back to article
Iqbal AM, Ghazni MS, Mubarik A, Zubair N, Jamal SF. The conversion of Wolff-Parkinson-White (WPW) pattern into WPW syndrome in the presence of ischemia: a case report. Cureus 2019;11:e4147. doi:10.7759/cureus.4147.
Open DOI Search in Google Scholar Back to article
Arruda MS, Mcclelland JH, Wang X, Beckman KJ, Widman LE, Gonzalez MD, Nakagawa H, Lazzara R, Jackman WM. Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-White syndrome. J Cardiovasc Electrophysiol 1998;9:2–12. doi:10.1111/j.1540-8167.1998.tb00861.x.
Open DOI Search in Google Scholar Back to article
Santinelli V, Radinovic A, Manguso F, Vicedomini G, Gulletta S, Paglino G, Mazzone P, Ciconte G, Sacchi S, Sala S, et al. The natural history of asymptomatic ventricular pre-excitation. A long-term prospective follow-up study of 184 asymptomatic children. J Am Coll Cardiol 2009;53:275–80. doi:10.1016/j.jacc.2008.09.037.
Open DOI Search in Google Scholar Back to article
Rao AL, Salerno JC, Asif IM, Drezner JA. Evaluation and management of Wolff-Parkinson-White in athletes. Sports Health 2014;6:326–32. doi:10.1177/1941738113509059.
Open DOI Search in Google Scholar Back to article
Waller BF, Gering LE, Branyas NA, Slack JD. Anatomy, histology, and pathology of the cardiac conduction system—Part V. Clin Cardiol 1993;16:565–69. doi:10.1002/clc.4960160710.
Open DOI Search in Google Scholar Back to article
Ali R, Tahir A, Nadeem M, Shakhatreh MI, Faulkner B. Antidromic atrioventricular reentry tachycardia with Wolff Parkinson White syndrome: a rare beast. Cureus 2018;10:e2642. doi:10.7759/cureus.2642.
Open DOI Search in Google Scholar Back to article
Baggish AL, Wood MJ. Athlete's heart and cardiovascular care of the athlete | EndNote Click Available online: https://kopernio.com/
Search in Google Scholar Back to article

The Risk of Sudden Death Associated with Symptomatic and Asymptomatic Ventricular Pre-excitation in Athletes

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