IJCS | Volume 32, Nº4, July/August 2019

DOI: 10.5935/2359-4802.20190065 428 CASE REPORT International Journal of Cardiovascular Sciences. 2019;32(4):428-432 Mailing Address: Marta Luísa Braga Centro Hospitalar de Sao Joao EPE - Cardiology - Alameda Professor Hernâni Monteiro Porto. Postal Code: 4200-319. Porto - Portugal E-mail: martabraga.hsj@gmail.com Sudden Cardiac Arrest in Athletes: Do not Miss Suspicious Details Marta Luísa Brag a, P aula Dia s, M ariana Vasconcelo s, R ui Almeid a, Paulo Araúj o, Maria Macie l Centro Hospitalar de São João EPE - Cardiology, Porto - Portugal Manuscript received on October 31, 2018, revised manuscript on May 06, 2019, accepted on May 22, 2019. Spots; Athletes; Physical Endurance; Risk Assessment; Sudden Death; Cardiac Arrest; Arrhythmias Cardiac; Arrhytmogenic Right Ventricular Dysplasia. Keywords Introduction Sudden cardiac death (SCD) related to sports activities is an unexpected and rare event, usually occurring in young and apparently healthy athletes. The main cause of SCD in young athletes (< 35 years old) is ventricular arrhythmia (VA) associated with arrhythmogenic disorders (e.g. hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy – ARVC, channelopathies). Some of these conditions can be suspected by routine pre- participation clinical evaluation, while others remain undetectable even after careful screening. 1-3 This paper presents the case of a professional athlete with undiagnosed ARVC, whose first manifestation was malignant VA and biventricular dysfunction. Case report A 19-year-oldwhitemale professional handball player participated in a regional league since he was 16. He had unremarkable medical or family history. His pre-season medical examination showed electrocardiogram (ECG) with sinus rhythm, inverted T wave in right precordial leads and occasional premature ventricular contractions (PVC) (Figure 1). For more information, his physician ordered 24-hour Holter monitoring, transthoracic echocardiography (TTE) and an exercise test. The 24-hour Holter monitoring revealed periods of sinus bradycardia and 3713 PVC occurring as isolated, pairs or triplets, independently of exertion. TTE and exercise test were described as normal and he was allowed to play. Two years later, the athlete collapsed due to cardiac arrest during a handball match, while he was defending an attack. His colleagues started cardiopulmonary resuscitation (CPR) immediately. The prehospital medical emergency team arrived 10 minutes later and detected ventricular fibrillation. After one shock, the patient showed signs of return to spontaneous circulation on the field. Afterwards, the young athlete presented another collapse in the emergency transport, with shockable rhythm. Advanced life support with defibrillation and mechanical compressions were started again and the patient recovered after a total of 20 minutes of CPR. The first ECG (figure 2A) at the emergency room showed sinus rhythm, right axis deviation, dominant R waves in V1 and elevation of ST segment in precordial leads. Bedside TTE revealed dilated right chambers with biventricular global systolic dysfunction. Emergent coronary angiography showed normal coronary arteries. Lab tests showed high sensitivity troponin I elevation with no other relevant alterations. Three days after the event, invasive mechanical ventilatory support and vasopressors were suspended and the patient recovered without neurological or cognitive deficits. Serial ECGs showed inverted T wave in right precordial leads (Figure 2B). TTE was repeated and confirmed dilatation of the right chambers with marked trabeculations in the right ventricle (RV) and biventricular global systolic dysfunction (Figure 3A-D). For further investigation, cardiac magnetic resonance (CMR) was performed, showing left ventricular (LV) Marta Luísa Braga, MD Centro Hospitalar Universitário de São João, Porto - Portugal martabraga.hsj@gmail.com