Sudden Cardiac Death In Young Athletes Research Articles

Case report: A case of an anomalous right coronary artery arising from the left coronary cusp.

Abstract
 An anomalous origin of the right coronary artery is usually asymptomatic. It is mostly found incidentally on an invasive diagnostic angiogram. It does lead to an increased risk of sudden cardiac death, especially in younger patients. We present a case of a 41-year-old who had presented to the hospital with complaints of chest pain. The patient was evaluated by cardiology who performed an angiography that identified an anomalous origin of the right coronary artery arising from the left coronary cusp but no evidence of coronary artery disease. Once identified, these anomalous vessels should be corrected surgically, as these conditions increase the risk of sudden cardiac death arrhythmia and ischemic events.
 
 INTRODUCTION
 Anomalous aortic origin of the right coronary artery (AAORCA) is an uncommon congenital malformation with varying clinical presentations ranging from asymptomatic to sudden cardiac death (SCD). Those with symptoms or high-risk lesions are usually managed by unroofing or reimplantation, coronary artery bypass graft (CABG), AAORCA treated with right internal memory artery graft with proximal RCA ligation.
 
 CASE DESCRIPTION
 A 41-year-old female patient with obesity and hypertension presented with a 1-year history of intermittent exertional substernal pressure radiating to left shoulder and back. The pain, which lasted about 10 minutes per episode, had been more frequent and intense over the past week.Upon initial evaluation, she was hypertensive at 150/90 mmHg and heart rate 60 bpm. Blood work was unremarkable, including negative serial troponin levels. Electrocardiography showed sinus bradycardia without ischaemic changes. Anomalous origin of RCA was incidentally discovered from computed tomography (CT) of the chest. Coronary angiography and ascending aortography were then performed, which revealed a patent RCA originating from the left coronary cusp (Fig. 1A). CT heart angiography with reconstruction revealed the RCA ostium in the left coronary cusp with a malignant course between the aorta and pulmonary artery and without an obvious intramural segment
 Discussion:
 
 An anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly that was first described in 1948 by White and Edwards. After carrying out angiography in 126,595 patients, Yamanaka and Hobbs reported the incidence of anomalous origin of the right and left coronary arteries as 136 (0.107%) and 22 (0.017%), respectively. The prevalence of an anomalous origin of RCA (ARCA) arising from the left coronary cusp with an inter-arterial course varies between 0.026% and 0.25%. An ARCA is more common than the anomalous origin of the left coronary artery (ALCA), but the latter is shown to be responsible for up to 85% of sudden cardiac deaths (SCD) related to the anomalous origins of arteries. Most coronary anomalies are detected incidentally on diagnostic angiography and are clinically insignificant; some, however, have been associated with an increased risk of SCD. It is second only to hypertrophic cardiomyopathy as a leading cause of SCD in young athletes. Mechanical compression of the RCA by the great vessels, which dilate and compress the RCA during periods of increased stroke volume, is the usual explanation for coronary ischemia. Patients usually have no ischemic changes on an electrocardiogram (ECG) at rest; however, multi-detector computed tomography (MDCT) is being used to evaluate the course of anomalous vessels outlying their relative positions to the aorta and the pulmonary artery. It also gives additional information regarding any stenotic lesion in these anomalous vessels. Echocardiography (Echo), magnetic resonance angiography (MRA), MCDT, and cardiac catheterization are all complementary diagnostic tools for evaluating anomalous coronary arteries [10]. While it is agreed that surgical correction is the standard of care for ALCA, when found, the management for right ARCA is more complicated. Treatment options for these patients include observation with medical therapy, percutaneous intervention (stenting), or surgery. Early diagnosis of coronary artery anomalies based on the patients’ symptoms can help decrease the incidence of sudden cardiac deaths, fatal arrhythmias, and ischemic events in the high-risk population.
 
 Conclusions 
 
 Coronary anomalies should be suspected in symptomatic young patients with a normal cardiac workup. Non-invasive imaging modalities such as a CTCA can help establish the diagnosis

The cardiac preparticipation sports evaluation.

Sudden cardiac death (SCD) is the leading cause of death in young athletes during sports participation. Preparticipation cardiovascular screening aims to identify those at an increased risk of SCD. This review aims to provide a background of SCD in young athletes, to discuss the various screening recommendations of major medical societies, and to review recent evidence and current practice. Numerous studies have evaluated various preparticipation screening practices, particularly regarding the inclusion of ECG as part of an initial evaluation to identify conditions with an increased risk of SCD. Some analyses have shown ECG inclusion to provide increased screening sensitivity and specificity, though others have shown no benefit when compared with evaluation with history and physical examination alone. Furthermore, in countries for which more extensive screening protocols have been employed, postimplementation statistics have not shown a significant decrease in SCD. SCD in young athletes primarily results from underlying cardiac disease. Various preparticipation screening recommendations exist globally, with the common goal of decreasing the rates of SCD by identifying youth at risk during sports participation. Current guidelines in the United States support universal preparticipation evaluation using history and physical examination, with cardiology referral if abnormalities are identified.

Absent Right Coronary Artery in an Active Young Female

Absent Right Coronary Artery in an Active Young Female

Risk of sudden cardiac death and preventive measures in athletes

Arrhythmias, which are fatal in some patients, can be triggered by sports in vulnerable people. It is estimated that 1:40,000–1:250,000 athletes will suffer a sudden cardiac death (SCD). However, female athletes appear to have some level of cardiac protection, since suffering from SCD considerably less than male athletes during sports. Athletes with underlying coronary, valvular or myocardial disease, as well as channelopathies, may be particularly prone to SCD from exercise- and sports-related physical activity. There are three main causes of SCD in young athletes: Sudden Arrhythmic Death Syndrome (56%), congenital anomalous coronary arteries (7%–14%), and hypertrophic cardiomyopathy (36%–48%). In the context of exercise, acute ischemia, myocardial infarction, and stroke risk are increased by catecholamine surge and exercise-induced stress. In middle-aged athletes, excessive cardiovascular activity is associated with a higher risk of mortality related to cardiovascular disease. It is possible to detect at-risk athletes by conducting cardiac screening, which involves a family history, physical examination, and a resting electrocardiogram. Consequently, efforts have been made to better understand the causes of SCD in athletes and to develop appropriate prevention methods.

Potential role of an athlete-focused echocardiogram in sports eligibility.

Sudden cardiac death (SCD) of an athlete is a rare but tragic event and sport activity might play a trigger role in athletes with underlying structural or electrical heart diseases. Preparticipation screenings (PPs) have been conceived for the potential to prevent SCD in young athletes by early identification of cardiac diseases. The European Society of Cardiology protocol for PPs includes history collection, physical examination and baseline electrocardiogram, while further examinations are reserved to individuals with abnormalities at first-line evaluation. Nevertheless, transthoracic echocardiography has been hypothesized to have a primary role in the PPs. This review aims to describe how to approach an athlete-focused echocardiogram, highlighting what is crucial to focus on for the different diseases (cardiomyopathies, valvulopathies, congenital heart disease, myocarditis and pericarditis) and when is needed to pay attention to overlap diagnostic zone (“grey zone”) with the athlete's heart. Once properly tested, focused echocardiography by sports medicine physicians may become standard practice in larger screening practices, potentially available during first-line evaluation.

Arrhythmogenic Cardiomyopathy: Molecular Insights for Improved Therapeutic Design.

Arrhythmogenic cardiomyopathy (ACM) is an inherited disorder characterized by structural and electrical cardiac abnormalities, including myocardial fibro-fatty replacement. Its pathological ventricular substrate predisposes subjects to an increased risk of sudden cardiac death (SCD). ACM is a notorious cause of SCD in young athletes, and exercise has been documented to accelerate its progression. Although the genetic culprits are not exclusively limited to the intercalated disc, the majority of ACM-linked variants reside within desmosomal genes and are transmitted via Mendelian inheritance patterns; however, penetrance is highly variable. Its natural history features an initial “concealed phase” that results in patients being vulnerable to malignant arrhythmias prior to the onset of structural changes. Lack of effective therapies that target its pathophysiology renders management of patients challenging due to its progressive nature, and has highlighted a critical need to improve our understanding of its underlying mechanistic basis. In vitro and in vivo studies have begun to unravel the molecular consequences associated with disease causing variants, including altered Wnt/β-catenin signaling. Characterization of ACM mouse models has facilitated the evaluation of new therapeutic approaches. Improved molecular insight into the condition promises to usher in novel forms of therapy that will lead to improved care at the clinical bedside.

Epidemiology of coronary abnormalities of discharge and branching and their clinical significance

Purpose.Until the mid-20th century they could be discovered only during autopsy, it means after death. With the introduction of coronary angiography it become possible to find them in a living person. Later on, new modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) enhanced futher our abilities. It is very important to discover coronary anomalies in a living person, because some of them could lead to sudden cardiac death (SCD). In fact, coronary artery anomalies are the second main cause of the SCD in young athletes. Another importance is driven by the fact, that some of them could lead to lifethreatening complications during cardiac surgery when unknown before the operation.Methods.We prospectively reviewed all coronary angiography films from 2011 to 2016 in our center. Coronary anomalies were reviewed and classified by two independent experienced operators. Patients with congenital heart disease and coronary fistulas were excluded.Results.Out of 5055 patients 148 (2.9%) had coronary artery anomalies of origin and distribution. Those were 120 men (81.1%) and 28 women (18.9%) with an age range between 29 to 88 years. The three most common anomalies were myocardial bridge (48.7%), separate origin of the conus branch (13.5%) and separate origin of the LAD and LCX (8.1%).Conclusion.In our study we found more or less the same types and incidence rates of coronary artery anomalies as in the world literature. We had apparently higher rates of myocardial bridges, compared to average number on angiography studies, but very close to authopsy study rates.

Echocardiographic diagnosis of congenital coronary artery abnormalities in a continuous series of adolescent football players.

Sudden cardiac death (SCD) in children and adolescents is rare. Several studies have reported a higher risk of SCD during athletic competition. High risk congenital coronary artery abnormalities are the second leading cause of SCD in young athletes in the USA. Echocardiographic assessment of coronary arteries has not been routinely used in screening programmes for junior athletes so far. Prospective cohort study in 1045 consecutive adolescent elite football players. All athletes underwent a standardized cardiovascular screening protocol with a medical history, a physical examination, 12-lead resting electrocardiogram and a complete transthoracic 2D-echocardiography. Two athletes (0.19%) showed a high-risk coronary artery abnormality (CAA) with a right coronary artery originating abnormal from the aorta and coursing inter-arterial. Low-risk CAAs were found in 16 athletes (1.53%). There was an ectasia of the left coronary artery (+3.9z and +4.3z) and a fistula from the left coronary artery in two cases (0.19%), respectively. In 1.05% ( n = 11) we found a high take-off (2.3-6.8 mm) and in one case (0.096%) there was a tangential take-off of the right main coronary artery. Variants of coronary arterial anatomy were identified in 335 of 1045 athletes (32.06%). Basic pre-participation screening tests including 12-lead or exercise electrocardiogram do not safely identify high-risk CAAs. In adolescent athletes an expert cardiologist is able to describe the origin and the proximal course of the coronary arteries and identify major abnormalities in most of the cases by transthoracic 2D-echocardiography.

Sudden Cardiac Arrest in Athletes: Do not Miss Suspicious Details

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.– This paper presents the case of a [...]

Sudden cardiac death in football players: Towards a new pre-participation algorithm.

Athletic pre-participation screening is essential for minimizing the risk for sudden cardiac death (SCD) in athletes participating in either competitive or leisure sporting activities. The primary causes of SCD in young athletes (<35 years of age) include hypertrophic cardiomyopathy, congenital anomalies of the coronary artery and arrhythmogenic right ventricular cardiomyopathy. Other abnormalities, such as malignant arrhythmia due to blunt trauma to the chest (commotio cordis), myocarditis, valvular disease, aortic rupture (in Marfan syndrome) and ion channelopathies (catecholaminergic polymorphic ventricular tachycardia, Brugada syndrome, long or short QT syndrome), also contribute to a lesser degree to SCD. Currently, clinical assessment, electrocardiogram (ECG) and echocardiography are the cornerstones of the pre-participation athletic evaluation. However, their low sensitivity raises queries as regards the need for the application of more sophisticated modalities, such as cardiovascular magnetic resonance (CMR). CMR offers precise biventricular assessment and is greatly reproducible without the inherent limitations of echocardiography; i.e., low quality of images due to the lack of appropriate acoustic window or operator's experience. Furthermore, myocardium replacement fibrosis, indicative of patients' increased risk for future cardiac events, can be effectively detected by late gadolinium enhanced (LGE) images, acquired 15 min post-contrast injection. Finally, diffuse myocardial fibrosis not identified by LGE, can also be detected by pre-contrast (native) T1, post-contrast T1 mapping and extracellular volume images, which provide detailed information about the underlying pathophysiologic background. Therefore, CMR is recommended in all football players with a positive family or personal history of syncope or SCD, abnormal/doubtful ECG or echocardiogram.

Exercise and Hypertrophic Cardiomyopathy: Time for a Change of Heart.

It has been more than a decade since the 35th Bethesda Conference published guidelines recommending against competitive sports participation for individuals with hypertrophic cardiomyopathy (HCM).1 These recommendations are predicated on the view that vigorous physical exertion creates an unstable substrate that increases susceptibility to sudden cardiac death (SCD). But what precisely is the risk of SCD, and is it really higher in athletic compared with nonathletic patients with HCM? The overall incidence of SCD in young athletic cohorts is exceedingly low, ≈1 to 3:100 000 person years, and is similar to the frequency of SCD in the young general population. Despite this finding, HCM has been thought to convey a disproportionately high risk because of early registry reports that HCM was the most common cause of SCD in young athletes. However, several subsequent studies have challenged this statistic. In the US National Collegiate Athletic Association, HCM accounted for only 8% of all sudden deaths. In a meta-analysis of retrospective cohort studies, registries, and autopsy series (1990–2014), structurally normal hearts were the most common finding on autopsies of young victims of SCD (26.7%; 95% confidence interval [CI], 21.0–32.3), with HCM attributed to a much smaller proportion (10.3%; 95% CI, 8.0–12.6).2 A structurally normal heart similarly represented the largest cohort (40%) of SCD in children and young adults in a prospective population study in Australia and New Zealand, even …

Evaluation of the Prevalence of Risk Indicators for Sudden Cardiac Death in Young Athletes

Background: Sudden cardiac death (SCD) in athletes during physical activity is rare. Objectives: To evaluate the warning signs for SCD in young athletes and correlate them with electrocardiographic data. Methods: This was a case-control, prospective study, and comparing athletes with sedentary individuals. The Sudden Cardiac Death Screening of Risk Factors (SCD-SOS) questionnaire was applied and resting electrocardiography was performed. Results: In total, 898 participants were included, 589 (65.6%) in the case group (athletes) and 309 (34.4%) in the control group (sedentary). Fainting episodes were significantly less frequent in athletes (odds ratio 0.252, p<0.001). Heart rates were not significantly different. The most common electrocardiographic findings were sinus arrhythmia, right bundle branch conduction disorder, and early repolarization. Conclusion: Young athletes had a lower frequency of risk indicators for sudden cardiac death. There was a positive correlation between fainting reported by athletes and the duration of the QRS complex.

Cardiac screening to prevent sudden death in young athletes

Sudden cardiac death (SCD) is a sudden and unexpected death caused by loss of heart of function. SCD may occur in any population, but when it occurs on the playing field in a young individual, communities worldwide are affected. Although these events are rare, media coverage of sudden cardiac arrests in young athletes have created the impression that these events are far more common than they appear. With a heightened awareness of SCD in young athletes, screening methods have been developed to try and prevent these events from occurring. The American Heart Associations (AHA) currently employs history and physical examination alone during the preparticipation physical exam (PPE), which clears a young athlete for participation in sports. There has been recent discussion on whether to include screening electrocardiogram (ECG) in the PPE especially after one study in Italy by Corrado et al. found that using routine ECG reduced the annual incidence of SCD by 90%. In this article we will discuss how effective the current screening recommendations are, whether routine ECG use should be included in the PPE and if it is cost effective, and review other screening modalities that may be useful in the detection of young athletes at risk for SCD.

International recommendations for electrocardiographic interpretation in athletes.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Incidence and Etiology of Sudden Cardiac Death: New Updates for Athletic Departments

Context:Sudden cardiac death (SCD) in a young athlete is a tragic event and is the leading medical cause of death in this population. The precise incidence of SCD in young athletes has been subject of debate, with studies reporting drastically different rates (1:917,000 athlete-years (AYs) to 1:3000 AYs) depending on the methodological design of the investigation or the targeted population.Evidence Acquisition:A literature search was performed in PubMed using the terms: incidence, sudden cardiac death, sudden death, sudden cardiac arrest, etiology, pathology, registry, athlete, young, children, and adolescents. Articles were reviewed for relevance and included if they contained information on the incidence of SCD in athletes or young persons up to the age of 35 years.Study Design:Clinical review.Level of Evidence:Level 5.Results:Studies of high quality and rigor consistently yield an incidence of 1:50,000 AYs in college athletes and between 1:50,000 and 1:80,000 AYs for high school athletes, with certain subgroups that appear to be at particularly high risk, including the following: men, basketball players, and African Americans. Initial reports suggest that the most common cause of SCD is hypertrophic cardiomyopathy (HCM). However, more comprehensive investigations in the United States and international populations—athletes, nonathletes, and military—support that the most common finding on autopsy in young individuals with SCD is actually a structurally normal heart (autopsy-negative sudden unexplained death).Conclusion:SCD is the leading cause of death in athletes during exercise and usually results from intrinsic cardiac conditions that are triggered by the physiologic demands of vigorous exercise. Current rates of SCD appear to be at least 4 to 5 times higher than previously estimated, with men, African Americans, and male basketball players being at greatest risk. Emerging data suggest that the leading finding associated with SCD in athletes is actually a structurally normal heart (autopsy-negative sudden unexplained death).

PRE-PARTICIPATION CARDIOVASCULAR SCREENING OF ELITE GEORGIAN ADOLESCENT ATHLETES: CLINICAL SIGNIFICANCE AND OUTCOMES

BackgroundA variety of cardiovascular abnormalities have been found to be responsible for sudden cardiac death(SCD) in competitive athletes. The lesions responsible for athletic field deaths differ with regard to age...

Medico-legal perspectives on sudden cardiac death in young athletes.

Sudden cardiac death (SCD) in a young athlete represents a dramatic event, and an increasing number of medico-legal cases have addressed this topic. In addition to representing an ethical and medico-legal responsibility, prevention of SCD is directly correlated with accurate eligibility/disqualification decisions, with an inappropriate pronouncement in either direction potentially leading to legal controversy. This review summarizes the common causes of SCD in young athletes, divided into structural (hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, congenital coronary artery anomalies, etc.), electrical (Brugada, congenital LQT, Wolf-Parkinson-White syndrome, etc.), and acquired cardiac abnormalities (myocarditis, etc.). In addition, the roles of hereditary cardiac anomalies in SCD in athletes and the effects of a positive result on them and their families are discussed. The medico-legal relevance of pre-participation screening is analyzed, and recommendations from the American Heart Association and European Society of Cardiology are compared. Finally, the main issues concerning the differentiation between physiologic cardiac adaptation in athletes and pathologic findings and, thereby, definition of the so-called gray zone, which is based on exact knowledge of the mechanism of cardiac remodeling including structural or functional adaptions, will be addressed.

Abstract 16387: Preventing Cardiovascular Disease and Sudden Cardiac Death by Pre-screening Athletes

Background: Cardiovascular disease (CVD) and sudden cardiac death (SCD) among young athletes (YA) remains consistent and continues to influence preventative practices and pre-screening debate. In the United States, screening for SCD in young athletes follows the American Heart Association 12-step screening questions focusing on personal history, family history, and physical examination. The European Society of Cardiology (ESC) outlines a pre-participation screening (PPS) method to minimize SCD and cardiac arrest (CA) by using family history, athlete’s history in sports, physical examination, and a resting 12-lead ECG. Negative findings allow athlete to continue with sports, whereas positive findings require athletes to continue with additional diagnostic tests (echo, stress test, etc.) Method: Using the U.S. National Registry of Sudden Death in Athletes from the National Heart, Lung, and Blood Institute Working Group, we analyzed the annual mortality rates of sudden cardiac death in young athletes in the U.S. compared to the sudden cardiac death rates as reported through the Veneto study. Results: In a 1980-2006 study, using the U.S. National Registry of Sudden Death in Athletes, 1866 sudden deaths were evaluated finding 690 cases were correlated to CVD, with a leading cause of hypertrophic cardiomyopathy. Research shows that every 3 days in the U.S., we lose an athlete to SCD. A study from 1979-2004 in the Veneto region in Italy reported an annual SCD incidence of 1.9 deaths/100,000 person-years in screened young athletes and 0.79 deaths/100,000 person-years in unscreened nonathletic participants. Additionally, the study found an 89% decrease in SCD in athletes with 3.6/100,000 person-years from 1979-1980 and a reported 0.4/100,000 person-years in 2003-2004. Conclusion: In the U.S., 690 sudden cardiac deaths out of 1866 sudden deaths (leading cause as hypertrophic cardiomyopathy) may have been detected using the PPS by adding an ECG to the pre-screening examination. It remains significant that the Veneto study demonstrated little change in SCD in unscreened non-athletes throughout 1979-2004 but notes a significant 89% decrease in SCD in screened athletes paralleling with the 1982 implementation of pre-participation screening.

(Plenary) Wearable Wireless Textile Based Nanosensor System for Early Detection of Concussion and Cardiac Arrest of Football Players

The prevalence of head injury and its subsequent effects among football players has been a persistent problem at all levels of the game. Research work over the past few decades has brought heightened awareness about the causes and long-term effects of severe or traumatic head injuries (TBI) and repeated concussions. The NFL and NCAA have implemented policies for prevention and protocols for diagnosis and treatment. An injury surveillance system is in place, which comprises of injury spotting, sideline evaluation protocol and subsequent diagnostic using brain imaging. But mild and moderate head injuries can still occur and go undetected. The cumulative effect of these mild traumatic brain injuries can cause long-term residual brain dysfunctions. Often mild TBI are detected upon manifestation of these dysfunctions. Improvement in impact detection and quantification, and injury diagnosis are required for timely medical intervention to prevent or minimize the damage due to head injury. In addition to that, a sensitive (neuro) feedback system is required for evaluation of therapeutics used for enabling players returning to play or cope with long term effects due to over-exposure to head injury. This requires a continuous unobtrusive monitoring of directional and rotational impact force, and monitoring of brain, cognitive and behavioral symptoms that is applicable to athletes of all ages. The sudden death of an individual resulting from a sudden failure in heart function is referred to as Sudden Cardiac Death (SCD). Rigorous exercise increases the risk of SCDs in young athletes with underlying cardiovascular disorders (CVD). A recent study has shown that up to 82% of individuals who succumbed to SCD were engaged in strenuous exercise during or immediately before the incident. Nearly 58% of SCDs reported between 1980 and 2006 have been reported in basketball and football athletes. In this talk, a wearable wireless textile based nanosensor system will be presented to monitor early warning symptoms of both concussion and cardiac arrest. Selected videos will be presented to show the efficacy of our nanosensor system network.

Left ventricular non-compaction and hypertrabeculation in the athlete: Distinguishing between pathology and physiology

We read with interest the letter by Stollberger and Finsterer [1] inresponse to our article [2] and we wish to thank the authors for givingus the opportunity to provide further considerations, based on theircomments.The possibility to correctly identify left ventricular non-compaction(LVNC) is fundamental in the context of pre-participation screening,given that cardiomyopathies are known as a primary cause for suddencardiac death in young athletes. However, at the present time, thereare uncertainties on the correct classification of LVNC, particularlywhenseeninathleteswherephysiologicalLVremodelingmaymorpho-logically mimic true myocardial disease.An interesting observation reported by Stollberg questionedwhether LV hypertrabeculation was present before training in ourcase series [2]. While 1 athlete fulfilled both the echocardiographicChin and Jenni criteria for LVNC [3,4] before the training, 3 of them ful-filled the Chin criteria and all the Jenni criteria after training. As a re-sponse to training stimulus, new trabeculae were identified and theyweremoreevidentascomparedwiththepre-trainingevaluation.Nota-bly, training was able to induce anincrease in both the non-compactedand compacted layers. The better visualization of LV trabeculae aftertraining can be explained not only by the direct stimulus related totraining, but also by the increase in LV cavity size induced by changesin hemodynamics.AssuggestedbyStollberg,thepresenceoffamilyhistoryiscrucialfortheclinicalevaluation,suchasthepresenceofsymptoms.Inourcasese-ries, none of the athletes had family history for cardiomyopathies, sud-dencardiacdeath,orheartfailure.Furthermore,nonewassymptomaticorpresentedsyncopeorarrhythmiasandnonehadsigns,symptoms,orbiochemical abnormalities related to neuromuscular disorders.Stollberg states that the intake of doping drugs is able to influencemuscular growth and could influence the pattern of LV hypertrophy.However, none of the athletes took drugs and this was confirmed byantidoping controls performed during the agonistic season, accordingto current regulation for the Italian Basketball League.Theexercise-inducedincreaseinLVtrabeculationwasaccompaniedalsobychangesat12-leadrestingECG[2].Thesechangeswerefoundin3 athletes after training, all of them of afro-Caribbean origin, and werenot interpreted as pathological, being a possible normal, race-relatedvariant,assuggestedbycurrentrecommendations[5,6].Notably,thelo-calization of negative T waves differs between patients suffering fromLVNC and athletes presenting with LV hypertrabeculation [7]: indeed,while the latter normally show anterior T-wave inversion, as found inour case series, the former have a high prevalence of T-wave inversionin the inferior and lateral leads [7]. However, we cannot negate thatthe contemporary presence of both LV hypertrabeculation and T-waveinversion in the precordial leads represents a challenge for clinicianswhen evaluating an athlete.In conclusion, our observation does not challenge the hypothesis thatLVNC is due to a disturbed compactionprocess of the embryogenic heart.Conversely,itsuggeststhatexercisecouldrepresentastimulusforthede-velopment of a LV hypertrabeculation pattern in certain subjects. Thus,according to this experience and to previous observations in athletes byother research groups [7–9], we suggest distinguishing between“hypertrabeculation” and “LVNC”. We believe that these two terms de-scribe a different phenomenon: indeed, isolated “hypertrabeculation”does potentially indicate the consequence of physiological adaptation ofthe LV to intensive training in predisposed individuals; it can be foundin the absence of pathological fidings, symptoms, or family history ofncardiomyopathies. Therefore, the optimization of echocardiographic im-aging in the last years should have at least in part in fluenced the recogni-tion of this entity. Conversely, “LVNC” represents a cardiomyopathy ableto induce life-threatening arrhythmias, LV dilatation and dysfunction,