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Transitory constrictive pericarditis in a professional top football player

After a mild respiratory infection, a top-class football player collapsed on the field at the end of a match

After a mild respiratory infection, 23 year old professional, top-class football player collapsed on the field at the end of a match in October 2003. Transitory 2nd degree AV-block (Wenckenbach type) and mild left ventricular dysfunction (ESVI 34.6 ml/m2, LVEF 53%), as well as a small pericardial effusion were noted both in echocardiography and MRI and he was withdrawn from sports for a period of 8 months. Cardiac catheterization revealed normal coronary angio, high end-diastolic pressures in both ventricles with "dip and plateau" configuration. Endomyocardial biopsy was unremarkable
Myocardial Disease


What would be your initial diagnosis? Would you terminate his professional football career?

In the following months our patient became spontaneously asymptomatic and tolerated physical exercise better and better. He had no fever, and no new syncope. Standard laboratory analyses were completely normal. Rheuma factor, anticardiolipin antibodies and 3 sputum PCR tests for tuberculosis were all negative. In the follow-up 24h EKG Holter monitoring (May 2004) there were no significant rhythm or conduction disorders apart from a single episode of IIIrd degree SA block with a 1.1 s pause and a permanent Ist grade AV block. Echocardiography also confirmed his recovery: ESVI decreased to 15.7 ml/m2 and LVEF increased to 74%. No pleural or pericardial effusion was present any more, and despite hyperechogenic signal from the entire pericardium there were no other echocardiography signs of constrictive pericarditis or restrictive cardiomyopathy. Chest x-ray (PA and left profile) revealed normal findings with no signs of calcifications. On follow-up cardiac catheterization, including exercise test on the lying bicycle-ergometer, volume challenge test, and dobutamine test there was no "dip-plateau" configuration in the ventricular curves, or other signs of constriction. During the lying bicycle stress test cardiac index increased from 4.1 at the baseline to 21.2 l/min/m2 at 250W. Ergospirometry, head-up tilt table test, and repeated Holter monitoring, echocardiography, and MRI revealed normal findings.

What would be your final diagnosis and your advice regarding his further participation in the competitive professional sports?

1. Initial diagnosis is constrictive pericarditis after an episode of viral respiratory infection, myopericarditis, rhythm and conduction disorders and syncope

According to the international guidelines for competitive sports constrictive pericarditis is a clear indication for cessation of the professional career and pericardiectomy. However, before making the final decision on the management, indications for surgery and permanent withdrawal from sports should be reassessed on several occasions, since, although rarely but still, constriction could be spontaneously transient with complete recovery of cardiac function, enabling successful return to competitive sports.

2. The final diagnosis is transient constrictive pericarditis

After comprehensive and repeated haemodynamic assessment, we have allowed him in September 2004 to continue his career of professional football player. During the further three years of follow - up there was no recurrence of pericardial constriction or other heart disease. Our patient is now a permanent member of the Serbian national team and very successfully plays in the French 1st football league!

Conclusion:

Myocardial and pericardial disease could lead to sudden cardiac death in top athletes if
the disease is not properly recognized or to unnecessary cessation of a successful career if the condition is over diagnosed. Comprehensive and repeated haemodynamic evaluation is essential in each specific case in order to establish the diagnosis and reach appropriate decision regarding the management and risks as well as the potentials for further sport career.

Notes to editor


Ristic Arsen, FESCProf. Seferovic Petar, FESC By Dr. Arsen D. Ristić and Prof. Petar M. Seferović, Department of Cardiology, Institute of Cardiovascular Diseases of the Clinical Centre of Serbia and Belgrade University School of Medicine, Belgrade, Serbia
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.