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Substrates of sudden cardiac death in young athletes

ESC Congress 2010

In the Cardiac Antomy live sessions there are usually formalin fixed and previously dissected hearts presented which relate to specific topics of cardiac anatomy, pathology or both.

However, on this occasion, Professor Basso had chosen to present a series of video recordings of cardiac dissections, which were selected from the more than 500 documented cases of sudden cardiac death that came to autopsy at the University of Padua over the years. Videos were of excellent quality and the attendees could follow the process of dissection step by step, which appeared particularly illustrative in case of demonstrating coronary artery pathology.

The presentation started with an introduction to the problem of sudden cardiac death (SCD) in young athletes: A survey in the Veneto region among 300 young people and athletes (12-35 years old) revealed an SCD incidence of 2.3/100,000/year among young athletes versus 0.9/100,000/year among non athletes. The cumulative death rate was 1/100,000/year, which equals other data such as those derived from the United States. So, sports activity in the young increases the risk of sudden death to some extent, but the type of underlying pathology appears to be clearly distinctive: for example , for (atherosclerotic) coronary artery disease, the relative risk is only mild (2.2), but RR increases dramatically to 79.0 in case of congenital coronary anomalies.

Moreover, it seems to be important to make a distinction between young, often competitive athletes in whom the spectrum of underlying pathology is very large , including congenital anomalies (coronary arteries), familial diseases (cardiomyopathies) and acquired disease (such as myocarditis), and the older age group, in which the sports activity is more often recreational. Moreover, in the older athletes, most sudden deaths relate to atherosclerotic coronary artery disease, mostly thrombotic coronary occlusion superimposed on a ruptured plaque.

The main culprits for sudden death in athletes are the aorta, the coronary arteries and the myocardium, while cardiac valves, the conduction system and ion channel apparatus are far less involved. Six hearts of young SCD victims were shown with abberant origin and/or proximal course of one of the coronary arteries. Among them 2 cases of double coronary ostia arising from the right sinus vasalva (in one heart an abberant circumflex artery and in the other heart anomalous origin of the left coronary artery). These conditions bear a major risk of SCD during excercise. This is in contrast to an anomalous right coronary artey arising from the left sinus, which is considered a relatively benign (also presented by Prof Basso in a non SCD subject).

The second series of hearts presented by Prof Basso were dealing with cardiomyopathies in young athletes, of which ARVC and familial Hypertrophic cardiomyopathy (HCM) are the most frequently encountered (and in the Italian cohort ARVC far more than HCM). Comparing the dissected hearts of several ARVC patients was particularly illustrative to show the marked variation in the extent and location of the fatty infiltration of the myocardium, and the frequent involvement of the left ventircle in the disease process.

In slightly more than one hour of time, Prof Basso was very succesful in visualizing the main aspects of the diverse spectrum of pathologies that underlies SCD in young athletes.




Substrates of sudden cardiac death in young athletes
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.