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Prof. Antonio Pelliccia,
The symposium was intended to discuss the criteria to appropriately allow athletes with cardiovascular disease to return to play after resolution of their pathologic condition. This issue is becoming of great relevance, in consideration of the increasing implementation of pre-participation screening, which allows detection of cardiovascular disorder at early stage in a large proportion of athletes, raising also the question of their appropriate management, from the stage of early identification to resolution until resumption, when possible, of sport participation.
Particular interest was deserved to the potential participation in competitive sport of patients with arrhythmogenic cardiomyopathies after ICD implantation. These individuals feel protected by the devices from ominous arrhythmias, have usually unhampered physical performance and ask to return to unlimited sport participation. However, as the speaker Dr. Hein Heidbuckel appropriately commented, the current scientific knowledge does not support this feeling, and several practical (inappropriate shocks) and ethical (should the patient be repeatedly exposed to increased risk for cardiac arrest?) considerations suggest prudence. Ongoing EU and USA observation registry will likely provide more firm data and allow better management in the future.
Prudence should be deserved also to athletes with congenital coronary artery anomalies (CCAA) after surgical management (re-implantation). The paucity of the observed cases in athletes, the contrasting reports from children with conditions requiring similar surgical procedures suggest that, at moment, the correction of incidentally found CCAA in a young athlete does not offer complete protection from incidence of re-stenosis and unfavourable consequences, as stated by Dr. Erik Mejoobom. Therefore, at present, competitive sport participation is not an indication for surgical re-implantation in young individuals with congenital coronary artery anomalies.
Other pathologic conditions that raise question regarding the modalities for return to the competitive sport participation are hypertrophic cardiomyopathy (HCM) and miocarditis. Prevalence of these pathologic conditions is relatively high in young athlete population and the risk for acute events has been underlined by the speakers, Dr. Sanjay Sharma and Fracois Carré, respectively. In both instances athletes harbouring these conditions urge to return to compete, for instance in HCM after ICD implantation, or resolution of systolic outflow obstruction. However, neither the substrate responsible for arrhythmic events, or the natural history of the disease are changed by these therapeutic options and, therefore, application of the current guidelines advising prudent restriction from competition is still valid. Same prudence is currently requested when treating patients with definite diagnosis of myocarditis, who should wait for complete resolution of the inflammatory signs, resumption of normal cardiac functional capacity in the absence of residual permanent alterations, such as myocardial fibrosis.
The symposium was provocative, by leading to the general attention of clinical cardiologists an emerging problem, in an area where scientific evidence is lacking and future investigations are needed.
Which athlete can re-enter his active sports career?
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