Congenital coronary artery anomalies in sports medicine. Why to know them

The anomalous origin of a coronary artery (AOCA) is a challenging topic, due to its rarity, the complexity of the pathophysiological aspects, the clinical presentation (often silent), the difficulty of diagnosis, and the potential risk of causing acute cardiovascular events up to sudden cardiac death, particularly when triggered by heavy physical exercise or sport practice. Increasing interest in sport medical literature is being given to this topic. This paper reviews current knowledge of AOCAs in the specific context of the athletic setting addressing epidemiological and pathophysiological aspects, diagnostic work-up, sports participation, individual risk assessment, therapeutic options, and return to play decision after surgery.

Italian return to play protocol after COVID-19 in young competitive and professional athletes: diagnostic yield and cost-benefit analysis

BACKGROUND

Return to play (RTP) protocols have been proposed to early detect cardiovascular involvement due to COVID-19 and reduce the risk of sports-related sudden cardiac death. However, uncertainties remain about the true prevalence of COVID-19 myopericarditis, the arrhythmic risk and the cost of this protocol.

METHODS

We collected data from 217 competitive and professional athletes of both genders who underwent RTP protocol (clinical history, resting and exercise ECG, and echocardiography). Holter monitoring and/or cardiac magnetic resonance (CMR) were performed in case of abnormalities. In 107 athletes, the RTP data were compared with those of preparticipation evaluation (PPE) performed prior to COVID-19 infection.

RESULTS

Out of 217 consecutive athletes evaluated with the RTP protocol, 7 underwent CMR: among these we found alterations compatible with myopericarditis in 3 (1.4%), with a cost per person of € 223.93 and a cost per diagnosis of € 16,197.53. Of the 107 athletes previously evaluated with PPE, 4 underwent RMC: we made a final diagnosis of myocarditis in 1 athlete (0.9%), whereas another athlete (0.9%) showed moderate pericardial effusion. The clinical presentation of both these athletes was characterized by the presence of ventricular arrhythmias newly detected during RTP. Compared to PPE, during RTP higher values were observed for shortness of breath, weight, heart rate and corrected QT interval, whereas lower values for sinus bradycardia and the E/A ratio of mitral flow.

CONCLUSIONS

The prevalence of myopericarditis was similar to that reported in previous cross-sectional and case-control studies. The availability of data recorded before COVID-19 was important in the evaluation of athletes with arrhythmias. The RTP protocol has proven to be less cost effective than normal PPE.

Myocardial bridge evaluation towards personalized medicine: study design and preliminary results of the RIALTO registry

Myocardial bridge (MB) is the most frequent inborn coronary artery variant in which a portion of the myocardium overlies an epicardial coronary artery segment. Although MB has long been considered a benign entity, a growing body of evidence has suggested its association with angina and adverse cardiac events. However, to date, no data on long-term prognosis are available, nor on therapies improving cardiovascular outcomes. We are currently conducting an ambispective, observational, multicentre, study in which we enrol patients with a clinical indication to undergo coronary angiography (CA) and evidence of MB, aiming to describe the incidence of symptoms and cardiovascular events at baseline and at long-term follow-up (FUP). The role of invasive full-physiology assessment in modifying the discharge therapy and eventually the perceived quality of life and the incidence of major cardiovascular events will be analysed. Basal clinical-instrumental data of eligible and consenting patients have been acquired after CA; FUP was performed 6, 12, and 24 months after the angiographic diagnosis of MB. The primary endpoint of the study is the incidence of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, myocardial infarction, cardiac hospitalization, and target vessel revascularization; the secondary endpoints are the rate of patients with Seattle Angina Questionnaire (SAQ) summary score <70 and the incidence of MACE in patients undergoing invasive intracoronary assessment. Among patients undergone FUP visits, we recorded 31 MACE at 6 months (11.6%), 16 MACE at 12 months (6.5%), and 26 MACE at 24 months (13.5%). The rate of patients with SAQ <70 is 18.8% at 6 months, 20.6% at 12 months, and 21.8% at 24 months. To evaluate the prognostic role of invasive intracoronary assessment, we compared MB patients who underwent only angiographic evaluation (Angio group) to those who underwent acetylcholine (ACH) provocative test with indication to calcium-channel blockers (CCBs) at discharge (Angio + ACH + CCBs group) and those who underwent functional assessment with fractional flow reserve (FFR) with indication to beta-blockers (BBs) at discharge (Angio + FFR + BBs group). After 2 years of FUP, the rate of MACE was significantly reduced in both Angio + ACH + CCBs group (6 vs. 25%, P = 0.029) and Angio + FFR + BBs group (3 vs. 25%, P = 0.005) compared with Angio group. The preliminary results of our study showed that MB may be a cause of angina and adverse cardiac events in patients referred to CA for suspected coronary artery disease (CAD). Full-physiology assessment unmasking MB-related ischaemia mechanisms, allowed to guide the treatment, personalizing the clinical management, improving the quality of life, and cardiovascular outcomes in patients with MB.

Bicuspid Aortic Valve and Premature Ventricular Beats in Athletes

BACKGROUND

The aim of this study was to identify a possible link between bicuspid aortic valve (BAV) and premature ventricular beats (PVBs), particularly from left and right ventricular outflow tracts, and to investigate possible associations between these arrhythmias and echocardiographic abnormalities.

METHODS

A comparison of sportspeople with and without BAV was performed to identify PVBs' occurrence in these two series. Then, subdividing the BAV group on the presence of cardiovascular complications due to BAV, we compared arrhythmic features between these two subgroups and echocardiographic findings between athletes with and without left and right outflow tract PVBs.

RESULTS

PVBs in 343 athletes with BAV were compared with 309 athletes without BAV, showing an increased frequency (29% vs. 11.8%, p < 0.001; OR 3.1; CI 2.1-4.7) and origin from the left (18.4% vs. 3.2%, p < 0.001, OR 6.7; CI 3.4-13.4) and right (15.2% vs. 3.6%, p < 0.001, OR 4.8; CI 2.5-9.5) outflow tracts compared to other ventricular areas (fascicular PVBs p = 0.81, other morphologies p = 0.58). No difference in PVBs' occurrence was found between near normal valve BAV and pathological BAV, nor was a difference in echocardiographic characteristics found between patients with and without outflow tract arrhythmias.

CONCLUSIONS

A possible causal link between BAV and PVBs was highlighted, but no association between PVBs and complicated BAV was emphasized.

'A bridge over troubled water': a case report

Background

Myocardial bridge (MB) is the most common inborn coronary artery variant, in which a portion of myocardium overlies a major epicardial coronary artery segment. Myocardial bridge has been for long considered a benign condition, although it has been shown to cause effort-related ischaemia.

Case summary 

We present the case of a 17-year-old female patient experiencing chest pain during physical activity. Since her symptoms became unbearable, electrocardiogram and echocardiography were performed together with a coronary computed tomography scan, revealing an MB on proximal-mid left anterior descending artery. In order to unequivocally unmask the ischaemic burden lent by MB, the patient underwent coronary angiography and physiological invasive test: instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) were calculated, both at baseline and after dobutamine infusion (5 µg/kg/min). At baseline, iFR value was borderline (= 0.89), whereas after dobutamine infusion and increase in the heart rate, the patient suffered chest pain. This symptom was associated with a decrease in the iFR value up to 0.77. Consistently, when FFR was performed, a value of 0.92 was observed at baseline, while after inotrope infusion the FFR reached the haemodynamic significance (= 0.79). Therefore, a medical treatment with bisoprolol was started.

Discussion 

Our clinical case shows the importance of a comprehensive non-invasive and invasive assessment of MB in young patients experiencing chest pain, with significant limitation in the daily life. The coronary functional indexes allow to detect the presence of MB-derived ischaemia, thus guiding the decision to undertake a medical/surgical therapy.

Diagnostic Workflow in Competitive Athletes with Ventricular Arrhythmias and Suspected Concealed Cardiomyopathies

The diagnosis of structural heart disease in athletes with ventricular arrhythmias (VAs) and an apparently normal heart can be very challenging. Several pieces of evidence demonstrate the importance of an extensive diagnostic work-up in apparently healthy young patients for the characterization of concealed cardiomyopathies. This study shows the various diagnostic levels and tools to help identify which athletes need deeper investigation in order to unmask possible underlying heart disease.

P485Re-interpretation of variants of uncertain significance in inherited cardiovascular diseases-A pilot study

Background- Identification of variants of uncertain significance (VUSs) poses relevant challenges in counseling and managing patients. They have an unknown impact on health, making the genetic tests clinically irrelevant. Recent studies demonstrate that a routine reclassification analysis enables to reclassify from 20% to 80% of this type of variant, improving risk stratification.

Purpose- We investigated whether, in the context of inherited cardiac conditions, a review of the updated literature, including new functional data, allele frequency (GnomAD) and segregation analysis may help in the variant reclassification.

Methods- Retrospective review of all VUSs in genes associated with inherited cardiac conditions identified in our cardiogenetic clinic between 2016 and 2018.

Results- Thirty-one VUSs, classified using ACMG guidelines, were identified in 26 cases with a confirmed or suspected diagnosis of inherited cardiovascular diseases, including Long QT syndrome, Brugada syndrome, Arrhythmogenic Cardiomyopathy and Hypertrophic Cardiomyopathy). Twentyfour variants were identified in well-defined causative genes (SCN5A, KCNQ1, KCNH2, KCNE1, DSP, DSG2, MYH7, TPM1, TNNI3, TNNT2, CACNA1C, MYL3) while the remaining variants were identified in minor genes with limited evidence to support their disease causation as, ANK2 and AKAP9 gene. Preliminary results of the reclassification analysis showed that two variants were downgraded to likely benign (LB) applying the BS1 criterion (allele frequency) and 4 variants were upgraded to likely pathogenic (LP) according to novel published data and family segregation studies. Moreover, further studies to assess cosegregation in other variants are still ongoing.

Conclusion- Based on our experience, 25% of variants of uncertain significance in well-defined causative genes, identified in patients with a confirmed or suspected diagnosis of inherited cardiovascular disease, were reclassified. These findings suggest that re-evaluation of genetic test results should be performed routinely in all diagnostic labs, in order to improve risk stratification and identification of family members at high risk.

Role of extensive diagnostic workup in young athletes and nonathletes with complex ventricular arrhythmias

BACKGROUND

Ventricular arrhythmias (VAs) are the most common cause of death in athletes. The differences in the electroanatomic substrate in athletes and nonathletes with complex VA are unknown.

OBJECTIVE

The purpose of this study was to compare the electroanatomic substrate of complex VA in athletes vs nonathletes.

METHODS

The study prospectively enrolled young athletes and nonathletes with VA. Patients underwent 2-dimensional echocardiography, cardiac magnetic resonance (CMR) imaging, coronary angiography, 3-dimensional electroanatomic mapping (3D-EAM), and 3D-EAM-guided endomyocardial biopsy (EMB). Follow-up included 24-hour electrocardiographic Holter or implantable cardioverter-defibrillator/loop recorder interrogation for VA recurrence.

RESULTS

Thirty-three patients were enrolled: 18 competitive athletes (56%) and 15 nonathletes (44%). Left ventricular and right ventricular (RV) findings by echocardiography and CMR did not show structural disease. Nine athletes (50%) were asymptomatic compared to 1 nonathlete (7%; P <.05). Unifocal origin of VA was reported in 14 athletes (93%) and 17 nonathletes (94%). Athletes showed a larger RV unipolar than bipolar scar (18 ± 17 cm² vs 3 ± 3.8 cm²; P = .04). Diagnostic yield of EMB was 50% in athletes and 40% in nonathletes. Among athletes, the final diagnosis was myocarditis in 2, arrhythmogenic ventricular right cardiomyopathy in 1, and focal replacement fibrosis in 1. Among nonathletes, EMB revealed focal replacement fibrosis in 4 cases. At median follow-up of 18.7 months, Kaplan-Meier curves showed lower VA recurrence in detrained athletes than nonathletes (53% vs 6%; P = .02).

CONCLUSION

This study showed the need for extensive diagnostic workup in apparently healthy young patients with complex VA in order to characterize concealed cardiomyopathies.

Are optical indices good proxies of seasonal changes in carbon fluxes and stress-related physiological status in a beech forest?

This study investigates the functionality of a Mediterranean-mountain beech forest in Central Italy using simultaneous determinations of optical measurements, carbon (C) fluxes, leaf eco-physiological and biochemical traits during two growing seasons (2014-2015). Meteorological variables showed significant differences between the two growing seasons, highlighting a heat stress coupled with a reduced water availability in mid-summer 2015. As a result, a different C sink capacity of the forest was observed between the two years of study, due to the differences in stressful conditions and the related plant physiological status. Spectral indices related to vegetation (VIs, classified in structural, chlorophyll and carotenoid indices) were computed at top canopy level and used to track CO₂ fluxes and physiological changes. Optical indices related to structure (EVI 2, RDVI, DVI and MCARI 1) were found to better track Net Ecosystem Exchange (NEE) variations for 2014, while indices related to chlorophylls (SR red edge, CL red edge, MTCI and DR) provided better results for 2015. This suggests that when environmental conditions are not limiting for forest sink capacity, structural parameters are more strictly connected to C uptake, while under stress conditions indices related to functional features (e.g., chlorophyll content) become more relevant. Chlorophyll indices calculated with red edge bands (SR red edge, NDVI red edge, DR, CL red edge) resulted to be highly correlated with leaf nitrogen content (R²>0.70), while weaker, although significant, correlations were found with chlorophyll content. Carotenoid indices (PRI and PSRI) were strongly correlated with both chlorophylls and carotenoids content, suggesting that these indices are good proxies of the shifting pigment composition related to changes in soil moisture, heat stress and senescence. Our work suggests the importance of integrating different methods as a successful approach to understand how changing climatic conditions in the Mediterranean mountain region will impact on forest conditions and functionality.

Estrogens as antioxidant modulators in human fertility

Among treatments proposed for idiopathic male infertility, antiestrogens, like tamoxifen, play a possible role. On the other hand, oxidative stress is a mechanism well recognized for deleterious effects on spermatozoa function. After reviewing the literature on the effects of estrogens in modulation of antioxidant systems, in both sexes, and in different in vivo and in vitro models, we suggest, also on the basis of personal data, that a tamoxifen treatment could be active via an increase in seminal antioxidants.