Revista de Medicina Desportiva (English) March 2018 - Page 13

only one ventricular extrasystole ; no pauses exceeding two seconds ;
• Treadmill Stress Test ( Bruce protocol ) with good exercise tolerance ( 13m10s ; 15.5 METS , 94 % of agepredicted maximum heart rate ); no dysrhythmic or hypertensive response ; WPW pattern throughout the test ( exercise and recovery ); without changes suggestive of myocardial ischemia ( Figure 3 ). Since pre-excitation was maintained throughout the stress test and 24-hour Holter , suggesting a persistent conduction pathway , it was decided that a electrophysiological study be performed to analyze the electrical properties of the accessory pathway .
The electrophysiological study was performed with placement of catheters by right femoral access to the coronary sinus , right ventricular apex and His bundle . Pre-excitation was intermittent , requiring administration of adenosine during mapping , detecting an atrioventricular fusion signal in the posteroseptal region . Despite being a low-risk pathway , it was decided to perform ablation of the accessory pathway , obtaining immediate success criteria . No events were observed during the procedure .
Among post-discharge care , it was recommended not to exercise in the first 15 days after the intervention and resume professional activity in a gradual manner . The athlete resumed her competitive sport activity one month after the intervention .
Discussion
The present case illustrates a clinical situation with implications in athlete evaluation . In the presence of a WPW pattern on a 12-lead resting ECG of an asymptomatic athlete , the risk of degenerating into ventricular fibrillation should be stratified .
Figure 2 – 12-lead resting ECG with a typical WPW pattern : PR < 120ms , delta wave ( arrows ) and QRS > 120ms .
Figure 3 – 12-lead ECG at peak effort , maintaining the typical WPW pattern ( delta wave – arrows ).
Signs of high risk are :
• young age (< 30 years )
• pre-excitation persistence in the ECG at rest and during exercise
• shorter RR interval in pre-excited atrial fibrillation (< 250ms )
• different pre-excitation morphologies ( suggestive of multiple pathways ) and
• asymptomatic paroxysmal atrial fibrillation . 5 In this case , a transthoracic echocardiogram was performed on the athlete to exclude structural pathology , a stress test and 24-hour Holter to evaluate the persistence of the WPW pattern and identify significant dysrhythmias . This investigation is crucial since 40 to 50 % of patients with WPW , victims of sudden death , were asymptomatic prior to the event . 6
Since the athlete maintained the WPW pattern throughout the stress test and 24-hour Holter ( persistent pattern ), possibly indicating an accessory pathway with a short and potentially malignant refractory period , an electrophysiological study was performed . During the study , an accessory pathway was identified in the intermittent posteroseptal region ( low risk ), with the question remaining of whether or not to perform catheter ablation at the same operative time .
Being an athlete with the objective of increasing exercise intensity and volume ( predominantly dynamic ), ablation was performed due to the low risk of complications of the procedure and high success rate (> 95 %) when performed in reference centers .
The American Society of Cardiology 7 recommends an invasive electrophysiological study in asymptomatic athletes only if the accessory pathway is not considered low risk . According to the European Society of Cardiology 5 , risk stratification through a electrophysiological study is recommended in all athletes , regardless of the competitive level . While this discrepancy remains , it seems appropriate to us for all athletes with a WPW pattern be observed by an electrophysiologist for risk stratification purposes through the realization of an electrophysiological study . The decision for ablation must be made on a case-bycase basis after weighing the risks and benefits . Continue in page 25
Revista de Medicina Desportiva informa march 2018 · 11
only one ventricular extrasystole; no pauses exceeding two seconds; • Treadmill Stress Test (Bruce proto- col) with good exercise tolerance (13m10s; 15.5 METS, 94% of age- predicted maximum heart rate); no dysrhythmic or hypertensive response; WPW pattern through- out the test (exercise and recov- ery); without changes suggestive of myocardial ischemia (Figure 3). Since pre-excitation was main- tained throughout the stress test and 24-hour Holter, suggesting a persistent conduction pathway, it was decided that a electrophysiological study be performed to analyze the electrical properties of the accessory pathway. The electrophysiological study was performed with placement of cath- eters by right femoral access to the coronary sinus, right ventricular apex and His bundle. Pre-excitation was intermittent, requiring administra- tion of adenosine during mapping, detecting an atrioventricular fusion signal in th ѕɽ͕хɕ)єܵɥͬѡ݅)Ё݅́Ѽəɴѥ)ѡͽѡ݅䰁х)єՍ́ɥѕɥ9ٕ)ݕɔ͕ٕɥѡɽɔ)е͍ɝɔЁ݅)ɕЁѼɍ͔ѡ)Ѐԁ́ѕȁѡѕٕѥ)ɕյɽͥѥ٥)ɅՅȸQѡє)ɕյȁѥѥٔЁѥش)䁽Ѡѕȁѡѕٕѥ)͍ͥ)Qɕ͕Ё͔Ʌѕ́)ͥՅѥݥѠѥ́)ѡєمՅѥ%ѡɕ͕)]A\ѕɸȵɕд) ѽѥѡє)ѡɥͬɅѥѼٕɥ)ձȁɥѥ͡ձɅѥ)ɔȃLȵɕѥ ݥѠ]A\ѕɸAH̰ф݅ٔ(ɽ̤EIL̸)ɔ̃Lȵ Ёахѡ]A\ѕɸф)݅ٔLɽ̤)Ḿɥͬɔ+$չ啅̤+$ɔ፥хѥͥѕѡ) ЁɕЁɥɍ͔+$͡ѕȁIHѕمɔ፥ѕ)ɥɥѥ̤+$ɕЁɔ፥хѥ)̀՝ѥٔձѥѠ)̤݅+$ѽѥɽ͵ɥ)ɥѥ)%ѡ͔́ɅѡɅ)ɑɅ݅́əɵ)ѡѡєѼ፱ՑՍɅ)ѡ䰁ɕ́ѕЁе)!ѕȁѼمՅєѡͥѕ)ѡ]A\ѕɸѥ)ͥЁɡѡ̸Q̴ٕ́)ѥѥ́ՍͥѼ)ѥ́ݥѠ]A\٥ѥ́Ր)Ѡݕɔѽѥɥ)Ѽѡٕи)Mѡѡєхѡ)]A\ѕɸѡɽ՝Ёѡɕ)ѕЁеȁ!ѕȀͥѕ)ѕɸͥ䁥ѥ̴)ͽѡ݅ݥѠ͡Ёѕ)ѥ䁵ЁɕɅѽɥ)ɽͥՑ݅́ȴ)ɵɥѡՑ䰁̴)ͽѡ݅݅́ѥѡ)ѕɵѕЁѕɽ͕хɕ)ɥͬݥѠѡՕѥɕ)ݡѡȁȁЁѼəɴѡѕ)ѥЁѡͅɅѥٔѥ) ѡєݥѠѡѥٔ)ɕͥɍ͔ѕͥ䁅)ٽյɕѱ䁑幅)ѥ݅́əɵՔѼѡ)܁ɥͬѥ́ѡɼ)ɔՍ́ɅєԔ)ݡəɵɕɕѕ̸)QɥM䁽 ɑ)܁ɕ́مͥٔ)ɽͥՑ䁥)ѽѥѡѕ́䁥ѡ̴)ͽѡ݅䁥́Ёͥɕ)ɥͬɑѼѡɽ)M䁽 ɑԀɥͬɅѥ)ѥѡɽ՝ɽͥ)Ց䁥́ɕ)ѡѕ̰ɕɑ́ѡѤ)ѥٕٔ]ѡ͍́ɕ)ɕ̰Ё͕́ɽɥєѼ)ȁѡѕ́ݥѠ]A\ѕɸ)͕ٕ䁅ɽͥ)ЁȁɥͬɅѥѥ͕)ѡɽ՝ѡɕѥɼ)ͥՑ丁Qͥ)ѥЁ͔)͔ͥ́ѕȁݕѡɥͭ)̸ ) ѥՔ)I٥ф5ѥلɵɍ ܀