Recently a young algerian soccer Player (15 yrs; 181cm, 70Kg) presented with the following ECG changes he had developed over the past three years (see PDF file EKGtg). Note preterminal T to T-Inversion alongside with elevated j-point at times (fragmenting).
There's no history of fainting or diziness during exercise or stress, no pectangina, no shortness of breath, no palpiation during rest, no tachycardia during rest, nor family history of sudden cardiac death.
During exercise testing ECG seemingly develops worsening of ST-segment depression (at times descending) with what seems to be normal T configuration in the leads II, III, aVF, V4-V6, only to normalize post exercise and then 4 minutes after testing change to the state as seen in ECG during rest.
Echocardiography was conducted showing normal configuration especially of RV with normal excursion, RVOT was 17mm showing no gradient, no pouches, no aneurysms, no valvular anormalities, no diastolic dysfunction (see attached file)
3-lead 24-h-holter was conducted showing SR with normal heartrate variation, no supra- or ventricular tachycardia, rarely ectopic beats (5 ES, 10 VES and 82 SVES), no blocks, no afib.
Cardiac MRI was conducted showing no major ARVD criterion (see attached files).
In general we think this is a rare documentation of development of ARVD with starting LV participation in the ECG prior to visible correlate in MRI. We changed intervall of visit to 6 month and will conduct cardiac MRI on a 12 month basis. After thorough discussion we did approve to FIFA licensing.
I would like to hear your opinion, thoughts, hints on this case.
Thanks Benito for one more ECG in young athlete. I do not think this boy has any structural heart disease. This type of high voltage and ST T changes are well described as part of Athlete's heart. The repolarisation abnormalities can be labile and can get attenuated or exaggerated during exercise - more often attenuated. I do not think he requires any more investigations for ARVD.
Thank you George for your thoughts on the case. Your opinion was considered a strong possibility and was therefore one reason we did approve licensing.
Thank you again for your thoughts on the case.
Regards
Thank you Andrei for your thoughts on the case.
You are totally right. Only 15% male or female this age show changes up to V3, which can be considered a normal variant. Beyond V3 need further investigation.
In addition he does develop these changes instead of them receding from prior changes! As you can see they were NOT present in the first ECGs conducted at rest.
A probable DD is the HCM, as matter of fact the reason follow up will be conducted on a 6 month schedule for licensing. So structural changes can not be seen.
As for ARVD...for our part it is still a remaining DD for septal involvement is not uncommon and changes in ECG precede structural findings most likely (ECG is much more sensitive in early stages);
For my part I will keep you updated.
I thank you again for your thoughts.
Regards
Dear colleague Evers,
we were not able to find any changes in late enhancement nor was there lack of perfusion. We did not conduct myocardial biopsy ...for we did not find a corelate for an inflammatory process.
Regards