Thursday-Abstracts

Thursday, May 30, 2013
S342 Vol. 45 No. 5 Supplement
D-59 Clinical Case Slide - Cardiovascular
May 30, 2013, 3:15 PM - 5:15 PM
Room: 103
1768 Chair: Aaron L. Baggish. Massachusetts General Hospital,
Boston, MA.
(No relationships reported)
1769 discussant: Sandra J. Hoffmann, FACSM. Idaho State University,
Pocatello, ID.
(No relationships reported)
1770 discussant: Warren B. Howe, FACSM. Bellingham, WA.
(No relationships reported)
1771 May 30, 3:15 PM - 3:35 PM
sudden Cardiac death--running
Kenneth Leclerc, James Watts, Mark Peele, Kevin Steel, Michael
Rose. San Antonio Military Medical Center, Fort Sam Houston, TX.
(No relationships reported)
hIsTOry: A 51-year-old male had sudden loss of consciousness while running on
a treadmill at the gym. He had been evaluated 4 months prior for a neurocardiogenic
syncopal event following a colonoscopy. Patient found to be without a pulse.
Bystander CPR was performed and the use of an automated external defibrillator
(AED) with successful restoration of a regular pulse. Interrogation of the AED
revealed ventricular fibrillation appropriately defibrillated to normal sinus rhythm.
PhysICaL EXaMINaTION: Heart rate 60, Blood pressure 130/81, Respiratory
rate 12. His breath sounds were clear to auscultation. His heart was regular in rate and
rhythm, normal S1 and S2 without murmur. He had no elevation in his jugular venous
pulsation and was without lower extremity edema.
PhysICaL EXaMINaTION:
1. Acute coronary syndrome
2. Arrhythmogenic right ventricular cardiomyopathy
3. Catecholaminergic polymorphic ventricular tachycardia
4. Brugada syndrome
5. Long QT syndrome
6. Torsades de Pointe
TEsT aNd rEsuLTs:
EKG
--Normal sinus rhythm, right axis deviation, and right bundle branch block
Echocardiogram
--Normal left ventricular size, wall thickness and function with moderate dilation of
the right ventricle and right atrium.
Coronary Angiography
--Luminal irregularities
Cardiac MRI
--Mildly dilated right ventricle with a mildly low right ventricular ejection fraction of
46.4% without other evidence for arrhythmogenic right ventricular dysplasia
Electrophysiology Study
--No accessory pathway found, no evidence of dual AV node physiology, and
normal corrected QT interval after epinephrine infusion. A monomorphic ventricular
tachycardia occurred after high dose (20mcg/min) isoproterenol infusion
Genetic Testing
--4 novel gene mutations coding for sarcomeric proteins (actinin, myosin, and titin).
FINaL WOrKING dIaGNOsIs:
Catecholamine sensitive ventricular tachycardia with aborted sudden death secondary
to apparent RV cardiomyopathy
TrEaTMENT aNd OuTCOMEs:
1. AICD placed for secondary prevention of sudden cardiac death
2. Suppressive long-acting beta-blocker therapy
3. Cardiac rehabilitation without recurrence of symptoms
4. Genetic counseling for the patient and first degree relatives
5. Further evaluation as to the role that the genetic variants may play into malignant
arrhythmias
1772 May 30, 3:35 PM - 3:55 PM
syncope and abnormal Electrocardiogram in an adolescent
Basketball Player
Jodi L. Zilinski, Miranda E. Contursi, Patricia A. Lowry, Caitlin
H. O’Callaghan, Michael A. Fifer, Gregory D. Lewis, Aaron L.
Baggish. Massachusetts General Hospital, Boston, MA.
(No relationships reported)
hIsTOry: A 17 year old Caucasian male basketball player presented following a
syncopal episode, which occurred during basketball practice. He had just completed
MEDICINE & SCIENCE IN SPORTS & EXERCISE ®
sprinting drills and was walking to the bench when he felt lightheaded and lost
consciousness for approximately 30 seconds. He sustained no injuries. He had recently
completed a course of azithromycin for an upper respiratory tract illness. He denied
antecedent chest pain, palpitations, and prior syncope.
PhysICaL EXaMINaTION:
Vital signs: Ht 1.78 meters, Wt 68.0 kg, Heart rate 50 bpm, Blood Pressure 112/62
mmHg
Healthy appearing. Lungs clear. Bradycardic regular rate, normal S1 and S2 without
murmur or gallop. Nonfocal neurologic examination.
PhysICaL EXaMINaTION:
Neurally mediated syncope
Cardiac arrhythmia
Anomalous origin of coronary artery
Structural heart disease (HCM, ARVC)
Athletic remodeling
Myocarditis
TEsT aNd rEsuLTs:
ECG: (Fig. a)
- Sinus bradycardia
- QTc 428 ms
- Increased precordial voltage
- Diffuse repolarization abnormalities
Echocardiogram:
- LV- asymmetric hypertrophy (LV mass 107 g/m 2 , wall measurements: interventricular
septum 9 mm, posterior wall thickness 12 mm)
- RV- normal structure and function
- Coronary Arteries- well visualized, normal coronary origins and proximal courses
Cardiac MRI: (Fig. B)
-LV mass 115 g/m 2
- Asymmetric LV hypertrophy (max wall thickness = 15 mm in inferior region)
- No T2 weighted edema, early or late gadolinium enhancement
- No RV hypertrophy
Cardiopulmonary Exercise Test (CPET):
- Exercise time: 12:54 min
- Peak workload 196 Watts
- Maximal oxygen uptake (VO2) 33.4 ml·kg -1 ·min -1 (75% predicted)
- Decreased peak O2 pulse consistent with abnormal stroke volume augmentation
- No arrhythmias
WOrKING dIaGNOsEs:
Hypertrophic cardiomyopathy vs. Athletic remodeling with neurally mediated syncope
TrEaTMENT aNd OuTCOMEs:
1. Prescribed detraining x 6 months
2. Repeat EKG (Fig. C): Persistent although less marked repolarization abnormalities
3. Repeat Cardiac MRI (Fig. d): Marked regression of LV wall thickness (max = 10
mm in inferolateral region) and LV mass 79 g/m 2 (Δ = -36 g/m 2 , % Δ = -31%)
Discussion with patient and family regarding prognostic uncertainties surrounding
“bizarre” ECG patterns in the absence of structural heart disease. Ultimately cleared
for participation with close follow-up.
1773 May 30, 3:55 PM - 4:15 PM
decreased Ejection Fraction - Baseball
Peter H. Seidenberg, Wayne J. Sebastianelli. Penn State
University, State College, PA. (Sponsor: Francis G. O’Connor,
FACSM)
(No relationships reported)
hIsTOry: A 19 year old freshman baseball catcher underwent routine screening
2D echocardiography as part of his initial preparticipation evaluation. He reports no
history of chest pain, syncope, dizziness, palpitations, or shortness of breath. His past
medical history is unremarkable. There is no history of recent illness. There is a history
of a severe flu-like illness 2-3 years ago, for which he did not seek medical attention.
There is no significant family medical history. He has no current or prior history of
smoking, alcohol use, drug use, or anabolic steroid use.
ACSM May 28 - June 1, 2013 Indianapolis, Indiana