Electroanatomic mapping in athletes: Why and when. An expert opinion paper from the Italian Society of Sports Cardiology

• Published in: International journal of cardiology 2023-07, Vol.383, p.166-174
• Main Authors: Dello Russo, Antonio, Compagnucci, Paolo, Zorzi, Alessandro, Cavarretta, Elena, Castelletti, Silvia, Contursi, Maurizio, D'Aleo, Antonio, D'Ascenzi, Flavio, Mos, Lucio, Palmieri, Vincenzo, Patrizi, Giampiero, Pelliccia, Antonio, Sarto, Patrizio, Delise, Pietro, Zeppilli, Paolo, Romano, Silvio, Palamà, Zefferino, Sciarra, Luigi
• Format: Article
• Language: English
• Subjects: Arrhythmias, Cardiac - diagnosis; Arrhythmias, Cardiac - pathology; Athletes; Cardiology; Cardiomyopathy; Death, Sudden, Cardiac - pathology; Death, Sudden, Cardiac - prevention & control; Electroanatomical mapping; Humans; Myocardium - pathology; Sports; Sports cardiology; Ventricular arrhythmias
• ISSN: 0167-5273; 1874-1754; 1874-1754
• DOI: 10.1016/j.ijcard.2023.05.013

Three-dimensional electroanatomical mapping (EAM) has the potential to identify the pathological substrate underlying ventricular arrhythmias (VAs) in different clinical settings by detecting myocardial areas with abnormally low voltages, which reflect the presence of different cardiomyopathic substrates. In athletes, the added value of EAM may be to enhance the efficacy of third-level diagnostic tests and cardiac magnetic resonance (CMR) in detecting concealed arrhythmogenic cardiomyopathies. Additional benefits of EAM in the athlete include the potential impact on disease risk stratification and the consequent implications for eligibility to competitive sports. This opinion paper of the Italian Society of Sports Cardiology aims to guide general sports medicine physicians and cardiologists on the clinical decision when to eventually perform an EAM study in the athlete, highlighting strengths and weaknesses for each cardiovascular disease at risk of sudden cardiac death during sport. The importance of early (preclinical) diagnosis to prevent the negative effects of exercise on phenotypic expression, disease progression, and worsening of the arrhythmogenic substrate is also addressed. •Three-dimensional electroanatomical mapping (EAM) has the potential to identify the pathological substrate underlying ventricular arrhythmias (VAs).•In athletes, EAM may enhance the efficacy of third-level diagnostic tests and cardiac magnetic resonance (CMR) in detecting concealed arrhythmogenic cardiomyopathies.•An electroanatomical mapping-guided endomyocardial biopsy may be considered as additional diagnostic tool among athletes presenting with complex ventricular arrhythmias and unclear findings after comprehensive clinical-imaging assessments and genetic testing.•The role of electroanatomical mapping is particularly relevant in the differentiation between myocarditis and forms of arrhythmogenic cardiomyopathy, especially if integrated with the biopsy and histological examination that allows sampling in an extremely precise way the areas of altered voltage, expression of myocardial fibrosis.