Introduction
Atrial fibrillation (AF) is the most common cardiac arrhythmia in
athletes1 and the interaction between sport activity
and AF is now widely accepted, especially in master athletes who
practice long-term endurance sport. Moreover, an association between
physical activity and common atrial flutter (AFL)2 has
been described. The mechanism is not fully understood and it is presumed
to be multifactorial. A specific trigger (atrial ectopy, sports
supplements and illicit drug use) in the presence of a suitable
substrate (genetic predisposition, cardiac remodeling with atrium
dilation, inflammation and fibrosis) and a modulator (autonomic
activation, electrolyte abnormalities, acid reflux disease) is the
foundation in onset and maintenance of AF in athletes. Lone AFL seems to
be a right-sided expression of the same pro-arrhythmic changes that lead
to AF in the left atrium.
Effective treatment of symptomatic AF is mandatory for sport
continuation both for European and Italian pre-participation protocols.
However, the management of AF in athletes is challenging. Reduction of
training volume and intensity may be effective, but in clinical practice
most athletes prefer to continue sport at the same level as before.
Rate-control strategy of the episodes is difficult to achieve in
athletes since beta-blockers are poorly tolerated and even prohibited in
some competitive sport. Moreover, pharmacological rhythm-control
strategy is poorly tolerated because of sinus bradycardia and/or
arterial hypotension. Long term antiarrhythmic drug therapy does not
represent the first choice in a young and otherwise healthy population.
Therefore, catheter ablation (CA) should be early considered in
athletes.
Furthermore, any form of anticoagulation can be a challenge due to
increased risk of bleeding with sport activities and it is a
contraindication to all sports with intrinsic risk or interpersonal
contact. There are no data regarding the safety of novel anticoagulants
in athletes with AF. Given the increasing age of athletes, it is not
rare to achieve a CHA2DS2-VASc score ≥ 1
that may indicate the need for stroke prevention, especially when the
arrhythmic burden is high (class IA for score ≥ 2, class IIaB for score
of 1). Efficient AF control through CA could also permit to stop
anticoagulant treatment in most athletes.
AF ablation is therefore an effective and safe therapeutic option and
recent international guidelines strongly recommend CA in paroxysmal AF
patient in whom at least one AAD has failed or is not well tolerated
(class I) and recommend AF ablation as first-line therapy in selected
patients (class IIa)3,4. All guidelines emphasize the
importance of high annual procedure volumes for operators and sites.
However, few data exist about the effectiveness of AF CA in athletes and
feasibility of resuming vigorous exercise afterwards.
Aims of our study were to analyze the efficacy and safety of AF CA in
athletes, to compare AF CA outcomes in athletes vs Non-Athletes (NA) and
to evaluate the feasibility of resuming vigorous exercise. We
additionally analyze the outcome of patients that underwent concomitant
AFL CA.