The Search for Syncope in a Young

AthleteE. Harrison, MD

35 yo man generally very healthy

Active military at MacDill AFB

Runs approx 6 miles daily without problems

At about 4 miles into run on Bayshore he had sudden sensation of being out of breath and was aware of being slightly dizzy. His next memory is of picking himself up off the ground

No characteristics of a seizure per bystanders

Never had an event like this in his life

Past Medical HistorySurgery on his arm after a dislocationNo hypertension, DM, dyslipidemiaHeart mumur as a child – no other cardiac issuesTook malaria prophylaxis for work overseas

Social HistoryNative of DetroitNever a smoker, no significant alcohol useActive duty in Air ForceMarried with one healthy child

Family HistoryFather alive age 63 with DM, Prostate CancerMother alive age 59 with HTNPaternal Uncle and Grandfather with CADThree sisters are all healthy

Review of SystemsNo active complaintsNo asthma or bronchitisNo palpitations or chest painsSome loose stool recently but not excessiveRemainder of systems negative

Physical ExaminationAfebrile, BP 130/80, HR 70, RR 16HEENT: small abrasion over right zygomaticNECK: normal carotids, no jvd, normal thyroidLUNGS: clearHEART: PMI normal, no murmur, regular, no heaves or liftsABD: soft, non-tenderEXT: good pedal pulsesSKIN: warm and dry, no edema, no rashesNEURO: non-focal examination

Labs at initial evaluationNormal electrolytesNormal PT/PTTK+ 4.2, BUN 11Hgb 14, crit 42

Chest Film – normal

CT Head – right maxillary sinus thickening otherwise normal

Baseline EKG

V/Q Scan – low probability for PE

EchocardiogramNormal ejection fractionNormal LV wall thicknessNo outflow tract obstructionRedundant mitral valve with no regurgitation

Tilt Table Testing – negative including isuprel

Neurologic ConsultationEEG awake and asleep are normalMRI is normal

Signal Averaged ECG

Exercise Stress Test

Nuclear Perfusion Scan

Bayshore Protocol ETT

Left & Right Heart Cath

HemodynamicsAorta 120/70LV 120/20RA Mean 10RV 28/10PA 24/12PCWP 14Cardiac output 6.7 (thermo), 4.68 (Fick)Ao Sat 97%, PA Sat 70% - Hgb 14.4

Left & Right Heart Cath

LV Gram in RAONormal sized LV with normal contractilityNo mitral regurgitationNo abnormalities of the aorta

Coronary AngiographyRCA arises from the left coronary cusp beneath the

left main coronary. It supplied a long PDA and RV branches but nothing to distal RCA and no evidence of an AV nodal branch. This was supplied by the distal circumflex

Normal left sided arteries

Post Bypass ETT

Coronary Anomalies

Coronary Anomalies

Congenital anomalies not uncommonly associated with SCD in athletes

Although relatively rare, events are often catastrophic and likely provoked by myocardial ischemia

Rarely discovered during life often due to lack of clinical suspicion

Amenable to surgical treatment, therefore timely identification is critical

Coronary Anomalies

Standard testing with ECG at rest or stress is unlikely to provide evidence of ischemia and thus not reliable as screening tests in large athletic populations

Premonitory cardiac symptoms not uncommonly occur shortly before sudden death

This suggest that exertional syncope or chest pain requires exclusion of this anomaly

J Am Coll Cardiol 2000;35:1493-501

Coronary Anomalies