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.