Six-month success of intracoronary stenting for anomalous coronary arteries associated with myocardial ischemia

[Angioplasty of an anomalous coronary artery : A complex procedure ?]

Coronary artery anomalies (ANOCOR) are congenital anomalies with various anatomical forms. Percutaneous treatment can be offered in certain situations, most often to address associated atherosclerotic disease or, more rarely, to correct a congenital stenosis. Due to the frequent difficulties of catheterization, percutaneous coronary interventions for ANOCOR are recognized as complex procedures. A thorough anatomical understanding facilitates the identification of the connection site and the initial ectopic course of an ANOCOR during coronary angiography. Selecting an appropriate catheter is a crucial step in the procedure. There is a higher prevalence of atherosclerotic disease along retroaortic courses compared to other ectopic courses. When treating atherosclerotic stenosis downstream of an ectopic course, techniques typically used for complex coronary procedures can be helpful. While angioplasty for congenital stenosis is technically feasible, its role in management algorithms remains to be defined. Currently, this type of percutaneous treatment may be offered to right ANOCOR with interarterial course in adults over 35 years old and with ischemic symptoms or myocardial ischemia.

Spectrum of the anomalous origin of the coronary arteries

The anomalous origin of the coronary arteries (AOCA) has several patterns. Most are functional and asymptomatic. However, some are associated with persistent chest pain and sudden cardiac death. Multiple imaging techniques are available for the assessment of AOCA. We present a report of 4 cases with AOCA, including the anomalous aortic origin of a coronary artery (AAOCA) of the right coronary artery, AAOCA of the circumflex artery, AAOCA of the left anterior descending artery, and AAOCA of the circumflex artery with retroaortic trajectory, in which the clinical manifestations throughout the cases are discussed, highlighting the similarity among patients despite having different patterns. Multiple imaging techniques are indispensable for assessing AOCA, where transthoracic echocardiogram is the first-line study, and cardiac computed tomography provides detailed cardiac and coronary anatomy.

Toward More Granular Guidelines in AAOCA: Associating Anatomical Details With Specific Surgical Strategies

Patients with anomalous aortic origin of a coronary artery (AAOCA) require imaging to clarify the multiple potential anatomic sites of obstruction (fixed or dynamic). Once repaired, the pathway of blood to the myocardium must not encounter: (1) intrinsic ostial stenosis, (2) obstruction from compression or distortion near the commissure or the intercoronary pillar, (3) stenosis where the artery exits the aortic wall (due to an acutely angled "take-off"), (4) compression due to a pathway between the great vessels, (5) stenosis or compression along an intramural course, or (6) compression due to an intramuscular (intraseptal/intraconal) course. Detailed anatomic evaluation of each of these locations allows the surgeon to select an appropriate repair strategy, and each of these abnormal anatomic features should be "matched" with a particular surgical correction. We speculate that the most common surgical repair, unroofing with or without tacking, is often inadequate, as in isolation, it may not allow for correction with a large orifice from the appropriate sinus, without an interarterial course. While the evidence base is insufficient to call these recommendations formal guidelines, these recommendations should serve as a basis for further validity testing, and ultimate evolution to more granular guidelines on AAOCA management.

Therapeutic Management of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva: Current Evidence, Proposed Approach, and the Unknowing

Anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) are a challenge because of their various anatomic and clinical presentation. Although the prevalence is low, the absolute numbers of detected ACAOS are increasing because of the growing use of noninvasive anatomical imaging for ruling out coronary artery disease. As evidence-based guidelines are lacking, treating physicians are left in uncertainty for the optimal management of such patients. The sole presence of ACAOS does not justify surgical correction, and therefore a thorough anatomic and hemodynamic assessment is warranted. Invasive and noninvasive multimodality imaging provides information to the clinical question whether the presence of ACAOS is an innocent coincidental finding, is responsible for the patient's symptoms, or even might be a risk for sudden cardiac death. Based on recent clinical data, focusing on the pathophysiology of patients with ACAOS, myocardial ischemia is dependent on both the extent of fixed and dynamic components, represented by anatomic high-risk features. These varying combinations should be considered individually in the decision making for the different therapeutic options. This state-of-the-art review focuses on the advantages and limitations of the common contemporary surgical, interventional, and medical therapy with regard to the anatomy and pathophysiology of ACAOS. Further, we propose a therapeutic management algorithm based on current evidence on multimodality invasive and noninvasive imaging findings and highlight remaining gaps of knowledge.

Interarterial course of anomalous right coronary artery: role of symptoms and surgical outcomes

Anomalous origin of right coronary artery with interarterial course (ARCA-IA) is a risk factor for sudden death and other cardiac complications. Surgical correction remains its gold standard treatment. We describe clinical characteristics, workup, surgical techniques and outcomes of ARCA-IA at our center. A retrospective analysis of cardiovascular database was performed. From March 2005 through January 2011, 11 patients with mean age of 53 ± 18 years were diagnosed with ARCA-IA. Reported symptoms included chest pain (64%), arrhythmia [27%; i.e. atrial flutter (9%), recurrent supraventricular tachycardia (9%), ventricular tachycardia (9%)], syncope (18%), dyspnea (9%) and aborted sudden cardiac death (9%). Chest pain (n = 7) was episodic and lasted longer than 6 months before diagnosis. Initial diagnosis was made at coronary computed tomography in two patients and at cardiac catheterization in nine patients. Four patients had positive stress test and were subsequently found to have ARCA-IA at cardiac catheterization. There was no operative mortality. Surgery (bypass with ligation of native vessel or translocation and reimplantation) was performed in seven patients. Three patients refused surgery, and in one patient, surgery was not considered due to comorbidities. Symptom relief was noted in all surgical patients. At mean follow-up of 36 months, two patients had noncardiac-related deaths whereas nine were asymptomatic. There were no deaths reported in patients treated surgically. Definitive surgery is indicated in symptomatic ARCA-IA and is associated with excellent long-term outcome. RCA dominance in ARCA-IA is an adverse marker with increased symptoms; this hypothesis should be tested in larger studies.

Hybrid cardiac imaging-guided optimal management of right anomalous coronary artery origin from the opposite sinus with interarterial course (R-ACAOS): a case report

Background

Determining the optimal management of right anomalous coronary artery from the opposite sinus (R-ACAOS) with an interarterial course (IAC) in middle-aged adults remains elusive. Hybrid cardiac imaging combining non-invasive and invasive approaches to identify high-risk anatomic features, as well as functional testing to assess potential ischaemic status by dynamic compression, can guide therapeutic decisions.

Case summary

A 65-year-old female was newly diagnosed with R-ACAOS with IAC, accompanied by suspected angina and two syncope episodes. She was initially considered as non-specific chest pain based on negative treadmill test (TMT) taken 10 years earlier. An anomaly of R-ACAOS with IAC travelling between the aorta and pulmonary artery was detected by coronary computed tomography angiography with a severe stenosis at the ostium, but with little evidence of atherosclerotic plaque. Exercise test (TMT) and single-photon emission computed tomography (SPECT) results were negative. Invasive imaging revealed a luminal area stenosis of 45% at the ostial right coronary artery, and a slit-like orifice anatomical feature, with a minimal lumen area of 5.81 mm2 at diastole determined by intravascular ultrasound. Based on hybrid cardiac imaging results and previous data from a case series, conservative management was recommended with strenuous exercise restrictions. The patient fared well during 12 months of follow-up after discharge.

Discussion

Hybrid cardiac imaging-guided conservative management including exercise restriction appears justifiable in such middle-aged adults with R-ACAOS accompanied by suspected angina in absence of ischaemia in stress-induced tests (TMT or SPECT), despite high-risk anatomical features of an IAC and slit-like orifice being present.

Place of Angioplasty for Coronary Artery Anomalies With Interarterial Course

Few patients with an anomalous aortic origin of a coronary artery (AAOCA) require a correction of this congenital anomaly. Current recommendations offer surgical repair as a first line therapy to prevent a sudden cardiac death as a main objective. However, these guidelines are focused on children and not based on randomized controlled studies. Furthermore, decision-making should be different in an adult population less exposed to the risk of sudden cardiac death. Current practices showed reluctance to offer a surgical treatment for right AAOCA associated with ischemic symptoms or myocardial ischemia. Our aim in this review is to expose the rationale for percutaneous coronary intervention in right AAOCA with interarterial course and to present the published results.

Technical success and long-term outcomes after anomalous right coronary artery stenting with cardiac computed tomography angiography correlation

INTRODUCTION

Anomalous origin of coronary arteries has been observed in about 0.35-2.10% of the population. Patients with anomalous right coronary artery (ARCA) may present with significant symptoms, arrhythmias or ACS, and at times sudden death. Traditionally, surgical correction has been the recommended treatment. However, these may be technically challenging, and bypass grafting for such anomalies has the potential for graft failure because of competitive flow. We sought to determine the intermediate and long-term outcomes of drug-eluting stent placement for patients with symptomatic ARCA. We also looked at angiographic findings suggestive of interarterial course as confirmed by subsequent computed tomography (CT) findings.

METHODS

Between January 2005 and December 2012, we enrolled 11 patients for elective percutaneous coronary intervention (PCI) of ARCA in a single center, prospective, nonrandomized fashion. Patients were followed up in clinic at 1 week, 3 months, 6 months, and 1 year, and then annually or more frequently if needed. All patients underwent a cardiac CT, as well as functional stress testing when needed to assess for recurrence of disease.

RESULTS

All 11 of our patients, who presented with significant symptomatic stenosis with an ARCA, were successfully treated with PCI. Mean follow-up duration was 8.5 years. The only two deaths during follow-up were related to noncardiac causes (sepsis), with a mortality rate of 18.2%. Two patients had a positive functional study and on subsequent coronary angiography, one of them had significant in-stent restenosis (target lesion revascularization of 9.1%) and one distal to the stent (target vessel revascularization 9.1%). We found the observation of a "slit-like lesion" on angiography to have a sensitivity of 100% and specificity of 86% for the diagnosis of interarterial course of the anomalous vessel seen on subsequent CT.

CONCLUSIONS

Our study results suggest that PCI of ARCA is an effective and low-risk alternative to surgical correction, with good procedural success and long-term outcomes. It can provide symptomatic relief in such patients and may reduce the risk of sudden death in younger patients, without the inherent risks associated with surgical repair.

Successful Percutaneous Coronary Intervention for Atherosclerotic Coronary Lesion with Anomalous Origin of the Right Coronary Artery

Congenital coronary artery anomalies, including anomalous origin of a coronary artery, can manifest as life-threatening conditions, such as myocardial infarction or arrhythmia, and may even lead to sudden death associated with specific congenital anatomical features. Such arteries can also develop atherosclerotic lesions. This report describes the case of a 75-year-old man who was admitted to our hospital due to exertional dyspnea. The right coronary artery was found to originate from the left coronary sinus and exhibit tight stenosis due to atherosclerosis, causing effort angina pectoris. This case highlights the fact that coronary artery anomalies can cause angina pectoris via both atherosclerotic and nonatherosclerotic effects, and successful revascularization was achieved noninvasively via percutaneous coronary angioplasty.

[Sudden cardiac death and anomalous connections of the coronary arteries: What is known and what is unknown?]

Some anomalous connections of the coronary arteries may be associated with a risk of sudden cardiac death. In opposite with others cardiac diseases at risk of sudden cardiac death, the relationship between these congenital abnormalities and the risk of sudden cardiac death are not well understood. A correction of the anomaly is generally indicated after an aborted sudden cardiac death. Primary prevention strategy after the discovery of an anomaly at risk is debated. Even if the absolute risk of sudden death is very low, a pre-participation screening in young athletes may be discussed due to a non-rare incidence.

Anomalous right coronary artery in a middle-aged patient: A case report and review of the literature

BACKGROUND

An anomalous right coronary artery originating from the left sinus of Valsalva is a rare, but often incidental, finding in middle-aged to elderly people. Prevalence is difficult to define, as well as determining potential harmful hemodynamic consequences. Moreover, the optimal treatment remains debatable.

CASE SUMMARY

The authors present a case of a middle-aged patient diagnosed with an anomalous right coronary artery causing ischemia, who was treated surgically.

CONCLUSION

By reviewing literature, the authors conclude that choice of treatment depends on age, symptoms, and certain anatomic features of this anomaly. However, there are no randomized trials available in this field.

Dynamic Evaluation of Coronary Anomalies Originating from the Opposite Sinus of Valsalva (ACAOS)

OPINION STATEMENT

Coronary anomalies originating from the opposite sinus of Valsalva (ACAOS) are a rare anomaly associated with sudden cardiac death. Dynamic, invasive evaluation using coronary angiography, intravascular ultrasound, and fractional flow reserve can more clearly identify important pathophysiologic variants and guide treatment. This dynamic evaluation can assist the clinician in the appropriate surgical and percutaneous treatment options and aid in patient counseling. Long-term outcomes data regarding treatment and prognosis is still lacking.

[Single coronary artery and right aortic arch]

Coronary anomalies are mostly asymptomatic and diagnosed incidentally during coronary angiography or echocardiography. However, they must be taken into account in the differential diagnosis of angina, dyspnea, syncope, acute myocardial infarction or sudden death in young patients. The case is presented of two rare anomalies, single coronary artery originating from right sinus of Valsalva and right aortic arch, in a 65 year-old patient with atherosclerotic coronary artery disease treated percutaneously.

Abnormal origins of the coronary arteries from the aortic root

Anomalous origin of a coronary artery from the aorta is a potentially serious anomaly that occurs in about 0.1-0.2% of the population. This percentage is small; however, it translates into about 4000 annual births with these anomalies. The clinical presentation of these anomalies is rare, and hence most are and will remain asymptomatic. The various anatomic anomalies are described, with anomalous origin of the left coronary artery that then passes between the aorta and pulmonary artery being the most serious of these anomalies. The pathophysiology resulting from these anomalies is described, as are methods for identifying those who require treatment; however, we still do not know the best methods of determining which patients need treatment.

Aortic root disease in athletes: aortic root dilation, anomalous coronary artery, bicuspid aortic valve, and Marfan's syndrome

Two professional athletes in the U.S. National Basketball Association required surgery for aortic root dilation in 2012. These cases have attracted attention in sports medicine to the importance of aortic root disease in athletes. In addition to aortic root dilation, other forms of aortic disease include anomalous coronary artery, bicuspid aortic valve, and Marfan's syndrome. In this review, electronic database literature searches were performed using the terms "aortic root" and "athletes." The literature search produced 122 manuscripts. Of these, 22 were on aortic root dilation, 21 on anomalous coronary arteries, 12 on bicuspid aortic valves, and 8 on Marfan's syndrome. Aortic root dilation is a condition involving pathologic dilation of the aortic root, which can lead to life-threatening sequelae. Prevalence of the condition among athletes and higher risk athletes in particular sports needs to be better delineated. Normative parameters for aortic root diameter in the general population are proportionate to anthropomorphic variables, but this has not been validated for athletes at the extremes of anthropomorphic indices. Although echocardiography is the favored screening modality, computed tomography (CT) and cardiac magnetic resonance imaging (MRI) are also used for diagnosis and surgical planning. Medical management has utilized beta-blockers, with more recent use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and statins. Indications for surgery are based on comorbidities, degree of dilation, and rate of progression. Management decisions for aortic root dilation in athletes are nuanced and will benefit from the development of evidence-based guidelines. Anomalous coronary artery is another form of aortic disease with relevance in athletes. Diagnosis has traditionally been through cardiac catheterization, but more recently has included evaluation with echocardiography, multislice CT, and MRI. Athletes with this condition should be restricted from participation in competitive sports, but can be cleared for participation 6 months after surgical repair. Bicuspid aortic valve is another form of aortic root disease with significance in athletes. Although echocardiography has traditionally been used for diagnosis, CT and MRI have proven more sensitive and specific. Management of bicuspid aortic valve consists of surveillance through echocardiography, medical therapy with beta-blockers and ARBs, and surgery. Guidelines for sports participation are based on the presence of aortic stenosis, aortic regurgitation, and aortic root dilation. Marfan's syndrome is a genetic disorder with a number of cardiac manifestations including aortic root dilation, aneurysm, and dissection. Medical management involves beta-blockers and ARBs. Thresholds for surgical management differ from the general population. With regard to sports participation, the most important consideration is early detection. Athletes with the stigmata of Marfan's syndrome or with family history should be tested. Further research should determine whether more aggressive screening is warranted in sports with taller athletes. Athletes with Marfan's syndrome should be restricted from activities involving collision and heavy contact, avoid isometric exercise, and only participate in activities with low intensity, low dynamic, and low static components. In summary, many forms of aortic root disease afflict athletes and need to be appreciated by sports medicine practitioners because of their potential to lead to tragic but preventable deaths in an otherwise healthy population.

Is endovascular therapy the right choice for treatment of functional compression of anomalous right coronary artery arising from left coronary sinus with interarterial course?

We report a case of successful percutaneous coronary intervention (PCI) for reversible ischaemia owing to an anomalous right coronary artery arising from the left coronary sinus with malignant interarterial course and not associated with obstructive coronary artery disease (CAD). PCI for treatment of functional compression of the ostioproximal intramural segment of the anomalous vessel, though described in the literature, is technically challenging, requiring appropriate hardware selection; the peculiar anatomical milieu, in the absence of atherosclerotic CAD, lends itself to an uncertain long-term outcome following endovascular therapy with stenting.

An interarterial course of anomalous coronary artery and an alternative surgical option

An interarterial course of anomalous left main coronary artery originating from the right aortic coronary sinus of valsalva is a rare condition among anomalous aortic origin of the coronary artery. Various surgical options are available. We performed an alternative procedure, that is, mobilisation of the pulmonic root, pulmonary bifurcation, and plication of the pulmonic root adjacent to the left main coronary artery, in a 12-year-old boy. Favourable results were achieved after 43 months of follow-up.

Anomalous aortic origin of coronary arteries from the opposite sinus: a critical appraisal of risk

Background

Anomalous aortic origin of the coronary artery (AAOCA) from the opposite sinus of Valsalva with an interarterial course has received much attention due to its association with sudden death in otherwise healthy individuals. AAOCA is relatively common and may have significant public health implications. While our knowledge of its pathophysiology and natural history remains incomplete, an emphasis has been placed on surgical correction.

Discussion

In 2005 we published a review examining the rates of sudden death with AAOCA, as well as complications of surgical management. Evidence now points even more strongly to lower rates of sudden death, while surgical outcomes data now better documents associated risks.

Summary

Armed with this updated information, we agree with the need for a national registry to better track patients with AAOCA. We submit that the risks of surgical management outweigh any benefits in the asymptomatic patient with anomalous right coronary artery, and expectant management should also be strongly considered even in asymptomatic patients with anomalous left coronary artery.

Anomalous origination of a coronary artery from the opposite sinus

Anomalous origination of a coronary artery from the opposite sinus (ACAOS) is estimated to be present in 0.2-2.0% of the population. In the majority of individuals, ACAOS has no hemodynamic or prognostic implications, but in a minority of cases, typically where the anomalous coronary artery takes an interarterial course to reach its correct myocardial territory, it can precipitate ischemia and sudden cardiac death (SCD). With the growing use of CT coronary angiography (CTCA) in the investigation of ischemic heart disease, we can expect increasing rates of incidental detection of this anomaly. Although CTCA and magnetic resonance coronary angiography can effectively characterize these lesions anatomically, they fail to describe and quantitatively assess the basic defect that leads to coronary insufficiency, such as mural intussusception. The key challenge lies in the identification of which patients are at risk of SCD and, therefore, who should be offered corrective surgical or (potentially) percutaneous intervention. Conventional, noninvasive stress testing has limited sensitivity, but emerging, invasive stress tests, which utilize intravascular ultrasonography and measurements of fractional flow reserve, show the potential to provide more-accurate hemodynamic and prognostic assessment.

Radionuclide evidence for reversible ischemia after percutaneous treatment of anomalous right coronary artery with dynamic compression by great vessels

Anomalous origin of the right coronary artery from the left sinus is a rare congenital anomaly, possibly related to myocardial ischemia by dynamic compression. We present a case of percutaneous treatment of this coronary anomaly resulting in regression of inducible ischemia, as demonstrated by radionuclide scintigraphy.

Anomalous interarterial left coronary artery: An evidence based systematic overview

BACKGROUND

Isolated anomalous left main coronary artery (ALMCA) from the right aortic sinus of Valsalva (RASV) with an interarterial course between the pulmonary trunk and aorta is a rare congenital abnormality. We performed an evidence based systematic overview spanning 4 decades to assess the prevalence, clinical features and management of this anomaly.

METHODS

A computerized search spanning 40 years was conducted to identify articles describing cases of ALMCA arising from the RASV with an interarterial course. The bibliographies of all relevant articles were also searched.

RESULTS

The search identified 264 cases. Age ranged from 3.5 months to 87 years. Male/female ratio was 2.9/1. Forty-nine percent of the cases were diagnosed postmortem. Cardiac catheterization was the most common diagnostic tool (41.7%) followed by echocardiography, magnetic resonance imaging (MRI) and computerized assisted tomography. Fifty-seven (21.6%) cases underwent surgical procedures with no mortality and low morbidity.

CONCLUSIONS

ALMCA from the RASV is associated with increased risk of sudden death, notably in young patients. Unfortunately the majority are diagnosed postmortem. More than a third present with sudden cardiac death. Echocardiography, computerized assisted tomography and cardiac MRI are valuable non-invasive diagnostic tools. Cardiac catheterization provides a definitive diagnosis in the majority. Surgical correction is the mainstay of treatment with low risk and good anatomic and functional results.

Coronary artery anomalies — a short review

Coronary artery anomalies are rare but sometimes important findings in the evaluation of the coronary artery. The majority of the anomalies are of benign prognosis, but others can be associated with cardiac symptoms and syndromes (angina, dyspnea, syncope, congestive heart failure, myocardial infarction and sudden death). The potentially serious anomalies include: ectopic coronary origin from the pulmonary artery; ectopic coronary origin from the opposite aortic sinus; and large coronary fistulae. Appropriate diagnosis is critical for recognition and management. Treatment can be performed by surgical or percutaneous approach. However, management is conservative in the majority of them. Contemporary diagnosis and clinical management of these anomalies are briefly reviewed and discussed in this article.

[Congenital coronary artery anomalies with origin in the contralateral sinus of Valsalva: which approach should we take?]

Recent years have witnessed a change in our perception of congenital coronary artery anomalies. From being regarded as simple coronary angiographic observations of little clinical significance, they have come to be seen as potential causes of sudden death in young people and of myocardial ischemia in adults. Diagnostic difficulties, a lack of knowledge about the mechanisms through which they produce myocardial ischemia, and their highly variable incidence have made congenital coronary artery anomalies of great interest to cardiologists. This article focuses on the group of coronary artery anomalies that is responsible for most clinical events: anomalies that have their origin in the contralateral sinus of Valsalva. Coronary artery anomalies are defined, their incidence is discussed, diagnostic criteria are given, and finally a treatment algorithm based on current knowledge is proposed.

Surgical therapy for anomalous aortic origin of the coronary arteries

Anomalous aortic origin of the coronary arteries is a rare defect and is associated with an increased risk of cardiac symptoms including sudden death. The most important subtypes are those in which the anomalous coronary artery arises from the wrong sinus as in anomalous left main coronary artery from the right sinus and anomalous right coronary artery from the left sinus. Ischemia can result when the flap-like orifice becomes obstructed, usually during exercise. Indications for surgical intervention are evolving. Currently, the favored approach for repair is an unroofing type of procedure that results in relocation of the coronary artery into the appropriate sinus of Valsalva.

Management of anomalous coronary arteries from the contralateral sinus

Anomalous origin of the coronary artery from the contralateral sinus of Valsalva, coursing between the aorta and pulmonary artery, has garnered much attention because of its association with sudden death. Current medical opinion is heavily skewed toward "successful" intervention. However, two key issues have not been critically analyzed: what is the true risk of sudden death from an anomalous coronary artery, and how does this risk balance against the risk of surgical intervention? Common misconceptions about risk derive from citations of autopsy data. In fact, the scant available data suggest a far lower absolute risk than commonly cited. The risks of surgical intervention, while likely quite low, remain real, and include aortic valve damage and neurological sequelae. The lack of long-term outcomes data precludes any definite recommendations in most patients. The decision to intervene is thus not straightforward, and should be approached cautiously and only after appropriate counseling of the patient.

Dysrhythmias and the Athlete

Young competitive athletes are perceived by the general population to be the healthiest members of society. The possibility that highly trained high school and college athletes may have a potentially serious cardiac condition that can predispose to life-threatening dysrhythmias or sudden cardiac death (SCD) seems paradoxical. The occurrence of SCD in young athletes from dysrhythmias is an uncommon but highly visible event. Media reports of sudden death in athletes have intensified the public and medical interest in medical, ethical, and legal issues related to cardiac disorders in the athlete. Developing screening strategies to identify conditions associated with sudden death has been the focus of attention of experts in the fields of arrhythmology and sports medicine and has resulted in Consensus Statements and Guidelines for evaluation of athletes. These guidelines provide information and recommendations for detection, evaluation, and management of athletes with cardiovascular disorders and criteria for eligibility and disqualification from participation in high-intensity and competitive sports. Differentiating normal exercise-induced physiologic changes in the heart from pathological conditions associated with sudden death is critical for developing screening strategies to identify athletes at high risk. This article discusses a case report of sudden cardiac death in an athlete followed by a brief review of various causes of cardiac dysrhythmias in young athletes and recommendations for screening and management of athletes with cardiovascular diseases.