Catheter ablation of idiopathic premature ventricular contractions in athletes without structural heart disease: impact on arrhythmic burden and return to sport

Background Premature ventricular contractions (PVCs) are frequently observed in athletes and are usually idiopathic and benign, most commonly arising from the right or left ventricular outflow tract (RVOT/LVOT) or fascicular system. However, the management of symptomatic or high-burden PVCs in athletes remains controversial, especially regarding eligibility and timing of return to sport after catheter ablation (CA). Data on procedural efficacy, safety and functional recovery in this population are still limited. Purpose To compare the efficacy, safety and functional outcomes of radiofrequency CA of idiopathic PVCs in competitive and leisure-time athletes without structural heart disease (SHD). Methods This single-centre retrospective study included 100 athletes aged ≥14 years who underwent CA for idiopathic PVCs between March 2019 and February 2025. All had preserved left ventricular ejection fraction and no SHD. Late gadolinium enhancement on cardiac MRI was allowed when unrelated to PVC origin or underlying cardiomyopathy. Patients were categorised as competitive (n=46) and leisure-time (n=54) athletes. Standard assessment included ECG, echocardiography and maximal exercise testing. Ablation was performed using a 3D electroanatomical mapping system. Follow-up included 24-hour Holter monitoring at 3–6 months and clinical evaluation at 9–15 months. Primary endpoint: PVC burden reduction. Secondary endpoint: return to sport. Results Competitive athletes were younger (29.7 ± 13 vs 44.5 ± 14.3 years, p<0.001) and predominantly male (80% vs 52%, p=0.002). RVOT was the most frequent PVC origin in both groups (54% vs 48%, p=ns). Baseline PVC burden was higher in leisure-time athletes (median 19 807 vs 10 750 PVCs/24 h, p=0.009). Acute procedural success was comparable (89% vs 83%, p=ns). Two minor complications occurred, one per group: a left bundle branch block and a vascular pseudoaneurysm. No major complications were observed. At follow-up, PVC burden decreased significantly in both groups, more markedly in competitive athletes (median 34.5 vs 274 PVCs/24 h, p=0.006). Return to sport occurred in 78% of competitive and 70% of leisure-time athletes (p=0.370), with 47% resuming competitive activity. Approximately 60% of the total cohort reported symptomatic improvement during sports participation. Conclusions Radiofrequency CA of idiopathic PVCs in athletes without SHD is a safe and highly effective option, irrespective of training level. Competitive athletes experienced a greater reduction in arrhythmic burden and a more complete functional recovery, supporting CA as a key component in managing symptomatic idiopathic PVCs and facilitating safe sport requalification.