Syncope and Scar in a Former Elite Basketball Player

Figures

• 

  Visual Summary. Clinical Course of a Former Elite Basketball Player Who Presented With Recurrent Exertional Syncope and Was Found to Have VT Arising From Myocarditis-Related Scar The timeline is presented relative to the day of hospital admission (day 0). Key diagnostic milestones include echocardiography revealing an akinetic apex, nuclear stress testing demonstrating apical scar, coronary angiography excluding obstructive coronary artery disease, and cardiac magnetic resonance (CMR) identifying subepicardial late gadolinium enhancement (LGE) in the basal-to-mid inferolateral wall, consistent with prior myocarditis. An electrophysiology study induced sustained monomorphic VT, prompting implantable cardioverter-defibrillator (ICD) placement for secondary prevention. An appropriate ICD shock for VT recurrence led to a medication change to nadolol. Epicardial VT ablation targeting the mid-lateral left ventricular scar was partially limited by phrenic nerve proximity. Serial fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging at 4 and 11 months postablation demonstrated complete resolution of FDG uptake, confirming postablation inflammation rather than cardiac…

• 

  Figure 1. Initial ECG Demonstrating Normal Sinus Rhythm, First Degree AV Block, Left Atrial Enlargement, and Intraventricular Conduction Delay AV = atrioventricular; ECG = electrocardiogram.

• 

  Figure 2. CMR Demonstrating Subepicardial LGE and Fat Deposition in the Basal to Mid Inferior Lateral and Inferior Walls, Suggesting Scar From Prior Myocarditis CMR = cardiac magnetic resonance; LGE = late gadolinium enhancement.

• 

  Figure 3. ECG Tracing Showing VT Morphology; Superior Axis, Right Bundle Branch Block Morphology, and V3 Transition ECG = electrocardiogram; VT = ventricular tachycardia.

• 

  Figure 4. Electrophysiology Study (A) Twelve-lead ECG of the ventricular tachycardia. The ventricular tachycardia has a right bundle branch block morphology with a V3 transition and right superior axis, which is consistent with exit site at the basal-mid inferolateral wall of the left ventricle. (B) Epicardial voltage map of the left ventricle. Purple areas show normal voltage, and other colors low voltage. The ablation target is denoted. Dark blue dots represent areas of phrenic nerve capture during high-output pacing, and the dashed cyan line denotes the projected phrenic nerve trajectory, showing a large overlap with the ablation target. (C) Ablation lesion set after phrenic displacement maneuvers. Dark blue dots represent areas of phrenic nerve capture. Red dots represent radiofrequency ablation lesions. ECG = electrocardiogram.