Working Diagnosis:
Atypical AV nodal reentrant tachycardia (AVNRT) (slow-slow) was confirmed by electrophysiology study, with successful ablation of the rightward inferior extension.

Treatment:
The patient underwent successful catheter ablation of the reentry circuit using 3D mapping (CARTO).

Outcome:
The patient underwent successful catheter ablation using 3D mapping (CARTO), targeting the rightward inferior extension. The procedure confirmed atypical AVNRT with cycle length 500-551 ms. Post-ablation testing showed no inducible tachycardia, even with isoproterenol challenge. No complications occurred during the procedure.

Post-procedure instructions included bedrest for 2 hours, monitoring for additional 2 hours, and avoiding vigorous activity for 2 weeks. Follow-up was scheduled with the Cardiologist 2 weeks after the procedure and Electrophysiologist 4 weeks after the procedure. Gradual return to basketball activities began after Cardiology clearance at 2 weeks, leading to full return to sport activity.

Author's Comments:
This case highlighted the importance of thorough cardiac evaluation in athletes with exercise-related symptoms. The patient's symptoms, though mild, led to detection of significant arrhythmia during stress testing. The systematic workup ruled out structural heart disease through comprehensive imaging, while the electrophysiology study identified the specific mechanism. The case demonstrated the limitations of a pre-participation exam history, when young athletes may not realize their symptoms are abnormal. This case additionally emphasized the effectiveness of catheter ablation in treating AVNRT in young athletes, allowing return to high-level competition after appropriate recovery.

Editor's Comments:
While there is limited evidence of the preparticipation physical evaluation in its effectiveness for identifying disabling conditions such as injury or illness, this can be optimized in a variety of ways. By clarifying symptoms, incorporating parents when needed, and using targeted questioning, the athlete may recall how their symptoms affect their athletic performance thus prompting an appropriate work-up. This case highlights the thoroughness of the physician to clarify symptoms, incorporate consultants, and provide a complete cardiac evaluation, which aided in the diagnosis of a treatable yet significant cardiac condition.

References:
Drezner JA, O'Connor FG, Harmon KG, et al. AMSSM position statement on cardiovascular preparticipation screening in athletes: current evidence, knowledge gaps, recommendations and future directions. Br J Sports Med. 2017;51(3):153-167.

Drezner JA, O'Connor FG, Harmon KG, et al. Electrocardiographic screening in asymptomatic athletes: current status and future directions. N Engl J Med. 2018;379(6):524-534.

Fuller CM, McNulty CM, Fox J, et al. Cardiovascular screening in college athletes with and without electrocardiography: a cross-sectional study. Am J Med. 1997;102(3):216-222.

Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people 12 to 25 years of age: a scientific statement from the American Heart Association and the American College of Cardiology. Circulation. 2014;130(15):1303-1334.

Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. Circulation. 2007;115(12):1643-1655.

Pelliccia A, Solberg EE, Papadakis M, et al. Recommendations for participation in competitive sport and leisure-time physical activity in individuals with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology. Eur Heart J. 2020;41(5):655-665.

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