Working Diagnosis:
Left Ventricular Non-Compaction Cardiomyopathy

Treatment:
Able to return to play with implantable cardiac monitor and automated external defibrillator nearby

Outcome:
The athlete's mother later stated his two uncles have a genetic cardiac defect. After a risk/benefit discussion with cardiology, the athlete was allowed to return to play with continuous external heart rhythm monitoring and availability of an automated external defibrillator nearby.

After the athlete had recurrent symptoms of syncope during practice, it was found that the event monitor had dislodged. He was admitted to the Emergency Room for 23 hours observation for continuous heart monitoring.

He completed an exercise stress test reaching 90% of his age-predicted maximum heart rate (12.7 METs) without reproducing symptoms.

A loop monitor was implanted to monitor for arrhythmias to help with risk stratification.

Two weeks after the implantable loop monitor was placed, the athlete returned to playing football.

He will continue routine follow up with our sports medicine team, including repeat cardiac MRI at one year.

Author's Comments:
Recent studies have shown that those with Left Ventricular Non Compaction Cardiomyopathy phenotype without high-risk features, such as arrhythmias or late gadolinium enhancement, are found to be low risk for morbidity and mortality.

Guidelines suggest that asymptomatic patients with normal systolic function can compete in high level sports until evidence proves otherwise.

Editor's Comments:
According to Coris et al, Isolated left ventricular non-compaction (LVNC)is a rare cardiomyopathy in athletes. Generally these athletes present with exertional syncope. Once the diagnosis has been made, the decision for the athlete to return to play is based on whether there is ventricular dysfunction. According to the AHA, the following are clearance recommendations:
1. Until more clinical information is available, participation in competitive sports may be considered for asymptomatic patients with a diagnosis of LVNC and normal systolic function, without important ventricular tachyarrhythmias on ambulatory monitoring or exercise testing, and specifically with no prior history of unexplained syncope (Class IIb; Level of Evidence C).
2. Athletes with an unequivocal diagnosis of LVNC and impaired systolic function or important atrial or ventricular tachyarrhythmias on ambulatory monitoring or exercise testing (or with a history of syncope) should not participate in competitive sports, with the possible exception of low-intensity class 1A sports, at least until more clinical information is available (Class III; Level of Evidence C).

References:
Bennett CE, Freudenberger R. The Current Approach to Diagnosis and Management of Left Ventricular Noncompaction Cardiomyopathy: Review of the Literature. Cardiol Res Pract. 2016;2016:5172308. doi: 10.1155/2016/5172308. Epub 2016 Jan 11. PMID: 26881173; PMCID: PMC4737020.
Coris, E.E., et al. Left Ventricular Non-Compaction in Athletes: To Play or Not to Play. Sports Med 46, 1249–1259 (2016)
Maron, BJ et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis,Circulation. vol 132, number 22, pg 273-280, 2015. doi: 10.1161/CIR.0000000000000239

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