Working Diagnosis:
Idiopathic, asymptomatic PVCs, with a significant PVC burden--up to 20% of beats--and a reduced ejection fraction, but no structural heart disease.

Treatment:
Treatment for excessive PVCs often includes anti-arrhythmic medications like calcium channel blockers or beta blockers. Other options include radiofrequency ablation or watchful waiting.
It was concluded that the patient was at slightly increased risk of sudden cardiac death from his ventricular arrhythmia because of the PVC burden and decreased EF. With knowledge of this risk conferred to the patient and family, as well as available options, decision was made to allow the athlete to compete in the current water polo season. There would be close observation by team physicians and an AED available at all athletic events.
Per the 36th Bethesda guidelines, patients with asymptomatic PVCs but without structural heart disease have no restrictions. Yet combined with the amount of PVCs and reduced EF in this case, recommendations are not as clear and are seen collectively as a potential risk for sudden cardiac death.

Outcome:
The athlete was allowed to play in the 2011 NCAA Division I Collegiate Water Polo Season. Follow-up was planned for the end of the season, or sooner if symptoms developed. If there was worsening of his condition at that time, definitive treatment could be pursued.
The athlete completed the entire season without problems or symptoms. At follow-up a Holter monitor showed the PVC burden decreased to 12,553 in a 24 hour period. No treatments were recommended, and he was told to follow-up in the electrophysiology clinic.

Author's Comments:
This patient's condition does not fit exactly into the current Bethesda guidelines, making the management a bit difficult and controversial. The physicians caring for this patient collectively thought it ethically questionable to perform more invasive studies or treatments, such as an EP study with radiofrequency ablation, on an asymptomatic individual. Informed consent was a large component of the outlined plan. More definitive treatment may still be pursued in the future, if needed.

Editor's Comments:
This case demonstrates how an astute physical examination can uncover conditions with potential to impact athletes, even if currently asymptomatic. It also illustrates the discussion that must occur between atlete, family and members of the Sports Medicine system in order to arrive at an agreed-upon course of management of conditions for which there may be little or no management guidelines.

References:
Biffi A. How to Magage Athletes with Ventricular Arrhythmias. Cardiol Clin. 2007 Aug;25(3):449-55.

"Cardiac Disorderes in Athletes". Rakel: Textbook of Family Medicine, 8th Ed. Co. 2011.

36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities. J Am Coll Cardiol. c. 2005.

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