Working Diagnosis:
Symptomatic supraventricular tachycardia thought to be due to recurrent right lateral accessory pathway, without evidence of Wolff-Parkinson-White morphology.

Treatment:
Oxygen was provided at a rate of twelve liters per cubic foot per minute with improvement of his shortness of breath. Simultaneously, ice was applied to the patients face. As respiratory symptoms improved, the athlete was able to perform repetitive Valsalva maneuvers which resulted in spontaneous return to normal sinus rhythm.

Outcome:
After a period of five minutes of treatment, a 12 lead electrocardiogram was obtained and showed sinus arrhythmia Case Photo #2 . After conversion to sinus rhythm the patient remained asymptomatic and was discharged into his parents care. It was recommended he discontinue strenuous physical activity until re-evaluation by Cardiology.

He was seen by the Pediatric Electrophysiology as an outpatient. At his consultation, there was no evidence Wolff-Parkinson-White morphology reoccurrence on electrocardiogram, and as a result, the risk of sudden cardiac death from arrhythmia was thought to be exceedingly low. However, it was thought the patient's episodes of recurrent supraventricular tachycardia were likely due to a recurrence of a right lateral accessory pathway. The physician discussed the possibility of continued observation, medical therapy, or repeat ablation with the athlete and his family. Ultimately, the patient was started on flecainide 50 milligrams twice daily in an attempt to control his symptoms. He was cleared for return to sport but was advised to stop competing and allow tachycardia to terminate should supraventricular tachycardia occur during competition.

Editor's Comments:
The annual risk of sudden cardiac death is estimated to be around 1 in 80,000 in high school athletes. Some high schools now provide their student athletes the opportunity to obtain free screening electrocardiograms. With increased use of screening electrocardiograms, it becomes important for a team physician to be able to differentiate findings suggestive of normal cardiac changes within an athletes heart from pathological findings. Wolff-Parkinson-White is a form of per-excitation cardiac arrhythmia. Pre-excitation cardiac arrhythmias are rarely a cause of sudden cardiac death, but the risk of sudden death increases if athletes have accessory pathways that have short refractory periods. Though not present in our patient's electrocardiograms, Wolff-Parkinson-White morphology is recognized by a slurred upstroke in the QRS complex, which is called a delta wave, PR interval less then 120 milliseconds, and a wide QRS equal to or greater than 120 milliseconds.

References:
Drezner JA, and et al. AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations. Clin J Sport Med. 26(5), September 2016

36th Bethesda Conference Report: eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities. Journal of American College of Cardiology. 45(8), 2005.

Drezner JA, and et al. International Criteria for Electrocardiographic Interpretation in Athletes: Consensus Statement. BJSM 51, 2017

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