Left Ventricular Non-Compaction in Athletes: To Play or Not to Play

Isolated left ventricular non-compaction (LVNC) has usually been viewed as a rare cardiomyopathy in athletes. However, with advances in diagnostic imaging techniques and increased use of pre-participation screening electrocardiograms (ECGs), apparent LVNC is being recognized in an increasing number of athletes. Given the lack of a true gold standard for diagnosis, significant debate continues regarding optimal diagnostic criteria. There are increasing data to support the possibility of over-diagnosing this cardiomyopathy in an athletic population due to the physiologic adaptation to the extreme preload and afterload characteristic of intense athletic participation. This appears to be particularly true in African-American or African-Caribbean athletes. The most common presenting symptom in the athlete with true LVNC is exertional syncope. Evaluation of the at-risk athlete will typically include a complete history, with attention to cardiac symptoms, family history of premature cardiovascular disease or sudden cardiac death (SCD), physical examination, 12-lead ECG, two-dimensional echocardiography, and, in some cases, cardiac magnetic resonance imaging with gadolinium contrast. In addition, stress echocardiography, 24- to 48-h Holter monitoring, or 30-day event monitoring for arrhythmias may be necessary to fully evaluate the athlete’s risk. Adverse outcomes with LVNC include ventricular dysfunction, arrhythmias, syncope, SCD, and thromboembolism. Asymptomatic athletes with hypertrabeculation of the left ventricle but normal ventricular function likely do not require restrictions on activity. Symptomatic individuals who meet criteria for LVNC, especially those with abnormal ventricular function and exercise-induced symptoms or arrhythmias, should be prohibited from participating in vigorous sports activities.