Sports activity and cardiovascular pathologies

The practice of sport undoubtedly brings many physiological benefits in every age of life: it increases the physical capacity and muscle strength of the individual, helps to keep the body weight under control and makes the osteoarticular and muscular systems more flexible and efficient. negligible of these benefits is represented by the improvement of the psychological conditions, in other words of the quality of life.
These aspects have an "even greater importance in the developmental age, a period in which sport also assumes a formative and educational role. In this context, the requests aimed at allowing sports activities even for children with heart disease appear to be completely justified, instances that have become more pressing since in recent years diagnostic and therapeutic advances, especially cardiac surgery, have allowed the recovery to active life of a number not negligible of children and adolescents previously destined for physical inactivity.
In our country, the current legislation binds doctors and citizens to the obligation of a preventive visit for the certification of competitive and non-competitive sporting fitness. This procedure involves specific medico-legal responsibilities on the part of the certifying doctor and, obviously, translates into the need , especially in the presence of heart disease, to carry out all the clinical and instrumental investigations necessary to establish the severity of the disease and the functional capacity of the subject. Ultimately it is necessary to define the compatibility of the heart disease with that specific sporting activity.
In the sports field, two different circumstances can be configured in which a "careful and precise cardiovascular evaluation is required, and precisely:

the case in which the person suffering from heart disease intends to undertake or continue a "sporting activity;
the case in which clinical and / or symptomatological data are discovered in a subject who practices or intends to practice sports.

In some cases there are similarities between the so-called heart of the sportsman and certain pathological pictures, such as for example the "heart enlargement of those who practice intense and prolonged background activity, the non-specific electrocardiographic alterations of the sportsman, ischemic pathology, heart murmurs of a benign nature and valvular pathology.
The presence of complex malformations (severity of the original lesions and frequent persistence of residual defects even after surgical correction) contraindicates, in itself, competitive practice. Among these we remember:

the transposition of the great arteries

the correct positioning of the great arteries

l "atresia of the tricuspid

pulmonary atresia

the double outlet right ventricle

the single ventricle

the atrioventricular canal

Ebstein's malformation

the anomalous origin of the coronaries

Marfan's syndrome

the Ehlers-Danlos syndrome.

Congenital heart diseases are cardiovascular diseases present at birth and due to developmental anomalies. In low percentage they refer to known causes (infections, drugs, ionizing radiation). In isolated or associated form, the possible malformations are very numerous, but only a dozen are of greater practical interest, as they are more frequent; these malformations may or may not involve cyanosis, ie a bluish color of the skin and mucous membranes.
In cases of abnormal blood flow from the right cavity of the heart to the left cavity (right-left shunt), there must be a surgical correction of the anomaly. Swimming, light-amateur gymnastics and other activities involving light muscle engagement will eventually be allowed. without the hassle of having to carry out strenuous and continuous training. The main forms of this group of heart diseases are represented by Fallot's tetralogy, by the complete transposition of the great vessels and by the atresia of the tricuspid valve.

Tetralogy of Fallot (TF), characterized by extensive interventricular communication with cavalier aorta and pulmonary stenosis, is the most frequent form of cyanogenic congenital heart disease. In patients with TF, as with other cyanogenic cardiopathies, sporting activity is impossible before the total corrective intervention which today is carried out at an increasingly precocious age and with increasingly better results.
However, despite the numerous discussions on the subject, at present it does not appear possible in our country, the granting, in subjects with correct TF, of eligibility for competitive sports. In fact, there is a documented risk of sudden death, especially in patients operated on with traditional techniques; this risk cannot be reliably quantified on the basis of postoperative clinical and instrumental data.

Left-to-right shunt includes atrial septal defects, ventricular septal defects, and common atrioventricular canal. In these cases, the hemodynamic evaluation of cardiopathies is necessary to establish the indication for surgical correction, which, moreover, must be done in an almost systematic manner. be granted any form of sporting activity, even at a competitive level.

The presence of a pulmonary valve stenosis (SP) can be suspected based on the detection of an expulsive systolic murmur in the lung area: with or without actual click, right ventricular hypertrophy on ECG and / or dilation of the artery pulmonary on chest X-ray. This affection, even in the most hemodynamically important forms, often occurs in a completely asymptomatic way, unlike aortic stenosis. The definition of the severity of the stenosis can be easily carried out with clinical, electrocardiographic and echocardiographic criteria (transvalvular gradient estimated with ECO-Doppler).
The minimal forms are defined by an estimated gradient of 50 mmHg.
INDICATIONS
In the minimum forms, the practice of all sports activities will be allowed as long as the functional capacity evaluated with a maximal effort test is normal.
In moderate forms, competitive activity with minimal cardiovascular effort is allowed.
The severe forms cannot participate in competitive sports before correction.
In the correct forms, after 6 months from the intervention, competitive fitness can be granted for all types of sport if the following criteria are met:
- surgery performed not by ventriculotomy;
- gradient <30 mmHg;
- mild pulmonary insufficiency;
- good right ventricular function (ejection fraction> 50% evaluated with radionuclide ventriculography).
In other cases, competitive fitness will be granted individually assessed.

Curated by: Lorenzo Boscariol