A Tough Decision For Tough Competitors

A 47-year-old man presents to the clinic for a follow-up visit after a recent ablation for atrial flutter (AFL). He has tetralogy of Fallot (TOF) that was repaired in infancy and included a ventriculotomy with a transannular patch. He subsequently had a surgical pulmonary valve (PV) repair at 15 years of age, followed by a transcatheter pulmonary valve replacement (TPVR) with a 22 mm Melody Transcatheter Pulmonary Valve (Medtronic, Minneapolis, Minnesota) in 2008.

At 42 years of age, he had nonsustained ventricular tachycardia (NSVT) and received a single-chamber implantable cardioverter-defibrillator (ICD) for primary prevention. At 43 years of age, he underwent a ventricular tachycardia (VT) ablation; since then, he has not had recurrent VT. At 46 years of age, he developed AFL, which was diagnosed after an inappropriate shock attributed to AFL conducting 1:1 at his set VT rate threshold.

During discussion about the management of his arrhythmias, he states that he would also like to discuss competitive exercise. He does not endorse any recent cardiorespiratory symptoms and is training for an upcoming Tough Mudder (Spartan Race Inc., Boston, Massachusetts) event, a 5 km race that includes rough terrain and obstacles.

An echocardiogram during his clinic visit reveals normal biventricular systolic function, moderate pulmonary stenosis, moderate PV regurgitation, and no residual shunting defects. His last cardiac magnetic resonance imaging, obtained 1 year before his presentation to the clinic, revealed right ventricular (RV) ejection fraction 58%, RV end-diastolic volume indexed 117 mL/m2, and left ventricular (LV) ejection fraction 48%. Interrogation of his ICD reveals a normally functioning device without any detected arrhythmias or delivered therapies following his ablation. An exercise stress test with standard Bruce protocol does not demonstrate any arrhythmias or signs of ischemia. His maximum heart rate is 137 bpm (76% predicted), his peak blood pressure is 140/60 mm Hg, and he does not have any desaturations. The resting electrocardiogram before exertion demonstrated stable normal sinus rhythm with a right bundle branch block (QRS 120 msec). His peak oxygen consumption (VO2) is 43.2 mL/kg/min (88% predicted), respiratory exchange ratio is 1.14, minute ventilation/carbon dioxide production is 24.6, and peak oxygen pulse is 23 mL/beat.

He asks to be cleared for this event and is confident that he can participate.

In this patient with repaired tetralogy of Fallot (rTOF), subsequent TPVR, and arrhythmia history with an ICD, which one of the following is the most appropriate guidance in addressing his risk of participating in a high-endurance obstacle race?

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