Perspective:

Athletes who train intensely are at risk of RV dysfunction, and intense physical conditioning is ill advised in patients with ARVC. The pattern of electroanatomic substrate observed during an electrophysiologic study by taking multiple endocardial voltage points throughout the right ventricle may be able to differentiate patients with ARVC and inflammatory cardiomyopathy, whose substrates are usually subtricuspid, and an isolated subepicardial RVOT scar, exclusively observed in endurance athletes. The ability to differentiate ARVC and post-inflammatory cardiomyopathy from exercise-induced arrhythmogenic remodeling has significant prognostic implications. The isolated subepicardial substrate can be successfully ablated epicardially. It appears that cardiac magnetic resonance imaging with gadolinium contrast may not be sensitive enough to detect this subepicardial scar in athletes. Interestingly, anterior subepicardial RVOT scar has also been described in patients with Brugada syndrome and Brugada-type electrocardiograms.