The issue of sports participation in athletes with an implantable cardioverter-defibrillator (ICD) has gained increasing attention. Contrary to what is often reported by the media, in Italy there is no absolute ban on competitive sports for individuals with an ICD: according to the 2023 COCIS guidelines, eligibility is determined not by the device itself, but by the underlying heart disease and the type of sport practiced. This document reviews the main international (AHA/ACC, ESC, HRS) and Italian guidelines, emphasizing that the indication for ICD implantation must follow the same criteria used for the general population, without considering the desire to practice sports as a determining factor. It then discusses the conditions under which, in Italy as well, athletes with an ICD may be allowed to return to competitive sports. Available evidence, including data from international registries, shows that sports participation in ICD carriers can be safe if performed under specialist supervision, although the risk of appropriate shocks is not negligible. This document also examines the advantages and limitations of different device types and proposes a flow-chart for ICD programming and follow-up, both at baseline and during exercise testing. Finally, it reaffirms that properly prescribed and monitored physical activity remains recommended for patients with ICDs due to its clinical and psychological benefits.

Although Brugada syndrome has traditionally been considered a primary electrical disease, accumulating evidence supports the presence of subtle structural abnormalities, particularly involving the right ventricular outflow tract. Nevertheless, the identification of overt myocardial scar and biventricular arrhythmogenic substrate should prompt consideration of an alternative diagnosis. We report the case of a 51-year-old man presenting with syncope during a febrile illness and a transient spontaneous type-1 Brugada ECG pattern. Initial evaluation was unremarkable. However, Holter monitoring revealed multifocal ventricular ectopy, including non-sustained ventricular tachycardia (NSVT) with both left and right bundle branch block morphologies, suggesting biventricular origin. Cardiac magnetic resonance showed a non-ischemic subepicardial scar, and electroanatomical mapping identified additional right ventricular abnormalities. Programmed stimulation induced sustained ventricular arrhythmias. These findings supported the presence of an underlying biventricular structural scar cardiomyopathy presenting with a fever-induced type-1 Brugada ECG pattern. The patient underwent transvenous ICD implantation. This case highlights the importance of a comprehensive multimodal diagnostic approach.

AIMS:Non-ischaemic left ventricular (LV) scar is increasingly recognized in athletes with preserved left ventricular ejection fraction (LVEF) and may represent a substrate for malignant ventricular arrhythmias. The role of electrophysiological study (EPS) with programmed ventricular stimulation (PVS) for risk stratification in this population remains unclear. This study aimed to evaluate the prognostic value of inducibility at EPS in symptomatic athletes with non-ischaemic LV scar and preserved LVEF. METHODS AND RESULTS:We prospectively enrolled 72 consecutive athletes (mean age 48.9 ± 13.1 years; 66.7% male) with documented non-ischaemic LV scar, preserved LVEF (≥50%), and arrhythmic symptoms (tachycardic palpitations, syncope/presyncope, and/or exercise-related ventricular arrhythmias) undergoing EPS. Inducibility was defined as sustained ventricular arrhythmias during PVS. The primary endpoint was the occurrence of major arrhythmic events (MAE), including sudden cardiac death, sustained ventricular tachycardia/ventricular fibrillation, or appropriate implantable cardioverter-defibrillator therapy. Twenty-three athletes (31.9%) were inducible (EPS+), while 49 (68.1%) were non-inducible (EPS-). Baseline characteristics were largely comparable between groups, although QRS duration was longer in inducible athletes (104.6 ± 15.2 ms vs. 95.5 ± 14.3 ms; P = 0.019). Twenty-three inducible athletes underwent ICD implantation (18 transvenous and 5 subcutaneous devices), whereas 16 non-inducible athletes received an implantable loop recorder. During a median follow-up of 42 months, 11 major arrhythmic events occurred. Nine events occurred among inducible athletes and consisted of sustained ventricular arrhythmias (monomorphic VT, polymorphic VT, or ventricular fibrillation) successfully terminated by appropriate ICD therapy, whereas two major arrhythmic events occurred among non-inducible athletes and required successful resuscitation followed by ICD implantation. No arrhythmic deaths occurred during follow-up. Event-free survival at 50 months was 40.6% in inducible athletes and 95.9% in non-inducible athletes (log-rank P < 0.001). CONCLUSION:In symptomatic athletes with non-ischaemic LV scar and preserved LVEF, inducibility at EPS identifies a subgroup at higher risk of MAE, whereas non-inducibility is associated with a low event rate. EPS may represent a useful adjunctive tool for arrhythmic risk stratification in athletes, particularly in those without conventional high-risk features.

Background: Intense physical exercise induces oxidative stress and inflammation in adult professional athletes, but data on adolescent elite athletes remain limited. Methods: Twenty-four elite adolescent soccer players were recruited and evaluated three times: pre-season baseline (T0), after one month of pre-season training (T1), and at the end of the first half of the competitive season (T2, approximately 4 months after T0). Saliva samples were collected as non-invasive surrogate indicators reflecting oxidative stress- and endothelial-related signaling. In vitro studies were performed on endothelial cells exposed to H2O2 concentrations observed in athletes. Results: Athletes showed a significant increase in salivary oxidative stress markers (NOX2 levels and H2O2) at T1 and T2 versus T0. Endothelial impairment was evidenced by reduced salivary NOx concentration and elevated endothelin (ET-1) levels. In vitro, endothelial cells exposed to H2O2 (8 μM) showed increased sNOX2-dp and ET-1 levels, reduced eNOS phosphorylation, and impaired tube formation (mesh number and area) compared with untreated cells. NOX2ds-tat treatment reduced cell damage and restored angiogenic capacity. Conclusions: Our findings indicate that adolescent elite athletes experience significant salivary oxidative stress- and endothelial-related alterations, potentially reflecting cardiovascular stress. These results underscore the importance of cardiovascular monitoring and the potential benefits of antioxidant strategies, even in young athletes participating in high-intensity sports.

Aim: Cardiac memory is classically expressed as persistent T wave changes following restoration of normal ventricular activation. Its manifestations in idiopathic intermittent left bundle branch block (ILBBB) remain incompletely characterized. The aim of this report is to describe a distinct electrocardiographic phenotype potentially related to cardiac memory. Methods: We retrospectively analyzed a homogeneous series of 14 patients with idiopathic, rate-dependent ILBBB, absence of demonstrable structural heart disease, homophasic T waves in leads V5–V6 during left bundle branch block (LBBB), and pseudo-ischemic T wave inversion in the right precordial leads during phases of normal conduction. Results: In all patients, memory-related negative T waves were observed during normal conduction, while concordant (homophasic) T waves were consistently present during LBBB. A close relationship emerged between the width of the intraventricular conduction zone and the severity of repolarization abnormalities: narrower conduction zones were associated with deeper T wave inversion during normal conduction. During follow-up, most patients progressed to permanent LBBB, without documented major arrhythmic events. Conclusions: These findings describe a distinctive and reproducible electrocardiographic phenotype within idiopathic ILBBB, likely related to cardiac memory. This pattern, provisionally designated homophasic idiopathic intermittent left bundle branch block and cardiac memory (OIL-CAME), warrants further confirmation in larger prospective studies.

CASE SUMMARY:A 65-year-old man with no known cardiovascular disease and no prior history of syncope presented to the emergency department with fatigue, abdominal pain, and fever and was admitted with a diagnosis of sepsis of abdominal origin. On initial evaluation, he was hemodynamically stable and denied cardiac symptoms. A resting 12-lead electrocardiogram (ECG) showed conduction abnormalities of uncertain significance, prompting a focused interpretative challenge. TAKE-HOME MESSAGES:Transient ECG signal saturation can create pseudo-conduction abnormalities that closely mimic advanced atrioventricular block. Evaluation of internal signal coherence is essential to differentiate true electrophysiologic disorders from acquisition-related artifacts.

INTRODUCTION:The Italian pre-participation screening (PPS) protocol includes family and personal medical history, physical examination, and a 12‑lead electrocardiogram (ECG). The aim of this study was to evaluate the prevalence of selected ECG abnormalities in an unselected athletic population from a multicenter Italian registry, and to assess their association with at-risk cardiovascular conditions. METHODS:This multicenter registry prospectively enrolled 12,758 elite and amateur athletes (62% males; median age 22.5 years, range 14-55 years) undergoing PPS according to the Italian national protocol (COCIS, 2017). ECGs were interpreted according to the International Criteria for Electrocardiographic Interpretation in Athletes, with the addition of selected markers (low QRS voltages, QRS fragmentation, and early repolarization with horizontal or descending ST segment). ECG patterns suggestive of Brugada syndrome and ventricular pre-excitation, although observed, were not included in the analysis. All subjects with ECG abnormalities underwent a second-line diagnostic work-up. RESULTS:A total of 129 abnormal ECGs were identified (1.01%). Among these, 25 athletes (19.3%) were disqualified because of an at-risk cardiovascular condition. CONCLUSION:The prevalence of selected ECG abnormalities in this multicenter registry was lower than that reported in previous studies. However, this finding should be interpreted in the light of the selective ECG criteria adopted. The abnormalities investigated showed a relevant predictive value for identifying at-risk conditions in a real-world, predominantly non-elite population.

Objective: The international cardiovascular guidelines emphasise self-care as a key factor for better health management in patients. Self-care incorporated into patient engagement is considered vital for the patient-provider relationship to alleviate the polipharmacological treatment burden. However, several cardiovascular (CV) patients struggle to adhere to recommendations. The present study aims to address this research gap by exploring the adherence and real-world effectiveness in a CV population. From this perspective, our cohort study attempted to determine self-care ability based on the relevance of self-efficacy and quality of life perception in adults with a CV condition. Methods: An observational study design was applied based on cohort analysis. A total of 76 patients at different stages of disease severity participated in the study. Two types of patient data were collected: medical data-drawn from clinical records and psychological data-collected through interviews and the following standardised questionnaires: the EuroQol Visual Analogue, Self-Care of Chronic Illness Inventory, Self-Care SelfEfficacy Scale. All clinical data were recorded during the outpatient scheduled follow-up. Results: Our results evidenced that patients with hypertension and heart failure need greater engagement actions and education support from providers to achieve the goal of medical treatments modelling health behaviour that prioritises monitoring ability over time. CV risk factors were more regulated in the self-care monitoring group than in the heart failure group; in CV diseases, patients with ischemic heart disease seemed more efficient in selfmonitoring than those with heart failure. Relevant results were obtained in self-efficacy perception; the comparison between hypercholesterolaemia and heart failure groups resulted in statistical significance, indicating that patients with hypercholesterolaemia perceive a higher ability to achieve positive outcomes for their own health; other patient groups did not seem to perceive high self-efficacy. Conclusion: In chronic diseases, such as cardiological conditions, monitoring ability seems to be a challenging clinical variable; the ability to check signs and symptoms, and actions associated with the complexity of physical signs and multimorbidity could be impacted over time. Our findings suggest that fostering self-efficacy capacity could induce better physical self-monitoring for enhanced well-being and greater self-confidence regarding the management of health-favouring behaviours and lifestyle-modelled changes.

ObjectiveWe conducted a scoping review of the literature focusing on combining biomarker detection and psychological evaluation according to the biopsychosocial approach to expound the multifactorial aspects of cardiological care.MethodThe search strategy was restricted to the 2014–2024 period. The core of this evidence-based analysis was the investigation of emotional and behavioural signs in cardiovascular (CV) risk/disease, the characteristics of adherence, and the efficacy of psychological treatments, especially highlighting the evidence of studies based on pre–post study design models for the investigation of psychological treatment efficacy in CV risk/disease.ResultsThe literature includes systematic reviews and meta-analyses on patient education for the effectiveness of psychological interventions on psychosocial aspects and, consequently, on adherence to therapeutic prescriptions. From this perspective, it is important to adopt the biopsychosocial approach in the prevention, evaluation, and management of CV disease to understand all determinants of disease and multidisciplinary treatments. Topics are arranged into six themes: (1) epidemiological aspects of the included studies, (2) medical and psychological insights into CV research protocols from an integrated biopsychological perspective, (3) evidence of emotional and behavioural symptoms in CV risk, (4) evidence of emotional and behavioural symptoms in CV disease, (5) characteristics of adherence and psychological treatment, and (6) evidence of pre- and post-psychological treatment in CV risk/disease.ConclusionsThis review demonstrates that interventions are required to address patient factors, such as emotional, behavioural, and cognitive dimensions, that can improve the quality of life and adherence to medication. The link between physical and mental care is crucial and should be supported by extensive evidence-based outcomes in terms of tailored actions in health monitoring and management of CV risk/disease clinical targets.

BACKGROUND:Premature ventricular contractions (PVCs) originating from the left ventricular summit (LVS) could be challenging to ablate due to anatomical reasons. AIM:To study the role of new irrigation technologies, like the TactiFlex catheter, could facilitate deeper radiofrequency (RF) penetration and thus increase success in the ablative treatment of this PVC subset. METHODS:Three PVCs focus (left bundle branch block morphology, inferior axis on the frontal plane, early R/S transition in V1-V2) were accurately mapped with Ensite X omnipolar technology. RESULTS:RF was delivered at mitroaortic continuity by TactiFlex catheter (4-9 lesions, max 35 W, 43 °C, 13 mL/minute, max 60 seconds, mean impedance drop 11.9 ± 1.7 ohms) with acute PVCs suppression but early recurrence in all cases. In one case, an anatomical approach in the posteroseptal right ventricular outflow tract was performed without acute success. After 6-10 hours, no PVCs/ventricular arrhythmias have been detected, and no arrhythmia recurrences in all 3 cases at a 180-day follow-up visit. These data were compared with a cohort of 10 patients with LVS PVCs with immediate disappearance treated with the same technology; the only difference, although not statistically significant, was in the greater drop in impedance (13.5 ± 2.1 ohms). CONCLUSION:Late PVCs elimination could be due to the porous flexible distal tip design of the TactiFlex catheter that allows deeper RF penetration in the myocardium due to a greater adhesion of the saline irrigation system to tissue. It is reasonable to assume that this new technology makes lesions more transmural, determining a delayed lesion maturation, thus not limited to the duration of energy delivery.

Brugada syndrome (BrS) is a genetic disorder marked by a characteristic electrocardiogram (ECG) pattern of ST-segment elevation and T-wave inversion in right precordial leads, which is associated with an increased risk of ventricular fibrillation in the absence of structural heart disease. Despite advancements in understanding its epidemiology, pathophysiology, and treatment, there is considerable variability in how sports cardiologists approach BrS. This expert opinion by the Italian Society of Sports Cardiology (SICSPORT) aim to review the current definition, diagnosis, epidemiology, genetics, risk stratification, and treatment of BrS and provide guidance for sport eligibility provides guidance for sports doctors and cardiologists in assessing competitive sports eligibility in athletes with BrS. A multiparametric approach to diagnosis and risk stratification is recommended, noting that the presence of a Brugada ECG pattern (BrP) does not confirm a BrS diagnosis. The risk of sudden cardiac death (SCD) is low in asymptomatic individuals with type 1 BrP, especially those with a drug-induced pattern. Pharmacological testing is not required for type 2 or 3 patterns without other risk factors. Low-risk individuals do not require therapy, while intermediate or high-risk patients may need pharmacological treatment, ICD implantation, or ablation. Asymptomatic individuals with type 2 or 3 BrP, no family history of SCD, and no other risk factors may be eligible for competitive sports, as well as asymptomatic type 1 BrP without risk factors and negative electrophysiological study. Conversely, sports eligibility should be denied in patients with BrS who have a history of syncope or cardiac arrest (high-risk subjects), regardless of ICD presence.

The COCIS 2023 guidelines represent the latest update on competitive sports eligibility for athletes with heart disease, developed by the Italian Society of Sports Cardiology and associated medical societies. These updated guidelines reflect advancements in cardiology and sports medicine and introduce clear class of recommendations and levels of evidence for assessing athletes with heart disease. This document focuses on the differences between the 2023 and 2017 versions, particularly regarding athletes with arrhythmias. The guidelines integrate new scientific evidence, including modifications to criteria for specific arrhythmic conditions like Wolf-Parkinson-White (WPW) Syndrome, Brugada Syndrome, long QT syndrome (LQTS), and premature ventricular beats (PVBs). Updates on the return-to-play timing after successful catheter ablation are also included. Key updates include the revised arrhythmic risk thresholds for WPW syndrome; these guidelines also expand recommendations for asymptomatic pre-excitation cases. In Brugada Syndrome, eligibility remains dependent on the presence of malignant arrhythmias and genetic risk factors, with scoring systems to aid risk stratification. For LQTS, eligibility is reconsidered for asymptomatic individuals with a negative phenotype and a positive genotype, with beta-blocker use. Additionally, the management of PVBs is refined, with new criteria for further investigation and risk assessment. COCIS 2023 introduces a more nuanced, evidence-based approach to the eligibility of athletes with arrhythmias. The guidelines provide clinicians with detailed recommendations for managing a variety of arrhythmic conditions. As scientific research advances, these guidelines will continue to evolve, ensuring safe athletic participation for individuals with cardiovascular conditions.

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We report a family with two affected brothers presenting hypertrophic cardiomyopathy, prolonged QT interval, and intellectual disability who, after a dozen years of inconclusive genetic testing, were found to share a previously undescribed variant c.549delA (p.Gly184Alafs*67) in the X-linked NAA10 gene. Their mother was heterozygous for the variant and had a long history of unexplained cardiac arrhythmia. NAA10 (N-alpha-acetyltransferase 10) is a component of the N-terminal acetyltransferase A complex (also called the NatA complex) necessary for N-alpha-acetylation, among the most common post-translational protein modifications in eukaryotic cells. Deleterious variants in the X-linked NAA10 gene cause a wide spectrum of clinical features, recently merged under the umbrella term of NAA10-related disease, mainly featuring intellectual disability, seizures, visual and cardiac abnormalities. Congenital heart defects and cardiac dysfunction/arrhythmias emerged as a very common manifestations of the disease both in males and females described in the medical literature. While atrial and ventricular septal defects dominated at pediatric age in both sexes, hypertrophic cardiomyopathy, and prolonged QT were observed in adult males and females, respectively. Our observations may help in the early recognition of NAA10-related disease based on previously underrecognized cardiac features, especially in females with unexplained arrhythmias and/or prolonged QT, and guide personalized management of this neglected condition.

Background: The aim of our study was to evaluate the effects of dapagliflozin on the ventricular arrhythmia burden (VAb) in patients with heart failure with reduced ejection fraction (HFrEF) and an implantable cardioverter defibrillator (ICD), correlating the possible reduction in arrhythmic events and ICD therapies with the basal functional capacity, as well as the remodeling parameters induced by treatment. Methods: A total of 117 outpatient ICD patients with a known diagnosis of HFrEF who underwent treatment with dapagliflozin were evaluated according to a prospective observational protocol. VAb (including sustained ventricular tachycardia, non-sustained ventricular tachycardia, ventricular fibrillation, and total ventricular events) and specific ICD therapies (anti-tachycardia pacing (ATP) and ICD shocks) were extrapolated from the devices' memory (events per patient per month) by comparing events in the observation period before and after the introduction of dapagliflozin. Results: The VAb was significantly reduced after dapagliflozin introduction (2.9 +/- 1.8 vs. 4.5 +/- 2.0, P = 0.01). The burden of appropriate ATPs was significantly reduced (0.57 +/- 0.80 vs. 0.65 +/- 0.91, P = 0.03), but not for ICD shocks. In patients with a more advanced functional class, a greater reduction in VAb was observed than in patients with a better initial functional capacity (2.2 +/- 0.8 vs. 5.5 +/- 1.8, P = 0.001 in the New York Heart Association (NYHA) III/IV group; 3.5 +/- 2.1 vs. 4.5 +/- 2.2, P = 0.02 in the NYHA I/II group). Considering two independent groups according to reverse remodeling (Delta left ventricular ejection fraction (LVEF) > 15%), a significant reduction in VAb was observed only in those patients who presented significant reverse remodeling (2.5 +/- 1.1 vs. 5.1 +/- 1.6, P = 0.01). A statistically significant interaction between the variation of total ventricular arrhythmias (VTA) and the basal NYHA class (F(1,115) = 142.25, P < 0.0001, partial eta(2) = 0.553), as well as between the variation of VTA and the Delta LVEF (F(1,115) = 107.678, P < 0.0001, partial eta(2) = 0.484) has been demonstrated using a two-way analysis of variance (ANOVA) test. Conclusions: In ICD outpatients with HFrEF, dapagliflozin treatment produces a reduction in arrhythmic ventricular events. This improvement is more evident in patients who have a worse functional class and thus a more precarious hemodynamic state, and in patients who present with significant ventricular reverse remodeling. Therefore, we can hypothesize that the hemodynamic and structural improvements induced by treatment represent, at least in the short-medium term, some of the principal elements justifying the significant reduction in VAb.

Artificial intelligence (AI) is redefining ECG interpretation, transforming it from a static diagnostic tool into a dynamic, predictive, and integrative instrument. Although widespread, traditional rule-based ECG analysis has limitations in accuracy and adaptability, especially in complex clinical settings. In contrast, AI-driven models, particularly those employing machine learning and deep learning architectures, have demonstrated improved diagnostic performance across a broad spectrum of cardiovascular diseases, including atrial fibrillation, acute myocardial infarction, hypertrophic cardiomyopathy, and valvular heart disease. Notably, AI-ECG is now able to detect subclinical ventricular dysfunction, stratify long-term risk, and anticipate major adverse events before overt clinical manifestations occur. In addition to diagnosis, AI-ECG is emerging as a decision support tool in scenarios characterized by diagnostic uncertainty, such as syncope and cardio-oncology, and may significantly optimize triage and resource allocation. Multiparametric approaches further extend its utility, enabling simultaneous prediction of structural, functional, and electrical cardiac parameters. Wearable devices integrated with AI improve continuous monitoring and may decentralize arrhythmia detection and sudden cardiac death prevention. Despite these advances, critical challenges remain. Poorly explainable AI models, algorithmic bias, overfitting, data governance, and regulatory uncertainty demand rigorous methodological scrutiny. In this framework, federated learning architectures may enable continuous multicenter model refinement and enhance methodological robustness while safeguarding data privacy. The European AI Act and methodological checklists promoted by scientific societies offer a framework to address these issues, fostering transparency, equity, and clinical validity. If validated and implemented responsibly, AI-enhanced ECG has the potential to enhance-not replace-clinical reasoning, advancing a precision medicine paradigm based on both technological innovation and human expertise.

Dapagliflozin, a sodium–glucose cotransporter–2inhibitor (SGLT2) is approved for the treatment of heart failure (HF) regardless of ejection fraction. The aim of our study is to evaluate the effects of dapagliflozin in the medium and short–term on left ventricular reverse remodeling, correlating the possible improvement with the basal functional capacity. 87 outpatients (mean age 70.1±11.1years) with a known diagnosis of HF have been evaluated within a dedicated follow–up pathway according to a prospective observational protocol. Patients with HF with reduced ejection fraction (HFrEF) who had their therapy optimised with the introduction of dapagliflozin were observed. Echocardiographic parameters were identified at the time of introduction of dapagliflozin and during the observation period (3 and 6 months), evaluating the trend and correlating the changes with basal functional capacity. Analysis of population data shows a significant improvement in the observation period (before vs after treatment) in mean left ventricular ejection fraction (LVEF) 24.9 ± 5.9% vs 29.7 ± 4.1% p=0.025, mean global longitudinal strain –12.5 ± 0.9 % vs –14.5 ± 1.3 % p=0.03, mean left ventricular end–systolic volume (LVESV) 95.2 ± 12.3 ml vs 103.1 ± 12.1 ml p=0.03, mean E/E’ 13.0 ± 1.2 vs 15.5 ± 2.1 p=0.035 (Tab 1). 52 patients (60%) had significant indices of reverse remodeling, identified in an improvement of LVEF ›15%. Observing the trend of change in mean LVEF, there is a significant improvement at the 3–month control, and a subsequent plateau (Fig 1). Dividing the population according to basal functional capacity, it is observed a significant improvement of mean LVEF only in the group with the most impaired functional class. Mean LVEF in NYHA I/II group before treatment 26.7 ± 3.9% vs after treatment 27.5 ± 4.1 % p=0.06, mean LVEF in NYHA III/IV group before treatment 24.8 ± 4.1 % vs after treatment 30.1 ± 4.3% p=0.02 (Fig 2). In patients with HFrEF, dapagliflozin treatment produces an improvement of left ventricular systolic function in the medium–short term. This improvement is more evident in the first three months after treatment start and in patients who have a basal worse functional class. Therefore, we can hypothesize that hemodynamic improvement induced by treatment it contributes, at least in the medium to short term, to the improvement of structural remodeling.Table 1 Figure 1 Figure 2

Left ventricular non-compaction (LVNC) is a rare primary cardiomyopathy with genetic etiology, resulting from an abnormality of myocardial development during embryogenesis. It carries an elevated risk of left ventricular dysfunction, thromboembolic events and malignant arrhythmias. We report the case of LVNC associated with paroxysmal atrial fibrillation and ankyrin 2 (ANK2) mutation at the genetic test. An 18-year-old competitive athlete visited our medical center to undergo the diagnostic investigations protocol preparatory to the release of the suitability for competitive practice. The echocardiographic examination shows LVNC without ventricular remodeling (left ventricular ejection fraction (LVEF) 53%, global longitudinal strain (GLS) -18.3%). The echocardiographic diagnosis was confirmed by cardiac magnetic resonance imaging (cMRI), which revealed dense hypertrabeculation in the left ventricular apex and lateral wall. The cardiogenetic investigation showed a c.9145C>T variant (p.Arg3049Trp) identified in the ANK2 gene. This mutation is associated in the literature with rare cases of LVNC. The patient underwent an extended Holter monitoring which excluded ventricular arrhythmic events but showed two brief episodes of paroxysmal atrial fibrillation. Despite the absence of significant ventricular remodeling, considering the presence of paroxysmal atrial fibrillation and the presence of a mutation in the ANK2 gene, which has several variants related to high-risk phenotypes, it has been decided to suspend the competitive practice, and is defined an adequate clinical-diagnostic follow-up.

Atrial fibrillation (AF) is the most common sustained supraventricular arrhythmia, affecting 2-3% of the adult population and contributing significantly to morbidity, mortality, and healthcare burden. Catheter ablation has become a cornerstone in the treatment of symptomatic, drug-refractory AF, with pulmonary vein isolation (PVI) established as the standard approach, especially in paroxysmal AF. Over the past three decades, ablation technologies have evolved considerably-from radiofrequency and cryoballoon to the recent advent of pulsed field ablation-enhancing procedural safety, efficiency, and lesion durability. Despite these technological advancements, long-term outcomes have plateaued, suggesting that success may depend not just solely on the energy source used, but also on a more individualized, mechanism-based approach. The classification of AF based on duration alone fails to capture the complexity of its underlying pathophysiology. Tailored strategies that consider arrhythmic mechanisms, electrophysiological triggers, and patient-specific substrates-especially in persistent AF-are increasingly recognized as essential for durable results. Tools such as high-density mapping, autonomic modulation, and substrate-targeted ablation are expanding therapeutic horizons. Moreover, special populations, such as athletes, present unique arrhythmic profiles influenced by structural and autonomic remodeling, requiring nuanced management. The integration of lifestyle interventions, neuromodulation techniques, and emerging genetic and pharmacological insights further supports a comprehensive, personalized approach. In this paper, we explore whether future success in AF ablation lies more in refining technology or in advancing our understanding of arrhythmic mechanisms to guide patient-specific therapy.