Considerations for the assessment of suspected myocarditis in the elite athlete in COVID-19 era

The Sars-CoV-2 pandemic has been a tough challenge since its initial spread in December 2019. Among clinical features of the disease, myocardial involvement has been proved in about 7% of affected patients, mostly in those with severe disease course. So far, no cases are described in healthy elite athletes. We presented the case of a 35-year-old male elite cyclist, who experienced flu-like symptoms in late February 2020, but came to our attention at the end of July 2020 for increased troponin levels, despite lack cardiac symptoms. Cardiovascular workout showed isolate PVBs with RBB morphology at the exercise-stress testing and a mid-wall/subepicardial late gadolinium enhancement in the lateral wall of left ventricle at cardiac magnetic resonance. The athlete was diagnosed with non-Covid related myocarditis since repeated serology tests for Sars-CoV-2 were negative. Accordingly, he decided to quit his professional career. According to the current evidence, given the uncertain sensitivity of serology testing for Covid disease, the only examination to exclude Sars-CoV-2 in myocarditis is the endomyocardial biopsy. Furthermore, given the relative rarity of myocardial involvement in who experienced no symptoms or a mild infection, the follow-up of athletes in this category for return to play could be reconsidered in terms of cost-effectiveness.