Dr. William Kraus, MD Duke University

1. Use of CPET to Evaluate COVID Pathology
William E. Kraus
7th Duke Sudden Cardiac Death Symposium
23 April 2022

7. Persistent Subacute Sequellae of Sars-CoV-2 Infection (PASC), Long-COVID and CPET, Return to Play
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8. Summary
• Mixture of Pathology: muscle, cardiac pulmonary
• Pulmonary Predominates

9. Sports Cardiology COVID Cases
•College Women’s Long Distance Athlete
•Middle-Aged Bicyclist with Early Fatigue

10. • College Senior long distance runner. Co-captain, third on XC team.
• Presents for evaluation of inability to run or perform up to pre-
pandemic standards.
• Severe case of COVID Dec 2020. Took months to recover.
• Contracted COVID again, same setting (home visit), Dec 2021.
• Three months later, cannot do workouts, gets to 50% normal capacity
and fatigue. Relates more to muscle weakness than central CR.
• Denies chest pain.
• Has primary amenorrhea.
College Women’s Long Distance Athlete

11. College Women’s Long Distance Athlete -2-
• Normal iron and TIBC, ferritin 24, H/H 13.1/40.9.
• EKG: NSR, rate 61, early repolarization. Normal athlete's ECG
• Echo: 1/21 and 2/22: Normal
• cMRI: normal, including with adenosine stress.
• Next Step?

12. College Women’s Long Distance Athlete -3-
• PFTs normal, over 100% all categories.
• Relative VO2, 54.1 mL/kg/min, 137%
• Absolute VO2, 3.01 L/min
• VE/VO2 slope, 28.1, 115%
• RER, 1.17
• VT, 32.3 mL/kg/min, 60% VO2
• VE/MVV, 82.3%
• O2-pulse, 15.9 mL/beat, 143.1%
• OUES, 2506, 114.1%
She has a lung limit to exercise
which is not uncommon for high
endurance athletes but again could
possibly be the cause of her
symptoms. and has been reported in
others after COVID infections JACC
Heart Failure 2021;9:927-937
Oberle:
1. Suspected exercise-induced
bronchoconstriction
following COVID -> Singulair.
2. Hyperventilation syndrome
vs dysfunctional breathing
syndrome post COVID

13. Middle-Aged Bicyclist with Early Fatigue
• Started racing competitively in 20’s. Right-handed.
• Has had h/o atrial fibrillation for 25 years.
• Ablations 12 years ago and then again 2 years ago.
• Had immediate recurrent a fib requiring cardioversion.
• Since last procedure has noticed marked decrease in exercise tolerance.
• Apparent after extended hard rides/aerobic workouts of over 60 min.
• Points to knees and reports excessive muscle fatigue rather than central.
• Fully vaccinated with Moderna. Within days of booster on 12/24
developed right eye scatoma and aphasia.

14. Middle-Aged Bicyclist with Early Fatigue -2-
• Brain imaging demonstrated left occipital ischemic event.
• TEE failed to demonstrate a source.
• Since CVA taking Eliquis and atorvastatin.
• PE unremarkable.
• EKG: 12/21: NSR, rate 59, short PR, LAD and IVCD
• Could CVA be related to vaccination?
• Next steps?

15. Case for Last Session – Arrhythmology Cases
Young Athlete with Sudden Cardiac Death

16. Kraus—SCD Case
• EC 23 y student athlete (varsity basketball player) at NCAA Division 1 mid-major.
• Second opinion regarding return to play six months following a cardiac arrest.
• Playing for third mid-major. Large social media following. Possible pro ball
candidate. Coming into last year of eligibility.
• Feb 2021 (5 months prior), collapsed in cardiac arrest while practicing basketball.
• Was witnessed and resuscitated with AED. Had 1 h ACLS on site.
• Lost mental function. Underwent hypothermia. Hospitalized for one month.
• No other cause for arrest yet identified.
• Acute MRI showed EF 41%, septal scarring.
• Recovery excellent. ICD monitoring failed to demonstrate ongoing dysrhythmias.

17. Kraus—SCD Case -2-
• Followed by local cardiology service. Prevented from participating in basketball
activities in last half of previous season.
• Has been working out without an issue. Seeks clearance for return to play.
• Unvaccinated for Sars-CoV-2.
• PE reveals robust, tall man with no physical or mental deficits.
• ECG: SR, sinus arrhythmia, 1st degree AVB, LVH, septal q-waves.
• Duke MRI (6 months after prior):
• Next step ?????
• Entertain return-to-play with gradual advancement of intensity of aerobic,
strength and competition.
• Insist on vaccination

19. Kraus—SCD Case -3-
• Gets vaccinated.
• Communication through patient and trainer liaison who attends cardiology
practice locally to college.
• Advanced to full practice two months later.
• Denies symptoms.
• Holter reveals PVCs and non-stustained VT.
• Before advancing to game participation a query of ICD reveals VT self-terminating
just before shock.
• College suspends all participation in formal college sponsored athletics
• Expresses interest in trying out for professional football.
• Resists follow-up monitoring through ICD
• Refuses follow-up MRI at one year.