Nonischemic Left Ventricular Scar

A 20-year-old soccer player died suddenly while watching a game with friends at home. At annual preparticipation screening, ECG was normal with consequent sport eligibility (Figure 1A). History for juvenile sudden death and hypertrophic cardiomyopathy was reported on the mother’s side of the family. Postmortem examination of the heart showed normal dimensions (weight, 347 g; wall thicknesses of left ventricle [LV] and septum 13 mm and right ventricle [RV], 3 mm), in the absence of aneurysms or chamber dilatation; a subepicardial scar-like grey rim was evident in the anterolateral and posterior LV free wall and in the septum (Figure 1B). Coronary arteries had a normal origin and course, with patent lumen. Histological examination revealed extensive subepicardial and intramural fibrous replacement with scarce fatty tissue infiltration, involving the entire LV circumference and the septum (Figure 1C). Right ventricular involvement was only focally detected, in the anterior wall. The features were in keeping with either chronic myocarditis or left-dominant arrhythmogenic cardiomyopathy (AC).Figure 1. A , Basal 12-lead ECG at annual preparticipation screening showing normal findings. B , Transverse section of the heart showing a subepicardial scar-like grey rim in the anterolateral and posterior LV free wall and in the septum, in the absence of wall thinning and aneurysm formation. …