Return-to-play in athletes with transvenous and subcutaneous implantable cardiac defibrillator: A meta-analysis

Arrhythmia in athletes can be career-threatening, and those with implantable cardioverter-defibrillators (ICDs) face significant challenges in returning to play due to concerns about safety, efficacy, and arrhythmic risk. Since the last meta-analysis, additional studies have been published, providing updated data that suggest both transvenous and subcutaneous ICDs (S-ICDs) may allow for a safe return to sports through individualized decision-making. This meta-analysis aimed to reassess the safety and efficacy of ICDs in athletes returning to play.

A systematic review and meta-analysis were conducted following the PRISMA guidelines. Six cohort studies including 1183 athletes with ICDs were analyzed, with five of them on transvenous ICDs and one on S-ICD. Primary outcomes included rates of appropriate and inappropriate shocks, shock-related physical injury, cardiac adverse events, and sports discontinuation. Subgroup and sensitivity analyses were performed to explore heterogeneity.

The pooled rate of appropriate shocks was 13% (95% CI 0.11-0.16), while inappropriate shocks occurred in 4% (95% CI 0.02-0.11). No shock-related physical injuries or cardiac adverse events during or shortly after sports were reported (0%). The rate of sports discontinuation was 2%, increasing to4% after sensitivity analysis. Transvenous ICDs showed lower inappropriate shock rates compared to S-ICD.

ICD use in athletes returning to play appears safe, with low adverse event rates and minimal sports discontinuation. These findings support tailored return-to-play decisions based on arrhythmia type, ICD programming, and psychological support, aligning with the 2024 HRS Class IIa recommendation.