Determinants of LV mass in athletes: the impact of sport, constitutional traits and cardiovascular risk factors.

BACKGROUND: Whether cardiovascular (CV) risk factors might impact Left Ventricular (LV) mass in athletes is unknown. METHODS: The impact of CV risk factors (Total/LDL cholesterol, triglycerides, positive family history, smoking, body fat, blood pressure), constitutional characteristics (age, sex, body mass index) and type of sport was assessed in 1111 Olympic athletes. RESULTS: Multivariate logistic regression analysis demonstrated a significant impact: BMI ≥ 30 kg/m2 (odds ratio [OR] = 2.8. 95° Confidence Interval [CI] 0.9-13.7; < 0.001; in males); age ≥ 20-year (OR = 2.1, CI 1.4-3.3; p < 0.001) in males; (OR = 2.3; CI 1.4-3.7) in females; systolic blood pressure ≥ 130 mmHg (OR = 1.1, CI 1.01-1.16; p < 0.001) in males; (OR = 1.03; CI 1.01-1.06; p < 0.03) in females; diastolic ≥ 85 mmHg (OR = 1.1, CI 1.03-1.2; p = 0.003) in males; (OR = 1.05, CI 1.02-1.08, p < 0.001) in females. No association was found for family history, smoking, body fat, LDL, total cholesterol, triglycerides. Overall, constitutional traits explain > 60% of the LV mass. Sport explains on average 14%, but large differences existed among disciplines, i.e., endurance showed the highest impact (55%, mixed: 20%, power: 17%, skill: 8%; p < 0.001). CONCLUSION: LV mass in athletes is largely governed by constitutional traits and type of sport, and independent from CV risk factors, except for systolic and diastolic blood pressure. Overall, constitutional traits explain more than 60% of LV mass. The impact of sport is largely different in relation to the discipline, and highest in endurance, moderate mixed and power and mild in skill disciplines.

Barlow disease: effect of mitral valve repair on ventricular arrhythmias in 82 patients in a retrospective long-term study.

BACKGROUND: Patients (pt) with mitral valve prolapse (MVP) due to Barlow disase (BD) have an increased incidence of ventricular arrhythmias (VA; including ventricular tachycardias VT) and sudden cardiac death (SCD). Data on the effect of MV repair on VA are scarce. METHODS: Pre- and postoperative VA in severe mitral regurgitation (MR) with MVP due to BD undergoing surgical mitral valve repair were analyzed. Patients with degenerative mitral valve disease not fulfilling BD criteria were excluded. Information was from charts, ECG/Holter ECG and/or pacemaker/ implantable cardioverter defibrillator (ICD) data. SCD, sustained VT>30 sec and/or ventricular fibrillation necessitating an ICD-shock were considered major events. Event probability was calculated using the Kaplan-Meier estimator throughout the follow-up period of 20.7 years. RESULTS: There were 82 pts (61% males), mean age at surgery 62±14 years. Bileaflet MVP was present in 54%, mitral annular dysjunction (MAD) in 37% and left ventricular ejection fraction (LVEF) <50% in 12%. MV repair included ring annuloplasty in all and artificial chords in 48%. Mean follow-up was 3.1 years (0.2 to 14.2 years). Postoperative rhythm surveillance by Holter ECG and/or pacemaker was available in 67%. A VA load of ≥10% and/or any VT was noted in 26% before and 32% after surgery (P=0.44). Postoperative VA load was not predicted by MAD, artificial chords, LVEF of <50%, age at surgery >50 years and/or residual ≥moderate MR (all P<0.05), it correlated only with bileaflet MVP (P=0.009). Major events occurred in 3 pts: SCD in 2 pts and ICD for sustained polymorphic VT in 1 pt (incidence 1.2%/year). The event probability of receiving a SCD or an ICD-shock was 4.9%. CONCLUSIONS: VA burden does not seem to change after MV repair in MVP due to BD. The occurrence of major arrhythmic events can not be predicted reliably, thus, patients with MVP due to BD may need lifelong postoperative follow-up, especially in bileaflet MVP which was an independent risk factor for increased VA burden in this retrospective long-term study in a small but well selected patient group.

Low QRS voltages in Olympic athletes: Prevalence and clinical correlates.

BACKGROUND: Recently, novel interest in low QRS voltages was prompted by the observation that low QRS voltages are present in arrhythmogenic cardiomyopathy patients, even before occurrence of symptoms/events. AIM: The purpose of this study was to assess prevalence and clinical correlates of low QRS voltages in Olympic athletes, evaluated and followed-up within our cardiovascular screening programme. METHODS: Five hundred and sixteen athletes consecutively examined (2010-2011) were included in this study. A low QRS voltage was defined as amplitude of QRS <0.5 mV in limb and/or <1.0 mV in precordial leads. Cardiovascular evaluation included 12-lead and exercise electrocardiogram, echocardiography and, selectively, additional tests to confirm diagnosis. Athletes were followed-up for 5 ± 2 (1-9) years. RESULTS: The majority of athletes (493; 96%) showed normal/increased R/S-wave voltages, but 23 (4%) had low QRS voltages. No differences were observed in low QRS voltage athletes compared to normal/increased QRS voltages for QRS duration, QTc and PR intervals, left ventricular cavity size and mass, or gender and sport participated. However, premature ventricular beats, occurred more frequently in low QRS voltages (39% vs 7%; p < 0.001), with patterns suggesting origin from left or right free wall. No diseases or events were registered in low QRS voltage athletes over the follow-up. CONCLUSIONS: In Olympic athletes, the prevalence of low QRS voltages was 4%. Athletes with low QRS voltages did not differ from other athletes according to sport participated in or cardiac dimensions. However, more frequently (39% vs 7%) they showed premature ventricular beats, originating from either the left or right free ventricular wall. Therefore, long-term follow-up with serial clinical evaluations is needed in low QRS voltage athletes, in order to definitely clarify the clinical significance.

Cardiovascular risk profile in Olympic athletes: an unexpected and underestimated risk scenario.

BACKGROUND: Prevalence of cardiovascular (CV) risk factors has been poorly explored in subjects regularly engaged in high-intensity exercise programmes. Our aim was, therefore, to assess the prevalence and distribution of CV risk factors in a large population of competitive athletes, to derive the characteristics of athlete's lifestyle associated with the best CV profile. METHODS: 1058 Olympic athletes (656 males, 402 females), consecutively evaluated in the period 2014-2016, represent the study population. Prevalence and distribution of CV risk factors was assessed, in relation to age, body size and sport. FINDINGS: Dyslipidemia was the most common risk (32%), followed by increased waist circumference (25%), positive family history (18%), smoking habit (8%), hypertension (3.8%) and hyperglycaemia (0.3%). Large subset of athletes (418, 40%) had none or 1 (414, 39%) risk factor, while only a few (39, 3.7%) had 3/4 CV risk factors. The group without risks largely comprised endurance athletes (34%). Ageing was associated with higher total and low-density lipoprotein cholesterol, triglycerides (p<0.001) and glycaemia (p=0.002) and lower high-density lipoprotein cholesterol. On multivariate logistic regression analysis, age, BMI and body fat were identified as independent predictors of increased CV risk. INTERPRETATION: Dyslipidemia and increased waist circumference are common in elite athletes (32% and 25%, respectively). A large proportion (40%) of athletes, mostly endurance, are totally free from risk factors. Only a minority (3%) presents a high CV risk, largely expression of lifestyle and related to modifiable CV risk factors.

RV Remodeling in Olympic Athletes.

OBJECTIVES: The aim of this study was to assess the impact of sex and different sports on right ventricular (RV) remodeling and compare the derived upper limits with widely used revised Task Force (TF) reference values. BACKGROUND: Uncertainties exist regarding the extent and physiological determinants of RV remodeling in highly trained athletes. The issue is important, considering that in athletes RV size occasionally exceeds the cutoff limits proposed to diagnose arrhythmogenic RV cardiomyopathy. METHODS: A total of 1,009 Olympic athletes (mean age 24 ± 6 years; n = 647 [64%] males) participating in skill, power, mixed, and endurance sport were evaluated by 2-dimensional echocardiography and Doppler/tissue Doppler imaging. The right ventricular outflow tract (RVOT) in parasternal long-axis (PLAX) and short-axis views, fractional area change, s' velocity, and morphological features were assessed. RESULTS: Indexed RVOT PLAX was greater in females than in males (15.3 ± 2.2 mm/m2 vs. 14.4 ± 1.9 mm/m2; p < 0.001). Both RVOT PLAX and parasternal short-axis view were significantly different among skill, power, mixed, and endurance sports: 14.3 ± 2.1 mm/m2 versus 14.7 ± 1.9 mm/m2 versus 14.0 ± 1.8 mm/m2 versus 15.7 ± 2.2 mm/m2, respectively (p < 0.001); and 15.2 ± 2.7 mm/m2 versus 15.3 ± 2.4 mm/m2 versus 14.8 ± 2.1 mm/m2 versus 16.2 ± 2.5 mm/m2, respectively (p < 0.001). The 95th percentile for indexed RVOT PLAX and parasternal short-axis view was 18 mm/m2 and 20 mm/m2, respectively. Fractional area change and s' velocity did not differ among the groups (p = 0.34 for both). RV enlargement compatible with major and minor TF diagnostic criteria for arrhythmogenic RV cardiomyopathy was observed in 41 (4%) and 319 (32%) athletes. A rounded apex was described in 823 (81%) athletes, prominent trabeculations in 378 (37%) athletes, and a prominent/hyperreflective moderator band in 5 (0.5%) athletes. CONCLUSIONS: RV remodeling occurs in Olympic athletes, with male sex and endurance practice playing the major impact. A significant subset (up to 32%) of athletes exceeds the normal TF limits; therefore, we recommend referring to the 95th percentiles here reported as referral values; alternatively, only major diagnostic TF criteria for arrhythmogenic RV cardiomyopathy may be appropriate.

Left Ventricular Noncompaction Diagnosis and Management Relevant to Pre-participation Screening of Athletes.

Left ventricular noncompaction (LVNC) has been extensively studied over the last years, and an increasing number of cases have been reported worldwide, with a large proportion comprising young and asymptomatic subjects, including athletes. The current epidemic of LVNC is likely the consequence of several causes, that is, the increased awareness of the disease and the refined cardiovascular imaging techniques. The current diagnostic methods, based uniquely on definition of morphologic findings, do not always resolve the overlap of a physiological myocardial architecture comprising a prominent trabecular pattern from a mild phenotypic expression of the real disease. Appropriate criteria for identification and management of LVNC in athletes have, therefore, become a novel challenge for cardiologists and sport physicians, who are required to solve the question of diagnosis and appropriate management in the setting of pre-participation cardiovascular screening. Indeed, although it is important to timely identify a true myocardial disease, to reduce the burden of adverse cardiac event in a young athlete, in contrast, a misdiagnosis of LVNC may lead to unwarranted restriction of the athlete lifestyle, with detrimental psychological, social, and economic consequences. This review report has been planned, therefore, to help physicians in diagnosing and managing athletes presenting with a morphologic pattern suggestive of LVNC with specific focus on criteria for advising sport participation.

3D echocardiographic delineation of mitral-aortic intervalular fibrosa pseudoaneurysm caused by bicuspid aortic valve endocarditis.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a rare complication of infective endocarditis of the aortic valve eventually resulting in coronary artery compression, stroke or rupture into the left atrium, aorta or pericardial space. A prompt diagnosis by either transthoracic or transesophageal echocardiography is mandatory to address the patient to cardiac surgery. We report the clinical case of a 25-year-old white man who was admitted to the emergency department for dyspnoea and fever. Echocardiographic examination showed a bicuspid aortic valve with a huge sessile vegetation and a pseudaneurysm of the mitral-aortic intervalvular fibrosa. In addition to conventional two-dimensional examination, three-dimensional echocardiography provided additional information of this complication, precisely delineating the lesions and addressing the cardiac surgeon in choosing the most appropriate operating strategy. Patient underwent then aortic root replacement and the pseudoaneurysm was closed by means of a bovine pericardial patch.

Epicardial real-time three-dimensional echocardiography in cardiac surgery: a preliminary experience.

PURPOSE: Intraoperative two-dimensional transesophageal echocardiography (2DTEE) is a widely accepted method to guide cardiac valve surgery. The aim of our study was to evaluate the feasibility, effectiveness, and incremental value of intraoperative epicardial real-time three-dimensional echocardiography (RT3DE). DESCRIPTION: Thirty consecutive patients (18 aortic and 12 mitral valve diseases) underwent intraoperative 2DTEE and RT3DE before and after cardiopulmonary bypass. Five observers compared independently 2DTEE to live and full volume images and to the surgical view, to assess the incremental value of RT3DE in depicting the different anatomic structures. EVALUATION: Epicardial RT3DE was feasible in all patients. Qualitative evaluation determined RT3DE superiority in depicting aortic cusp morphologic lesions; left ventricular outflow tract spatial relationships with mitral apparatus and aortic root; and both anterior and posterior mitral leaflet scallops, particularly posterior commissure. CONCLUSIONS: In our study, epicardial RT3DE has been demonstrated to improve morphologic definition of anatomic valvular lesions and their relationship with cardiac adjacent structures. It may be a valid substitute when the 2DTEE approach is contraindicated, or it could have a complementary role, coupled with 2DTEE, to give additional information for surgical planning.