COVID-19 in Female and Male Athletes: Symptoms, Clinical Findings, Outcome, and Prolonged Exercise Intolerance-A Prospective, Observational, Multicenter Cohort Study (CoSmo-S).

BACKGROUND: An infection with SARS-CoV-2 can lead to a variety of symptoms and complications, which can impair athletic activity. OBJECTIVE: We aimed to assess the clinical symptom patterns, diagnostic findings, and the extent of impairment in sport practice in a large cohort of athletes infected with SARS-CoV-2, both initially after infection and at follow-up. Additionally, we investigated whether baseline factors that may contribute to reduced exercise tolerance at follow-up can be identified. METHODS: In this prospective, observational, multicenter study, we recruited German COVID elite-athletes (cEAs, n = 444) and COVID non-elite athletes (cNEAs, n = 481) who tested positive for SARS-CoV-2 by PCR (polymerase chain reaction test). Athletes from the federal squad with no evidence of SARS-CoV-2 infection served as healthy controls (EAcon, n = 501). Questionnaires were used to assess load and duration of infectious symptoms, other complaints, exercise tolerance, and duration of training interruption at baseline and at follow-up 6 months after baseline. Diagnostic tests conducted at baseline included resting and exercise electrocardiogram (ECG), echocardiography, spirometry, and blood analyses. RESULTS: Most acute and infection-related symptoms and other complaints were more prevalent in cNEA than in cEAs. Compared to cEAs, EAcon had a low symptom load. In cNEAs, female athletes had a higher prevalence of complaints such as palpitations, dizziness, chest pain, myalgia, sleeping disturbances, mood swings, and concentration problems compared to male athletes (p < 0.05). Until follow-up, leading symptoms were drop in performance, concentration problems, and dyspnea on exertion. Female athletes had significantly higher prevalence for symptoms until follow-up compared to male. Pathological findings in ECG, echocardiography, and spirometry, attributed to SARS-CoV-2 infection, were rare in infected athletes. Most athletes reported a training interruption between 2 and 4 weeks (cNEAs: 52.9%, cEAs: 52.4%), while more cNEAs (27.1%) compared to cEAs (5.1%) had a training interruption lasting more than 4 weeks (p < 0.001). At follow-up, 13.8% of cNEAs and 9.9% of cEAs (p = 0.24) reported their current exercise tolerance to be under 70% compared to pre-infection state. A persistent loss of exercise tolerance at follow-up was associated with persistent complaints at baseline, female sex, a longer break in training, and age > 38 years. Periodical dichotomization of the data set showed a higher prevalence of infectious symptoms such as cough, sore throat, and coryza in the second phase of the pandemic, while a number of neuropsychiatric symptoms as well as dyspnea on exertion were less frequent in this period. CONCLUSIONS: Compared to recreational athletes, elite athletes seem to be at lower risk of being or remaining symptomatic after SARS-CoV-2 infection. It remains to be determined whether persistent complaints after SARS-CoV-2 infection without evidence of accompanying organ damage may have a negative impact on further health and career in athletes. Identifying risk factors for an extended recovery period such as female sex and ongoing neuropsychological symptoms could help to identify athletes, who may require a more cautious approach to rebuilding their training regimen. TRIAL REGISTRATION NUMBER: DRKS00023717; 06.15.2021-retrospectively registered.

COVID-19 in German Competitive Sports: Protocol for a Prospective Multicenter Cohort Study (CoSmo-S).

Objective: It is unclear whether and to what extent COVID-19 infection poses health risks and a chronic impairment of performance in athletes. Identification of individual health risk is an important decision-making basis for managing the pandemic risk of infection with SARS-CoV-2 in sports and return to play (RTP). Methods: This study aims 1) to analyze the longitudinal rate of seroprevalence of SARS-CoV-2 in German athletes, 2) to assess health-related consequences in athletes infected with SARS-CoV-2, and 3) to reveal effects of the COVID-19 pandemic in general and of a cleared SARS-CoV-2 infection on exercise performance. CoSmo-S is a prospective observational multicenter study establishing two cohorts: 1) athletes diagnosed positive for COVID-19 (cohort 1) and 2) federal squad athletes who perform their annual sports medical preparticipation screening (cohort 2). Comprehensive diagnostics including physical examination, laboratory blood analyses and blood biobanking, resting and exercise electrocardiogram (ECG), echocardiography, spirometry and exercise testing added by questionnaires are conducted at baseline and follow-up. Results and Conclusion: We expect that the results obtained, will allow us to formulate recommendations regarding RTP on a more evidence-based level.

Athletes with valvular heart disease and competitive sports: a position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology.

This article provides an overview of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology on sports participation in individuals with valvular heart disease (VHD). The aim of these recommendations is to encourage regular physical activity including sports participation, with reasonable precaution to ensure a high level of safety for all affected individuals. Valvular heart disease is usually an age-related degenerative process, predominantly affecting individuals in their fifth decade and onwards. However, there is an increasing group of younger individuals with valvular defects. The diagnosis of cardiac disorders during routine cardiac examination often raises questions about on-going participation in competitive sport with a high dynamic or static component and the level of permissible physical effort during recreational exercise. Although the natural history of several valvular diseases has been reported in the general population, little is known about the potential influence of chronic intensive physical activity on valve function, left ventricular remodelling pulmonary artery pressure, and risk of arrhythmia. Due to the sparsity of data on the effects of exercise on VHD, the present document is largely based on clinical experience and expert opinion.

Rationale and design of MultiSELECt: A European Multicenter Study on the Effect of Lipoprotein(a) Elimination by lipoprotein apheresis on Cardiovascular outcomes.

BACKGROUND: Dyslipidemia is a well-known risk factor for atherosclerosis and subsequent cardiovascular disease (CVD). While low density lipoprotein cholesterol (LDL-C) is well-established and taken into consideration for risk management and therapy, lipoprotein(a) is another established CVD risk factor frequently not undergoing screening due to a lack of medical treatment options. For patients suffering from CVD due to massive elevation of Lp(a) in presence of normal LDL-C levels, lipoprotein apheresis is the only available treatment option. While this constellation is an accepted indication for lipoprotein apheresis (LA) in Germany, prospective studies including a control group are still lacking. OBJECTIVE: Primary objective of this trial is to evaluate the clinical benefit of lipoprotein apheresis on myocardial infarction, PCI, CABG and death from cardiovascular disease in subjects with elevated Lp(a). This study evaluates the clinical benefit of weekly LA in subjects with progressive cardiovascular disease, as accepted by the German Federal Joint Committee (treatment group). Comparator will be well-matched subjects under maximum tolerated lipid lowering therapy without access to LA treatment (control group). METHODS: MultiSELECt, is a prospective, multicenter, multinational, two-arm matched-pair cohort study designed to directly compare subjects with significantly elevated Lp(a) approved for LA subsequently undergoing weekly apheresis treatment versus a continuation of maximal medical therapy. The follow-up period will be 2 years after the baseline visit and until at least 60 events of the primary end-point occurred in the control group. A central trial expert committee will review all subjects with respect to their potential indication for LA according to established German guidelines in a blinded fashion. All control subjects will be contacted monthly via telephone visits to compensate for the more frequent visits during apheresis. Approximately 150 matched pairs will be necessary to detect an event reduction of at least 10% in subjects under LA treatment. CONCLUSION: The MultiSELECt trial provides the unique opportunity to demonstrate the efficiency of LA on CVD in patients with elevated Lp(a) under strongly controlled conditions.

Incidence of elevated lipoprotein (a) levels in a large cohort of patients with cardiovascular disease.

BACKGROUND: Recently it has been demonstrated that elevated lipoprotein (a) (LPA) levels are associated with an increased risk of cardiovascular disease across multiple ethnic groups. However, there is only scanty data about the incidence of elevated LPA levels in different patient cohorts. As a consequence, we aimed to examine whether patients with elevated LPA levels might be seen more often in a cardiovascular center in comparison to the general population. METHODS: We reviewed LPA concentrations of 52,898 consecutive patients who were admitted to our hospital between January 2004 and December 2014. We subdivided them into different groups according to their LPA levels. Data was compared to available information in medical literature. RESULTS: 26.4% of the patients had LPA levels >30 mg/dl which is in line with the data from literature. Mean level of LPA concentration in our study was twice as high in comparison to the general population (25.8% vs. 13.3%). 4.6% had LPA levels >98 mg/dl (general population <0.3%). CONCLUSION: In patients admitted to a cardiovascular center the proportion of LPA >30 mg/dl is comparable to the general population but mean levels over all are twice as high and the proportion of patients with LPA levels of >98 mg/dl is extremely higher.

Lipoprotein (a) and coronary heart disease - is there an efficient secondary prevention?

Lipoprotein (a) (Lp (a)) is one risk factor for the development of cardiovascular diseases. Several studies have shown that Lp (a) hyperlipoproteinaemia has a particular influence on the development of coronary heart disease (CHD). A retrospective single-centre observation study was performed to evaluate the effectiveness of lipid apheresis on the basis of consecutively performed percutaneous coronary interventions (PCI) in patients with high Lp (a) values and angiographically documented CHD.In 23 pts (male 18, age 60.04 ± 0.58 years) with angiographically documented CHD (first manifestation 48.00 ± 9.41 years), elevated LDL cholesterol (144.39 ± 92.01 mg/dl) and Lp (a) (133.04 ± 39.68 mg/dl), 49 PCI and 3 coronary artery bypass grafting (CABG) procedures had been performed prior to the initiation of lipid apheresis. Following the initiation of weekly lipid apheresis, LDL cholesterol was 99.43 ± 36.53 mg/dl and Lp (a) 91.13 ± 33.02 mg/dl. In a time interval of 59.87 ± 49.49 months (median 51.00, range 1-153 months) 15 pts did not require an additional PCI. In 8 pts (7 pts 3­vessel disease, 1 pt 2­vessel disease) 14 PCI - no CABG - were performed after 69.38 ± 71.67 months (median: 32.50, range 17-232 months). The incidence of PCI could thus be reduced by 71.43%.

[Homozygous hypercholesterolemia - new therapeutic options in cases with complete lack of LDL- receptor]. / Familiäre homozygote Hypercholesterinämie.

Homozygous hypercholesterolemia is an extremely rare genetic disorder caused by mutations in the LDL receptor gene or occasionally by mutations in other genes like proprotein convertase subtilisin / kexin 9 (PCSK9). Gold standard of homozygous hypercholesterolemia therapy is apheresis, accompanied by high-dose statin and ezetimibe therapy. The cholesterol-lowering effect can be supported by new agents like inhibitors of microsomal triglyceride transfer protein (lomitapide), or by enhancing LDL catabolism through inhibition of the PCSK9 activity. We present the case of a young woman with homozygous hyperlipidemia due to a mutation c.1200 C> A(p.Tyr400*) in the LDLR gene that introduces a stop-codon at amino acid position 400. This truncated LDLR cannot mediate a membrane-bound uptake of LDL cholesterol. A combined therapy including simvastatin, ezetimibe and apheresis did not lead to satisfactory LDL levels. By adding lomitapide, a dramatic receptor-independent reduction of LDL was achieved.

Electrical Myostimulation (EMS) Improves Glucose Metabolism and Oxygen Uptake in Type 2 Diabetes Mellitus Patients--Results from the EMS Study.

AIMS: In patients with type 2 diabetes mellitus (T2DM) exercise training is recommended to improve glycemic control. Electrical myostimulation (EMS) of skeletal muscles is a new method to increase exercise capacity in patients with chronic heart failure. The aim of this study was to investigate the effects of EMS in T2DM on glucose metabolism, body composition, and exercise performance using a newly designed stimulation suit that involves trunk, leg, and arm muscles. SUBJECTS AND METHODS: Fifteen individuals (nine males; 61.7±14.8 years old) were trained for 10 weeks twice weekly for 20 min with EMS. Effects on glucose, glycosylated hemoglobin (HbA(1c)), oxygen consumption, and body composition were evaluated. RESULTS: There was a significant increase of oxygen uptake at the aerobic threshold from 12.3±0.8 to 13.3±0.7 mL/kg/min (P=0.003) and of maximal work capacity from 96.9±6.4 to 101.4±7.9 W (P=0.046), with a concomitant trend for improved maximal oxygen uptake (from 14.5±0.9 to 14.7±0.9 mL/kg/min [P=0.059]). Fasting blood glucose level decreased from 164.0±12.5 to 133.4±9.9 mg/dL (P=0.001), and HbA(1c) level decreased from 7.7±0.3% to 7.2±0.3% (P=0.041), whereas mean total weight (from 101.5±4.0 to 103.1±4.3 kg) and proportion of body fat (from 38.8±3.2% to 40.3±3.4%) remained statistically unchanged. CONCLUSIONS: EMS can improve glucose metabolism and functional performance in T2DM patients. These data suggest that EMS might emerge as a novel additional therapeutic mode of exercise training and might help patients to overcome their sedentary lifestyle.

[Extracardiac manifestation of elevated lipoprotein(a) levels--cumulative incidence of peripheral arterial disease and stenosis of the carotid artery]. / Extrakardiale Manifestation der Lipoprotein(a)-Erhöhung--Gehäuftes Auftreten von peripherer arterieller Verschlusskrankheit und Stenosen der Arteria carotis.

BACKGROUND: Elevated lipoprotein(a) (Lp(a)) levels are an accepted risk factor for coronary heart disease. The role of Lp(a) in the development of extracardiac arteriosclerosis like peripheral arterial disease (PAD) and stenosis of the arteria carotis (ACIS) has hardly been documented so far. We aimed to investigate the incidence of extracardiac arteriosclerosis in individuals with elevated Lp(a) values. METHODIK: In our center, we measured Lp(a) levels in 31,734 consecutive patients over 5 years. Of these, 1411 patients were selected retrospectively for the presented analysis. Patients were matched according to age, sex, and other accepted cardiovascular risk factors and were assigned to 6 groups according to their Lp(a) values. Retrospectively, we analysed the incidence of PAD and ACIS. RESULTS: In the group with Lp(a) values < 2 mg/dl the incidence of PAD was 1.9 % (ACIS 2.8 %), in the group with Lp(a) 23-29 mg/dl 7.3 % (6.1 %), 30-60 mg/dl 9.0 % (8.3 %), 60-91 mg/dl 11.4 % (7.9 %), 91-110 mg/dl 8.6 % (6.0 %) and > 110 mg/dl 12.7 % (10.9 %). None of the patients had LDL levels > 130 mg/dl or HbA1c 6.1 %. CONCLUSION: Elevated Lp(a) levels seem to be associated with an increased incidence of PAD and ACIS. Even Lp(a) concentrations between 23 and 29 mg/dl show a threefold increased risk of PAD when compared to patients with Lp(a) < 2 mg/dl. However, these findings have to be verified in large prospective studies. In this context cut-off values have to be reevaluated as well.

Cost-effectiveness of pre-participation screening of athletes with ECG in Europe and Algeria.

The aim of this study is to evaluate the cost-effectiveness of ECG in combination with family and personal history and physical examination in order to detect cardiovascular diseases that might cause sudden death in athletes. The study was conducted on a cohort of 6,634, mainly young professional and recreational athletes, 1,071 from Algeria and 5,563 from Europe (France, Germany and Greece). Each athlete underwent medical history, physical examination, and resting 12-lead ECG. 293 athletes (4.4 %), 149 in Europe (2.7 %) and 144 in Algeria (13.4 %) required further tests, and 56 were diagnosed with cardiovascular disease and thus disqualified. The cost-effectiveness ratio (CER) was calculated as the ratio between the cost of screening and the number of statistical life-years saved by the intervention. The estimated reduced risk of death deriving from treatment or disqualification resulted in the saving of 79.1 statistical life-years in Europe and 136.3 in Algeria. CER of screening was 4,071 purchasing-power-parity-adjusted US dollars ($PPP) in Europe and 582 $PPP in Algeria. The results of this study strongly support the utilisation of 12-lead ECG in the pre-participation screening of young athletes, especially in countries where secondary preventive care is not highly developed.

Elite athletes with mitral or aortic regurgitation and their cardiopulmonary capability.

BACKGROUND: Aortic or mitral valvular regurgitation (left cardiac valvular regurgitation, LCVR) of less than second-degree (< degree II) occasionally found in competitive athletes is of questionable relevance. Precisely detectable by echocardiography there is scarce published data that clarifies cardiopulmonary capacity or any limitations LCVR < degree ll may cause. METHODS: In this single-centre study we consecutively recruited highly trained athletes (n= 14) with LCVR < degree ll detected in 2D echo. Not included were athletes with multi- or right-cardiac valvular dysfunction and structural heart disease other than bicuspid aortic valve or mitral valve prolaps. Target parameters were determined by 2D echo and spiroergometry. RESULTS: There were no significant differences with regard to age and body mass index. Echocardiographically determined muscle mass index was increased in both groups (134 14.7 vs 129.6+/-27.5; P=0.69), whereas the left-ventricular end-diastolic diameter index was significant higher in the LCVR < degree II group (27.3 +/- 1.3 vs 25.2 +/- 2.4; P = 0.04). However, there were no significant differences with regard to (oxygen uptake) V02, at baseline (athletes with LCVR < degree II 5.7 +/- 0.9 vs controls 5 +/- 0.96, P= 0.06), at the anaerobic threshold (athletes with LCVR < degree II 47.3 +/-8.4 vs controls 47.4 +/- 5, P= 0.97) and maximally (VO2max; athletes with LCVR < degree II 57.7 6.3 vs controls 57.1 +/- 5.1, P= 0.81). Neither levels of lactate nor of brain natriuretic peptide differed significantly. CONCLUSION: High level athletes presenting with aortic or mitral regurgitation < degree II in are not disadvantaged with regard to their cardiopulmonary capability.

Electrical myostimulation improves left ventricular function and peak oxygen consumption in patients with chronic heart failure: results from the exEMS study comparing different stimulation strategies.

AIMS: Electromyostimulation (EMS) of thigh and gluteal muscles is a strategy to increase exercise capacity in patients with chronic heart failure (CHF). The aim of this non-randomised pilot study was to investigate the effects of different stimulation strategies in CHF patients using a newly developed stimulation suit also involving trunk and arm muscles [extended electromyostimulation (exEMS)] in comparison with EMS therapy limited to gluteal and leg muscles (limEMS). METHODS: 60 individuals joined the EMS training programme. Stable CHF patients (NYHA class II-III) received either exEMS (22 patients, 15 males, mean age 59.95 ± 13.16 years) or limEMS (12 patients, 9 males, 62.75 ± 8.77 years). 26 participants served as healthy control group (CG) receiving exEMS. Training was performed for 10 weeks twice weekly for 20 min, and the level of daily activity remained unchanged. Effects on exercise capacity, oxygen uptake, left ventricular function (EF) and biomarkers were evaluated. RESULTS: There was a significant increase of oxygen uptake at aerobic threshold in all groups (exEMS: 13.7 ± 3.9-17.6 ± 5.1 ml/kg/min (+28.46%, p < 0.001); limEMS 13.6 ± 3.0-16.0 ± 3.8 ml/kg/min (+17.6 %, p = 0.003); CG 15.0 ± 4.9-17.0 ± 6.4 ml/kg/min (+13.3%, p = 0.005). LVEF increased from 38.3 ± 8.4 to 43.4 ± 8.8% (+13.3%, p = 0.001) (limEMS 37.1 ± 3.0-39.5 ± 5.3% (+6.5%, p = 0.27); CG 53.9 ± 6.7-53.7 ± 3.9% (-0.4%, p = 0.18). In CHF patients changes in oxygen consumption and LVEF were higher in the exEMS group than in limEMS (not significant). Maximal workload improved in healthy controls (p = 0.002) but not in CHF patients. CONCLUSION: Extended EMS can improve oxygen uptake and EF in CHF. In patients with limited EMS and in control patients without heart failure but extended EMS, oxygen uptake can be improved but EF is unaltered. For all groups, NT proBNP is unaffected by EMS.

Position paper: proposal for a core curriculum for a European Sports Cardiology qualification.

Sports cardiology is a new and rapidly evolving subspecialty. It aims to elucidate the cardiovascular effects of regular exercise and delineate its benefits and risks, so that safe guidance can be provided to all individuals engaging in sports and/or physical activity in order to attain the maximum potential benefit at the lowest possible risk. The European Society of Cardiology (ESC) advocates systematic preparticipation cardiovascular screening in an effort to identify competitive athletes at risk of exercise-related cardiovascular events and sudden cardiac death. However, the implementation of preparticipation screening is hindered because of lack of structured training and as a result lack of sufficient expertise in the field of sports cardiology. In 2008 the European Society of Cardiology published a core curriculum for the general cardiologist, in which sports cardiology was incorporated within the topic 'Rehabilitation and Exercise Physiology'. However, the exponential rise in knowledge and the growing demand for expertise in the field of sports cardiology dictates the need to systematically structure the knowledge base of sports cardiology into a detailed curriculum. We envisage that the curriculum would facilitate more uniform training and guideline implementation throughout Europe, and safeguard that evaluation and guidance of competitive athletes or individuals who wish to engage in leisure-time sports activities is performed by physicians with expertise in the field. The current manuscript provides a comprehensive curriculum for sports cardiology, which may serve as a framework upon which universities and national and international health authorities will develop the training, evaluation and accreditation in sports cardiology.

HELP apheresis in hypercholesterolemia and cardiovascular disease: efficacy and adverse events after 8,500 procedures.

INTRODUCTION: Low density lipoprotein (LDL-C) apheresis is a last treatment option for hypercholesterolemic patientsresistant to conservative lipid-lowering therapy. In a retrospective analysis of 8,533 heparin-induced extra-corporeal LDL precipitation apheresis treatments (HELP), we evaluated the efficacy of LDL reduction, the rate of adverse events, and the progression of atherosclerosis. METHODS: Between July 1992 and April 2009, we performed 8,533 HELP apheresis therapies in patients with familial hypercholesterolemia (FH). Inclusion criteria were FH with insufficient lipidological status under optimal drug therapy and diet, and at least 50 HELP therapies. Left ventricular function and valvular status was checked prior to the first apheresis therapy and at the end of the individual HELP program. Blood samples were taken directly before and after each therapy. Blood count, electrolytes, total cholesterol, LDL-C, high density lipoprotein (HDL-C), triglycerides, lipoprotein (a) (Lp(a)), and fibrinogen were measured. Adverse events were documented weekly. RESULTS: We evaluated 27 patients (19 men) with FH (age 49.2 ± 12.5 years (range 10-67 years)). The number of HELP treatments once weekly was between 50 and 790 applications. Mean follow-up time was 7.0 ± 5.2 years (range 1.3-16.6 years). Prior to the individual apheresis program, 44.4% of the patients had a three vessel disease (VD; 25.9% two VD, 25.9% one VD) and 7.4% had a peripheral arterial occlusive disease. During the time of HELP treatment, none of the patients had a myocardial infarction; 3.7% had one percutaneous coronary intervention (PCI), 11.1% two PCI, 14.8% three PCI, 11.1% ≥ PCI. The patients received 1.2 ± 1.6 (range 0-5) PCI during follow-up time. Adverse events directly associated with HELP therapy were very rare (< 3%). Mean elimination of LDL-C was 63.49 ± 7.1%. DISCUSSION: The HELP apheresis therapy was well accepted by the patients in our programs. Adverse events during HELP apheresis were rare. This data is in line with the experiences published by other authors who reported an adverse event rate of 3.6% in adults. The LDL-HDL ratio, one of the strongest predictors of premature CHD events, improved significantly during the apheresis program. CONCLUSION: HELP is a safe, comfortable, and highly effective treatment in which adverse events are rare. It can reduce the burden of atherosclerosis, with no myocardial infarction and a low coronary intervention rate in our patients.

Pre-competition cardiac screening in professional handball players - setting up at the EHF European Handball Championship 2010 in Austria.

In many sports, regular cardiac screening for exercise-associated sudden cardiac death is still not provided. To set up the current situation in top-skilled handball players qualified for the 2010 European Handball Championship in Austria, a standardised questionnaire was sent to every team. The fact that only 42.7% of the players returned the questionnaire may lead to the conclusion that the awareness of the problem is quite low. However, 82% of these players have been screened according to current recommendations. Half of the teams were screened inhomogeneously: 5 players (4.1%) have not been screened within the last years, 1 athlete (0.8%) was screened without an ECG. While 69% of the athletes got their first screening only after the age of 18, 16 players (13.1%) never went through a specific screening ever. We identified 17 athletes (13.9%) with a highly suspicious history, 2 of them (1.6%) never underwent a medical screening at all.

Consensus document regarding cardiovascular safety at sports arenas: position stand from the European Association of Cardiovascular Prevention and Rehabilitation (EACPR), section of Sports Cardiology.

Mass gathering events in sports arenas create challenges regarding the cardiovascular safety of both athletes and spectators. A comprehensive medical action plan, to ensure properly applied cardiopulmonary resuscitation, and wide availability and use of automated external defibrillators (AEDs), is essential to improving survival from sudden cardiac arrest at sporting events. This paper outlines minimum standards for cardiovascular care to assist in the planning of mass gathering sports events across Europe with the intention of local adaptation at individual sports arenas, to ensure the full implementation of the chain of survival.

Real-time three-dimensional transoesophageal echocardiography during percutaneous transcatheter occlusion of mitral periprosthetic paravalvular leak.

We present the case of an 86-year-old female patient with a history of mitral valve replacement due to relevant stenosis. After surgery, an increasing periprosthetic valvular leak (PVL) became obvious causing regurgitation and an increasing haemolysis. Conventional two-dimensional transoesophageal echocardiography (2D TEE) showed a defect of 15 mm length located from the lateral to the posterior circumference subdivided by two surgical sutures into three parts. The patient refused additional surgical therapy. Hence, we suggested a percutaneous transcatheter occlusion of the leakage with a 12 × 5 mm Amplatzer(®) Vascular Plug III device (AVP) (AGA Medical Corporation, Plymouth, MA, USA). The placement of the device was supported indispensably by real-time three-dimensional TEE. The device occluded the leakage nearly completely and downgraded the regurgitation from moderate to neglectable. Also haemolytic parameters improved significantly. V-wave decreased promptly from 70 to 35 mmHg after placing AVP. Percutaneous closure of PVL by AVP, a self-expandable nitinol device approved for peripheral vessel occlusion, is described in limited cases with more or less successful results. It is graded as a technically demanding procedure reserved to poor surgical candidates. The main challenge is finding and intubating the leakage and the correct placement of the device. Three-dimensional TEE seems to be superior to conventional 2D TEE as it allows an easier guidance of the device into the defect. Hence, it is strongly recommended for this intracardiac intervention.

Systolic and early diastolic left ventricular velocities assessed by tissue Doppler imaging in 100 top-level handball players.

BACKGROUND AND OBJECTIVE: Echocardiographic tissue Doppler imaging (TDI) has been proposed for the differentiation of physiologic left ventricular hypertrophy and pathologic left ventricular hypertrophy in athletes. In addition, cutoff values for systolic (S'<9 cm/s) and early diastolic (E'<9 cm/s) myocardial velocities had been defined. The aim of our study was the analysis of the morphologic cardiac changes by standard echocardiography, and the myocardial velocities S' and E' by TDI in top-level handball players with respect to the predefined cutoff values. PATIENTS AND METHODS: Pulsed-wave TDI of the systolic and early diastolic velocities was performed at the lateral and septal mitral annulus (MA) in the four-chamber view in 100 athletes (100 Caucasian men; professional handball players of the first German handball league and the German national team; mean age 25.8+/-4.8 years). RESULTS: Global and regional left ventricular systolic function was normal in all athletes. They showed an eccentric hypertrophy of the left ventricle (LV), which was characterized by an increased mass of the LV (287.3+/-58.4 g), and an increased end diastolic diameter of the LV (LVEDD: 58+/-5.9 mm), but no echomorphologic signs of pathologic hypertrophy or hypertrophic cardiomyopathy. TDI showed a systolic velocity S' of the MA of 9.3+/-1.5 cm/s at the septal and 10.5+/-2.1 at the lateral MA. Ten of the 100 athletes showed a S'<9 cm/s at both sides of the MA. TDI showed an early diastolic velocity E' of the MA of 13.2+/-2.8 cm/s at the septal and of 16.6+/-3.4 cm/s at the lateral MA. None of the 100 athletes showed reduced systolic or early diastolic velocities below the proposed cutoff values (S' and E'<9 cm/s) at any sides of the MA. CONCLUSION: Our study provides further insights into systolic and diastolic function as assessed by TDI in top-level handball players. Owing to the large cohort of individuals, our findings might be helpful as reference values for the echocardiographic assessment of handball players, who are performing a moderate static and high dynamic sport.