Cataldo Pisicchio

Long-Term Clinical Consequences of Intense, Uninterrupted Endurance Training in Olympic Athletes

OBJECTIVES The aim of this study was to assess incidence of cardiac events and/or left ventricular (LV) dysfunction in athletes exposed to strenuous and uninterrupted training for extended periods of time. BACKGROUND Whether highly intensive and uninterrupted athletic conditioning over a long period of time might be responsible for cardiac events and/or LV dysfunction is unresolved. METHODS We assessed clinical profile and cardiac dimensions and function in 114 Olympic athletes (78% male; mean age 22 +/- 4 years), free of cardiovascular disease, participating in endurance disciplines, who experienced particularly intensive and uninterrupted training for 2 to 5 consecutive Olympic Games (total, 344 Olympic events), over a 4- to 17-year-period (mean 8.6 +/- 3 years). RESULTS Over the extended period of training and competition, no cardiac events or new diagnoses of cardiomyopathies occurred in the 114 Olympic athletes. Global LV systolic function was unchanged (ejection fraction: 62 +/- 5% to 63 +/- 5%; p = NS), and wall motion abnormalities were absent. In addition, LV volumes (142 +/- 26 ml to 144 +/- 25 ml; p = 0.52) and LV mass index (109 +/- 21 g/m(2) to 110 +/- 22 g/m(2); p = 0.74) were unchanged, and LV filling patterns remained within normal limits, although left atrial dimension showed a mild increase (37.8 +/- 3.7 mm to 38.9 +/- 3.2 mm; p < 0.001). CONCLUSIONS In young Olympic athletes, extreme and uninterrupted endurance training over long periods of time (up to 17 years) was not associated with deterioration in LV function, significant changes in LV morphology, or occurrence of cardiovascular symptoms or events.

Prevalence and Clinical Significance of Aortic Root Dilation in Highly Trained Competitive Athletes

Background— Few data are available that address the impact of athletic training on aortic root size. We investigated the distribution, determinants, and clinical significance of aortic root dimension in a large population of highly trained athletes. Methods and Results— Transverse aortic dimensions were assessed in 2317 athletes (56% male), free of cardiovascular disease, aged 24.8±6.1 (range, 9 to 59) years, engaged in 28 sports disciplines (28% participated in Olympic Games). In males, aortic root was 32.2±2.7 mm (range, 23 to 44; 99th percentile=40 mm); in females, aortic root was 27.5±2.6 mm (range, 20 to 36; 99th percentile=34 mm). Aortic root was enlarged ≥40 mm in 17 male (1.3%) and ≥34 mm in 10 female (0.9%) subjects. Over an 8-year follow-up period, aortic dimension increased in these male athletes (40.9±1.3 to 42.9±3.6 mm; P<0.01) and dilated substantially (to 50, 50, and 48 mm) in 3, after 15 to 17 years of follow-up, in the absence of systemic disease. Aortic root did not increase significantly (34.9±0.9 to 35.4±2.1 mm; P=0.11) in female athletes. Multiple regression and covariance analysis showed that aortic dimension was largely explained by weight, height, left ventricular mass, and age (R2=0.63; P<0.001), with type of sports training having a significant but lower impact (P<0.003). Conclusions— An aortic root dimension >40 mm in highly conditioned male athletes (and >34 mm in female athletes) is uncommon, is unlikely to represent the physiological consequence of exercise training, and is most likely an expression of a pathological condition, mandating close clinical surveillance.

Three-Dimensional Echocardiographic Characterization of Left Ventricular Remodeling in Olympic Athletes

The aim of the present study was to assess, using 3-dimensioanl echocardiography, the morphologic characteristics, determinants, and physiologic limits of left ventricular (LV) remodeling in 511 Olympic athletes (categorized in skill, power, mixed, and endurance sport disciplines) and 159 sedentary controls matched for age and gender. All subjects underwent 3-dimensional echocardiography for the assessment of LV volumes, ejection fraction, mass, remodeling index (LV mass/LV end-diastolic volume), and systolic dyssynchrony index (obtained by the dispersion of the time to minimum systolic volume in 16 segments). Athletes had higher LV end-diastolic volumes (157 ± 35 vs 111 ± 26 ml, p <0.001) and mass (156 ± 38 vs 111 ± 25 g, p <0.001) compared to controls. Body surface area and age had significant associations with LV end-diastolic volume (R(2) = 0.49, p <0.001) and mass (R(2) = 0.51, p <0.001). Covariance analysis showed that also gender and type of sport were significant determinants of LV remodeling; in particular, the highest impact on LV end-diastolic volume and mass was associated with male gender and endurance disciplines (p <0.001). Regardless of the type of sport, athletes had similar LV remodeling indexes to controls (1.00 ± 0.06 vs 1.01 ± 0.07 g/mL, p = 0.410). No differences were found between athletes and controls for the ejection fraction (62 ± 5% and 62 ± 5%, p = 0.746) and systolic dyssynchrony index (1.06 ± 0.40% and 1.37 ± 0.41%, p = 0.058). In conclusion, 3-dimensional echocardiographic morphologic and functional assessment of the left ventricle in Olympic athletes demonstrated a balanced adaptation of LV volume and mass, with preserved systolic function, regardless of specific disciplines participated.

Patterns of Left Ventricular Longitudinal Strain and Strain Rate in Olympic Athletes

BACKGROUND Two-dimensional speckle-tracking echocardiography is an emerging modality for the assessment of systolic and diastolic myocardial deformation in a broad variety of clinical scenarios. However, normal values and physiologic limits of left ventricular strain and strain rate in trained athletes are largely undefined. METHODS Two hundred consecutive Olympic athletes (grouped into skill, power, mixed, and endurance disciplines) and 50 untrained controls were evaluated by two-dimensional speckle-tracking echocardiography. Left ventricular global systolic longitudinal strain (GLS), systolic strain rate, early diastolic strain rate (SRE) and late diastolic strain rate (SRA) were calculated. RESULTS GLS was normal, although mildly lower, in athletes compared with controls (-18.1 ± 2.2% vs -19.4 ± 2.3%, P < .001), without differences related to type of sport. Systolic strain rate was also lower in athletes (-1.00 ± 0.15 vs -1.11 ± 0.15 sec(-1), P < .001), with the lowest value in endurance disciplines (-0.96 ± 0.13 sec(-1), P < .001). No difference existed for SRE (1.45 ± 0.32 vs 1.51 ± 0.35 sec(-1), P = .277), while SRA was lower in athletes (0.67 ± 0.25 vs 0.81 ± 0.20 sec(-1), P < .001). Both SRE (1.37 ± 0.30 sec(-1), P < .001) and SRA (0.62 ± 0.23 sec(-1), P < .001) showed the lowest values in endurance disciplines. The fifth and 95th percentiles calculated as reference values in athletes were as follows: for GLS, -15% and -22%; for systolic strain rate, -0.8 and -1.2 sec(-1); for SRE, 1.00 and 2.00 sec(-1); and for SRA, 0.30 and 1.20 sec(-1). CONCLUSION The present study shows that highly trained athletes have normal GLS and strain rate parameters of the left ventricle, despite mild differences compared with untrained controls. These data may be implemented as reference values for the clinical assessment of the athletes and to support the diagnosis of physiologic cardiac adaptations in borderline cases.

European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) joint position statement: recommendations for the indication and interpretation of cardiovascular imaging in the evaluation of the athlete’s heart

Antonio Pelliccia (Chairperson), Stefano Caselli (Co-chairperson)*, Sanjay Sharma, Cristina Basso, Jeroen J. Bax, Domenico Corrado, Antonello D’Andrea, Flavio D’Ascenzi, Fernando M. Di Paolo, Thor Edvardsen, Sabiha Gati, Maurizio Galderisi, Hein Heidbuchel, Alain Nchimi, Koen Nieman, Michael Papadakis, Cataldo Pisicchio, Christian Schmied, Bogdan A. Popescu, Gilbert Habib, Diederick Grobbee, and Patrizio Lancellotti (Chairperson)

Prominent left ventricular trabeculations in competitive athletes: A proposal for risk stratification and management

BACKGROUND Recently, an unexpectedly large prevalence of Left Ventricular Non Compaction (LVNC) has been reported in athletes, raising the question of the appropriateness of current diagnostic criteria. We sought to describe prevalence and clinical characteristics of athletes with suspected LVNC in a large cohort of Olympic athletes. METHODS Over 29months, 2501 consecutive athletes underwent a cardiac evaluation including physical examination, ECG, exercise test and echocardiography. Additional investigations (Cardiac Magnetic Resonance and/or genetic testing) were selectively performed in athletes with abnormal ECGs, ventricular arrhythmias, borderline LV dysfunction or positive family history. RESULTS Of the 2501 athletes, 36 (1.4%) showed prominent trabeculations suggestive for LVNC. Of these, 3 (0.1%) were considered to be affected by LVNC, based on presence of LV dysfunction (ejection fraction<50%) and/or positive family history and genetic testing; these athletes were cautiously restricted from competitions and entered a clinical follow-up program. The remaining 33 athletes, in the absence of LV impairment or familial cardiac diseases, were considered normal (n=24) or unlikely affected (n=9), regardless of the extent of the trabeculations. CONCLUSIONS In a large athlete population, a marked LV trabecular pattern was seen in 1.4%. Only a small subset of these athletes (0.1%) showed familial, clinical and morphologic changes supporting the diagnosis of LVNC. In the vast majority of the athletes, the increased trabeculations were not associated with LV dysfunction and/or positive family history, likely representing a morphologic LV variant, deprived of clinical significance.

Are Olympic athletes free from cardiovascular diseases? Systematic investigation in 2352 participants from Athens 2004 to Sochi 2014

Context Olympic athletes represent model of success in our society, by enduring strenuous conditioning programmes and achieving astonishing performances. They also raise scientific and clinical interest, with regard to medical care and prevalence of cardiovascular (CV) abnormalities. Objective Our aim was to assess the prevalence and type of CV abnormalities in this selected athletes cohort. Design, setting and participants 2352 Olympic athletes, mean age 25±6, 64% men, competing in 31 summer or 15 winter sports, were examined with history, physical examination, 12-lead and exercise ECG and echocardiography. Additional testing (cardiac MRI, CT scan) or electrophysiological assessments were selectively performed when indicated. Main outcome measures Prevalence and type of CV findings, abnormalities and diseases found in Olympic athletes over 10 years. Results A subset of 92 athletes (3.9%) showed abnormal CV findings. Structural abnormalities included inherited cardiomyopathies (n=4), coronary artery disease (n=1), perimyocarditis (n=4), myocardial bridges (n=2), valvular and congenital diseases (n=45) and systemic hypertension (n=10). Primary electrical diseases included atrial fibrillation (n=2), supraventricular reciprocating tachycardia (n=14), complex ventricular tachyarrhythmias (non-sustained ventricular tachycardia, n=7; bidirectional ventricular tachycardia, n=1) or major conduction disorders (Wolff-Parkinson-White (WPW), n=1; Long QT syndrome (LQTS), n=2). Conclusions Our study revealed an unexpected prevalence of CV abnormalities among Olympic athletes, including a small, but not negligible proportion of pathological conditions at risk. This observation suggests that Olympic athletes, despite the absence of symptoms or astonishing performances, are not immune from CV disorders and might be exposed to unforeseen high-risk during sport activity.

UPPER LIMITS AND CLINICAL CORRELATES OF BLOOD PRESSURE RESPONSE TO EXERCISE IN OLYMPIC ATHLETES

Scarce information exist relative to the behavior of blood pressure during exercise in high-level athletes. We sought to define the upper limits of blood pressure response in elite athletes and describe clinical and morphologic characteristics of those with higher values. 1,140 athletes, divided

LONG-TERM SIGNIFICANCE OF EXERCISE-INDUCED VENTRICULAR TACHYARRHYTHMIAS IN ATHLETES WITHOUT CARDIOVASCULAR ABNORMALITIES

Abstract Category: 27. Clinical Electrophysiology—Ventricular ArrhythmiasSession-Poster Board Number: 1057-382 Authors: Luisa Verdile, Emanuele Guerra, Elvira De Blasiis, Roberto Ciardo, Filippo Quattrini, Fernando M. Di Paolo, Cataldo Pisicchio, Barbara Di Giacinto, Alessandro Biffi, Antonio Pelliccia, Institute of Sport Medicine and Science, Roma, Italy Background: Sudden death in athletes is presumably related to life-threatening ventricular arrhythmias occuring during sport activities. There are few data on clinical significance and risk for ventricular arrhythmias induced by exercise in athletes without apparent structural heart disease. To assess long-term clinical significance of exercise-induced tachyarrhythmias in athletes.Methods: We selected 12 athletes without cardiovascular abnormalities and frequent and/or complex ventricular arrhythmias. Selection criteria were the occurrence of ≥10 premature ventricular depolarization (PVDs) and/or ≥ 1 couplet induced by exercise test.The follow-up period was 9,18 ± 4,66 years during which the athletes underwent clinical evaluations, ECG and color-doppler echocardiography, 24-hours Holter monitoring and selectively, electrophysiologic study and cardiac magnetic resonance with late enhancement.Results: During the follow-up no athlete developed symptoms, events or evidence of cardiomyopathies. In 6 athletes (50%) the arrhythmias disappeared (in 2 athletes) or was substantially reduced (in 4).In 3 athletes arrhythmia was unchanged and in 2 worsened. These latter athletes underwent successfull radio-frequency ablation to allow resumption of athletic activity. A right ventricular outflow tract PVDs morphology was documented in 8 athletes (67%).Conclusions: Exercise induced ventricular arrhythmias in athletes without evidence of structural heart disease are associated with a good clinical outcome and with a trend of reduction over 9 years of follow-up.

A Young Rower with an Unusual Left Ventricular Hypertrophy

This 18-year-old male, elite rower was referred for cardiologic evaluation to our Institution for the presence of abnormal repolarization pattern on the 12-lead ECG, performed elsewhere in the setting of national preparticipation screening program. The athlete was engaged in daily training sessions of approximately 6 hours(h), mostly on the water but also in the gym. He had competed in several international events, including Olympic Games, and was gold and silver medallist in the World Rowing Championship. The personal history was negative for symptoms or cardiac disease. The father had systemic hypertension with mild renal dysfunction. No other known cardiovascular diseases or premature (<50 years) sudden cardiac death among relatives were reported.