Flavio D’Ascenzi

Morphological and Functional Adaptation of Left and Right Atria Induced by Training in Highly Trained Female Athletes

Background—Exercise is able to induce atrial remodeling in top-level athletes. However, evidence is mainly limited to men and based on cross-sectional studies. The aim of this prospective, longitudinal study was to investigate whether exercise is able to influence left and right atrial morphology and function also in female athletes. Methods and Results—Two-dimensional echocardiography was performed before season and after 16 weeks of intensive training in 24 top-level female athletes. Left and right atrial myocardial deformation was assessed by two-dimensional speckle-tracking echocardiography. Left atrial volume index (24.0±3.6 versus 26.7±6.9 mL/m2; P<0.001) and right atrial volume index (15.66±3.09 versus 20.47±4.82 mL/m2; P<0.001) significantly increased after training in female athletes. Left atrial global peak atrial longitudinal strain and peak atrial contraction strain significantly decreased after training in female athletes (43.9±9.5% versus 39.8±6.5%; P<0.05 and 15.5±4.0% versus 13.9±4.0%; P<0.05, respectively). Right atrial peak atrial longitudinal strain and peak atrial contraction strain showed a similar, although non-significant decrease (42.8±10.6% versus 39.3±8.3%; 15.6±5.6% versus 13.1±6.1%, respectively). Neither biventricular E/e′ ratio nor biatrial stiffness changed after training, suggesting that biatrial remodeling occurs in a model of volume rather than pressure overload. Conclusions—Exercise is able to induce biatrial morphological and functional changes in female athletes. Biatrial enlargement, with normal filling pressures and low atrial stiffness, is a typical feature of the heart of female athletes. These findings should be interpreted as physiological adaptations to exercise and should be considered in the differential diagnosis with cardiomyopathies.

Left ventricular twisting as determinant of diastolic function: a speckle tracking study in patients with cardiac hypertrophy.

Purpose: Left ventricular hypertrophy (LVH) can develop in response to training with morphological changes in the heart and to pathological increase in afterload such as in essential hypertension. Deformation analysis using two‐dimensional (2D) strain echocardiography can detect early systolic function abnormalities in patients with LVH. The aim of this study was to characterize left ventricular twisting (LVT) modifications, in professional athletes, compared with control subjects and with patients with hypertensive cardiopathy. Methods: Seventy‐six patients were enrolled: 37 professional athletes with cardiac hypertrophy (group A), 22 patients with early hypertensive cardiopathy (group B) cross‐matched for LV mass index, and 17 healthy controls (group C), with no evidence of cardiac hypertrophy. All patients had no concomitant cardiac disease. All patients were investigated at rest using transthoracic echocardiography. LVT was obtained with speckle tracking analysis, using dedicated software. Results: LVT was reduced in group A compared to group B and C (group A: 8.0°± 2.4°; group C: 10.3°± 2.3°; group B: 16.0°± 4.2°; P < 0.01). In overall population, LVT showed a significant correlation with transmitral flow pattern (r =–0.58, P < 0.01) and with age (r =–0.57, P < 0.01). LVT showed the best predictive value to diagnose diastolic dysfunction (AUC: 0.86, P < 0.0001). Conclusions: 2D strain can identify specific patterns of myocardial deformation in professional athletes, controls, and patients with early hypertensive cardiopathy. In our study LVT showed a parallel trend with modifications of diastolic function and could represent a promising tool to differentiate functional cardiac hypertrophy from hypertensive cardiac hypertrophy. (Echocardiography 2011;28:892‐898)

Dynamic changes in left ventricular mass and in fat-free mass in top-level athletes during the competitive season.

Background Previous cross-sectional studies have demonstrated that fat-free mass (FFM) is an important determinant of left ventricular mass (LVM) in athletes. However, cross-sectional investigations have not the ability to detect the dynamic adaptation occurring with training. We hypothesized that LVM adapts concurrently with the increase of FFM induced by exercise conditioning. We sought to study the relationship between the variations of LVM and of FFM occurring in top-level soccer players during the season. Methods Twenty-three male top-level athletes were recruited. LVM was assessed by echocardiography and FFM by dual-energy X-ray absorptiometry. Serial measurements were performed pre-season, after 1 month, at mid- and end-season, and after 2 months of detraining. Results LVM significantly increased at mid-season versus pre-season values, reaching the highest value at the end of the season (p < 0.05). While body weight did not vary during the study period, FFM significantly increased (p < 0.05 for mid-/end-season vs. pre-season data). After the detraining, no significant differences were observed between pre-season and detraining echocardiographic data. The only independent predictors of LVM were left ventricular stroke volume and FFM (R = 0.36, p = 0.005; R = 0.35, p = 0.005, respectively). When ΔLVM index was set as dependent variable, the only independent predictor was ΔFFM (R = 0.87, p = 0.002). Conclusions Changes in LVM occur in close association with changes in FFM, suggesting that the left ventricle adapts concurrently with the increase of the metabolically active tissue induced by training, i.e. the FFM. Therefore, the dynamic changes in FFM and LVM may reflect a physiological adaptation induced by intensive training.

Spontaneous coronary artery dissection in a middle-age woman: percutaneous treatment guided by intracoronary imaging techniques.

: Angiographic diagnosis and treatment of spontaneous coronary artery dissection is challenging. Complementary use of intracoronary imaging can provide information to guide percutaneous treatments, particularly in these challenging settings. Here we report a case of a 52-year-old woman presenting with an anterior ST-segment elevation myocardial infarction caused by a spontaneous, long, and spiral dissection of the left anterior descending artery. Intracoronary imaging allowed us to visualize the entry port of the coronary dissection which was not sealed by the first angio-guided stenting. This case demonstrates that, beyond merely diagnostic information, the intracoronary imaging is able to provide information to guide percutaneous treatments, particularly in challenging settings in which coronary angiography reveals its limitations.

Two-dimensional and three-dimensional left ventricular deformation analysis: a study in competitive athletes.

Two-dimensional (2D) speckle-tracking echocardiography (STE) has clarified functional adaptations accompanying the morphological features of ‘athlete’s heart’. However, 2D STE has some limitations, potentially overcome by three-dimensional (3D) STE. Unfortunately, discrepancies between 2D- and 3D STE have been described. We therefore sought to evaluate whether dimensional and functional differences exist between athletes and controls and whether 2D and 3D left ventricular (LV) strains differ in athletes. One hundred sixty-one individuals (91 athletes, 70 controls) were analysed. Athletes were members of professional sports teams. 2D and 3D echocardiography and STE were used to assess LV size and function. Bland–Altman analysis was used to estimate the level of agreement between 2D and 3D STE. Athletes had greater 2D and 3D-derived LV dimensions and LV mass (p < 0.0001 for all), while 2D- and 3D-derived LV ejection fraction did not differ as compared with controls (p = 0.82 and p = 0.89, respectively). Longitudinal, radial, and circumferential strains did not differ between athletes and controls, neither by 2D nor by 3D STE. Three-dimensional longitudinal and circumferential strain values were lower (p < 0.0001 for both) while 3D radial strain was greater, as compared with 2D STE (p < 0.001). Bland–Altman plots demonstrated the presence of an absolute systematic error between 2D and 3D STE to analyse LV myocardial deformation. 3D STE is a useful and feasible technique for the assessment of myocardial deformation with the potential to overcome the limitations of 2D imaging. However, discrepancies exist between 2D and 3D-derived strain suggesting that 2D and 3D STE are not interchangeable.

The Young Community of the European Association of Preventive Cardiology: The future in motion

The mission of the European Association of Preventive Cardiology (EAPC) is to promote excellence in research, practice, education and policy in cardiovascular health, primary and secondary prevention. To accomplish that, collaboration with a representative group of professionals working in the field of preventive cardiology is pivotal. Therefore, young professionals (i.e. physicians, researchers and allied professionals interested in cardiovascular prevention, basic science, cardiac rehabilitation and sports cardiology aged less than 40 years) are essential to drive the future agenda of the association and they need to find a common home within its structure, hence the development of a young community. Young professionals play a pivotal role within the association. They are fresh from school loaded with the most recent knowledge. They have the drive to change the world. They are open for interaction, regardless of the specific scientific background, and to collaborate in common scientific projects and research. They are familiar with the latest gizmos and are used to communicate through social media. In addition, a survey among young cardiologists of the European Society of Cardiology (ESC) identified a need for strong young communities within the ESC. Since 2009, 10 young communities have been created, representing and accommodating young professionals from different fields in cardiology (e.g. general cardiology, interventional cardiology). In 2015, the EAPC Young Community (YC) was created to increase interaction among young professionals interested in prevention, rehabilitation and sports cardiology, to share experiences and ideas for new research projects. The first YC meeting was held during the EuroPrevent 2015 in Lisbon where young EAPC members under 40 years of age were invited and had a first exchange of research interests and discussion for future plans. The first dedicated EAPC YC scientific session during EuroPrevent 2017, in Malaga, created a stimulating platform for the interaction between junior and senior researchers in the field of preventive cardiology.

Echocardiographic evaluation of paediatric athlete’s heart

Cardiac remodelling induced by athletic conditioning, the so-called ‘athlete’s heart’, is considered a physiologic adaptation to training with no clinical consequences. Despite an increasing number of children being involved in competitive sports, the trend for more intensive training loads and the very young age at which pre-adolescents are being encouraged to start competitive events, most of the studies on athlete’s heart have been carried out in adults or, rarely, in adolescent individuals. Unfortunately, data derived from adults cannot be transferable to children, as they are physically less mature and exposed to a shorter intensity and duration of training, and, as a consequence, the magnitude of cardiac adaptation is less than that described in adult athletes. Recently, studies on paediatric athlete’s heart have been published, demonstrating that the physiological adaptation of athlete’s heart can be observed also in children practising competitive sports and refuting the notion of a ‘maturational threshold’ that must be surpassed for significant cardiac dimensional influences of training to be manifested. Accordingly, these preliminary data suggest that the application of normative reference values derived from the general population could be a potential source of misdiagnosis and should be applied with caution in children practising sport. Although the distinction between training-induced remodelling and life-threatening cardiac pathologies is crucial, differentiating between paediatric athlete’s heart and cardiovascular abnormalities remains a clinical challenge, particularly in children engaged in a high-intensity/ high-volume training programme. Therefore, studies aimed to establish normative references values are welcome. A recent meta-analysis describes structural and functional manifestations of paediatric athlete’s heart by electrocardiogram and echocardiography, providing relevant clinical information about means and 95% confidence intervals of echocardiographic data of left ventricular size and function on more than 14,000 children practising competitive sports. In the study by Cavarretta and collaborators 2151 consecutive, healthy, peri-pubertal male athletes practising soccer (mean age 12.4 1.4 years, range 8–18 years; training volume: 7.2 1.1 h/week) were retrospectively evaluated in order to establish normal echocardiographic measurements of left heart (aortic root, left atrium and left ventricular dimensions and mass) in relation to age, weight, height, body mass index, body surface area and training hours. In this paper, the authors offer a promising tool in the echocardiographic evaluation of the tricky grey zone between athlete’s heart and pathology in children, providing equations for calculating Z scores for left ventricular, left atrial and aortic size in paediatric athlete’s heart. Calculation of Z scores involves assessment of the distribution of measurement values across a range of body sizes in the normal population and, specifically for athletes, in the normal population of subjects practising competitive sports. The Z score of a measurement is the number of standard deviations of that value from the mean value at a particular body surface area (BSA). In other words, a Z score of zero corresponds to a measurement equal to the population mean for that particular BSA, a Z score of þ2 or a measurement that is two standard deviations above or below the mean for that particular BSA, thresholds that usually represent the upper or lower limits of normal. Z scores can be converted to percentiles, though the magnitude of an abnormality is much easier to appreciate with Z scores than with percentiles. Given the widely recognised impact of chronological age and somatic growth on paediatric echocardiographic variables, Z scores – accounting for the effect of body size and chronological age – are useful for differential diagnosis when normative data are available. Indeed, the recommendations for quantification methods of paediatric echocardiography, endorsed by the writing group of the American Society of Echocardiography Paediatric and Congenital

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.