Rachel Lord

Predominance of normal left ventricular geometry in the male ‘athlete's heart’

Aims This study evaluated (a) global LV adaption to endurance versus resistance training in male athletes, (b) LV assessment using by modern imaging technologies and (c) the impact of scaling for body size on LV structural data. Methods A prospective cross-sectional design assessed the LV in 18 elite endurance-trained (ET), 19 elite resistance-trained (RT) and 17 sedentary control (CT) participants. Standard 2D, tissue Doppler and speckle tracking echocardiography assessed LV structure and function. Indexing of LV structures to body surface area (BSA) was undertaken using ratio and allometric scaling. Results Absolute and scaled LV end-diastolic volume (ET: 43.7±6.8; RT: 34.2±7.4; CT 32.5±8.9 mL/m1.5; p<0.05) and LV mass (ET: 29.8±6.6; RT: 25.4±8.7; CT 25.9±6.4 g/m2.7; p < 0.05) were significantly higher in ET compared with RT and CT. LV wall thickness were not different between ET and RT. 65% of ET and 95% of RT had normal geometry. Stroke volume was higher in ET compared with both RT and CT (p<0.05). Whilst regional tissue velocity data were not different between groups, longitudinal and basal circumferential strain (ε) was reduced in RT compared with ET. Conclusions In this comprehensive evaluation of the male athletes heart (AH), normal LV geometry was predominant in both athlete groups. In the ET, 30% demonstrated an eccentric hypertrophy with no concentric hypertrophy in RT. Cardiac ε data in RT require further evaluation, and any interpretation of LV size should appropriately index for differences in body size.

Gender Differences in Ventricular Remodeling and Function in College Athletes, Insights from Lean Body Mass Scaling and Deformation Imaging

Several studies suggest gender differences in ventricular dimensions in athletes. Few studies have, however, made comparisons of data indexed for lean body mass (LBM) using allometry. Ninety Caucasian college athletes (mixed sports) who were matched for age, ethnicity, and sport total cardiovascular demands underwent dual-energy x-ray absorptiometry scan for quantification of LBM. Athletes underwent comprehensive assessment of left and right ventricular and atrial structure and function using 2-dimensional echocardiography and deformation imaging using the TomTec analysis system. The mean age of the study population was 18.9 ± 1.9 years. Female athletes (n = 45) had a greater fat free percentage (19.4 ± 3.7%) compared to male athletes (11.5 ± 3.7%). When scaled to body surface area, male had on average 19 ± 3% (p <0.001) greater left ventricular (LV) mass; in contrast, when scaled to LBM, there was no significant difference in indexed LV mass -1.4 ± 3.0% (p = 0.63). Similarly, when allometrically scaled to LBM, there was no significant gender-based difference in LV or left atrial volumes. Although female athletes had mildly higher LV ejection fraction and LV global longitudinal strain in absolute value, systolic strain rate and allometrically indexed stroke volume were not different between genders (1.5 ± 3.6% [p = 0.63] and 0.0 ± 3.7% [p = 0.93], respectively). There were no differences in any of the functional atrial indexes including strain or strain rate parameters. In conclusion, gender-related differences in ventricular dimensions or function (stroke volume) appear less marked, if not absent, when indexing using LBM allometrically.

The impact of remote ischemic preconditioning on cardiac biomarker and functional response to endurance exercise.

Remote ischemic preconditioning (RIPC; repeated short reversible periods of ischemia) protects the heart against subsequent ischemic injury. We explored whether RIPC can attenuate post‐exercise changes in cardiac troponin T (cTnT) and cardiac function in healthy individuals. In a randomized, crossover design, 14 participants completed 1‐h cycling time trials (TT) on two separate visits; preceded by RIPC (arms/legs, 4 × 5‐min 220 mmHg), or SHAM‐RIPC (20 mmHg). Venous blood was sampled before and 0‐, 1‐, and 3‐h post‐exercise to assess high sensitivity (hs‐)cTnT and brain natriuretic peptide (NT‐proBNP). Echocardiograms were performed at the same time points to assess left and right ventricular systolic (ejection fraction; EF and right ventricular fractional area change; RVFAC, respectively) and diastolic (early transmitral flow velocities; E) function. Baseline hs‐cTnT was not different between RIPC and SHAM. Post‐exercise hs‐cTnT levels were consistently lower following RIPC (18 ± 3 vs 21 ± 3; 19 ± 3 vs 23 ± 3; and 20 ± 2 vs 25 ± 2 ng/L at 0, 1 and 3‐h post‐exercise, respectively; P < 0.05). There was no main effect of time, trial, or interaction for NT‐proBNP and left ventricular EF or RVFAC (all P < 0.05). A main effect of time was evident for E which transiently declined immediately after exercise to a similar level in both trials (0.85 ± 0.04 vs 0.74 ± 0.04 m/s, respectively; P < 0.05). In summary, RIPC was associated with lower hs‐cTnT levels after exercise but there was no independent effect of RIPC for NT‐proBNP or LV systolic and diastolic function. The lower hs‐cTnT levels after RIPC suggests that further research should evaluate the role of ischemia in exercise‐induced elevation in hs‐cTnT.

Acute response and chronic stimulus for cardiac structural and functional adaptation in a professional boxer

The individual response to acute and chronic changes in cardiac structure and function to intense exercise training is not fully understood and therefore evidence in this setting may help to improve the timing and interpretation of pre-participation cardiac screening. The following case report highlights an acute increase in right ventricular (RV) size and a reduction in left ventricular (LV) basal radial function with concomitant increase at the mid-level in response to a weeks increase in training volume in a professional boxer. These adaptations settle by the second week; however, chronic physiological adaptation occurs over a 12-week period. Electrocardiographic findings demonstrate an acute lateral T-wave inversion at 1 week, which revert to baseline for the duration of training. It appears that a change in training intensity and volume generates an acute response within the RV that acts as a stimulus for chronic adaptation in this professional boxer.

Predicting Mortality in Pulmonary Arterial Hypertension: Can It Really Be That Simple?

Echocardiography plays an important role in the diagnosis and monitoring of cardiac structure and function in patients with pulmonary arterial hypertension (PAH) [(1)][1]. The routine application of resting echocardiography allows for the noninvasive assessment of pulmonary and right ventricular (RV

Reproducibility and feasibility of right ventricular strain and strain rate (SR) as determined by myocardial speckle tracking during high-intensity upright exercise: a comparison with tissue Doppler-derived strain and SR in healthy human hearts.

This study aimed to establish feasibility for myocardial speckle tracking (MST) and intra-observer reliability of both MST and tissue velocity imaging (TVI)-derived right ventricular (RV) strain (ϵ) and strain rate (SR) at rest and during upright incremental exercise. RV ϵ and SR were derived using both techniques in 19 healthy male participants. MST-derived ϵ and SR were feasible at rest (85% of segments tracked appropriately). Feasibility reduced significantly with progressive exercise intensity (3% of segments tracking appropriately at 90% maximum heart rate (HRmax)). Coefficient of variations (CoVs) of global ϵ values at rest was acceptable for both TVI and MST (7–12%), with low bias and narrow limits of agreement. Global SR data were less reliable for MST compared with TVI as demonstrated with CoV data (systolic SR=15 and 61%, early diastolic SR=16 and 17% and late diastolic SR=26 and 31% respectively). CoVs of global RV ϵ and SR obtained at 50% HRmax were acceptable using both techniques. As exercise intensity increased to 70 and 90% HRmax, reliability of ϵ and SR values reduced with larger variability in MST. We conclude that RV global and regional ϵ and SR data are feasible, comparable and reliable at rest and at 50% HRmax using both MST and TVI. Reliability was reduced during higher exercise intensities with only TVI acceptable for clinical and scientific use.

Exploratory insights from the right-sided electrocardiogram following prolonged endurance exercise

Abstract Background: Prolonged strenuous exercise has a profound effect on cardiac function. The right heart may be more susceptible to this imposition; yet, right-sided chest leads have not been utilised in this setting. Methods: Thirty highly trained athletes at the 2014 Western States 100-mile Endurance Run from Squaw Valley to Auburn, California (body mass 68 ± 12 kg, age 45 ± 10 years, 57 ± 15 miles per week) were recruited for the study. Pre- and post-race, a right-sided 12-lead ECG was obtained and data were extracted for P, R and S waves, J point, ST segment and T wave amplitude. Data were compared using Students T-test and statistical significance set as P < .05. Results: There was a significant increase in P wave amplitude (29%) and QTc interval (4%) pre- to post-race from standard 12-lead ECG. From the right-sided12-lead ECG, a 23% (P = .01) and 38% (P = .03) increase in J point amplitude in V1R and V2R and a 22% (P = .05) increase in ST segment integral in V2R and V3R were evident. T wave inversion was evident in leads V2R–V6R in 50–90% of athletes, respectively. Close examination revealed marked heterogeneity in individual ECGs. Conclusions: Completion of a 100-mile ultra-marathon resulted in significant changes in the right-sided ECG alongside more marked responses in specific individuals. P wave, ST segment and T wave changes post-race are indicative of acute exercise-induced right heart electrical adaptation.

Right Ventricular Structure and Function in the Veteran Ultramarathon Runner: Is There Evidence for Chronic Maladaptation?

Background It has been proposed that chronic exposure to prolonged strenuous exercise may result in maladaptation of the right ventricle (RV). The aim of this study was to establish RV structure and function, including septal insertion points, using conventional echocardiography and myocardial strain (&egr;) imaging in a veteran population of ultramarathon runners (UR) and age‐ and sex‐matched controls. Methods A retrospective study design provided 40 UR (>35 years old; mean ± SD training experience, 18 ± 12 years) and 24 sedentary controls who had previously undergone conventional two‐dimensional, tissue Doppler and speckle‐tracking echocardiography to measure RV size and function. Peak RV &egr; and strain rate (SR) were assessed from the base, mid, and apical lateral wall. SR were assessed during systole (SRs’), early diastole (SRe′) and late diastole (SRa′). Regional assessment of RV insertion points was made at the basal inferoseptum and apical septum using left ventricular (LV) longitudinal &egr; and at the anteroseptum and inferoseptum using LV circumferential and radial &egr;. Results All structural indices of RV size were significantly larger in UR. RV regional and global peak &egr; were not different between groups, whereas basal RV SR was significantly lower in UR. UR had significantly higher peak LV circumferential &egr; (anteroseptum, −26% ± 8% vs −21% ± 6%; inferoseptum, −25% ± 6% vs −16% ± 9%) and higher peak LV longitudinal &egr; (apical septum, −28% ± 7% vs −22% ± 4%) compared with controls. There was regional heterogeneity in UR that was not observed in controls with significantly lower longitudinal &egr; at the basal inferoseptal insertion point when compared with the global &egr; (−19% ± 2% vs −22% ± 4%). Conclusions Myocardial &egr; imaging highlights no overt maladaptation in this cohort of veteran UR, although lower insertion point &egr;, compared with global &egr;, in UR may warrant further investigation. HighlightsThere is no evidence of overt RV maladaptation in veteran ultrarunners.There is regional variation, specifically at the RV insertion points within the LV seen in veteran ultrarunners, but not matched controls.RV enlargement is a common finding in veteran ultrarunners.

120 Left Ventricular Longitudinal Strain-Volume Relationships in Elite Athletesd

Introduction It is well established that left ventricular (LV) adaption occurs in response to chronic physiological conditioning. There is also evidence highlighting functional differences in myocardial strain imaging between athletes from sporting disciplines. This difference may be a consequence of the vague classification of sport i.e. not taking into account relative static and dynamic components and/or merely a consequence of chamber enlargement. We sought to utilise a novel simultaneous assessment of longitudinal strain and LV volume in athletes classified in the 4 corners of Mitchell’s classification of sporting disciplines. The primary aim was to determine relative longitudinal strain throughout the cardiac cycle and its specific contribution to LV volume change in these athletes. Methods 92 elite male athletes were studied and sub classified based on sporting discipline in accordance with the Mitchell’s classification. (Group IA low static-low dynamic n = 20, Group IC low static-high dynamic n = 25, Group IIIA high static-low dynamic n = 21, Group IIIC high static-high dynamic n = 26). Conventional echocardiography of the LV was undertaken. The raw temporal global longitudinal strain values were exported and divided into 5% time increments across the cardiac cycle. Concomitant LV volumes were traced at each 5% time increment to provide simultaneous strain-volume loops. The strain-volume relationship was assessed by applying a polynomial regression analysis for each systolic and diastolic curve to derive absolute values for% end diastolic volumes (EDV). Results Conventional and peak strain indices are presented in table 1. Athletes in group IC and IIIC had larger LV end diastolic volumes (EDV) compared to athletes in groups IA and IIIA (50 ± 6 and 54 ± 8 ml/(m2)1.5 vs. 42 ± 7 and 43 ± 2 ml/(m2)1.5 respectively). Group IIIC also had significantly larger mean wall thickness (MWT) compared to all groups. Peak strain was variable between groups but once normalised for EDV all groups, with exception of IIIC, required similar strain to generate the same% reduction in EDV (see Figures 1 and 2). Conversely group IIIC required greater longitudinal strain for any given% volume which correlated to MWT (r = 0.4, p < 0.0001).Abstract 120 Table 1 Echocardiographic Parameters PARAMETER GROUP IA GROUP IC GROUP IIIA GROUP IIIC LVDd index (mm/(m2)0.5) 37 ± 3† 39 ± 3 37 ± 3† 40 ± 2*‡ LVEDV index (ml/(m2)1.5) 42 ± 7^† 50 ± 6*‡ 43 ± 2^† 54 ± 8*‡ EF (%) 60 ± 7 58 ± 7 59 ± 5 59 ± 7 MWT index (mm/(m2)0.5) 6.0 ± 0.4† 6.3 ± 0.6 6.3 ± 0.6 6.7 ± 0.7* MaxWT index (mm/(m2)0.5) 6.6 ± 0.7† 7.0 ± 0.7† 7.1 ± 0.7 7.6 ± 0.9*^ LV Mass Index (g/(m)2.7) 33 ± 8† 37 ± 8 35 ± 9† 42 ± 9*‡ LVMass/LVEDV (g/ml) 1.4 ± 0.2 1.4 ± 0.3 1.4 ± 0.3 1.5 ± 0.3 Longitudinal Strain (%) -20 ± 3^‡ -16 ± 2*† -18 ± 2*† -20 ± 3^‡ Symbol denotes P > 0.05 to IA=*, IC=^, IIIA=‡, IIIC=†Abstract 120 Figure 1 Temporal Assessment of Simultaneous Strain and VolumeAbstract 120 Figure 2 Derived Strains for% EDV in the EF range 10 to 70% Conclusion There are physiological differences between athletes with the largest LV demonstrated in athletes from group IIIC. These athletes also have greater resting longitudinal contribution to volume change which, in part, is related to an increased wall thickness. The variance in peak strain seen in the other athlete groups was solely related to chamber size with no intrinsic differences in contractility or relaxation.

Right Ventricular Structure and Function in Senior and Academy Elite Footballers.

Right ventricular (RV) adaptation is a common finding in the athletes heart. The aim of this study was to establish the extent of RV structural and functional adaptation in elite and academy professional footballers compared to age‐matched controls.