Echocardiography of the young athlete: Where are the limits? 24 èmes Journées Européennes de la Société Française de cardiologie janvier 2014

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1 Echocardiography of the young athlete: Where are the limits? 24 èmes Journées Européennes de la Société Française de cardiologie janvier 2014 Sylvain GUERARD LYON-BRON

2 Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company Company One Company Two Company Three Company Four Company Five Company Six Company Seven

3 You said athlete? Training 6-8h/week; > 6 month; > 60% VO2 max No symptom and powerful VO2 > 150% Fagard R. Heart 2003

4 Athlete s Heart Pluim BM et al, Circulation, 2000, 101 : Urhausen A et Kinderman W, Sports Med, 1999, 28(4) : LEFT VENTRICULAR DILATATION LVWT : +2 to 3 mm LVED: +3 to 6 mm LEFT VENTRICULAR HYPERTROPHY

5 LVED > 60 mm? 442 athletes, 13 sports 5.8% > 60 mm (max 65 mm) in males 0 % > 60 mm in females Whyle GP Eur. J. App. Physiol. 2004;92: athletes 38 sports LVEDD 55 mm (43-70) males vs 48 mm (38-66) females 14% > 60 mm Pelliccia Ann Intern Med 1999;130: 3 Ultrarunners (100kms) 291 athlètes : LVEDD 61,8 ± 6,9 mm LVEDD > 70 mm: 11% Nagashima JACC 2003;42: adolescent athletes 15,7 years (14-18) LVED 50,8 mm vs 47,9 LVEDDi 29,3 mm/m2 vs 28,3 18% 55 mm Mc KENNA Heart 2005;91:495 LVEDD index mm/m2 BSA Teenagers: 29-30, Males: 31-32, and Females: mm/m2

6 Distribution of LVWT in athletes: 3500 Highly trained british athletes LVWT > 12mm in 1.5% Maximal value 16 mm Basavarajaiah S J Am Coll Cardiol 2008;51: Our personal serie 200 athletes LVWT : 9.5 ± 1.5 No > 13 mm 1232 elite athletes 357 females 875 males Kervio G et al. 2008

7 Distribution of LVWT in athletes: the female athletes 240 nationally ranked black athletes and 200 white athletes 21 ± 4,6 years LVWT : 9,2±1,2 vs 8,6±1,2 mm (p<0.001) Only 8 black female athletes (3%) > 11mm None white > 11mm Rawlins J Circulation 2010;121: Italian female athletes LVWT maxi :12 mm Pelliccia A, Maron BJ et al. J Am Med Assoc 1996;276:211-5

8 Left Ventricular Hypertrophy in black athletes 300 Black athletes vs 300 White athletes 18% Basavarajaiah S J Am Coll Cardiol 2008;51: % Papadakis M Br.J.Sports Medecine 2012

9 Distribution of LVWT in athletes: the junior elite athletes 720 junior elite athletes vs 250 teenager 15,7 ± 1,4 years LVWT : 9,5±1,7 vs 8,4±1,4 3 males (0.4%) > 12 mm > 16 years No female > 11mm Sharma S JACC 2002;40: teenagers top-level athletes years 66 males + 41 females LVWT 8,1±1,2 mm (6-11 mm) Griffet V. Ann Card Angeiol 2013; 62:

10 Athlete s Heart or HCM Male athlete 15 mm white 16 mm black Female athlete 11 mm white 13 mm black teenager (12-18) 11 mm female 12 mm male Impact of extreme anthropometry +++ Riding NR B.Jr.Sports medecine 2012

11 Effectif Left ventricular diastolic function Hypernormal function 35 athletes (22 years) long distance competitive swimmer Ea (cm/s): 28 +/- 6 vs 16 +/- 4 cm/s Pio Caso et al.: Am J Cardiol highly trained rowing athletes (20,7 years) Ea (cm/s): 19,2 +/-3,8 vs 14,8 +/-3,5 cm/s S.Zoncu et al. J Am Soc Echocardiogr 2002 Distribution des valeurs de Ea % % e : 18.6 ± 3.0 cm/s E/e : 5.2 ± Valeurs de Ea Griffet V Arch Mal Cœur Vaiss 2007;100(10):809-15

12 e /a and s mitral (pulsed DTI) 650 athletes 350 endurance athletes (ATE) 280 power athletes (ATP) e and a inferospetal and anterolateral sites e /a > 1 (both sites) in 100% e 16±5 cm/s (anterolateral) 14±3 cm/s (inferoseptal) e a D Andrea A. JASE 2010;23: handball players infero-septal and antero-lateral sites e : 16,6±3,4 cm/s (anterolateral) 13,2±2,8 cm/s (inferolateral) none with s <9 cm/s and e <9 cm/s at any sites of the mitral annulus Butz T EJCVPR 2010;17:342 Pathological LV hypertrophy e (inferior or latéral) < 16 cm/s Se=100% Sp=95% s moyen (4 sites) < 9 cm/s Se=73% Sp=97% s

13 Is it enough?

14 2D strain: speckle tracking Regional and global longitudinal strain 20 athletes, 15 HCM and 18 controls GLS -15,2% vs -8,1% vs -16,0% Cut off -10% Se 86% Sp 95% Combination of DTI (s +e/2 ) and 2DS (GLS) cut off values Se=100% Sp=95% BUTZ Th Int.J Cardiovasc Imaging 2010;27: athletes (280 ATP and 370 ATE) LV GLS -17% overall, -17,2% ATP, -18,1% ATE 90% of athletes: GLS -16% s 10 cm/s, e 16 cm/s D Andrea A. JASE 2010;23:1281

15 Rugbyman: IVWT 13 mm, e = 9,55 cm/s, GLS= -14% 45 bodybuilders vs controls IVWT (mm) 2DS (GLS%) 25 steroids + 12,3-15 ± 5 20 steroids - 11,2-20 ± 6 25 controls 9,3-19 ± 6 D Andréa Br. J. Sport Méd.

16 Trabeculations or LV non compaction 1146 athletes (14-35 yrs ) vs 415 controls 63.3% males Higher prevalence of increased LV trabeculation 18.3% vs 7% 8.1% fulfilled conventional criteria of LVNC Location Apical in LV non compaction (68% vs 47%) Infero-septal in athlète (53% vs 27%) 10 (0.9%) : reduced systolic function, marked repolarisation changes No reveal adverse in follow-up during 48 month Gati S. Heart 2013

17 Aortic root dilatation in athletic population Pellicia A circulation 2010;122: Remodeling of the aortic root 2317 athletes 24,8±6,1 years 56% males 32,2 mm (males) vs 27,5 mm (females) 99th percentile value: 40 mm in males 34 mm in females cycling water polo swimming basketball

18 Left atrial volume index in highly trained athletes Diamètre TM de l OG: > 40 mm dans 17 à 20% Kervio G. et coll 2008 Pellicia A. JACC athletes: 370 ATE ATS (28,4±10,2 years) LA vol. index: 27,8±9,3 ml/m 2 LA diameter 34,4±5,5 mm Males: ml/m2 vs Females: ml/m ml/m2 Independent predictors: >34ml/m2 Type and duration of training LVED volume D Andrea A. Am Heart J 2010;159:

19 Determinants of echocardiographic left atrial 418 healthy individuals, 41,7±15,6 years 157 competitives athletes (38%), LA vol.index : 32.2±9 ml/m ± 9.6 vs 28.4 ± 5.8 ml/m2 28,4±5,8 ml/m2 38,9±9,6 ml/m2 Determinants: LVEDV index LVmass index Competitive sports Age NISTRI S. Eur J Echocardiogr. 2011;12:

20 Range of right heart measurements in top-level athletes D Andréa A. International Journal of cardiology 2013;164: top-level athlètes, 395 (ATE), 255 (ATS) vs 230 controls 28,4 ±10,1 years, 63% males RV and RA in ATE % ATS and controls early diastolic RV function whereas RV systolic index were comparable

21 RV morphology and function 430 athletes (210 STA et 220 ETA) vs 250 controls 27,4 years, 61,7% males RV 2D 3D diameter volume PAPs D Andréa A. JASE 2012;25: RV systolic indexes # - TAPSE - DTI RV peak systolic velocity

22 RV in athletes or ARVC? Oxborough D JASE % of 102 athlètes : RV outflow tract values > major criteria of ARVC RV scalled to BSA Normal Systolic Index 40% > 35 mm 57%> 42 mm Ratio RV/LV < 1,17 Speckle tracking > -15%

23 When suspected pathology? LV end diastolic diameter > 65 mm > 30 mm/m 2 adolescents> 31 mm/m 2 males or > 32 mm/m 2 females LVWT > 13 mm in males, 12 mm in females, 11 mm in adolescents Diastolic dysfunction E<A, e, e /a, s Aortic root diameter > 40 mm in males or > 34 mm in females LA vol. index 33 ml/m 2 Training < 8 h/week VO2 max < %