Echographic tricky aspects in the athlete's heart

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1 Paris 2016 ; January 13-16th 26 th European days of the French Society of Cardiology Sports and cardiology: an explosive cocktail? Echographic tricky aspects in the athlete's heart Eric Abergel Clinique Saint-Augustin, Bordeaux

2 Disclosure Statement of Financial Interest 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 none Daiichi Sankyo, MSD none none none none none

3 Cardiovascular causes of sudden death in young competitive athletes Maron BJ Circulation 2006;114:1633. USA Most common Hypertrophic CM (33%) Congenital coronary artery anomaly (14%) Less common Myocarditis Valvular heart disease (AS, Mitral prolapse) Atherosclerotic CAD Dilated CM ARVC Aortic rupture (Marfan) Corrado D JACC 2003;42:1959. Italian Most common ARVC (22%) Atherosclerotic CAD (18%) Congenital coronary artery anomaly (13%) Less common Myocarditis Mitral prolapse Premature CAD Dilated CM Hypertrophic CM (2%) Aortic rupture (Marfan)

4 Echocardiography in athletes: many potential pitfalls These diagnosis can be suspected in healthy athletes Overestimation of wall thickness (doctor!) Interpretation of LVH /other parameters HCM Interpretation of LVEF Interpretation of LV dilation Interpretation of a restrictive LV filling DCM Interpretation of RV dilation ARVC

5 Thickness: wrong measurement frequent, not innocent Referred for HCM, WT>> 15 mm Overestimation of septal thickness A current etiology of HCM in sport Tricuspid Subvalvular apparatus False chordae tendineae

6 Thickness: interpretation well codified HCM: Maximal WT 15 mm ; possible with WT mm Elliott PM. EHJ 2014;35: FEMALE (age 14-35) 720 M and F (age 14-18) 600 MALE (age 14-35) 3% (8 athletes) 0.4% (3 athletes) 6 3 Rawlins J. Circulation Sharma. JACC Basavarajaiah S. JACC Female Athlete 11 mm white 13 mm black Teenager (14-18 yold) 12 mm men 11 mm women Male Athlete 15 mm white 16 mm black...male adults athletes with maximal LVWT mm are in a grey zone Rare: around 2% of athletes, 5% of HCM Maron BJ. Circulation 2006;114:1633.

7 LVH : HCM or athlete s heart? Wrong measurement is not always a beginner s mistake Solution: don t focus only on wall thickness ; other parameters+++ Large LV cavity Very good LV relaxation Strongly support athlete s heart Question a WT>16 mm

1 (45-65) Among 53 with LVH > 12 mm 50 had dilated LV cavity (>56 mm) Basavarajaiah S. JACC 2008;51:1033.

8 LV cavity size: the most important discriminator between HCM and physiologic LVH 3500 elite athletes (75% male) LVIDd (mm)= 58.5±5.1 (45-65) Among 53 with LVH > 12 mm 50 had dilated LV cavity (>56 mm) Basavarajaiah S. JACC 2008;51: adolescents with HCM No LVD > 48 mm Maron BJ. JAMA 1999;281: HCM /28 elite athletes LVH Grey zone mm Cut-off LV diameter 54 mm Caselli S. Am J Cardiol 2014;114:1383.

9 LV cavity size: the most important discriminator 286 world class male cyclists (Tour de France) 25 cyclists with Maximal LVWT >13 mm 23 with LVIDd > 55 mm LVIDd (mm) 55 mm 13 mm MaxWT (mm) Abergel E. JACC 2004;44:144.

10 3D echo: Ratio LVmass/end diastolic volume 152 healthy volunteers ; 19 rowers ; 23 DCM ; 26 HCM 2.40±0.67 HCM 1.12±0.14 Athletes Volunteers 1.03±0.12 DCM 0.55±0.09 De Castro S. Heart 2007;93:205.

7 Cardim 2003 15 Rower 13.3±2.0 18.9±3.4 Butz 2010 100 Hanball 13.2±2.8 16.6±3.

11 Mitral e (Pulsed DTI) e Author Number Subjects e infseptal cm/s e antlateral cm/s Caso Water Polo 13±3 16±4 Claessens Triathletes 16.3±1.7 Cardim Rower 13.3± ±3.4 Butz Hanball 13.2± ±3.4 D Andrea Endurance/power 14±3 16±5 Caselli All sports 13.8±2.2 ND Geske Sedentary HCM 5.3± ±2.3

E/A ratio and e 1145 Olympic athletes (61% men),

Very suspicious All HCM have abnormal relaxation

12 E/A ratio and e 1145 Olympic athletes (61% men), 154 controls Caselli S. JASE 2015;28:236. E/A ratio (tip of the leaflets) e septal Athletes: E/A ratio always>1 Athletes: e septal always>8 cm/s Very suspicious All HCM have abnormal relaxation Abnormal relaxation: e sept< 8 cm/s Nagueh SF. JASE 2009 ;22:107.

13 Global LV longitudinal strain: a false friend? Football (n=28) mm Soccer (n=29) <13 mm Caselli S. J Am Soc Echocardiogr 2015;28:245 HCM (n=26) Controls (n=17) GLS% ± 4% ± 7.7% ± 2.0% * Bodybuilders AAS+(n=25) HCM (n=21) Bodybuilders AAS-(n=20) Controls (n=17) GLS% -17 ± 2% -15 ± 3% -18 ± 2% Kansal VM. AJC 2011;108:1322 Olympic Athletes (n=200) Controls (n=50) P value GLS% -18.1±2.2 (-15,-22) -19.4±2.3 (-16,-23) <.001 Richand V. AJC 2007;100: Controls (n=25) GLS% -15±5** -20±6-19±6 D Andrea A. Br J Sports Med 2007;13:149

14 HCM or Athlete's heart? Man > years old, wall thickness mm Athlete's heart LVIDd (> mm) E/A > 1 always e septal > 8 cm/s always» usually > cm/s Normal LV Longitudinal strain» caution: GLS may be low in athletes Normal mitral valve (morphology, position) No outflow obstruction (rest and exercise); possible after exercise HCM LVIDd < 48 mm E/A < 1 e < 8 cm/s Low LV Longitudinal strain Abnormal mitral valve (morphology, position)

What about athletes with HCM vs sedentary HCM - 106 athletes with HCM (14-35

LVEDD 51 mm (AUC 0.82) e 11 cm/s (AUC 0.

15 What about athletes with HCM vs sedentary HCM athletes with HCM (14-35 years); 101 sedentary HCM - 15 Moderate HCM athletes vs 55 LVH healthy athletes LVEDD 51 mm (AUC 0.82) e 11 cm/s (AUC 0.88) In athletes with high suspicion for HCM, other non invasive cardiac tests are necessary Sheikh N. Circulation CVI 2015;8:xxx

16 MRI: the solution? Not always. Compare Echo and MRI in difficult cases

17 Physiological dilation or dilated cardiomyopathy? 1309 athletes, 38 sports (max impact: endurance cycling, swimming, Rowing, soccer) Majority with LVIDd<60 mm ; 14% with LVIDd>60 mm LVIDd: Men 55 mm (43-70 mm) LVIDd: Women 48 mm (38-66 mm) Follow up to 12 years without symptom Pelliccia. Ann Intern med 1999;130:23 Spirito AJC 1994;74:802 Restrictive mitral inflow is frequent Endurance Combined Strength Controls p Pluim BM Circulation 2000;101: studies ; 1451 athletes all sports

18 LVEF (%) LV Dilation : how to interpret? Dilation is usual, low LVEF is not rare 286 cyclists participating to the Tour de France (1995 et 1998) /286: LVIDd > 60 mm 17/286: LVID>60mm and LVEF<52% Abergel E. Am Heart J 1998;136:818 Abergel E. JACC 2004;44: LVIDd (mm) Suspicion of DCM in athletes: LV Dilation + Low LVEF+ DD Supporting athlete heart: High e ; LV contractile reserve Galderisi M EHJCVI 2015;16:353

consensus of the European Association of Cardiovascular Imaging Galderisi M EHJCVI 2015;16:353 «Exercise stress echo

19 Exercise echocardiography American football (static ++ endurance +) 156 athletes, 40% with LVEF between 50 and 55% (low normal) Exercise echo : appropriate hyperdynamic EF (76 ± 14%) Abernethy III JACC 2003;41: expert consensus of the European Association of Cardiovascular Imaging Galderisi M EHJCVI 2015;16:353 «Exercise stress echo in athletes with EF < 45 50% at rest to test if there is contractile reserve (=EF increase>70%) during exercise. Rest Exercise

675 consecutive reasonable athletes competing at

20 RV dilation: normal adaptation or ARVC? Major ARVC criteria Regional RV akinesia, dyskinesia and RVOTp 32 mm (>19 mm/m 2 ) Marcus F. Circulation 2010;121: consecutive reasonable athletes competing at the regional, national, or international level Zaidi A. Circulation 2013;127:1783.

Adapted RV thresholds are required in athletes Parameter ASE nl 102 (86M) athletes 301 Male athletes 74 Female athletes RVOT Prox LA 33 mm 40 mm (20 mm/m 2 ) 37 mm (21 mm/m 2 ) RV basal diameter 42

21 Adapted RV thresholds are required in athletes Parameter ASE nl 102 (86M) athletes 301 Male athletes 74 Female athletes RVOT Prox LA 33 mm 40 mm (20 mm/m 2 ) 37 mm (21 mm/m 2 ) RV basal diameter 42 mm < 38 mm/(m 2 ) mm (28 mm/m 2 ) Rudski LG. JASE 2010;23:685. Oxborough D. JASE 2012;25: mm (28 mm/m 2 ) Zaidi A. Circulation 2013;127:1783. Zaidi white 300 black Controls RVFAC 42±8% (44±8%) 42±9% (42±9%) S 15±3 cm/s (15±2) S 15±3 cm/s (15±1) La Gerche 2011/ endurance male Controls RVFAC 52±6% (52±8%) strain basal -22% (- 27%, p=0.018) Similar contractile reserve (exercise echo)

22 Normal adaptation or ARVC? Parameter Athletes ARVC RV dilation RV function RV Longitudinal strain Predominant RV basal enlargement No wall motion abnormality Normal or low Predominant RVOT enlargement Wall motion abnormality Low Exercise Echo Contractile reserve; nl strain No Contractile reserve LV dilation Yes No dilation RVOT proximal Long axis Dilation 40 mm man 37 mm woman 22 mm/m 2 both sex > 40 mm man > 37 mm woman

23 Large LVDD > mm E/A>1 E > cm/s Normal mitral valve No wall motion abnormality Predominant RV basal enlargment Strain nl/low ; Exercise nl HCM WT mm Avoid overestimation RVOT mm ARVC Athlete Heart Grey Zone DCM LVID mm ± Low LVEF at rest Exercise echo: Nl LVEF ± Restrictive mitral flow High E

25 Left atrium Volume index in highly trained athletes 615 athletes (370 endurance ; 245 strength-trained) D Andrea A. Am H J 2010;159:1155

26 Other physiological modifications Proportional dilation of both ventricles Echo and MRI study Scharhag J. JACC 2002;40:1856. Inferior vena cava dilation 58 high level athletes, swimmers++» 23 ± 5 mm vs 11 ± 1 mm (30 controls) Goldhammer E. JASE 1999;12:988. Aortic root dilatation very uncommon 0,26% chez 1929 athletes years old (basketball) Frequent MR Kinoshita N. AmHJ 2000;139:723. Douglas PS. AJC 1989 ; 64 : 209.

27 Echocardiographic pitfalls in the diagnosis of HCM Prasad K. Heart 1999;82 (supp III):III8.

Take into account load to interpret FS/LVEF Endurance or combined: Low LVEF at rest is not rare Low preload at rest LVEF (Simpson)= 53% LVd = 58 mm LVs = 42 mm FS = 28%

28 Take into account load to interpret FS/LVEF Endurance or combined: Low LVEF at rest is not rare Low preload at rest LVEF (Simpson)= 53% LVd = 58 mm LVs = 42 mm FS = 28% LVEF Lifters Runners Controls End-systolic wall stress Professional soccer player Paris Saint Germain season 2001 Colan SD. JACC 1987;9:776.

29 How can we explain asymmetric RV remodeling? Important increase in pulmonary artery pressure in athletes during exercise REST PEAK EXERCISE Author/ TR gdt controls TR gdt athletes TR gdt controls TR gdt athletes Bossone hockey players 12 mmhg (9-15) 21 mmhg (18-23) 21 mmhg (15-27) 47 mmhg (38-55) La Gerche endurance male 22 ± 4 mmhg 22±4 mmhg 47±7 mmhg 61±13 mmhg Pressure excess counterbalanced by reduction in cavity and/or increase in wall thickness? (T=P r/h) La Gerche A. Med Sci Sports Exerc 2011;43:974

30 Echo: similar RV and LV remodeling in endurance athletes? 127 endurance athletes: cardiac enlargement occurs symmetrically in both right and left cavities Henriksen. Eur Heart J 1996;25:263. RV LV 102 endurance athletes Asymetric enlargement. Normality threshold for RV/LV ratio < 1.17 Oxborough D. JASE 2012;25:263.

31 How can we explain asymmetric RV remodeling 39 endurance athletes, 14 non athletes MRI (Ventricular size r and thickness h ), Exercise echo (SPAP) ESS (SPAP x r/2h) LV RV Exercise induces a relative increase in RVES-stress which exceeds LVES-stress. In athletes, greater RV enlargement and greater wall thickening may be a product of this disproportionate load excess. La Gerche A. Med Sci Sports Exerc 2011;43:974

Hypertrophic Cardiomyopathy or «Athlete s Heart»

Hypertrophic Cardiomyopathy or «Athlete s Heart» S. GUERARD, J-R. CAIGNAULT, V. GRIFFET Desgenettes Military Hospital LYON Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest