Background COVID-19 has been associated with myocardial abnormalities on cardiac magnetic resonance imaging (CMR). We report a case of COVID-19 myocarditis in an elite athlete. Case Summary A male, 21-year-old elite football player had tested positive for SARS-CoV-2 on a polymerase-chain-reaction test and was referred for cardiac evaluation after experiencing palpitations after returning to sports (RTS). Biochemical evaluation demonstrated elevated NT-proBNP and high-sensitive Troponin T (hsTNT). Echocardiography demonstrated LV function within normal ranges for athletes but with diminished basal, posterolateral, and septal strain. CMR showed increased T1 values and late gadolinium enhancement (LGE) in the basolateral and mid-ventricular posterior segments. Focal COVID-19 myocarditis was diagnosed and the patient remained restricted from sports, in line with the 2020 ESC sports cardiology guidelines. Two months later his electrocardiogram showed inferoposterolateral T-wave inversion. Serial imaging studies were performed to optimise RTS timing. CMR showed persistently increased T1/T2 values and persistent LGE at five and seven months. At nine months, FDG-PET-CT demonstrated no pathologically increased cardiac FDG-uptake. Subsequent exercise ECGs and Holters demonstrated no complex ventricular arrhythmias. The patient made a complete return to elite competitive sports, without any adverse events at fifteen months of follow-up. Discussion Cardiac symptoms in athletes post-COVID-19 should prompt cardiac evaluation. As COVID-19 myocarditis inflammation can persist beyond the three to six months of recommended sports restriction, a more personalised approach to RTS timing can be warranted. In cases with myocardial oedema without other signs of inflammation, FDG-PET-CT can be of added value to assess active myocardial inflammation.

Background and aimThe efficacy of pre-COVID-19 and post-COVID-19 infection 12-lead ECGs for identifying athletes with myopericarditis has never been reported. We aimed to assess the prevalence and significance of de-novo ECG changes following COVID-19 infection.MethodsIn this multicentre observational study, between March 2020 and May 2022, we evaluated consecutive athletes with COVID-19 infection. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes.Results511 soccer players (median age 21 years, IQR 18–26 years) were included. 17 (3%) athletes demonstrated de-novo ECG changes, which included reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7); and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed evidence of inflammatory cardiac sequelae. All 30 athletes who underwent a mandatory CMR scan had normal findings. Athletes revealing de-novo ECG changes had a higher prevalence of cardiac symptoms (71% vs 12%, p<0.0001) and longer median symptom duration (5 days, IQR 3–10) compared with athletes without de-novo ECG changes (2 days, IQR 1–3, p<0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 20%.Conclusions3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with cardiac inflammation. Most affected athletes exhibited cardiac symptoms; however, de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.

IntroductionThe cardiovascular benefits of physical exercise are well-known. However, vigorous exercise has also been associated with adverse cardiac effects. To improve our understanding of cardiovascular adaptation to exercise versus maladaptation and pathology, the limits of adaptation should be firmly established using state-of-the-art diagnostic modalities. We therefore initiated the Evaluation of Lifetime participation in Intensive Top-level sports and Exercise (ELITE) cohort to investigate the longitudinal (beneficial and pathological) cardiovascular effects of intensive elite sports and exercise.Methods and analysisELITE is a prospective, multicentre, longitudinal cohort study. Elite athletes, from the age of sixteen, are recruited in The Netherlands. The primary objective is to determine the association between elite sports and exercise-induced cardiac remodelling, cardiac pathology, and health benefits over time. Secondary objectives include determining and identifying genetic profiles of elite athletes, and how these are associated with cardiac indices. ELITE will collect data from consultations, electrocardiography, echocardiography and cardiac magnetic resonance imaging, and training- and injury data. ELITE will also collect blood for biobanking and cardiogenetics. Follow-up will take place at intervals of two to five years, and after the elite athletes’ professional careers have ended. In addition, a subcohort of ELITE has been established to investigate cardiac sequelae following infections associated with myocardial involvement, including SARS-CoV-2. ELITE is a prospective observational study; therefore, analyses will be primarily explorative.Ethics and disseminationThis study has been approved by the Medical Ethics Review Board of the Amsterdam University Medical Centers (NL71682.018.19). The results of the study will be disseminated by publication in peer-reviewed journals (Netherlands Trial Register number: NL9328).