Case report: the role of multimodal imaging to optimize the timing of return to sports in an elite athlete with persistent COVID-19 myocardial inflammation

Abstract

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.

Return to play of young and adult professional athletes after COVID-19: A scoping review

“…Most studies refer to cardiac diseases, myocarditis, sudden cardiac death (SDC) and main diagnostic tests (particularly, cardiac magnetic resonance imaging - CMRI) for a safe RTP. 15 , 17 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 A further group of studies argues about the low incidence of COVID-19 effects related to cardiac injuries for competitive professional athletes. 15 , 50 , 56 , 57 Current protocols also capture other long-term symptoms such as palpitations, chest pain, breathlessness, as well as fatigue and brain fog.…”

“… 58 , 59 , 60 Preliminary assessment with additional electrocardiogram (ECG) and echocardiogram (ECHO) before RTP is advised for athletes presenting mild to moderate COVID-19 symptoms. 59 , 61 Daems et al 52 also suggest imaging techniques such as position emission tomography-computed tomography (PET-CT) with fluorodeossiglucosio (F-FDG), when CMRI demonstrates persistent myocardial oedema with late gadolinium enhancement (LGE). Other scholars 17 , 50 , 51 , 53 , 54 point out to a thorough investigation of the myocarditis in terms of epidemiology, pathophysiology and clinical presentation of COVID-19.…”

“…This cluster highlights mass screening and risk assessment and methods of the analysed works (i.e. cohort-studies, and prospective-studies), 53 , 57 , 59 , 80 , 81 , 82 , 83 , 84 , 85 other than addressing the cases for male 52 , 70 , 77 , 85 and female athletes. 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 …”

“…The gender/sport sub-group addresses issues for male athletes: Stokes et al 69 consider professional rugby players in UK; Pedersen et al 85 focus on Danish elite soccer players; Milovancev et al 70 take into account Serbian volleyball athletes; Mehrsafar et al 86 consider Iranian professional footballers; Gattoni et al 77 provide an illustration on professional soccer players; and Daems et al 52 detail on elite football players. In contrast, few studies by De Sire et al 78 and Bruinvels et al 88 consider recommendations and requirements for female athletes.…”

“…pneumonia) 70 , 77 , 87 and cross-sectional studies 70 ; 3) sports disciplines such as basketball, volley, football/rugby, and soccer. 46 , 52 , 68 , 69 , 77 , 78 , 85 , 86 , 91 , 92 , 93…”