Left Ventricular Fibrosis in Middle-Age Athletes and Physically Active Adults

Abstract

Introduction Cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) and T1 mapping techniques enable the quantification of focal and diffuse myocardial LGE, respectively. Studies have shown evidence of fibrosis in middle-age athletes, but not relative to physically active (PA) adults who perform recommended physical activity levels. Therefore, we examined cardiac remodeling and presence of left ventricular (LV) LGE and T1 values in both recreational middle-age endurance athletes (EA) and PA adults. Methods Healthy EA and PA adults (45–65 yr) completed a standardized 3-T CMR protocol with ventricular volumetry, LV LGE, and T1 mapping. Results Seventy-two EA and 20 PA participants (mean age, 53 ± 5 vs 56 ± 4 yr; P < 0.01; V˙O2peak = 50 ± 7 vs 37 ± 9 mL·kg−1·min−1, P < 0.0001) were examined, with CMR data available in 89/92 participants. Focal LV LGE was observed in 30% of participants (n = 27/89): 33% of EA (n = 23/69; 33%) and 20% of PA (n = 4/20; 20%). LGE was present at the right ventricular hinge point (n = 21/89; 23.5%) or identified as ischemic (n = 2/89; 2%) or nonischemic (n = 4/89; 4%). Focal LV LGE was observed similarly in both EA and PA (P = 0.25). EA had larger LV chamber sizes and T1 native values (1169 ± 35 vs 1190 ± 26, P = 0.02) compared with PA, with similar LV ejection fraction. Global extracellular volume (ECV) was similar in both EA and PA (22.6% ± 3.5% vs 21.5% ± 2.6%, P = 0.26), with no relationship between global ECV and LV mass (r = −0.16, P = 0.19). Conclusions Focal LGE at the right ventricular hinge point was detected at the same frequency in both groups, was unrelated to demographic or clinical indices, and was found without evidence of global ECV expansion in EA, suggesting a physiologic remodeling response. The long-term clinical implications of hinge-point LGE require clarification using prospective, long-term follow-up studies.

A Novel Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) Biomarker—Anti-DSG2—Is Absent in Athletes With Right Ventricular Enlargement

“…7,16 In a larger sample of endurance athletes from which our study was drawn, RV end diastolic volume index in elite endurance athletes was larger than in less trained physically active adults (11218 vs 9214 P=0.001), and RV mass index was proportionally increased (19.03.5 vs 15.73.4) implying little change in relative wall thickness. This implies that RV dilation in the endurance athletes, in our population, is not accompanied by significant RV hypertrophy or wall thinning 14 The majority of athletes experienced biventricular LV and RV remodeling, with slightly larger RV volumes (median LV/RV EDVi 0.90) in keeping with previous observations. This LV:RV balance has been previously proposed as a way to distinguish the athlete's heart from abnormal RV remodeling in disease states such as ARVC where RV predominant remodeling is observed.…”

“…Athletes underwent cardiac magnetic resonance imaging (CMR), 24-hour Holter monitoring, and signal-averaged ECG (SAECG) as part of a larger study (n = 92). 14 The subset with RV enlargement, as defined by the ARVC Task Force Criteria Major size criteria, 6 were eligible for the study; inclusion criteria were a RVEDVi > 110mL/m 2 for men, and 100mL/m 2 for women on CMR imaging. Eligible participants consented to participate in this additional study, which included the collection of a blood sample to determine the presence of the anti-DSG2 antibody.…”

Sudden cardiac death risk in contact sports increased by myocarditis: a case series

“…Using CMR late gadolinium enhancement mapping (LGE), asymptomatic focal myocardial LGE has been identified in up to 30% of athletes and non-athletes. 27 An association with ventricular arrhythmia has not been documented, but subepicardial LV LGE has been associated with ventricular arrhythmias and appears not to be a benign condition. 28 These lesions are typical of post-myocardial scarring but may also be associated with non-ischaemic cardiomyopathies (arrhythmogenic dysplasia).…”

Cardiac magnetic resonance T2 mapping and feature tracking in athlete’s heart and HCM

“…In addition, focal fibrosis has been described in athletes, e.g. at the insertion points of the right ventricle [44,45]. Especially in the acute phases of myocardial alterations, this could influence and increase T2, thereby masking the differences of T2 values in the particular segments (segments 2, 3, 8, and 9).…”

“…This is likely due to the low number of athletes receiving contrast agent. LGE is still assumed as an essential component to differentiate the LVH groups, although focal fibrosis has been described at the insertion points of the right ventricle in athletes [45].…”