RPS 1003a - Emerging applications: cardio-oncology and athletes' hearts

Purpose:

To analyse the impact of an endurance competition on left (LV) and right ventricular (RV) function by feature-tracking strain analysis by cine cardiac magnetic resonance imaging (CMR) in competitive male and female triathletes.

Methods and materials:

50 asymptomatic triathletes (45 ±10 years, 20% female) with more than 10 weekly training hours were studied by CMR performed on a 1.5T system with a 5-channel cardiac coil before and after an endurance competition (1.3 ±0.5 km of swimming, 59.9 ±72.5 km of cycling, and 15.9 ±11.5 km of running). Functional and morphological LV parameters were determined using CVi42 (circle cardiovascular imaging). Global peak systolic longitudinal, radial, and circumferential myocardial strains were analysed using Segment (Medviso, Sweden). Blood tests were performed before the competition and at the time of the CMR.

Results:

Troponin T (6 ±4 pg/ml vs. 51 ±77 pg/ml, P<0.0001), NT-proBNP (45 ±73 pg/ml vs. 116 ±99 pg/ml, P<0.0001), and creatine kinase isoenzyme MB (10 ±14 U/I vs. 32 ±19 U/l, P<0.0001) increased significantly after the competition. Radial and circumferential LV strain increased from baseline to post-competition with 39 ±11% vs. 44 ±11% (P<0.05) and -16 ±4% vs. -18 ±3% (P<0.05). LV longitudinal strain showed a trend for decrease (-17 ±2% vs. -17 ±2%, P=0.054). Circumferential RV strain increased significantly post-competition (-6 ±3% vs. -7 ±2%, P<0.01), whereas RV longitudinal strain remained constant (-9 ±3% vs. -9 ±4%, P=0.668). LV ejection fraction did not change (63 ±7% vs. 62 ±6%, P=0.607).

Conclusion:

Cardiac biomarkers are markedly elevated following strenuous endurance exercise in healthy male and female triathletes with normal LV ejection fraction. LV radial, circumferential, and RV circumferential strain increases. LV longitudinal strain decreases post-competition.

Limitations:

Different competition formats.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

There is evolving evidence that the cumulative effects of intensive endurance exercise may induce a broad spectrum of cardiac adaptation/remodelling patterns. Even if the common features of the athlete’s heart are well-known, whether changes in cardiac strain parameters occur in response to training is less well-studied. We aimed at understanding and characterising these changes in CMR derived-strain parameters in highly trained endurance athletes.

Methods and materials:

93 highly trained endurance athletes (>12 hours training/week at least during the last 5 years) and 72 age and gender-matched controls (52% male, mean age 35±5.1 years) underwent a resting-CMR. Biatrial and biventricular dimensions and function were assessed, as well as the presence of myocardial fibrosis by LGE. We evaluated radial, circumferential, and longitudinal strain of both ventricles and left atrium from feature tracking (FT) of cine images.

Results:

High endurance training load was associated with larger bi-ventricular and bi-atrial sizes, mildly reduced the systolic function of both ventricles, as compared to controls (P < 0,05). LGE was significantly more prevalent in athletes (n=33, 35.4% vs 4,2%; P<0,001), with a constant pattern in the right ventricle (RV) insertion points. Left ventricle circumferential and radial strain, RV circumferential, radial and longitudinal strain, and left atrium strain were all lower in athletes than in controls; p<0.05.

Conclusion:

The strain values from FT in our group of highly-trained endurance athletes were lower than in the control group. This was observed together with harmonic biventricular dilation and with the presence of LGE confined to the RV insertion point. The clinical impact of these strain values is currently uncertain and still warrants further investigation.

Limitations:

No long-term follow-up available.

Ethics committee approval

Institutional review-board approval was obtained. Subjects provided written informed consent.

Funding:

Partially funded by AGAUR(M. Sanz-de la Garza,MD,PhD). GrantDEP2013-44923-P.

Purpose:

To assess ventricular morphology and parameters of diastolic function between professional soccer players and competitive triathletes compared to sedentary controls using cine feature-tracking CMR.

Methods and materials:

23 soccer players (22±4 years), 19 triathletes (28±6 years), and 16 controls (26±3 years) underwent CMR. Chambers volume and left ventricular mass were determined and correlated with global myocardial strain. Peak systolic longitudinal (LS), circumferential (CS), and radial (RS) strains were analysed on cine CMR images using feature-tracking software.

Results:

Athletes displayed higher myocardial mass (P<0.001) compared to the controls. The longitudinal ventricular strain was significantly reduced in athletes in comparison to the controls (P<0.01 for the right ventricle (RV) and P<0.05 for LV) as well as radial LV strain (P<0.05). Both athletic groups were characterised by eccentric hypertrophy. However, in comparison to triathletes, soccer players revealed higher LV mass (87±15 vs. 75±13 g/m2, P<0.05). Furthermore, soccer players experienced a greater decrease in the longitudinal strain of LV (-16±2 vs. -17±2%, P<0.05) and RV (-18±2 vs. -20±3%, P<0.05), as well as in radial LV strain (38±8 vs. 43±7%, P<0.05). An increase in LV mass correlated with a decrease in the longitudinal strain (r=0.47, P<0.001) and radial strain (r=-0.28, P<0.05).

Conclusion:

Reduction of global myocardial strain in athletes correlates with the level of LV hypertrophy. Detrimental effects on myocardial mechanics due to an increased level of sport-induced hypertrophy pronounced in soccer players cannot be excluded.

Limitations:

The presence of myocardial fibrosis and its potential influence on LV strain cannot be excluded.

Ethics committee approval

Ethics comitee aproval (Ärztekammer Hamburg). Written informed consent was obtained.

Funding:

No funding was received for this work.

Purpose:

To assess the role of coronary CT-angiography (CCTA) and non-invasive detection of coronary atherosclerosis (cATS) in the assessment and clinical management of master athletes (MA) during the pre-participation screening (PPS).

Methods and materials:

We retrospectively examined 167 MA who underwent CCTA in our hospital since 2006, analysing symptoms, stress-test ECG, cardiovascular risk profiles (SCORE), and CCTA findings.

Results:

Among the whole enrolled population, 153 (91.6%) MA underwent CCTA for equivocal/positive stress-test ECG with/without symptoms, 13 (7.8%) just for clinical symptoms, and 1 (0.6%) due to family history. The CCTA showed the presence of cATS in 69 MA (41.3%), congenital coronary anomalies (anomalous origin or deep myocardial bridge) in 8 (4.8%), and both in 7 (4.2%). A negative CCTA was observed in 83 MA (49.7%). The risk-SCORE (age, hypertension, hypercholesterolemia, and smoking) was a good indicator for the presence of moderate/severe cATS on CCTA. However, mild/moderate cATS was present in 17.8% of MA clinically stratified at a low risk-SCORE.

Conclusion:

CCTA may be helpful in the PPS of MA with an abnormal stress test ECG and/or clinical symptoms engaged in competitive sports with high cardiovascular involvement, while the invasive coronary angiography is more indicated in athletes with positive stress-test ECG and high clinical risk. Age, gender, presence of symptoms, and clinical risk-SCORE assessment may help sports-physicians/cardiologists to decide whether to request a CCTA or not.

Limitations:

n/a

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To assess the CCTA, added to clinical-profiles, in the diagnosis, management, and follow-up of athletes with anomalous-origin of left- (AOLCA) and right-coronary-artery (AORCA) from the wrong-sinus.

Methods and materials:

Subjects with suspected AOLCA/AORCA at the trans-thoracic-echocardiography (TTE) or with inconclusive-TTE underwent CCTA to rule out/confirm and characterise the anatomical findings: partial- (pINT) or full- (INT) inter-arterial-course, high-take-off (HTO), acute-take-off-angle (ATO), slit-like-origin (SLIT), intramural-course (IM), intraarterial-course-length (LEN), and lumen-reduction/hypoplasia (HYPO).

Results:

CCTA identified 28 athletes: 6-AOLCA (3-males, 20.3±11.0years), 22-AORCA (18 males, 29.1±16.5years); 26/28 (92.9%) suspected at TTE. Clinical symptoms were present only in 13 athletes (46.4%; 10-AORCA). Four subjects (3-AORCA) had abnormal rest ECG and 11 (40.7%) (9-AORCA) abnormal stress ECG. INT course was observed in 15 athletes (53.6%): 6/6-AOLCA and 9/22-AORCA (40.9%). HTO/ATO occurred in 1 and 3/6 AOLCA-patients, HTO in 12/22 (54.5%) and ATO in 21/22 (95.5%) in AORCA. Slit-like-origin was never recorded in AOLCA and present in 7/22 AORCA (31.8%). Suspected IM resulted in 3-AOLCA (50%), always with HYPO/ATO and in one case HTO, whereas IM was suspected in 6/22 AORCA (27.3%), in all cases with HYPO, observed in 12/22 AORCA (54.5%). No statistically significant differences resulted between asymptomatic/symptomatic subjects regarding the prevalence of pINT/INT-courses, HTO/ATO, and slitlike-ostium. A slight significant relationship between suspected proximal IM (r=0.47,p<0.05) and proximal HYPO of anomalous-vessel (r=0.65,p<0.01) resulted in AORCA and confirmed on AOLCA/AORCA pooled analysis (r=0.58,p<0.01 for HYPO). All AOLCA/AORCA athletes were disqualified from competitive sports and warned to avoid vigorous physical efforts. Surgery was recommended to all AOLCA athletes and to 13 AORCA (3-asymptomatic), but only 6 underwent surgery. No MACE/ischemic symptoms/signs occurred during a mean-follow-up of 49.6±39.5 months.

Conclusion:

CCTA is an accurate/mandatory diagnostic technique for the detection of anomalous-coronary-anatomy and risk-stratification, providing essential information for safe/effective clinical management of athletes, with important prognostic and sport-activity implications.

Limitations:

n/a

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To compare cardiac MR (CMR) texture analysis (TA) features extracted from the whole left ventricle (wLV-ROI) with those obtained on a representative single short-axis section with a circumferential ROI (c-ROI) or with a ROI on the interventricular septum (s-ROI).

Methods and materials:

Retrospective single-centre study in 85 patients submitted to CMR from Jan 17 to Feb 18 with a negative report (i.e. no late gadolinium enhancement, no contractile dysfunction, normal LVEF, and volumes). MRI was performed with a 1.5-T system with cardiac coil; b-SSFP sequences in the short-axis at end-diastole were analysed using a freeware software (3DSlicer). wLV-ROI and c-ROI segmentation was performed semi-automatically with a brush tool on an intensity threshold-based mask; s-ROI was segmented manually. 107 TA features for segmentation were extracted with the pyRadiomics library. Interobserver and intraobserver agreement tests were performed in a subset of 20 patients after a 4-week pause. The intraclass correlation coefficient (ICC) was used to compare TA data from wLV-ROI, c-ROI, and s-ROI, and to measure inter and intraobserver agreement.

Results:

The comparison between wLV-ROI and c-ROI, and between wLV-ROI and s-ROI, obtained ICC>0,8 for 5 first-order features: Median, RootMeanSquared, 90Percentile, 10Percentile, Mean. Additionally, 2 shape features had ICC>0,8 for c-ROI: Maximum2DDiameterSlice and MinorAxisLength. We observed good inter and intraobserver agreement for 76 features (ICC>0,8).

Conclusion:

The agreement between TA features obtained with wLV-ROI and smaller samples is limited to first-order radiomic metrics suggesting the need for whole-ventricle analysis for diffuse myocardial disease. No superior order feature, except for 2 of shape, can be reliably obtained unless segmenting the whole LV. The reproducibility is good (ICC>0,8 for >70% of the features).

Limitations:

Single-centre, retrospective, small sample.

Ethics committee approval

All patients gave written consent to CMR.

Funding:

No funding was received for this work.

Purpose:

Daunorubicin (DNR) serves as the backbone of many anti-cancer treatment strategies, but DNR-induced cardiotoxicity was rarely reported compared with doxorubicin (DOX).

Methods and materials:

38 adult male New Zealand white rabbits weighing 2 to 4 kg were included in this study. There were divided into 3 groups including control subjects and the DNR subjects with 3 or 4 mg/kg respectively. The CMR imaging included the function, native T1 mapping, and LGE. The time points were 2 weeks and 4 weeks. Some subjects were sacrificed for histological evaluation at the end of CMR scan.

Results:

In the group of controls rabbits and DNR rabbits, the EF was decreased from 2 weeks to 4 weeks (controls 62.32±7.95% vs. 2 weeks 56.29±5.64% vs. 4 weeks 52.41±11.35%). For the T1 mapping analysis, the global native T1 values in rabbits with 4mg/kg weekly at 2 and 4 weeks were significantly higher than the controls (P <0.05) and all modelling rabbit had higher T1 values than controls. Most of the DNR rabbits (94.68%) were without the presence of LGE and a few of the subjects (5.32%) showed the LGE positive in subendocardial or the free wall. The Masson stain showed diffuse extracellular collagen deposition in the LV myocardium.

Conclusion:

Native T1 mapping could detect diffuse myocardial injury in 4 weeks caused by daunorubicin. The higher cumulative dose and longer time may result in a more severe myocardium injury.

Limitations:

This is preliminary research and short of follow-up in the protection of the cardiotoxicity. And we will do further research for the comprehensive assessment of the myocardial injury.

Ethics committee approval

Our research was approved by the animal ethic institution.

Funding:

This work is supported by the clinical research funding (K1519) in our institution.