Range of right heart measurements in top-level athletes: The training impact

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Abstract

Objectives

To explore the full range of right heart dimensions and the impact of long-term intensive training in athletes.

Background

Although echocardiography has been widely used to distinguish the athlete's heart from pathologic left ventricular (LV) hypertrophy, only few reports have described right ventricular (RV) and right atrial (RA) adaptations to extensive physical exercise.

Methods

650 top-level athletes [395 endurance- (ATE) and 255 strength-trained (ATS); 410 males (63.1%); mean age 28.4 ± 10.1; 18–40 years] and 230 healthy age- and sex-comparable controls underwent a transthoracic echocardiographic exam. Along with left heart parameters, right heart measurements included: RV end-diastolic diameters at the basal and mid-cavity level; RV base-to-apex length; RV proximal and distal outflow tract diameters; RA long and short diameters; and RA area. Tricuspid annular plane systolic excursion and RV tissue Doppler systolic peak velocity were assessed as indexes of RV systolic function. Pulmonary artery systolic pressure (PASP) was estimated from the peak tricuspid regurgitant velocity.

Results

ATS showed increased sum of wall thickness and relative wall thickness, whereas left atrial volume, LV end-diastolic volume, LV stroke volume and PASP were significantly higher in ATE. RV and RA measurements were all significantly greater in ATE than in ATS and controls. ATE also showed improved early diastolic RV function, whereas RV systolic indexes were comparable among groups. On multivariate analysis, type and duration of training (p < 0.01), PASP (p < 0.01) and LV stroke volume (p < 0.001) were the only independent predictors of the main RV and RA dimensions in athletes.

Conclusions

This study delineates the upper limits of RV and RA dimensions in highly-trained athletes. Right heart measurements were all significantly greater in elite endurance-trained athletes than in age- and sex-matched strength athletes and controls. This should be considered as a “physiologic phenomenon” when evaluating athletes for sports eligibility.

Introduction

Hemodynamic overload due to long-term training typically involves both left and right ventricles, inducing changes in cardiac structure globally described as “athlete's heart” [1], [2].

Cardiac adaptations may vary according to the type of sport. In particular, isotonic exercise associated with endurance sports is responsible for a chronic volume overload, with a predominant increase in left ventricular (LV) mass and end-diastolic diameters (eccentric hypertrophy). On the other hand, isometric exercise, typical of strength disciplines, induces a prevalent increase in LV mass and wall thickness (concentric hypertrophy) [3], [4].

Although standard Doppler echocardiography has been widely used to distinguish the athlete's heart from pathologic LV hypertrophy, only few reports have described right ventricular (RV) and right atrial (RA) adaptations to extensive physical exercise in highly-trained athletes [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. The reasons for this imbalance appear to be related to the complex shape of the RV cavity and its position beneath the sternum, making imaging, measurement and functional assessment much more complex than the LV chamber.

The aim of the present study was therefore to explore the full range of right heart dimensions and the impact of long-term intensive training in a large population of competitive athletes.

Section snippets

Study population

From June 2008 to March 2010, 660 top-level athletes were referred to the Sports Medicine outpatient clinic of Monaldi Hospital, Naples (Italy) for cardiovascular pre-participation screening [16], and afterwards to our echocardiographic laboratory for the purpose of the present study. Among these 650 athletes, 615 had been previously involved in our previous study about the effects of competitive sport training on pulmonary artery systolic pressures [17]. We also studied 230 age- and

Results

The clinical characteristics of the study population are described in Table 1. Mean age was comparable among groups. In accordance with the effects of different training protocols, ATS showed higher resting values of heart rate, body surface area and systolic blood pressure than ATE and controls.

ATS showed increased sum of wall thickness (septum + LV posterior wall), LV relative wall thickness and ESSc, whereas LA volume and LV end-diastolic volume were greater in ATE (Table 2).

All RV and RA

Discussion

A considerable body of echocardiographic studies has described the morphological and functional adaptations of the left ventricle in athletes [1], [2], [3], [4], but only few researches have addressed the impact of long-term intensive training on right heart structure and function.

In this regard, previous reports comparing small cohort of athletes with healthy controls have shown that: i) RV inflow and outflow tract dimensions are significantly greater in athletes; ii) RV tricuspid annulus

Acknowledgments

All the authors are grateful to Prof. Luigi D'Andrea for being constant font of inspiration. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

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