Aortic root dimensions in elite athletes

Aortic root/left ventricular diameters golden ratio in competitive athletes

BACKGROUND

The athlete's heart is a well-known phenomenon characterized by a harmonic remodelling that affects the cardiac chambers. However, whether mild-to-moderate aortic dilatation can be considered normal in athletes is debated. This study aimed to evaluate the ratio between left ventricular (LV) size and aortic dimensions, reporting the normal values of the ratio between the aortic root diameters at the level of the sinuses of Valsalva and LV diameters (AoD/LVEDD ratio) in a wide cohort of competitive athletes.

MATERIALS AND METHODS

Competitive athletes were compared with sedentary subjects and patients with aortic dilatation. 1901 subjects who underwent echocardiography from 2019 to 2022 were retrospectively enrolled: 993 athletes (74% males, mean age 26 ± 7 years), 410 sedentary (74.1% males, mean age 29 ± 11 years) and 498 patients with aortic dilatation (74.3% males, mean age 56 ± 7 years).

RESULTS

Patients with aortic dilatation had both an absolute (39.2 ± 2.4 mm) and indexed (19.4 ± 2.2 mm/m2) aortic diameter larger than athletes (30.6 ± 3.2 mm; 16.1 ± 1.5 mm/m2, p < 0.05) and sedentary subjects (30.5 ± 3.1 mm; 16.5 ± 1.6 mm/m2, p < 0.05), with no differences between athletes and sedentary subjects. The AoD/LVEDD ratio was lower in athletes (0.59 ± 0.06) compared to controls (0.65 ± 0.05, p < 0.05) and patients with aortic dilatation (0.81 ± 0.06, p < 0.05). The patients with aortopathy had the lowest LVEDD/AoD ratio, while competitive athletes had the highest, with values of 1.71 ± 0.16 in the latter (overall p value<0.001).

CONCLUSIONS

In this study, we reported the AoD/LVEDD and LVEDD/AoD ratio values in a cohort of healthy athletes, additional parameters that could help confirm the harmonic remodelling in the athlete's heart.

The athlete's heart: insights from echocardiography

The manifestations of the athlete's heart can create diagnostic challenges during an echocardiographic assessment. The classifications of the morphological and functional changes induced by sport participation are often beyond 'normal limits' making it imperative to identify any overlap between pathology and normal physiology. The phenotype of the athlete's heart is not exclusive to one chamber or function. Therefore, in this narrative review, we consider the effects of sporting discipline and training volume on the holistic athlete's heart, as well as demographic factors including ethnicity, body size, sex, and age.

Aortic Root Diameter in Highly-Trained Competitive Athletes: Reference Values According to Sport and Prevalence of Aortic Enlargement

BACKGROUND

Studies exploring the extent of aortic root dilation across the different types of sport are limited. We aimed to define the physiological limits of aortic remodelling in a large population of healthy elite athletes in comparison with nonathletic controls.

METHODS

A total of 1995 consecutive athletes evaluated at the Institute of Sports Medicine (Rome, Italy) and 515 healthy controls underwent a comprehensive cardiovascular screening. The aortic diameter was measured at the level of the sinuses of Valsalva. The 99th percentile from the mean of the aortic diameter in the control population was used to define an abnormally enlarged aortic root dimension.

RESULTS

Athletes showed a larger aortic root diameter (30.6 [± 3.3] vs 28.1 [± 3.1] mm, P value < 0.001) than controls. The difference was evident in male and female athletes, regardless of sport- predominant component and level of intensity. The 99th percentile value for aortic root diameter in control male and female subjects was 37 mm and 32 mm, respectively. Based on these values, 50 (4.2%) male and 21 (2.6%) female athletes would have been diagnosed with an enlarged aortic root. However, aortic root diameter of clinical relevance-ie, ≥ 40 mm-was observed in only 17 male athletes (0.85%) and did not exceed > 44 mm.

CONCLUSIONS

Athletes show a mild, although significant, increased aortic dimension in comparison with healthy controls. The degree of aortic enlargement varies in relation to type of sports and sex. Eventually, only a small minority of athletes exhibited a markedly enlarged aortic diameter (ie, ≥ 40 mm) in a range of clinical relevance.

Long-Term Endurance Exercise Training Alters Repolarization in a New Rabbit Athlete’s Heart Model

In the present study, the effect of long-term exercise training was investigated on myocardial morphological and functional remodeling and on proarrhythmic sensitivity in a rabbit athlete’s heart model. New-Zealand white rabbits were trained during a 12-week long treadmill running protocol and compared with their sedentary controls. At the end of the training protocol, echocardiography, in vivo and in vitro ECG recordings, proarrhythmic sensitivity with dofetilide (nM) were performed in isolated hearts, and action potential duration (APD) measurements at different potassium concentrations (4.5 and 2 mM) were made in the isolated papillary muscles. Expression levels of the slow component of delayed rectifier potassium current and fibrosis synthesis and degradation biomarkers were quantified. Echocardiography showed a significantly dilated left ventricle in the running rabbits. ECG PQ and RR intervals were significantly longer in the exercised group (79 ± 2 vs. 69 ± 2 ms and 325 ± 11 vs. 265 ± 6 ms, p &lt; 0.05, respectively). The in vivo heart rate variability (HRV) (SD of root mean square: 5.2 ± 1.4 ms vs. 1.4 ± 0.2 ms, p &lt; 0.05) and Tpeak-Tend variability were higher in the running rabbits. Bradycardia disappeared in the exercised group in vitro. Dofetilide tended to increase the QTc interval in a greater extent, and significantly increased the number of arrhythmic beats in the trained animals in vitro. APD was longer in the exercised group at a low potassium level. Real-time quantitative PCR (RT-qPCR) showed significantly greater messenger RNA expression of fibrotic biomarkers in the exercised group. Increased repolarization variability and higher arrhythmia incidences, lengthened APD at a low potassium level, increased fibrotic biomarker gene expressions may indicate higher sensitivity of the rabbit “athlete’s heart” to life-threatening arrhythmias.

The Role of Multimodality Imaging in Athlete's Heart Diagnosis: Current Status and Future Directions

“Athlete’s heart” is a spectrum of morphological and functional changes which occur in the heart of people who practice physical activity. When athlete’s heart occurs with its most marked expression, it may overlap with a differential diagnosis with certain structural cardiac diseases, including cardiomyopathies, valvular diseases, aortopathies, myocarditis, and coronary artery anomalies. Identifying the underlying cardiac is essential to reduce the potential for sudden cardiac death. For this purpose, a spectrum of imaging modalities, including rest and exercise stress echocardiography, speckle tracking echocardiography, cardiac magnetic resonance, computed tomography, and nuclear scintigraphy, can be undertaken. The objective of this review article is to provide to the clinician a practical step-by-step approach, aiming at distinguishing between extreme physiology and structural cardiac disease during the athlete’s cardiovascular evaluation.

Echocardiographic evaluation of the Athlete's heart

Cardiac response to prolonged, intense exercise induces phenotypic and physiologic adaptive changes that improve myocardial ability to meet oxygen demands. These adaptations, termed "athletes' heart," have been extensively studied. The importance of this entity arises from the increasing numbers of athletes as well as the drive for physical fitness in the general population leading to adaptive cardiac changes that need to be differentiated from life-threatening cardiovascular diseases. A number of pathologic entities may share phenotypic changes with the athletes' heart such as hypertrophic cardiomyopathy, dilated cardiomyopathy, Marfan's syndrome, and arrhythmogenic right ventricular cardiomyopathy. Cardiologists need to be cognizant of these overlapping findings to appropriately diagnose diseases and prevent catastrophic outcomes especially in young and healthy individuals who may not show any symptoms until they engage in intense exercise. It is equally important to recognize and distinguish normal, exercise-adaptive cardiac changes to provide accurate screening and guidance to young elite athletes. Echocardiography is a valuable modality that allows comprehensive initial evaluation of cardiac structures, function, and response to exercise. Several different echocardiographic techniques including M-Mode, 2D echo, Doppler, tissue Doppler, color tissue Doppler, and speckle tracking have been used in the evaluation of cardiac adaptation to exercise. The following discussion is a review of literature that has expanded our knowledge of the athlete's heart.

Association of Ascending Aortic Dilatation and Long-term Endurance Exercise Among Older Masters-Level Athletes

Importance

Aortic dilatation is frequently encountered in clinical practice among aging endurance athletes, but the distribution of aortic sizes in this population is unknown. It is additionally uncertain whether this may represent aortic adaptation to long-term exercise, similar to the well-established process of ventricular remodeling.

Objective

To assess the prevalence of aortic dilatation among long-term masters-level male and female athletes with about 2 decades of exercise exposure.

Design, Setting, and Participants

This cross-sectional study evaluated aortic size in veteran endurance athletes. Masters-level rowers and runners aged 50 to 75 years were enrolled from competitive athletic events across the United States from February to October 2018. Analysis began January 2019.

Exposures

Long-term endurance exercise.

Main Outcomes and Measures

The primary outcome was aortic size at the sinuses of Valsalva and the ascending aorta, measured using transthoracic echocardiography in accordance with contemporary guidelines. Aortic dimensions were compared with age, sex, and body size-adjusted predictions from published nomograms, and z scores were calculated where applicable.

Results

Among 442 athletes (mean [SD] age, 61 [6] years; 267 men [60%]; 228 rowers [52%]; 214 runners [48%]), clinically relevant aortic dilatation, defined by a diameter at sinuses of Valsalva or ascending aorta of 40 mm or larger, was found in 21% (n = 94) of all participants (83 men [31%] and 11 women [6%]). When compared with published nomograms, the distribution of measured aortic size displayed a rightward shift with a rightward tail (all P < .001). Overall, 105 individuals (24%) had at least 1 z score of 2 or more, indicating an aortic measurement greater than 2 SDs above the population mean. In multivariate models adjusting for age, sex, body size, hypertension, and statin use, both elite competitor status (rowing participation in world championships or Olympics or marathon time under 2 hours and 45 minutes) and sport type (rowing) were independently associated with aortic size.

Conclusions and Relevance

Clinically relevant aortic dilatation is common among aging endurance athletes, raising the possibility of vascular remodeling in response to long-term exercise. Longitudinal follow-up is warranted to establish corollary clinical outcomes in this population.

The impact of demographic, anthropometric and athletic characteristics on left atrial size in athletes

The structural adaptations of the “athlete's heart” include left atrial (LA) enlargement. A literature search was performed based on PubMed listings up to November 2, 2019 using “athletes AND left atrium,” “athletes AND LA,” “sports AND left atrium,” “sports AND LA,” “exercise AND left atrium,” and “exercise AND LA” as the search terms. Eligible studies included those reporting the influence of demographic, anthropometric and athletic characteristics on LA size in athletes. A total of 58 studies were included in this review article. Although LA volume has been reported to be greater in males compared to females when indexed for body surface area (BSA), there was no difference between sexes. The positive association between LA size and age in athletes may reflect the increase in body size with maturation in nonadult athletes and the training age of endurance athletic activity in adult athletes. Caucasian and black athletes have been demonstrated to exhibit similar LA enlargement. The positive association of LA size with lean body mass (LBM) possibly accounts for the relationship of LA size with BSA. LA enlargement has been reported only in endurance‐trained, but not in strength‐trained athletes. LA size appears to increase with an increase in both the volume and intensity of endurance training. LA size correlates independently with the training age of endurance athletes. The athlete's characteristics that independently determine LA size include LBM, endurance training, and training age.

Left ventricular hypertrophy in athletes: How to differentiate between hypertensive heart disease and athlete’s heart

Athlete’s heart is typically accompanied by a remodelling of the cardiac chambers induced by exercise. However, although competitive athletes are commonly considered healthy, they can be affected by cardiac disorders characterised by an increase in left ventricular mass and wall thickness, such as hypertension. Unfortunately, training-induced increase in left ventricular mass, wall thickness, and atrial and ventricular dilatation observed in competitive athletes may mimic the pathological remodelling of pathological hypertrophy. As a consequence, distinguishing between athlete’s heart and hypertension can sometimes be challenging. The present review aimed to focus on the differential diagnosis between hypertensive heart disease and athlete’s heart, providing clinical information useful to distinguish between physiological and pathological remodelling.

Cardiovascular Care of Masters Athletes

Masters athletes (MA), men and woman older than 35 years who participate in competitive athletics, is a rapidly growing population that is increasingly encountered in clinical cardiovascular practice. Although the high levels of exercise typically performed by MA confer numerous health advantages, no amount of exercise confers complete immunity from cardiovascular disease. The review was written to cover the clinical management of MA with cardiovascular disease. Focus is dedicated to four of the most common clinical scenarios including atrial fibrillation, myocardial fibrosis, coronary artery disease, and dilation of the ascending aorta.

Normal basic 2D echocardiographic values to screen and follow up the athlete's heart from juniors to adults: What is known and what is missing. A critical review

In the last few years, multiple echocardiographic nomograms have been published. However, normal values calculated in the general population are not applicable to athletes, whose hearts may be enlarged and hypercontractile. Accordingly, athletes require specific nomograms. Our aim is to provide a critical review of echocardiographic nomograms on two-dimensional (2D) measures for athletes. We performed a systematic search in the National Library of Medicine for Medical Subject Headings and free text terms including echocardiography, athletes, normal values and nomograms. The search was refined by adding the keywords heart, sport, elite, master, children and young. Twenty-eight studies were selected for the final analysis. Our research revealed that currently available ranges of normality for athletes reported by different authors are quite consistent, with limited exceptions (e.g. atria, aorta). Numerical and methodological limitations, however, emerged. Numerical limitations included a limited sample size (e.g. < 450 subjects) of the population assessed and the paucity of data in women, non-Caucasian athletes, and junior and master athletes. Some data on M-mode measurements are available, while those for some specific structures (e.g. left atrial (LA) area and volumes, right ventricular diameters and aorta) are limited or rare (e.g. LA area). There was heterogeneity in data normalization (by gender, sport type and ethnicity) and their expression was limited to mean values (Z-scores have rarely been employed), while variability analysis was often lacking or incomplete. We conclude that comprehensive nomograms using an appropriate sample size, evaluating a complete dataset of 2D (and three-dimensional) measures and built using a rigorous statistical approach are warranted.

Exploring the Aortic Root Diameter and Left Ventricle Size Among Lithuanian Athletes

Background and objectives: Aortic rupture is known as one of the potential causes of sudden cardiac death in athletes. Nevertheless, adaptation strategies for aortic root dilation in athletes vary. The purpose of this study was to investigate aortic root adaptation to physical workload and to determine if aortic roots and left ventricle sizes are contingent upon the physical workload. Materials and Methods: Echocardiography was applied to 151 subjects to measure the aortic root at aortic valve annulus (AA) and at sinus of Valsalva (VS). 122 were athletes (41 females and 81 males) and 29 were non-athletes (14 females and 15 males). Of the 41 female athletes, 32 were endurance athletes, and 9 were strength athletes. From 81 male athletes, 56 were endurance athletes, and 25 were strength athletes. AA and VS mean values for the body surface area were presented as AA relative index with body surface area (rAA) and VS relative index with body surface area (rVS). Left ventricle (LV) measures included LV end-diastolic diameter (LVEDD), interventricular septum thickness in diastole (IVSTd), LV posterior wall thickness in diastole (LVPWTd), LV mass (LVM), LV mass index, and LV end-diastolic diameter index (LVEDDI). Results: Results indicated that VS was higher in female athletes (28.9 ± 2.36 mm) than in non-athletes (27.19 ± 2.87 mm, p = 0.03). On the other hand, rAA was higher in strength athletes (12.19 ± 1.48 mm/m²) than in endurance athletes (11.12 ± 0.99 mm/m², p = 0.04). Additionally, rVS and rAA were higher in female strength athletes (17.19 ± 1.78 mm/m², 12.19 ± 1.48 mm/m²) than female basketball players (15.49 ± 1.08 mm/m², p = 0.03, 10.75 ± 1.06 mm/m², p = 0.02). No significant differences regarding aortic root were found between male athletes and non-athletes. Statistically significant positive moderate correlations were found between VS and LVEDD, LVM, IVSTd, LVPWTd, rVS, and LVEDDI parameters in all athletes. Conclusion: The diameter of Valsalva sinus was greater in female athletes compared to non-athletes. The rAA mean value for body surface area was greater in female athletes practising strength sports as compared to their counterparts who were practising endurance sports. The diameter of the aortic root at sinuses positively correlated with the LV size in all athletes.

Echocardiographic measurements of aortic root diameter (ARD) in collegiate football Athletes at pre-participation evaluation

BACKGROUND

Some remodelling of the aortic root may be expected to occur with exercise but can already vary due to different body sizes, compositions and genetic predispositions. Attributing the cause of borderline aortic root diameter (ARD) values to either physiological or pathological conditions in American college football athletes is difficult as there is very limited normal reference values in this population. Body surface area (BSA) specific norms are thought to be useful in other cardiac measurements of football athletes.

METHODS

A retrospective cohort review of pre-participation examination (PPE) transthoracic echocardiogram data from collegiate football athletes was performed. ARD was analysed by field position (linemen, n=137; non-linemen, n=238), race (black, n=216; white, n=158) and BSA for predictive value and associations. Values were compared with non-athlete norms, and collegiate football athlete-specific normal tables were created.

RESULTS

Only 2.7% of football athletes had ARD measurements above normal non-athlete reference values and the mean athlete ARD values were lower than non-athlete values. No athletes had an aortic root >40 mm or were disqualified due to underlying cardiac pathology. Univariate analyses indicated linemen position and increasing BSA was associated with larger values for ARD. BSA outperformed race in predicting ARD. Normal tables were created for ARD stratified by BSA group classification (low, average and high BSA). Proposed clinical cut-offs for normal and abnormal values are reported for raw echocardiograph metrics and their BSA indexed scores.

CONCLUSIONS

Non-athlete reference values for ARD appear applicable for defining upper limits of normal for most collegiate football athletes. BSA-specific normal values may be helpful in interpreting results for athletes that exceed non-athlete norms.

Suitability of the porcine aortic model for transcatheter aortic root repair

OBJECTIVES

To treat aortic valve disease and concomitant root disease with transcatheter techniques, 'composite graft' implants are required. Our goal was to assess the suitability of the porcine aortic root for transcatheter root repair tests.

METHODS

Eight pig hearts explanted from domestic pigs used in experimental surgery were compared to data from the literature on human hearts. The measured diameters included those of the annulus, sinuses of Valsalva, coronary ostia, sinotubular junction, ascending aorta, innominate artery and aortic arch. The measured distances were from the coronary ostia to the nadir of the corresponding annulus; from the innominate artery to the nadir of the corresponding annulus; from the small curvature of the arch to the nadir of the corresponding annulus.

RESULTS

The mean weight of the pigs was 89 ± 5.4 kg. The mean aortic annulus diameter was 20 ± 1.2 mm (human: 23.0 ± 2.5 mm), the sinus of Valsalva diameter was 20.5 ± 0.5 mm (human: 31.4 ± 3.4 mm) and the sinotubular junction diameter was 20 ± 0.9 mm (human: 27.2 ± 3.0 mm). The diameter of the mean ascending aorta was 19 ± 0.7 mm (human: 29.3 ± 4 mm); the diameter of the innominate artery was 8.5 ± 0.7 mm, that of the aortic arch was 15 ± 0.7 mm and that of the coronary ostia was 5 ± 0.5 mm (left) and 4.7 ± 0.5 mm (right) (human: 4.8 ± 0.5 mm and 3.7 ± 0.9 mm). The distances from the left and right coronary orifices to the corresponding annuli were 8 ± 1.5 mm and 14 ± 2.4 mm, respectively (human: 14.7 ± 1.3 mm; 15.4 ± 1.7 mm). The distances from the innominate artery to the nadirs of the left and right coronary annuli were 44 ± 4.3 mm and 41 ± 4 mm (human: 80 ± 17 mm). The distance from the curvature of the small arch to the annulus was 35 ± 4.9 mm.

CONCLUSIONS

The porcine heart can be used as an experimental model to design and test new devices for catheter-based composite repair of the aortic root. Nevertheless, caution is required in using devices with tailored dimensions that must be adapted to the smaller pig's root.

Preparticipation Cardiovascular Screening of Student-Athletes with Echocardiography: Ethical, Clinical, Economic, and Legal Considerations

PURPOSE OF REVIEW

To identify whether the use of echocardiography is a viable approach for the screening of athletes for the prevention of sudden cardiac death when considering ethical, clinical, economic, and legal issues.

RECENT FINDINGS

Ethical musings, echocardiographic findings, economic calculations, and legal analysis suggest that echocardiographic screening may reduce sudden cardiac death on the athletic field. Ethical, clinical, economic, and legal considerations suggest echocardiographic screening is a viable option to meet the societal goal to prevent athletic field sudden death.

Arterial adaptations in athletes of dynamic and static sports disciplines - a pilot study

BACKGROUND

Structural and functional arterial adaptations with regard to the type and level of training in young athletes are understudied. Our research aimed at evaluating them in two types of exercise (dynamic and static) and two levels of engagement (high and recreational).

METHODS

A total of 76 volunteers formed five groups. Group A included 17 high-level dynamic sports athletes 30·9 ± 6·4 years old, group B 14 recreational ones aged 28·7 ± 6·2 years, group C 15 high-level static sports athletes 26·4 ± 3·9 years old and group D 16 recreational ones, aged 25·8 ± 4·8 years. Fourteen sedentary men 30 ± 3·8 years old formed control group E. Structural indices of left cardiac chambers and thoracic aorta were echographically obtained, as well as common carotid intima-media thickness (cIMT). Furthermore, applanation tonometry was conducted, at rest and during a handgrip strength test, for the acquisition of central arterial pressure parameters, carotid-femoral pulse wave velocity (cfPWV) and total arterial compliance (C_τ ).

RESULTS

No significant differences in structural arterial markers were observed. However, group A obtained the highest handgrip central systolic pressure values (13·1% compared to group D, P<0·05). Resting cfPWV was lower in group B by 13·8% (P<0·05) than C and by 16·7% (P<0·01) than E, whereas C_τ was higher in group Β by 33·3% than C (P<0·05) and by 40·9% than E (P<0·01).

CONCLUSION

Functional arterial exercise-induced adaptations become apparent at an early age, without being in conjunction with structural ones. Recreational dynamic exercise results in the most favourable arterial characteristics.

Aortic expansion induces lumen narrrowing in anomalous coronary arteries: a parametric structural finite element analysis

Anomalous aortic origin of coronary arteries (AAOCA) is a congenital disease that can lead to cardiac ischemia during intense physical activity. Although AAOCA is responsible for sudden cardiac death (SCD) among young athletes and soldiers, the mechanisms underlying the coronary occlusion during physical effort still have to be clarified. The present study investigates the correlation between geometric features of the anomaly and coronary lumen narrowing under aortic root dilatations. Idealized parametric computer-aided designed (CAD) models of the aortic root with anomalous and normal coronary are created and static finite element (FE) simulations of increasing aortic root expansions are carried out. Different coronary take-off angles and intramural penetrations are investigated to assess their role on coronary lumen narrowing. Results show that increasing aortic and coronary pressures lead to lumen expansions in normal coronaries, particularly in the proximal tract, while the expansion of anomalous coronary is impaired especially at the ostium. Concerning the geometric features of the anomaly, acute take-off angles cause elongated coronary ostia, with an eccentricity increasing with aortic expansion; the impact of intramural penetration of coronary on its luminal narrowing is limited. The present study provides a proof of concept of the biomechanical reasons underlying the lumen narrowing in AAOCA during aortic expansion, promoting the role of computational simulations as a tool to assess the mechanisms of this pathology.

Correlating possible predisposing demographics and systemic conditions with the aortic root

Background

The aortic root is an aggregate of various components that connects the left ventricle to the aorta. The most predominant pathologies have been associated with the dilation of the aortic root leading to aneurysms.

Aim

This study is designed to measure the role of systemic morbidities such as hypertension, diabetes, and body mass index (BMI) on the dimension of the aortic root.

Materials and Methods

Participants were volunteers of African descent who were recruited during and after an organized health fair by the medical students' body from All Saints University, School of Medicine. 169 participants consisting of 62 males and 107 females with ages ranging from 9 to 84 years agreed to volunteer by signing the consent after which a questionnaire was administered and a preliminary clinical procedure was used to check for blood pressure (BP), blood glucose (BG), and BMI. The measurement of the aortic root was carried out by an experienced single investigator who was not aware of the purpose of measurements, using a DUS-5000 ultrasound machine (Miami, Florida, USA) at a low-frequency micro-convex transducer preset to "adult cardiac" with a default frequency of 4 MHz.

Results

Among the participants, 35.03%, 47.80%, and 29.11% had normal BP, BG, and BMI readings, respectively. The Chi-squared analysis identified a significant correlation between the diameter of the aortic annulus (AA) and BMI. Diastolic BP is also correlated with the diameter of the AA. Sinus of Valsalva (SV) showed an unusual correlation with BG as opposed to BP and BMI.

Conclusion

The disparity in how a systemic factor individually correlates with the AA and the SV is not clear. The study targets to provide educational concept in this regard.

Ascending Aortic Dimensions in Former National Football League Athletes

BACKGROUND

Ascending aortic dimensions are slightly larger in young competitive athletes compared with sedentary controls, but rarely >40 mm. Whether this finding translates to aortic enlargement in older, former athletes is unknown.

METHODS AND RESULTS

This cross-sectional study involved a sample of 206 former National Football League (NFL) athletes compared with 759 male subjects from the DHS-2 (Dallas Heart Study-2; mean age of 57.1 and 53.6 years, respectively, P<0.0001; body surface area of 2.4 and 2.1 m², respectively, P<0.0001). Midascending aortic dimensions were obtained from computed tomographic scans performed as part of a NFL screening protocol or as part of the DHS. Compared with a population-based control group, former NFL athletes had significantly larger ascending aortic diameters (38±5 versus 34±4 mm; P<0.0001). A significantly higher proportion of former NFL athletes had an aorta of >40 mm (29.6% versus 8.6%; P<0.0001). After adjusting for age, race, body surface area, systolic blood pressure, history of hypertension, current smoking, diabetes mellitus, and lipid profile, the former NFL athletes still had significantly larger ascending aortas (P<0.0001). Former NFL athletes were twice as likely to have an aorta >40 mm after adjusting for the same parameters.

CONCLUSIONS

Ascending aortic dimensions were significantly larger in a sample of former NFL athletes after adjusting for their size, age, race, and cardiac risk factors. Whether this translates to an increased risk is unknown and requires further evaluation.

The Palm-Heart Diameter: A Prospective Simple Screening Tool for Identifying Heart Enlargement

BACKGROUND:

Several speculations have linked the size of the fist to be equal to the size of the heart. However, the substantial scientific report still lacks to support this theory.

AIM:

This study aims to provide the validity of the fist-heart assumption by correlating the palm and heart diameters while benchmarking it as a reference tool for determining the normal heart size.

MATERIALS AND METHOD:

Volunteers from the public were recruited during a health fair organised by the school. A self-administered questionnaire for necessary information was distributed after the volunteers signed the consent forms. The palm of both hands was measured in duplicates using a flexible ruler. Ultrasound examination was used in measuring the diameter of the heart with the landmark being from the anterior fibrous pericardium to the lowest part of the posterior fibrous pericardium. The level of significance was kept at P < 0.05.

RESULTS:

A total of 275 people, consisting of 123 males and 152 females participated in the study. The age range was from 15 to 80 years with a mean age of 28.16 ± 16.18. The measurement showed that the size of both palms correlated with the heart diameter, p < 0.05. Other factors such as age and height showed a substantial level of correlation. However, this correlation ceased with older participants. Palm size did not correlate among participants with previously diagnosed prehypertension. However, participants with previously diagnosed hypertension with good medication compliance maintained the correlation.

CONCLUSION:

This study establishes the correlation between the palm and heart diameters. Since the heart tissue and the upper limb share a similar embryonic origin, being the mesoderm, this study prospects the fact that heart enlargement could be preliminarily identified by measuring the size of the hand.

Relationship of Echocardiographic Z Scores Adjusted for Body Surface Area to Age, Sex, Race, and Ethnicity: The Pediatric Heart Network Normal Echocardiogram Database

BACKGROUND

Published nomograms of pediatric echocardiographic measurements are limited by insufficient sample size to assess the effects of age, sex, race, and ethnicity. Variable methodologies have resulted in a wide range of Z scores for a single measurement. This multicenter study sought to determine Z scores for common measurements adjusted for body surface area (BSA) and stratified by age, sex, race, and ethnicity.

METHODS AND RESULTS

Data collected from healthy nonobese children ≤18 years of age at 19 centers with a normal echocardiogram included age, sex, race, ethnicity, height, weight, echocardiographic images, and measurements performed at the Core Laboratory. Z score models involved indexed parameters (X/BSAα) that were normally distributed without residual dependence on BSA. The models were tested for the effects of age, sex, race, and ethnicity. Raw measurements from models with and without these effects were compared, and <5% difference was considered clinically insignificant because interobserver variability for echocardiographic measurements are reported as ≥5% difference. Of the 3566 subjects, 90% had measurable images. Appropriate BSA transformations (BSAα) were selected for each measurement. Multivariable regression revealed statistically significant effects by age, sex, race, and ethnicity for all outcomes, but all effects were clinically insignificant based on comparisons of models with and without the effects, resulting in Z scores independent of age, sex, race, and ethnicity for each measurement.

CONCLUSIONS

Echocardiographic Z scores based on BSA were derived from a large, diverse, and healthy North American population. Age, sex, race, and ethnicity have small effects on the Z scores that are statistically significant but not clinically important.

Athletes and the Aorta: Normal Adaptations and the Diagnosis and Management of Pathology

OPINION STATEMENT

Over a hundred years ago, physicians first recognized that participation in regular, vigorous training resulted in enlargement of the heart. Since that time, the term "athlete's heart" has entered the medical lexicon as a global expression encompassing the electrical, functional, and morphological adaptations that develop in response to physical training. Exercise-induced adaptations of the aorta, which is also exposed to large hemodynamic stresses during prolonged endurance exercise or resistance training, are less well recognized. Young athletes tend to have slightly larger aortas than their sedentary counterparts; however, this rarely exceeds normal ranges for the general population. A systematic approach is advised when presented with an athlete with aortic enlargement. The size of the aorta needs to be first put in the context of the athlete's age, sex, size, and sporting endeavors; however, even in the largest young athletes, the aortic root rarely exceeds 4 cm in men or 3.4 cm in women. A comprehensive evaluation is advised which includes a detailed family history and a thorough physical examination evaluating for signs of any defined connective tissue disorder associated with aortopathy. Downstream testing is then tailored for the individual and may include further tomographic imaging, opthalmology review, and genetic testing. This should ideally be performed at a specialist center. Management of athletes with an aortopathy includes tailoring athletic activity, medical management with strict impulse control, and, in some cases, prophylactic surgery. The issue of sporting eligibility should be individualized and if disqualification is necessary, this should be undertaken by a sports cardiologist or an expert in aortic disease with experience in dealing with an athletic population.

Fitness Is Independently Associated with Central Hemodynamics in Metabolic Syndrome

PURPOSE

Fit individuals with metabolic syndrome (MetS) have lower mortality risk compared with less fit counterparts, despite the presence of obesity as a component of the syndrome. To understand the importance of fitness in treating this condition, we examined the association of fitness and fatness with central hemodynamic indices that are known independent predictors of cardiovascular events.

METHODS

Sixty-eight individuals with MetS participated in this cross-sectional study. Central hemodynamics is calculated from radial applanation tonometry and comprised aortic reservoir pressure, backward pressure wave (Pb), reflection magnitude (RM), and augmentation index at 75 bpm (AIx75). Cardiorespiratory fitness (CRF) and body fat percentage (BF%) were determined via indirect calorimetry during maximal exercise testing and dual-energy x-ray absorptiometry, respectively.

RESULTS

CRF was inversely associated with aortic reservoir pressure (r = -0.29, P = 0.02), Pb (r = -0.42, P < 0.001), RM (r = -0.48, P < 0.001), and AIx75 (r = -0.65, P < 0.001). BF% was also correlated with AIx75 (r = 0.37, P < 0.05) and RM (r = 0.36, P < 0.005) but at a weaker association compared with CRF. Multiple regression analysis revealed CRF as a predictor of aortic reservoir pressure (β = -0.52, P = <0.01), Pb (β = -0.41, P < 0.03), and AIx75 (β = -0.45, P = 0.01), independent of BF% and other confounding factors.

CONCLUSIONS

CRF predicts central hemodynamics independent of BF% and other confounding factors. This suggests that CRF improvement may be a higher priority when compared with fat loss for lowering the risk of cardiovascular mortality in MetS individuals.

Anatomy of the aortic root: implications for aortic root reconstruction

Since the introduction of valve-preserving root replacement and aortic annuloplasty, precise understanding of the aortic root anatomy has emerged as a key to successful aortic valve-preservation surgery. Fundamentally, surgeons need to know the precise anatomical definition and structure of the aortic root, including its normal dimensions, know the anatomy of the coronary arteries, and understand the cardiac conduction system. Surgeons must be able to clearly distinguish normal and abnormal structures, and recognize the effects of aortic valve regurgitation or root expansion on dimensions and geometric relationships within the aortic root. Possessing a detailed understanding of the aortic root, surgeons can select appropriately sized grafts and achieve optimum annular fixation. This review covers the essentials of aortic root anatomy and provides tips for correct and safe performance of aortic valve-preservation surgery with a view toward durable late outcomes.

Reference Values of Aortic Root in Male and Female White Elite Athletes According to Sport

BACKGROUND

There is limited information regarding the aortic root upper physiological limits in all planes in elite athletes according to static and dynamic cardiovascular demands and sex.

METHODS AND RESULTS

A cross-sectional study was performed in 3281 healthy elite athletes (2039 men and 1242 women) aged 23.1±5.7 years, with body surface area of 1.9±0.2 m² and 8.9±4.9 years and 19.2±9.6 hours/week of training. Maximum end-diastolic aortic root diameters were measured in the parasternal long axis by 2-dimensional echocardiography. Age, left ventricular mass, and body surface area were the main predictors of aortic dimensions. Raw values were greater in males than in females (P<0.0001) at all aortic root levels. Dimensions corrected by body surface area were higher in men than in women at the aortic annulus (13.1±1.7 versus 12.9±1.7 mm/m²; P=0.007), without significant differences at the sinus of Valsalva (16.3±1.9 versus 16.3±1.9 mm/m²; P=0.797), and were smaller in men at the sinotubular junction (13.6±1.8 versus 13.8±1.8 mm/m²; P=0.008) and the proximal ascending aorta (13.8±1.9 versus 14.1±1.9 mm/m²; P=0.001). Only 1.8% of men and 1.5% of women had values >40 mm and 34 mm, respectively. Raw and corrected aortic measures at all levels were significantly greater in sports, with a high dynamic component in both sexes, except for corrected values of the sinotubular junction in women.

CONCLUSIONS

Aortic root dimensions in healthy elite athletes are within the established limits for the general population. This study describes the normal dimensions for healthy elite athletes classified according to sex and dynamic and static components of their sports.

Acute and Chronic Response to Exercise in Athletes: The "Supernormal Heart"

During last decades, most studies have examined the exercise-induced remodeling defined as "athlete's heart". During exercise, there is an increased cardiac output that causes morphological, functional, and electrical modification of the cardiac chambers. The cardiac remodeling depends also on the type of training, age, sex, ethnicity, genetic factors, and body size. The two main categories of exercise, endurance and strength, determine different effects on the cardiac remodeling. Even if most sport comprise both strength and endurance exercise, determining different scenarios of cardiac adaptation to the exercise. The aim of this paper is to assemble the current knowledge about physiologic and pathophysiologic response of both the left and the right heart in highly trained athletes.

Comparison of arterial stiffness/compliance in the ascending aorta and common carotid artery in healthy subjects and its impact on left ventricular structure and function

Arterial stiffness and compliance parameters from two adjacent elastic arteries [aorta and common carotid artery (CCA)] were compared and their relationship with left ventricular (LV) structure and function and clinical parameters was assessed. 584 healthy subjects were prospectively enrolled [mean age 47.8 ± 18.4 years, range 16-94; 318 (54.4%) men]. They underwent comprehensive transthoracic echocardiography; M-mode diameters were measured at the level of the ascending aorta in systole and diastole and by echo-tracking at the level of the left CCA. The β-stiffness, pressure-strain elastic modulus, arterial compliance and one-point pulse wave velocity were derived. A significant correlation was observed between aortic and CCA stiffness and compliance parameters (p < 0.0001 for all). At multiple regression analysis, CCA stiffness parameters were constantly correlated with age and systolic blood pressure, and accounted for up to 56% of the variability (vs. only 29% in aortic stiffness and compliance). CCA stiffness parameters were found to better predict LV structure, diastolic function than aortic stiffness parameters. Aortic and CCA stiffness and compliance were found to correlate with each other and with age, with the correlation being higher for CCA stiffness. At multiple regression analysis, CCA stiffness parameters were better predictors of LV structure and function than aortic stiffness.

Aortic compliance variation in long male distance triathletes: A new insight into the athlete's artery?

OBJECTIVES

To assess cardiac and vascular adaptations in long-distance male triathletes and the influence of an increased training volume on these parameters.

DESIGN

Case-control study using long-distance male triathletes (Tri) (n=12) and an age-matched cohort of sedentary volunteers (Ctrl).

METHODS

All participants gave an informed consent and underwent a Cardiovascular Magnetic Resonance imaging (CMR) exam to measure left and right ventricle functional parameters, and aortic parameters (surface, strain, compliance, pulse wave velocity). This exam was repeated in the triathletes' group after an increased training volume of at least 2h/week for six weeks.

RESULTS

Compared to control volunteers, triathletes presented at baseline a typical pattern of athlete's heart (higher end-diastolic, end-systolic and stroke volumes index, p≤0.009, and lower cardiac rate, p=0.015) but similar vascular characteristics except a trend towards an enlarged ascending aorta (surface 942±106 vs 812±127mm², p=0.058). Between the two visits, the triathletes increased their weekly training time from 9.67±2.43 (Tri1) to 12.15±3.01h (Tri2): no modifications were found regarding cardiac parameters, but compliance and distensibility of the ascending aorta increased, from 2.60 to 3.34mm²/mmHg (p=0.028) and from 3.36 to 4.40×10^-3mmHg^-1 (p=0.048) respectively.

CONCLUSIONS

Using CMR, we showed that vascular characteristics of the ascending aorta may vary along the sport season in endurance athletes. This remodelling could be considered as a physiological adaptation, but could eventually lead to an adverse vascular remodelling.

The multi-modality cardiac imaging approach to the Athlete's heart: an expert consensus of the European Association of Cardiovascular Imaging

The term 'athlete's heart' refers to a clinical picture characterized by a slow heart rate and enlargement of the heart. A multi-modality imaging approach to the athlete's heart aims to differentiate physiological changes due to intensive training in the athlete's heart from serious cardiac diseases with similar morphological features. Imaging assessment of the athlete's heart should begin with a thorough echocardiographic examination.Left ventricular (LV) wall thickness by echocardiography can contribute to the distinction between athlete's LV hypertrophy and hypertrophic cardiomyopathy (HCM). LV end-diastolic diameter becomes larger (>55 mm) than the normal limits only in end-stage HCM patients when the LV ejection fraction is <50%. Patients with HCM also show early impairment of LV diastolic function, whereas athletes have normal diastolic function.When echocardiography cannot provide a clear differential diagnosis, cardiac magnetic resonance (CMR) imaging should be performed.With CMR, accurate morphological and functional assessment can be made. Tissue characterization by late gadolinium enhancement may show a distinctive, non-ischaemic pattern in HCM and a variety of other myocardial conditions such as idiopathic dilated cardiomyopathy or myocarditis. The work-up of athletes with suspected coronary artery disease should start with an exercise ECG. In athletes with inconclusive exercise ECG results, exercise stress echocardiography should be considered. Nuclear cardiology techniques, coronary cardiac tomography (CCT) and/or CMR may be performed in selected cases. Owing to radiation exposure and the young age of most athletes, the use of CCT and nuclear cardiology techniques should be restricted to athletes with unclear stress echocardiography or CMR.

Impact of specific training and competition on myocardial structure and function in different age ranges of male handball players

Handball activity involves cardiac changes and demands a mixture of both eccentric and concentric remodeling within the heart. This study seeks to explore heart performance and cardiac remodeling likely to define cardiac parameters which influence specific performance in male handball players across different age ranges. Forty three players, with a regular training and competitive background in handball separated into three groups aged on average 11.78±0.41 for youth players aka “schools”, “elite juniors” 15.99±0.81 and “elite adults” 24.46±2.63 years, underwent echocardiography and ECG examinations. Incremental ergocycle and specific field (SFT) tests have also been conducted. With age and regular training and competition, myocardial remodeling in different age ranges exhibit significant differences in dilatation’s parameters between “schools” and “juniors” players, such as the end-diastolic diameter (LVEDD) and the end-systolic diameter of the left ventricle (LVESD), the root of aorta (Ao) and left atrial (LA), while significant increase is observed between “juniors” and “adults” players in the interventricular septum (IVS), the posterior wall thicknesses (PWT) and LV mass index. ECG changes are also noted but NS differences were observed in studied parameters. For incremental maximal test, players demonstrate a significant increase in duration and total work between “schools” and “juniors” and, in total work only, between “juniors” and “seniors”. The SFT shows improvement in performance which ranged between 26.17±1.83 sec to 31.23±2.34 sec respectively from “seniors” to “schools”. The cross-sectional approach used to compare groups with prior hypothesis that there would be differences in exercise performance and cardiac parameters depending on duration of prior handball practice, leads to point out the early cardiac remodeling within the heart as adaptive change. Prevalence of cardiac chamber dilation with less hypertrophy remodeling was found from “schools” to “juniors” while a prevalence of cardiac hypertrophy with less pronounced chamber dilation remodeling was noted later.

Cardiovascular and Musculoskeletal Assessment of Elite US Volleyball Players

OBJECTIVE

The aim of this study was to characterize the cardiovascular and musculoskeletal systems of elite volleyball players, including aortic dimensions. Previous studies have shown that the upper limit of normal aortic sinus diameter for male and female athletes is 4 and 3.4 cm, respectively.

DESIGN

Cross-sectional analysis.

SETTING

United States Olympic Volleyball Training Facility and Rady Children's Hospital San Diego.

PARTICIPANTS

Seventy (37 male) members of the US national volleyball team.

MAIN OUTCOME MEASURES

Athletes underwent evaluation that included medical and family histories, targeted physical examinations specifically focusing on abnormalities present in Marfan syndrome (MFS), and transthoracic echocardiograms. Cardiac chamber and great artery size, valve function, and coronary artery origins were assessed.

RESULTS

Three male athletes (8%) had an aortic sinus diameter ≥4 cm, one of whom also had an ascending aorta >4 cm. Two female athletes (6%) had aortic sinus diameter ≥3.4 cm, and another had an ascending aorta of 3.4 cm. There were no other intracardiac or arterial abnormalities. Individual musculoskeletal characteristics of MFS were common among the athletes but not more frequent or numerous in those with aortic dilation.

CONCLUSIONS

The prevalence of aortic root dilation in this population of athletes was higher than what has previously been reported in other similar populations. Further study is needed to determine whether these represent pathological changes or normal variations in tall athletes.

CLINICAL RELEVANCE

This study adds to the existing knowledge base of athlete's heart, with specific attention to aortic dimensions in elite volleyball players. The data are relevant to similar athletes' medical care and to preparticipation cardiac screening in general.

Diseases of the Aorta in Elite Athletes

Sudden cardiovascular deaths in athletes are rare and only a fraction are due to aortic events. There has been concern that the hemodynamic load during exercise may lead to aortic dilation, but aortic dimensions in endurance and strength-trained athletes are only slightly larger than those in sedentary comparison subjects. The presence of a bicuspid aortic valve without significant valvular dysfunction and normal aortic dimensions should not influence eligibility to practice sport. Patients with genetic syndromes associated with aortopathy generally should be restricted from vigorous sports participation. This article reviews the diagnosis and management of diseases of the aorta in athletes.

Echocardiography in the evaluation of athletes

Echocardiography is currently a widely available imaging technique that can provide useful data in the field of sports cardiology particularly in two areas: pre-participation screening and analysis of the cardiac adaptation induced by exercise.

The application of pre-participation screening and especially, the type and number of used diagnostic tests remains controversial. Echocardiography has shown though, higher sensitivity and specificity as compared to the ECG, following a protocol adapted to athletes focused on ruling out the causes of sudden death and the most common disorders in this population. It is still a subject of controversy the actual cost of adding it, but depending on the type of sport, echocardiography might be cost-effective if added in the first line of examination.

Regarding the evaluation of cardiac adaptation to training in athletes,  echocardiography has proved to be useful in the differential diagnosis of diseases that can cause sudden death, analysing both the left ventricle (hypertrophy cardiomyopathy, dilated cardiomyopathy, left ventricle non compaction) and the right ventricle (arrhythmogenic right ventricular cardiomyopathy).

The aim of this paper is to review the current knowledge and the clinical practical implications of it on the field of echocardiography when applied in sport cardiology areas.

Cardiovascular Adaptation and Remodeling to Rigorous Athletic Training

Exercise-induced cardiac remodeling is a complex process by which the cardinal hemodynamic stresses of pressure and volume lead to a host of structural or functional adaptations. In aggregate, the constellation of changes that accompany this process serve to facilitate athletic performance by minimizing the cardiac work inherent in athletic activity. Although several key determinants of athletic cardiac adaptation have been described, observed variability across athlete cohorts remains an incompletely understood area. Ongoing and future work are required to further understand this process and ultimately to determine where the boundary lies between adaptive physiology and maladaptive disease.

Physical activity measured by accelerometry and its associations with cardiac structure and vascular function in young and middle-aged adults

BACKGROUND

Physical activity is associated with several health benefits, including lower cardiovascular disease risk. The independent influence of physical activity on cardiac and vascular function in the community, however, has been sparsely investigated.

MEASURES AND RESULTS

We related objective measures of moderate- to vigorous-intensity physical activity (MVPA, assessed by accelerometry) to cardiac and vascular indices in 2376 participants of the Framingham Heart Study third generation cohort (54% women, mean age 47 years). Using multivariable regression models, we related MVPA to the following echocardiographic and vascular measures: left ventricular mass, left atrial and aortic root sizes, carotid-femoral pulse wave velocity, augmentation index, and forward pressure wave. Men and women engaged in MVPA 29.9±21.4 and 25.5±19.4 min/day, respectively. Higher values of MVPA (per 10-minute increment) were associated with lower carotid-femoral pulse wave velocity (estimate -0.53 ms/m; P=0.006) and lower forward pressure wave (estimate -0.23 mm Hg; P=0.03) but were not associated with augmentation index (estimate 0.13%; P=0.25). MVPA was associated positively with log(e) left ventricular mass (estimate 0.006 log(e) [g/m(2)]; P=0.0003), left ventricular wall thickness (estimate 0.07 mm; P=0.0001), and left atrial dimension (estimate 0.10 mm; P=0.01). MVPA also tended to be positively associated with aortic root dimension (estimate 0.05 mm; P=0.052). Associations of MVPA with cardiovascular measures were similar, in general, for bouts lasting <10 versus ≥10 minutes.

CONCLUSIONS

In our community-based sample, greater physical activity was associated with lower vascular stiffness but with higher echocardiographic left ventricular mass and left atrial size. These findings suggest complex relations of usual levels of physical activity and cardiovascular remodeling.

Aortic valve repair update

The key for successful valve repair is full understanding of the regurgitant mechanism and sufficient evaluation of the valve. Currently, multidetector computed tomography has been introduced for evaluation. The aortic valve can be analyzed in details preoperatively. The main causes of aortic regurgitation (AR) in the adult population are degenerative leaflet change and annulus dilatation. Restoration to normal structure can be accomplished mainly by plication. Central leaflet plication near the Arantius nodule is a simple technique for redundant tissue. For leaflet deficiency, pericardial patch plasty may be an option. No universal technique exists for plication of the aortic annulus. The valve-sparing aortic root replacement firmly stabilizes the ventriculo-aortic junction (VAJ) and assures repair durability even in patients with mild to moderate root dilatation. Subcommissural annuloplasty (Cabrol stitch) does not seem sufficient for the prevention of VAJ dilatation. Circumferential annuloplasties may have a greater potential. However, convenient device for annular plication is still in development. The bicuspid aortic valve is a congenital heart valve lesion. A basic technique is free margin plication of the fused leaflet. Aortic root dilatation may contribute to AR severity. Valve-sparing aortic root replacement may improve repair durability. Considering the great advances in valve repair, young patients with AR should be informed that valve repair is a promising option for surgical treatment.

The Role of Multimodality Cardiac Imaging for the Assessment of Sports Eligibility in Patients with Bicuspid Aortic Valve

Bicuspid aortic valve (BAV) cannot be considered an innocent finding, but it is not necessarily a life-threatening condition. Athletes with BAV should undergo a thorough staging of the valve anatomy, taking into consideration hemodynamic factors, as well as aortic diameters and looking for other associated significant cardiovascular anomalies by use of a multimodality cardiac imaging approach. Furthermore an accurate follow-up is mandatory with serial cardiological controls in those allowed to continue sports.