How native T1 and T2 mapping is influenced by sex and training load? Cardiac magnetic resonance imaging in young elite athletes and less active individuals

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This study was financed by the Ministry of Innovation and Technology NRDI Office within the framework of the Artificial Intelligence National Laboratory Program. LS is supported by the EACVI Research Grant 2021.

Introduction

Cardiac adaptation due to regular and intense exercise is a well-known phenomenon. Cardiac magnetic resonance (CMR) imaging is a well suited, highly reproducible technique that has a vital role in differentiating physiological adaptation and pathological alterations. Native T1 and T2 mapping enable the quantitative assessment of tissue characteristics without the administration of contrast material. These techniques are increasingly used in studies aiming to consider subtle differences. However, the sex-and training-dependence of native T1 and T2 mapping values remains incompletely understood.

Purpose

We aimed to describe the differences in native T1 and T2 mapping among healthy athletes and less active individuals.

Methods

We enrolled healthy elite athletes (n=88, 56 male, 25±5 years) and healthy volunteers (n=82, 46 male, 25±3 years) to undergo CMR examinations at our Centre. Healthy elite athletes performed high sports activity levels (>10 hours/week) and competed nationally or internationally. Sex- and age-matched healthy volunteers engaged in ≤6 hours/week of sports activity. Standardized CMR protocol included short- and long-axis cine images covering the entire left (LV) and right (RV) ventricle and native T1 and T2 mapping in basal, midventricular and apical slices.

Results

Athletes had consistently higher LV and RV volumes and mass indexes compared to healthy volunteers (p<.001 for all). Native T1 mapping was lower in athletes than in the control group (T1: 954±24 ms vs 970±23 ms; p <.001). T1 mapping showed a moderately strong negative correlation to markers of cardiac adaptation, including LV mass, end-diastolic volume and stroke volume indexes (p<.001 for all). Moreover, we found a negative correlation between native T1 and training hours (Rho: -0.302; p<.001). On the other hand, native T2 mapping showed no difference between athletes and less active controls. Furthermore, T2 correlated with LV shape features but not with training hours. We found that mapping values differed between sexes, both in the athletic and control groups. Females showed slightly higher values compared to their male counterparts (T2: 46±2 vs 43±2; p<.001). Finally, native T1 mapping was associated with training hours and sex in our multiple linear regression model, adjusted for age, resting heart rate, body mass index, body surface area and LVM (p<.001). While T2 mapping was associated only with sex considering the same covariates.

Conclusion

Our study demonstrates the importance of sex-matched controls in CMR studies evaluating mapping parameters. Moreover, the consideration of exercise load seems paramount in the case of T1 mapping.

Relapsing Klebsiella pneumoniae meningitis in a patient with COVID-19

Klebsiella pneumoniae is a common cause of potentially life‐threatening infection. This report describes a relapsing healthcare‐associated Klebsiella pneumoniae meningitis in a 60‐year‐old patient who had SARS‐CoV‐2 infection. During their initial admission for COVID‐19 pneumonitis and treatment with corticosteroids, the patient developed signs and symptoms suggestive of bacterial meningitis. Blood and cerebrospinal fluid cultures confirmed Klebsiella pneumoniae as the causative organism. The patient was treated with a prolonged course of high‐dose meropenem and made an apparent recovery. Four days after hospital discharge, the patient re‐presented critically unwell. Klebsiella pneumoniae was once again isolated from cerebrospinal fluid. During their second admission, the patient deteriorated despite antimicrobial treatment, and life‐sustaining therapies were withdrawn. This case highlights that all COVID‐19 patients receiving immunosuppressive therapy should be monitored for potential opportunistic infection. Prompt recognition and early antimicrobial therapy are key to improving patient outcomes.

Training- and sex related alterations of global feature-tracking strain values of highly trained athletes using cardiac magnetic resonance imaging

Introduction

Cardiac magnetic resonance imaging (CMR) is a reference method for assessing the morphological and functional parameters of the heart, and more recently, strain analysis can detect mechanical features. Based on echocardiographic data, strain parameters may help to differentiate between physiological athlete adaptation and pathological hypertrophy, however, there are still little data available among elite athletes regarding strain values using CMR.

Aims

Our aim was to study the strain characteristics of the athlete's heart using CMR imaging.

Methods

Overall, 228 (149 male, 24±5 years) highly trained adult (18–35 years), Caucasian athletes (≥10h training hours/ week) who underwent CMR examination as part of their screening were included in our study. Cine movie images in long- and short axis views were performed. Standard CMR parameters including left- and right ventricular (LV and RV) volumes, ejection fraction and muscle masses were measured. Feature-tracking strain analyses were performed, global LV longitudinal, circumferential and radial strain and RV longitudinal strain were calculated. CMR parameters of athletes were compared with healthy sex- and age matched sedentary control groups (n=105, 55 men).

Results

Athletes competed in mixed (n=99), endurance (n=99) and power (n=30) sport disciplines, and performed sport activity in quite high training hours (average: 21±5 hours/week). Regarding standard CMR parameters we found pronounced sports adaptation in both male and female athletes compared to sex- and age matched controls including lower LV and RV ejection fraction (p<0.05), elevated LV and RV volumes and masses (p<0.001). Strain analysis also revealed differences between athletes and controls: LV- GLS, GCS, GRS were lower in athletes compared to controls, regardless of their sex (p<0.05). RV-GLS was slightly lower in male athletes compared to male controls. Examining the effects of sport disciplines, we found the most marked sport adaptation in the case of endurance athletes. Training hours showed a positive correlation with LV-GLS and GCS values, and a negative correlation with GRS (p<0.001). We found that male athletes had more pronounced cardiac adaptation compared to females (p<0.001), and their LV-GLS and GRS values were lower (GLS: male athletes: −20±2% vs. female athletes: −22±2%; p<0.001), while GCS and RV-GLS showed no difference between sexes.

Conclusion

Our results suggest that in addition to standard CMR parameters, global strain values also show a small but consistent change during sport adaptation. Moreover, our results support the use of sex specific strain normal values in highly trained athletes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was financed by the Research Excellence Programme of the Ministry for Innovation and Technology in Hungary within the framework of the Bioimaging Thematic Programme of Semmelweis University. LS was supported by the ÚNKP-20-3-II-SE-61 New National Excellence Program of the Ministry for Innovation and Technology from the source of the National Research, Development and Innovation Fund.

Cardiopulmonary examinations of athletes returning to high-intensity sport activity following SARS-CoV-2 infection

 

During the pandemic, several studies were carried out on the short-term effects of acute SARS-CoV-2 infection in athletes. As some cases of young athletes with serious complications like myocarditis or thromboembolism and even sudden death were reported, strict recommendations for return to sport were published. However, we have less data about athletes who have already returned to high-intensity trainings after a SARS-CoV-2 infection.

Athletes underwent cardiology screening (personal history, physical examination, 12-lead resting ECG, laboratory tests with necroenzyme levels and echocardiography) 2 to 3 weeks after suffering a SARS-CoV-2 infection. In case of negative results, they were advised to start low intensity trainings and increase training intensity regularly until achieving maximal intensity a minimum of 3 weeks later. A second step of cardiology screening was also carried out after returning to maximal intensity trainings. The above mentioned screening protocol was repeated and was completed with vita maxima cardiopulmonary exercise testing (CPET) on running treadmill. If the previous examinations indicated, 24h Holter ECG recording, 24h ambulatory blood pressure monitoring or cardiac MR imaging were also carried out. Data are presented as mean±SD.

Two-step screening after SARS-CoV-2 infection was carried out in 111 athletes (male:74, age:22.4±7.4y, elite athlete:90%, training hours:14.8±5.8 h/w, ice hockey players:31.5%, water polo players:22.5%, wrestlers:18.9%, basketball players:18.0%). Second screenings were carried out 94.5±31.5 days after the first symptoms of the infection. A 5% of the athletes was still complaining of tiredness and decreased exercise capacity. Resting heart rate was 70.3±13.0 b.p.m., During CPET examinations, athletes achieved a maximal heart rate of 187.3±11.6 b.p.m., maximal relative aerobic capacity of 49.2±5.5 ml/kg/min, and maximal ventilation of 138.6±31.2 l/min. The athletes reached their anaerobic threshold at 87.8±6.3% of their maximal aerobic capacity, with a heart rate of 93.3±3.7% of their maximal values. Heart rate recovery was 29.9±9.2/min. During the CPET examinations, short supraventricular runs, repetititve ventricular premature beats + ventricular quadrigeminy and inferior ST depression were found in 1–1 cases. Slightly higher pulmonary pressure was measured on the echocardiography in 4 cases. Hypertension requiring drug treatment was found in 5.4% of the cases. Laboratory examinations revealed decreased vitamin D3 levels in 26 cases, decreased iron storage levels in 18 athletes. No SARS-CoV-2 infection related CMR changes were revealed in our athlete population.

Three months after SARS-CoV-2 infection, most of the athletes examined had satisfactory fitness levels. However, some cases of decreased exercise capacity, decreased vitamin D3 or iron storage levels, arrhythmias, hypertension and elevated pulmonary pressure requiring further examinations, treatment or follow-up were revealed.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary; The research was financed by the Thematic Excellence Programme of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University

Frequent constriction-like echocardiographic findings in elite athletes following mild COVID-19: in the grasp of SARS-CoV-2?

 

The COVID-19 pandemic had a major impact on the sports community as well. Despite the vast majority of athletes experiencing mild symptoms, potential cardiac involvement and complications have to be explored to support a safe return to play. Accordingly, we were aimed at a comprehensive echocardiographic characterization of post-COVID athletes (P-CA) by comparing them to a propensity-matched healthy, non-COVID athlete (N-CA) cohort.

One hundred and seven elite athletes with COVID-19 were prospectively enrolled after an appropriate quarantine period and formed the P-CA group (23±6 years, 23% female). From our retrospective database comprising 425 elite athletes, 107 age-, gender-, body surface area-, and weekly training hours-matched subjects were selected as a reference group using propensity score matching (N-CA group). All athletes underwent a comprehensive clinical investigation protocol comprising 2D and 3D echocardiography. Left (LV) and right ventricular (RV) end-diastolic volumes (EDVi) and ejection fractions (EF) were quantified using dedicated softwares. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall versus septal longitudinal strain (FWLS/SLS) were also calculated. In order to describe septal flattening (SF – frequently seen in P-CA), LV eccentricity index (EI) was measured.

P-CA and N-CA athletes had comparable LV and RV EDVi (P-CA vs N-CA; 77±12 vs 78±13mL/m²; 79±16 vs 80±14mL/m², respectively). P-CA group had significantly higher LV EF (58±4 vs 56±4%, p<0.001) and GLS (−18.2±1.8 vs −17.6±2.2%, p<0.05). Eccentricity index was significantly lower in P-CA (0.89±0.10 vs 0.99±0.04, p<0.001), which was attributable to a distinct subgroup of P-CA athletes with a prominent SF (n=34, 32%), further provoked by inspiration. In this subgroup, the eccentricity index was markedly lower compared to the rest of the P-CA group (0.79±0.07 vs 0.95±0.07, p<0.001).

In the SF subgroup, LV EDVi was significantly higher (80±14 vs 75±11 mL/m², p<0.001), while RV EDVi did not differ (82±16 vs 78±15mL/m²). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (0.92±0.09 vs 0.97±0.08, p<0.01). Interestingly, P-CA athletes with SF experienced fatigue (17 vs 34%, p<0.05) or chest pain (0 vs 15%, p=N/A) less frequently during the course of the infection; however, the presence of a mild pericardial effusion was more common (41 vs 12%, p<0.01).

Elite athletes following COVID-19 showed distinct morphological and functional cardiac changes compared to a propensity score-matched control athlete group. These results are mainly driven by a subgroup, which presented with some echocardiographic features characteristic of constrictive pericarditis (septal flattening, lower FWLS/SLS ratio, pericardial effusion). Follow-up of athletes and further, higher case number studies are warranted to determine the clinical significance and potential effects on exercise capacity of these findings.

Funding Acknowledgement

Type of funding sources: None.

Tissue characteristics of the athlete"s heart: differentiation of physiological and pathological hypertrophy using parametric T1 and T2 mapping

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Fund of Hungary

Background

Intensive physical exercise leads to structural and functional cardiac adaptation termed athlete’s heart. Cardiac magnetic resonance (CMR) has an important role in the differentiation of physiological adaptation and pathological conditions. Beside the precise measurement of the ventricular volumes, mass, and function, it provides tissue specific information. Recently, native T1 mapping technique has been applied as a non-contrast method to detect myocardial fibrosis. Previous studies suggested that native T1 mapping can identify myocardial pathology before other CMR imaging techniques. T2 mapping values are elevated in case of myocardial edema.

Purpose

The aim of our study was to investigate the differences in CMR characteristics especially the native T1 and T2 mapping values of highly trained healthy athletes, healthy controls and patients with hypertrophic cardiomyopathy (HCM).

Methods

A total of 43 healthy athletes (water polo, swimming, football, 22 ± 8 training hours/week), 27 non-athlete healthy control and 25 HCM patients were involved in the study. Our inclusion criteria were: age &gt;18 years,  in the athlete group &gt;7 training hours per week . We evaluated the left ventricular (LV) end-systolic, end-diastolic (EDVi) and stroke volume (SVi) index, mass index (LVMi), ejection fraction (EF) and maximal end-diastolic wall thickness (EDWT). In a basal short axis slice the native T1 and T2 mapping values were evaluated.

Results

Athletes had significantly higher LV volumes compared to the control and HCM group (LVEDVi 114 ± 13 vs. 86 ± 11; 84 ± 15  ml/m2, LVSVi 64 ± 7 vs. 51 ± 7; 54 ± 10 ml/m2, respectively, p &lt; 0.0001). HCM patients had the highest LVMi (72 ± 14 g/m2) and EDWT (18 ± 4 mm) compared to athletes and controls, athletes had higher LVMi (60 ± 11 vs. 42 ± 8 g/m2) and EDWT (10 ± 2 vs. 8 ± 1 mm) compared to the controls (p &lt; 0.001). The native T1 mapping values differed significantly in the three groups, athletes had the lowest, HCM patients had the highest T1 values (athletes: 956 ± 19 ms, controls: 971 ± 20 ms, HCM patients: 993 ± 39 ms; p &lt; 0.0001). There was no difference in the T2 mapping values between athletes and controls (44 ± 2 vs. 43 ± 2 ms), HCM patients had higher T2 values (45 ± 2 ms) compared to the other two groups (p &lt; 0.01).

Conclusion

Intensive and regular training may lead to tissue specific changes of the myocardium. T1 and T2 mapping are potentially useful tools for differentiating between athlete"s heart and patients with hypertrophic cardiomyopathy.

Abstract Figure. T1 mapping in HCM and athlete

The influence of vigorous training on the structure and cardiorespiratory fitness in adolescent athletes

Introduction

The functional and morphological adaptation of the cardiovascular system to vigorous exercise in adolescents is less understood compared to adult athletes. Therefore, the differential diagnosis of normal cardiovascular adaptation from the possible pathological alterations is challenging. Cardiovascular magnetic resonance is an important method for assessing ventricular function and morphology. Maximal oxygen uptake (VO2 max) has been established as a reliable measure of the maximal ability to produce metabolic power aerobically.

Aims

The aim of this study was to examine left (LV) and right (RV) ventricular morphologic and functional remodeling in elite adolescent athletes using cardiac magnetic resonance imaging (CMR) and cardiopulmonary exercise test (CPET).

Methods

Between 2017 and 2019 116 asymptomatic adolescent (14–20 years) athletes (&gt;6 training hour/week) underwent CMR and CPET as part of a detailed sports cardiology screening. Cine movie images were performed for the quantification of the LV and RV volumes, masses and ejection fraction, and advanced post processing included feature-tracking strain analysis. CPET was performed on a dedicated athlete protocol.

Results

All athletes participated in sports with a high dynamic component. Male athletes (n=74, 16±1 years) demonstrated higher LV and RV end –diastolic volume index (EDVi), stroke volume index (SVi) and mass index (Mi) compared with female athletes (p&lt;0.001). We found significant difference regarding the global circumferential strain (GCS) and mechanical dispersion (MD) of male and female athletes (GCS −34±4 vs. −31±5%; MD 4±2 vs. 7±4% p&lt;0.05). VO2 showed positive correlation with the LV and RV volumetric parameters (EDVi, SVi) and Mi (p&lt;0.001) and the absolute value of GCS (p&lt;0.05), and negative correlation with the MD (p&lt;0.001). In 36 athletes the VO2 max exceeded the age-adjusted expected VO2 max by 130%, which was categorized as excellent. Besides gender, age, and body surface area CMR based LVEDVi and LVMi were independent predictors of VO2 max.

Conclusion

The functional and morphological adaptation of the adolescent cardiovascular system shows noteworthy differences between male and female athletes. VO2 max correlates with several CMR based values including LV and RV volumetric parameters, masses and strain parameters such as GCS and MD.

Strain analysis of an adolescent athlete

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. ÚNKP-19-3-I New National Excellence Program of the Ministry for Innovation and Technology.

Cardiac magnetic resonance features of acute myocarditis presenting as acute coronary syndrome

Background

Clinical presentation of myocarditis varies, one specific form of myocarditis appears with the clinical signs of acute coronary syndrome (ACS). Cardiac magnetic resonance (CMR) is an important method for assessing ventricular function and morphology, additionally provides accurate tissue specific and functional information of the heart.

Aims

Our aim was to investigate the characteristics, and prognosis of myocarditis presenting with ACS symptoms.

Methods

113 patients with the clinical signs of ACS but nonobstructed coronary arteries in whom the CMR revealed acute myocarditis were included in our study. CMR was performed in acute phase and at 3–6-month follow-up. Left ventricular (LV) volumes, mass and strain parameters expressing myocardial deformity were determined. Additional images were taken to represent tissue specific information. Relationships between laboratory and CMR parameters were investigated. Parameters predicting changes in LV ejection fraction (LVEF) were analyzed by logistic regression.

Results

A total of 113 patients with myocarditis (98 males, 31±11 years) underwent acute and follow-up CMR. Sixty two patients reported fever or infection before the beginning of their complaints, most commonly gastroenteritis (33%) and pharyngitis (32%). The creatinine kinase MB value measured in the acute phase showed positive correlation with the extent of necrosis, and the global longitudinal- and circumferential strain. The extent of the LV necrosis showed negative correlation with LVEF and positive correlation with global circumferential strain (GCS) (p&lt;0.05). On the control CMR examination LVEF and all global strain values improved, fibrosis persisted in 82% of cases but shrank (15±11 vs 5±4 g) and LV mass decreased (p&lt;0.01) compared to the acute phase. Compared to the acute phase, 21% of the patients had lower LVEF on the follow-up CMR. Lower initial LVEF, worse acute GCS, and greater LV necrosis were independent predictors of LVEF reduction in the logistic regression model. During a median follow-up of 6-years of patients treated at our clinic (n=39) no patient suffered cardiac death, heart failure, or documented ventricular arrhythmia but 21% of them had recurrent myocarditis.

Conclusion

Myocarditis mimicking ACS affects predominantly young men and shows functional improvement and good prognosis on follow-up, but it may reoccur in some cases. The reduction of LV function on control CMR may be predicted by worse initial LVEF, GCS, and a larger LV scar.

Strain, LGE in acute phase and follow-up

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Direct effects of chemoradiotherapy following esophagectomy

BACKGROUND

Esophageal cancer is a major cause of morbidity and mortality, but despite continuing research, few effective therapies have been identified. In recent years, surgical resection following chemoradiotherapy has been associated with improved survival in several clinical models.

AIM

In a prospective, observational study, we evaluated the direct effects of chemoradiotherapy on postoperative mortality, morbidity, and inflammatory response in patients following esophagectomy.

METHODS

The study cohort was divided into two groups: the first group received preoperative chemoradiotherapy, while the second group had surgical intervention without prior treatment. Nutritional status was evaluated for the members of both patient groups at various time points.

RESULTS

Preoperative chemoradiotherapy did not influence morbidity or organ function, and the postoperative inflammatory response did not show immunosuppressive side effects directly after surgery.

CONCLUSION

Preoperative chemoradiotherapy does not improve postoperative organ function, inflammatory response or nutritional status in the patients. These findings may help to improve outcome in patients with esophageal cancer in the future.

Effect of glutamine in patients with esophagus resection

Glutamine is the most abundant amino-acid in the extra- and intracellular compartments of the human body, which accounts for over 50% of its free amino-acid content. Utilization of glutamine peptides is explicitly useful, resulting in a decrease in the number of postoperative infectious complications, period of hospitalization, and therapeutic costs. This article aims to study the effects of glutamine on systemic inflammatory response, morbidity, and mortality after esophagectomy. A prospective, randomized, double-blind, and controlled trial was used. Following sealed-envelope block randomization, the patients were divided into two groups. Members of the glutamine group (group G) received glutamine (Dipeptiven, Fresenius) as continuous infusion for 6 hours at 0.5 g/kg for 3 days prior to, and 7 days following surgery; while patients of the control group were given placebo. We examined 30 patients in group G, and 25 patients as controls. In both patient groups, the levels of total protein, albumin, pre-albumin, retinol binding protein, transferrin, transferring-saturation, C-reactive protein, procalcitonin, lymphocte, Interleukin-6, Interleukin-8, tumor necrosis factor alpha, and serum lactate were determined prior to surgery (t(0)), directly after surgery (t(u)), following surgery on day 1 (t(1)), day 2 (t(2)), and day 7 (t(7)). For statistical analysis Mann-Whitney U test and chi-square test were used. There was no significant difference between the two groups regarding age, male/female ratio, and SAPS II scores. Intensive care unit morbidity and mortality was similar in both groups (group G: 24 survivors/6 nonsurvivors;

CONTROL

17 survivors/8 nonsurvivors; P= 0.607). Daily Multiple Organ Dysfunction Score did not differ significantly between the two groups. The observed inflammatory markers followed the pattern we described without significant difference. Based on our study, the glutamine supplementation that we used had no influence on morbidity, mortality, or postoperative inflammatory response after esophagectomy.