Sport and cardiology :
an explosive cocktail ?
Fibrosis and athlete’s heart :
Impact of CMR
Frédéric SCHNELL
Service de Médecine du Sport – CHU Rennes
Laboratoire de Physiologie – Université Rennes 1
INSERM U 1099
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Screening
Eligibility evaluation of asymptomatic athletes is now routinely performed in many
European countries (SFC, ESC, IOC, FIFA)
Corrado D. Eur Heart J. 2004
Ljungqvist A. Br J Sports Med. 2009
Dvorak J. Clin J Sport Med. 2009
CMR: powerful tool to diagnose cardiomyopathy
if abnormalities on first line screening
(PTWI, complex ventricular arrhythmia, abnormal Echo)
Schnell F. Circ. 2015
La Gerche A. JACC cardiovasc Imaging. 2013
⇒ Increased use of CMR leads to findings
that raise questions
Breuckmann F. Radiology. 2009
Wilson M. J Appl Physiol. 2011
La Gerche A. Eur Heart J. 2012
DGE in athletes ?
Prevalence of DGE in asymptomatic veteran athletes: 12-50%
Breuckmann F. Radiology. 2009
Wilson M. J Appl Physiol. 2011
La Gerche A. Eur Heart J. 2012
=> Different forms of DGE pattern
• Associated with
a “labelled” cardiomyopathy
Chan RH, Circulation 2014; Bogaert J, Radiology 2014; Masci PG, Circ Heart Fail 2014
• Ischemic pattern
Alexandre J. JCMR 2013
• Isolated sub-epicardial DGE
Schnell, BJSM 2015
• Small patches at insertion points
La Gerche A, Eur Heart J 2012
Breuckmann F. Radiology. 2009
Associated with a “labelled”
cardiomyopathy : HCM
Diagnosis HCM vs athlete:
LGE on CMR is a clinical feature that favour the diagnosis of HCM in
athletes (Level C)
Elliott PM, 2014 ESC Guidelines on diagnosis and management of HCM, Eur Heart J 2014
Prognosis:
Relationship between LGE and cardiovascular mortality,
heart failure death and all-cause death, NSVT
Chan RH, Prognostic value of quantitative contrast- enhanced CMR for the evaluation of
sudden death risk in patients with HCM. Circ 2014.
=> Confer specific recommandations
Associated with a “labelled” cardiomyopathy :
DCM
Diagnosis athlete vs DCM ?
LGE: typically mid-wall
30% of patients with DCM
Mordi I. T1 and T2 mapping for early diagnosis of dilated non-ischaemic cardiomyopathy in middleaged patients and differentiation from normal physiological adaptation. Eur H J CV Imag 2015
“Whether contrast-CMR can differentiate patients with borderline LV enlargement
and low-normal or mildly reduced ejection fraction from DCM is unresolved.”
Maron, Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 3: HCM, ARVC and
Other Cardiomyopathies, and Myocarditis; JACC 2015
Associated with a “labelled” cardiomyopathy :
DCM
Prognosis: An adverse prognostic indicator
Masci PG. Incremental prognostic value of myocardial fibrosis in patients with non-ischemic cardiomyopathy without CHF. Circ Heart Fail 2014
Composite end point: cardiac death, CHF, aborted SCD
LGE
=> Confer specific recommandations
Ischemic pattern
Diagnosis: former coronary event
=> Confer specific recommandations
Prognosis: Increased risk of events in the general population
Alexandre J. Scar extent evaluated by late gadolinium enhancement CMR: a powerful predictor of long term appropriate ICD therapy in patients
with coronary artery disease. JCMR 2013
Isolated sub-epicardial DGE
Schnell F. Subepicardial delayed gadolinium enhancement in asymptomatic athletes: let sleeping dogs lie? BJSM 2015
Isolated sub-epicardial DGE
Symptoms - Functional status - LV function - Arrythmia
•
3 athletes were excluded from competitive sport
– 2 on the basis of LV dysfunction at rest and during exercise, combined with malignant exercise
related ventricular arrhythmias (NSVT)
– 1 was stopped because of NSVT during exercise
Schnell F. Subepicardial delayed gadolinium enhancement in asymptomatic athletes: let sleeping dogs lie? BJSM 2015
Isolated sub-epicardial DGE
Mean FU: 2.6±2.1 years
Only 1 remained asymptomatic & no LV function dysfunction
& no arrhythmia (FU 3.4 years)
Schnell F. Subepicardial delayed gadolinium enhancement in asymptomatic athletes: let sleeping dogs lie? BJSM 2015
Isolated sub-epicardial DGE : Etiology ?
• Scar from a previous myocarditis
Myocarditis can be asymptomatic
Intensive sport can weaken immune function
Wilson M. BMJ Case Rep. 2009
• Left dominant arrhythmogenic cardiomyopathy
Very similar presentation
BUT no RV involvement & no familial history was reported
Sen-Chowdhry S. JACC 2008
Role of Strenuous repeated exercise ?
Affect negative remodelling and scar formation in the presence of another trigger
(inflammation due to myocarditis or genetic cardiomyopathy)
In animal models: exercise during the initial days of infections => replacement fibrous scar
In athletes: SCD were reduced after recommendations not to train while infected
Reyes MP. J Infect Dis. 1981; Wesslén L. Eur Heart J. 1996
Small patches at insertion points
• LGE in 6 / 12 (50%) elite veteran athletes
but not in 17 young novice athletes or 20 older non-athletes.
Wilson M; Diverse patterns of myocardial fibrosis in lifelong, veteran endurance athletes. J Appl Physiol 2011
• LGE in 5/39 endurance athletes (13%)
LGE + more extensive history of training + greater cardiac dimensions
Only IVS at site of RV attachment
= pattern described in patients with pulmonary hypertension
= increased interventricular wall stress due to chronic RV pressure
overload
La Gerche A; Exercise-induced right ventricular dysfunction and structural remodelling in endurance
athletes. Eur H J 2012
Due to exercise ? benign ?
CONCLUSION
• Associated with
a “labelled” cardiomyopathy
Part of the diagnosis
Poorer prognosis
• Ischemic pattern
• Isolated sub-epicardial DGE
Scar Myocarditis ?
Not benign
comprehensive initial evaluation and a close follow-up are mandatory
• Small patches at insertion points
More data is needed in order to better characterize
prevalence and outcome [email protected]
Benign ?
related to increased
afterload of the RV ?