Echocardiography in Athletes in Primary Prevention of Sudden Death

Abstract

Echocardiography is a noninvasive imaging technique useful to provide clinical data regarding physiological adaptations of athlete's heart. Echocardiographic characteristics may be helpful for the clinicians to identify structural cardiac disease, responsible of sudden death during sport activities. The application of echocardiography in preparticipation screening might be essential: it shows high sensitivity and specificity for identification of structural cardiac disease and it is the first-line imagining technique for primary prevention of SCD in athletes. Moreover, new echocardiographic techniques distinguish extreme sport cardiac remodeling from beginning state of cardiomyopathy, as hypertrophic or dilated cardiomyopathy and arrhythmogenic right ventricle dysplasia. The aim of this paper is to review the scientific literature and the clinical knowledge about athlete's heart and main structural heart disease and to describe the rule of echocardiography in primary prevention of SCD in athletes.

Keywords: Athlete's heart; cardiomyopathy; echocardiography; myocardial work; prevention; speckle tracking strain; sudden cardiac death.

Figure 1

Athlete's preparticipation screening according to Italian Guidelines

Figure 2

Differential diagnosis between physiological and pathological adaptation to training. (a) “bull's eyes” and “athletes” heart of a Caucasian cyclist, with parallel increase in cavity diameters and wall thickness; (b) end-stage hypertrophic cardiomyopathy with mild reduction of left ventricular systolic function and mild enlargement of cavity diameters; (c) apical hyper trophic cardiomyopathy well detected by contrast echocardiography; (d) arrhythmogenic right ventricular dysplasia with right ventricular dilatation and trabeculation. LV: left ventricle; RV: right ventricle

Figure 3

Speckle tracking strain bull's eyes eyes in different models of physiologic or pathologic left ventricular hypertrophy. Note the normal deformation in athlete, in contrast with diffuse impairment in aortic stenosis and hypertrophic cardiomyopathy. Conversely, in cardiac amyloidosis, a typical pattern of apical sparing is observed

Figure 4

Strain and myocardial work analyses in physiological and pathological left ventricular hypertrophy. Upper panels: two-dimensional strain (a) and myocardial work (b) in a power athlete, with normal both global longitudinal strain and myocardial work efficiency. Lower panels: two-dimensional strain (c) and myocardial work (d) in a hypertrophic cardiomyopathy. Note the impairment in both global and regional strain (especially in the interventricular septal region) as well as the reduced myocardial efficiency

Figure 5

Standard echocardiography focused on coronary artery origin from ascending aorta. In a normal individual (a) the separate origin of left main trunk and right coronary artery is easily detected. In a pathologic individual (symptomatic for chest pain) (b) a common origin of left main trunk from right coronary artery is well evidenced

Figure 6

Master endurance athlete coming to our department for syncope during competition and nonsustained ventricular tachycardia by electrocardiogram. (a) Right ventricle apical bulging by standard echocardiography, confirmed (b) by cardiac magnetic resonance (see arrows); (c) normal left ventricle and right ventricle diameters, with normal left ventricle systolic function; (d) midventricular left ventricle late enhancement pattern in the inferolateral wall