RV Remodeling in Olympic Athletes

Flavio D’Ascenzi, Cataldo Pisicchio, Stefano Caselli, Fernando M. Di Paolo, Antonio Spataro, Antonio Pelliccia

The aim of this study was to assess the impact of sex and different sports on right ventricular (RV) remodeling and compare the derived upper limits with widely used revised Task Force (TF) reference values. Uncertainties exist regarding the extent and physiological determinants of RV remodeling in highly trained athletes. The issue is important, considering that in athletes RV size occasionally exceeds the cutoff limits proposed to diagnose arrhythmogenic RV cardiomyopathy. A total of 1,009 Olympic athletes (mean age 24 ± 6 years; n = 647 [64%] males) participating in skill, power, mixed, and endurance sport were evaluated by 2-dimensional echocardiography and Doppler/tissue Doppler imaging. The right ventricular outflow tract (RVOT) in parasternal long-axis (PLAX) and short-axis views, fractional area change, s' velocity, and morphological features were assessed. Indexed RVOT PLAX was greater in females than in males (15.3 ± 2.2 mm/m(2) vs. 14.4 ± 1.9 mm/m(2); p < 0.001). Both RVOT PLAX and parasternal short-axis view were significantly different among skill, power, mixed, and endurance sports: 14.3 ± 2.1 mm/m(2) versus 14.7 ± 1.9 mm/m(2) versus 14.0 ± 1.8 mm/m(2) versus 15.7 ± 2.2 mm/m(2), respectively (p < 0.001); and 15.2 ± 2.7 mm/m(2) versus 15.3 ± 2.4 mm/m(2) versus 14.8 ± 2.1 mm/m(2) versus 16.2 ± 2.5 mm/m(2), respectively (p < 0.001). The 95th percentile for indexed RVOT PLAX and parasternal short-axis view was 18 mm/m(2) and 20 mm/m(2), respectively. Fractional area change and s' velocity did not differ among the groups (p = 0.34 for both). RV enlargement compatible with major and minor TF diagnostic criteria for arrhythmogenic RV cardiomyopathy was observed in 41 (4%) and 319 (32%) athletes. A rounded apex was described in 823 (81%) athletes, prominent trabeculations in 378 (37%) athletes, and a prominent/hyperreflective moderator band in 5 (0.5%) athletes. RV remodeling occurs in Olympic athletes, with male sex and endurance practice playing the major impact. A significant subset (up to 32%) of athletes exceeds the normal TF limits; therefore, we recommend referring to the 95th percentiles here reported as referral values; alternatively, only major diagnostic TF criteria for arrhythmogenic RV cardiomyopathy may be appropriate.