Increased myocardial mass and attenuation of myocardial strain in professional male soccer players and competitive male triathletes

Society for Cardiovascular Magnetic Resonance reference values ("normal values") in cardiovascular magnetic resonance: 2025 update

Quantitative assessment of morphological and functional cardiac parameters by cardiovascular magnetic resonance (CMR) is essential for research and routine clinical practice. Beyond established parameters of chamber size and function, tissue properties such as relaxation times play an increasing role. Normal reference ranges are required for interpretation of results obtained by quantitative CMR. Since the last publication of the "normal values review" in 2020 many new publications related to CMR reference values have been published, which were integrated in this update. The larger sample size provides greater statistical confidence in the estimates of upper and lower limits, and enables further partitioning, e.g., by age and ethnicity for several parameters. Previous topics were expanded by new sections.

Reduced myocardial strain of interventricular septum among male amateur marathon runners: a cardiac magnetic resonance study

OBJECTIVES

To analyze the long-term effect of multiple marathons on cardiac structure and function in amateur marathon runners compared with healthy controls.

DESIGN

Cross-sectional study using male amateur marathon runners (n = 32) and age-matched cohort of male healthy controls (n = 12).

METHODS

A total of 32 male amateur marathon runners (age 44 ± 7 years) and 12 male healthy controls (age 42 ± 8 years) underwent cardiac magnetic resonance (CMR). The relevant parameters of cardiac structure and function were studied employing feature-tracking strain analysis.

RESULTS

Amateur marathon runners showed lower heart rates, body mass index and body surface area. The left ventricular (LV) mass index, LV end-diastolic volume index and right ventricular end-systolic volume index were significantly higher in amateur marathon runners compared with healthy controls. Furthermore, walls of interventricular septum (IVS) in amateur marathon runners were thicker than healthy controls. There was no significant difference between two groups in the global myocardial strain (MS) in LV. However, the segmental radial and circumferential strains of the LV were lower in amateur marathon runners compared to healthy controls, specifically in the 8th and 9th segments. Finally, we also found as the total running intensity increased, so did global longitudinal strain.

CONCLUSIONS

We reported higher wall thickness and lower regional radial and circumferential strain in the IVS region in amateur marathon runners, suggesting that prolonged and high-intensity exercise may cause cardiac remodeling. Further studies are needed to investigate whether this is an adaptive or maladaptive change in amateur marathon runners.

Myocardial function including estimates of myocardial work in young adults born very preterm or with extremely low birthweight - a cohort study

BACKGROUND

Preterm birth and low birthweight have been associated with increased risk of heart failure and cardiovascular disease in young adulthood. However, results from clinical studies of myocardial function are not consistent. Echocardiographic strain analyses allow detection of early stages of cardiac dysfunction, and non-invasive estimates of myocardial work can provide additional information on cardiac function. We aimed to evaluate left ventricular (LV) myocardial function including measures of myocardial work in young adults born very preterm (gestational age < 29 weeks) or with extremely low birthweight (< 1000 g) (PB/ELBW), compared with term-born age- and sex matched controls.

METHODS

63 PB/ELBW and 64 controls born in Norway in the periods 1982-1985, 1991-1992, and 1999-2000 were examined with echocardiography. LV ejection fraction (EF) and LV global longitudinal strain (GLS) were measured. Myocardial work was estimated from LV pressure-strain loops after determination of GLS and construction of a LV pressure curve. Diastolic function was evaluated by determination of the presence or absence of elevated LV filling pressure, including measures of left atrial longitudinal strain.

RESULTS

The PB/ELBW with mean birthweight 945 (standard deviation (SD) 217) grams, mean gestational age 27 (SD 2) weeks, and mean age 27 (SD 6) years had LV systolic function mainly within normal range. Only 6% had EF < 50% or impaired GLS >-16%, but 22% had borderline impaired GLS between - 16% and - 18%. Mean GLS in PB/ELBW (-19.4% (95% confidence interval (CI) -20.0, -18.9)) was impaired compared to controls (-20.6% (95% CI -21.1, -20.1)), p = 0.003. Lower birthweight was associated to more impaired GLS (Pearson correlation coefficient - 0.2). Means of EF, measures of diastolic function including left atrial reservoir strain, global constructive and wasted work, global work index and global work efficiency was similar in PB/ELBW and controls.

CONCLUSION

The young adults born very preterm or with extremely low birthweight had impaired LV-GLS compared to controls, although systolic function mainly within normal range. Lower birthweight was associated with more impaired LV-GLS. These findings could indicate an elevated lifetime risk of developing heart failure in preterm born individuals. Measures of diastolic function and myocardial work were similar compared to controls.

Hypertrophic cardiomyopathy or athlete's heart? A systematic review of novel cardiovascular magnetic resonance imaging parameters

Hypertrophic cardiomyopathy (HCM) is a common cause of sudden cardiac death in athletes. Cardiac Magnetic Resonance (CMR) imaging is considered an excellent tool to differentiate between HCM and athlete's heart. The aim of this systematic review was to highlight the novel CMR-derived parameters with significant discriminative capacity between the two conditions. A systematic search in the MEDLINE, EMBASE and Cochrane Reviews databases was performed. Eligible studies were considered the ones comparing novel CMR-derived parameters on athletes and HCM patients. Therefore, studies that only examined Cine-derived volumetric parameters were excluded. Particular attention was given to binary classification results from multi-variate regression models and ROC curve analyses. Bias assessment was performed with the Quality Assessment on Diagnostic Accuracy Studies. Five (5) studies were included in the systematic review, with a total of 284 athletes and 373 HCM patients. Several novel indices displayed discriminatory potential, such as native T1 mapping and T2 values, LV global longitudinal strain, late gadolinium enhancement and whole-LV fractal dimension. Diffusion tensor imaging enabled quantification of the secondary eigenvalue angle and fractional anisotropy in one study, which also proved capable of reliably detecting HCM in a mixed athlete/patient sample. Several novel CMR-derived parameters, most of which are currently under development, show promising results in discerning between athlete's heart and HCM. Prospective studies examining the discriminatory capacity of all promising modalities side-by-side will yield definitive answers on their relative importance; diagnostic models can incorporate the best performing variables for optimal results.

Left ventricular deformation in athletes playing sports with high dynamics-insights from the three-dimensional speckle-tracking echocardiographic MAGYAR-Sport Study

Background

Earlier results suggest the role of speckle-tracking echocardiography (STE)-derived left ventricular (LV) strains in screening and could help better understanding of adaptation to exercise. The present retrospective cohort study aimed to investigate three-dimensional STE-derived LV strains representing its deformation in athletes playing sports with high dynamics with different grades of static components of their training.

Methods

The study consisted of 67 athletes (mean age: 23.6±6.4 years, 39 males). This group of athletes was further divided into the following groups: Group C.I. (high dynamic/low static) (n=12), Group C.II. (high dynamic/moderate static) (n=22) and Group C.III. (high dynamic/high static) (n=33). The control group comprised 83 age- and gender-matched non-athletic healthy volunteers (mean age: 23.6±3.2 years, 50 males).

Results

Global LV longitudinal strain (LS) representing LV lengthening or shortening (-18.5%±3.0% vs. -16.3%±2.3%, P<0.05), LV circumferential strain (CS) representing LV widening or narrowing (-29.9%±5.2% vs. -28.1%±4.8%, P<0.05) and LV area strain (AS; combination of LS and CS; -43.7%±5.4% vs. -40.9%±4.8%, P<0.05) were increased in elite athletes as compared to those of non-athlete controls. All apical LV strains proved to be increased in all athletes with enhanced basal radial strain (RS, representing LV thickening and thinning) and LS and midventricular LS, AS and 3D strain (3DS, combination of RS, LS and CS).

Conclusions

Increased LV-LS, LV-CS and LV-AS represents enhanced LV deformation in longitudinal and circumferential directions in athletes playing sports with high dynamics. This enhancement is not related to the grade of the static component of training. Some regional differences in LV strains could be detected.

Certainties and Uncertainties of Cardiac Magnetic Resonance Imaging in Athletes

Prolonged and intensive exercise induces remodeling of all four cardiac chambers, a physiological process which is coined as the “athlete’s heart”. This cardiac adaptation, however, shows overlapping features with non-ischemic cardiomyopathies, such as dilated, arrhythmogenic and hypertrophic cardiomyopathy, also associated with athlete’s sudden cardiac death. Cardiac magnetic resonance (CMR) is a well-suited, highly reproducible imaging modality that can help differentiate athlete’s heart from cardiomyopathy. CMR allows accurate characterization of the morphology and function of cardiac chambers, providing full coverage of the ventricles. Moreover, it permits an in-depth understanding of the myocardial changes through specific techniques such as mapping or late gadolinium enhancement. In this narrative review, we will focus on the certainties and uncertainties of the role of CMR in sports cardiology. The main aspects of physiological adaptation due to regular and intensive sports activity and the application of CMR in highly trained athletes will be summarized.

State-of-the-art myocardial strain by CMR feature tracking: clinical applications and future perspectives

Based on conventional cine sequences of cardiac magnetic resonance (CMR), feature tracking (FT) is an emerging tissue tracking technique that evaluates myocardial motion and deformation quantitatively by strain, strain rate, torsion, and dyssynchrony. It has been widely accepted in modern literature that strain analysis can offer incremental information in addition to classic global and segmental functional analysis. Furthermore, CMR-FT facilitates measurement of all cardiac chambers, including the relatively thin-walled atria and the right ventricle, which has been a difficult measurement to obtain with the reference standard technique of myocardial tagging. CMR-FT objectively quantifies cardiovascular impairment and characterizes myocardial function in a novel way through direct assessment of myocardial fiber deformation. The purpose of this review is to discuss the current status of clinical applications of myocardial strain by CMR-FT in a variety of cardiovascular diseases. KEY POINTS: • CMR-FT is of great value for differential diagnosis and provides incremental value for evaluating the progression and severity of diseases. • CMR-FT guides the early diagnosis of various cardiovascular diseases and provides the possibility for the early detection of myocardial impairment and additional information regarding subclinical cardiac abnormalities. • Direct assessment of myocardial fiber deformation using CMR-FT has the potential to provide prognostic information incremental to common clinical and CMR risk factors.

Acute impact of an endurance race on biventricular and biatrial myocardial strain in competitive male and female triathletes evaluated by feature-tracking CMR

Objectives

Cardiac adaptation in endurance athletes is a well-known phenomenon, but the acute impact of strenuous exercise is rarely reported on. The aim of this study was to analyze the alterations in biventricular and biatrial function in triathletes after an endurance race using novel feature-tracking cardiac magnetic resonance (FT-CMR).

Methods

Fifty consecutive triathletes (45 ± 10 years; 80% men) and twenty-eight controls were prospectively recruited, and underwent 1.5-T CMR. Biventricular and biatrial volumes, left ventricular ejection fraction (LVEF), FT-CMR analysis, and late gadolinium imaging (LGE) were performed. Global systolic longitudinal (GLS), circumferential (GCS), and radial strain (GRS) were assessed. CMR was performed at baseline and following an endurance race. High-sensitive troponin T and NT-proBNP were determined. The time interval between race completion and CMR was 2.3 ± 1.1 h (range 1–5 h).

Results

Post-race troponin T (p < 0.0001) and NT-proBNP (p < 0.0001) were elevated. LVEF remained constant (62 ± 6 vs. 63 ± 7%, p = 0.607). Post-race LV GLS decreased by tendency (− 18 ± 2 vs. − 17 ± 2%, p = 0.054), whereas GCS (− 16 ± 4 vs. − 18 ± 4%, p < 0.05) and GRS increased (39 ± 11 vs. 44 ± 11%, p < 0.01). Post-race right ventricular GLS (− 19 ± 3 vs. − 19 ± 3%, p = 0.668) remained constant and GCS increased (− 7 ± 2 vs. − 8 ± 3%, p < 0.001). Post-race left atrial GLS (30 ± 8 vs. 24 ± 6%, p < 0.0001) decreased while right atrial GLS remained constant (25 ± 6 vs. 24 ± 6%, p = 0.519).

Conclusions

The different alterations of post-race biventricular and biatrial strain might constitute an intrinsic compensatory mechanism following an acute bout of endurance exercise. The combined use of strain parameters may allow a better characterization of ventricular and atrial function in endurance athletes.

Key Points

• Triathletes demonstrate a decrease of LV global longitudinal strain by tendency and constant RV global longitudinal strain following an endurance race.

• Post-race LV and RV global circumferential and radial strains increase, possibly indicating a compensatory mechanism after an acute endurance exercise bout.

• Subgroup analyses of male triathletes with focal myocardial fibrosis did not demonstrate alterations in biventricular and biatrial strain after an endurance race.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08401-y.

Left-Ventricular Reference Myocardial Strain Assessed by Cardiovascular Magnetic Resonance Feature Tracking and fSENC-Impact of Temporal Resolution and Cardiac Muscle Mass

Aims: Cardiac strain parameters are increasingly measured to overcome shortcomings of ejection fraction. For broad clinical use, this study provides reference values for the two strain assessment methods feature tracking (FT) and fast strain-encoded (fSENC) cardiovascular magnetic resonance (CMR) imaging, including the child/adolescent group and systematically evaluates the influence of temporal resolution and muscle mass on strain.

Methods and Results: Global longitudinal (GLS), circumferential (GCS), and radial (GRS) strain values in 181 participants (54% women, 11–70 years) without cardiac illness were assessed with FT (CVI42® software). GLS and GCS were also analyzed using fSENC (MyoStrain® software) in a subgroup of 84 participants (60% women). Fourteen patients suffering hypertrophic cardiomyopathy (HCM) were examined with both techniques. CMR examinations were done on a 3.0T MR-system.

FT-GLS, FT-GCS, and FT-GRS were −16.9 ± 1.8%, −19.2 ± 2.1% and 34.2 ± 6.1%. fSENC-GLS was higher at −20.3 ± 1.8% (p < 0.001). fSENC-GCS was comparable at−19.7 ± 1.8% (p = 0.06). All values were lower in men (p < 0.001). Cardiac muscle mass correlated (p < 0.001) with FT-GLS (r = 0.433), FT-GCS (r = 0.483) as well as FT-GRS (r = −0.464) and acts as partial mediator for sex differences. FT-GCS, FT-GRS and fSENC-GLS correlated weakly with age. FT strain values were significantly lower at lower cine temporal resolutions, represented by heart rates (r = −0.301, −0.379, 0.385) and 28 or 45 cardiac phases per cardiac cycle (0.3–1.9% differences). All values were lower in HCM patients than in matched controls (p < 0.01). Cut-off values were −15.0% (FT-GLS), −19.3% (FT-GCS), 32.7% (FT-GRS), −17.2% (fSENC-GLS), and −17.7% (fSENC-GCS).

Conclusion: The analysis of reference values highlights the influence of gender, temporal resolution, cardiac muscle mass and age on myocardial strain values.

Moderately trained male football players, compared to sedentary male adults, exhibit anatomical but not functional cardiac remodelling, a cross-sectional study

Background

Elite athletes have been the subject of great interest, but athletes at an intermediate level of physical activity have received less attention in respect to the presence of cardiac enlargement and/or hypertrophy. We hypothesized that playing football, often defined as demanding less endurance components than running or cycling, would still induce remodelling similar to sports with a dominating endurance component.

Methods

23 male football players, age 25+/− 3.9 yrs. underwent exercise testing, 2D- and 3D- echocardiography and cardiac magnetic resonance (CMR). The results were compared with a control group of engineering students of similar age. The athletes exercised 12 h/week and the control subjects 1 h/week, p < 0.001.

Results

The football players achieved a significantly higher maximal load at the exercise test (380 W vs 300 W, p < 0.001) as well as higher calculated maximal oxygen consumption, (49.7 vs 37.4 mL x kg^− 1 x min^− 1, p < 0.001) compared to the sedentary group. All left ventricular (LV) volumes assessed by 3DEcho and CMR, as well as CMR left atrial (LA) volume were significantly higher in the athletes (3D-LVEDV 200 vs 154 mL, CMR-LVEDV 229 vs 185 mL, CMR-LA volume 100 vs 89 mL, p < 0.001, p = 0.002 and p = 0.009 respectively). LVEF and RVEF, LV strain by CMR or by echo did not differentiate athletes from sedentary participants. Right ventricular (RV) longitudinal strain, LA and right atrial (RA) strain by CMR all showed similar results in the two groups.

Conclusion

Moderately trained intermediate level football players showed anatomical but not functional cardiac remodelling compared to sedentary males.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00263-0.

Quantification of Myocardial Deformation Applying CMR-Feature-Tracking-All About the Left Ventricle?

Purpose of Review

Cardiac magnetic resonance-feature-tracking (CMR-FT)-based deformation analyses are key tools of cardiovascular imaging and applications in heart failure (HF) diagnostics are expanding. In this review, we outline the current range of application with diagnostic and prognostic implications and provide perspectives on future trends of this technique.

Recent Findings

By applying CMR-FT in different cardiovascular diseases, increasing evidence proves CMR-FT-derived parameters as powerful diagnostic and prognostic imaging biomarkers within the HF continuum partly outperforming traditional clinical values like left ventricular ejection fraction. Importantly, HF diagnostics and deformation analyses by CMR-FT are feasible far beyond sole left ventricular performance evaluation underlining the holistic nature and accuracy of this imaging approach.

Summary

As an established and continuously evolving technique with strong prognostic implications, CMR-FT deformation analyses enable comprehensive cardiac performance quantification of all cardiac chambers.