Right ventricular assessment of the adolescent footballer's heart

INTRODUCTION

Athletic training can result in electrical and structural changes of the right ventricle that may mimic phenotypical features of arrhythmogenic right ventricular cardiomyopathy (ARVC), such as T-wave inversion and right heart dilatation. An erroneous interpretation may have consequences ranging from false reassurance in an athlete vulnerable to cardiac arrhythmias, to unnecessary sports restriction in a healthy individual. The primary aim of this study was to define normal RV dimension reference ranges for academy adolescent footballers of different ethnicities. Secondary aims include analysis of potential overlap between this adolescent group with ARVC criteria and comparison with normal adult ranges.

RESULTS

Electrocardiographic (ECG) and echocardiographic data of 1087 academy male footballers aged between 13 and 18 years old (mean age 16.0 ± 0.5 years), attending mandatory cardiac screening were analysed. Ethnicity was categorised as white (n = 826), black (African/Caribbean; n = 166) and mixed-race (one parent white and one parent black; n = 95). Arrhythmogenic right ventricular cardiomyopathy major criteria for T-wave inversion was seen in 3.3% of the cohort. This was more prevalent in black footballers (12%) when compared to mixed race footballers (6.3%) or white footballers (1%), P < 0.05. Up to 59% of the cohort exceeded adult reference ranges for some of the right ventricular parameters, although values were similar to those seen in adult footballers. There were no differences in right ventricular dimensions between ethnicities. In particular, the right ventricular outflow tract diameter would fulfil major criteria for ARVC dimension in 12% of footballers. Overall, 0.2% of the cohort would fulfil diagnosis for 'definite' arrhythmogenic right ventricular cardiomyopathy and 2.2% would fulfil diagnosis for 'borderline' arrhythmogenic right ventricular cardiomyopathy for RV dimensions and ECG changes. This was seen more frequently in black footballers (9.9%) than mixed race footballers (3.9%) or white footballer (0.6%), P < 0.05. Among athletes meeting definite or borderline arrhythmogenic right ventricular cardiomyopathy criteria, no cardiomyopathy was identified after comprehensive clinical assessment, including with cardiac magnetic resonance imaging, exercise testing, ambulatory electrocardiograms and familial evaluation.

CONCLUSION

Right heart sizes in excess of accepted adult ranges occurred in as many as one in two adolescent footballers. Structural adaptations in conjunction with anterior T-wave inversion may raise concern for ARVC, highlighting the need for evaluation in expert settings.

Prevalence and Clinical Significance of Electrocardiographic Complete Right Bundle Branch Block in Young Individuals

BACKGROUND AND AIMS

There is limited information on the clinical significance of complete right bundle branch block (CRBBB) in young individuals. The aim of this study was to determine the prevalence and significance of CRBBB in a large cohort of young individuals aged 14-35 years old.

METHODS

From 2008 to 2018, 104,369 consecutive individuals underwent a cardiovascular assessment with a health questionnaire, electrocardiogram, clinical consultation, and selective echocardiography. Follow-up was obtained via direct telephone consultations. Mean follow-up was 7.3 ± 2.7 years.

RESULTS

CRBBB was identified in 154 (0.1%) individuals and was more prevalent in males compared with females (0.20% vs. 0.06%; p<0.05) and in athletes compared with non-athletes (0.25% vs. 0.14%; p<0.05). CRBBB-related cardiac conditions were identified in 7 (5%) individuals (4 with atrial septal defect, 1 with Brugada syndrome, 1 with progressive cardiac conduction disease and 1 with atrial fibrillation). Pathology was more frequently identified in individuals with non-isolated CRBBB compared with individuals with isolated CRBBB (14% vs 1%; p < 0.05) and in individuals with a QRS duration of ≥130 milliseconds (ms) compared with individuals with a QRS of <130ms (10% vs 1%; p<0.05).

CONCLUSION

The prevalence of CRBBB in young individuals was 0.1% and was more prevalent in males and athletes. CRBBB-related conditions were identified in 5% of individuals and were more common in individuals with non-isolated CRBBB and more pronounced intraventricular conduction delay (QRS duration of ≥130ms). Secondary evaluation should be considered for young individuals with CRBBB with symptoms, concerning family history, additional electrocardiographic anomalies or significant QRS prolongation (≥130ms).

The potential therapeutic effect of metformin in type 2 diabetic patients with severe COVID-19

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is regarded as a chief risk factor for(coronavirus disease 2019 (COVID-19) owing to dysregulation of the expression of angiotensin-converting enzyme 2 (ACE2) and chronic low-grade inflammatory disorders. Metformin, an insulin-sensitizing agent for managing T2DM, has pleiotropic anti-inflammatory and oxidant potentials, which may lessen the risk of diabetic complications. So, we aimed to reveal the potential role of metformin monotherapy in treating T2DM patients with COVID-19.

PATIENTS AND METHODS

In this prospective cohort study, 60 hospitalized T2DM patients with COVID-19 on metformin plus standard anti-COVID-19 treatments compared to 40 hospitalized T2DM patients with COVID-19 on other diabetic pharmacotherapy like insulin and sulfonylurea, were recruited. Inflammatory and oxidative stress biomarkers and radiological and clinical outcomes were assessed at admission time and at the time of discharge.

RESULTS

The results of this study illustrated that metformin treatment in T2DM patients with COVID-19 was more effective in reducing inflammatory and oxidative stress biomarkers with significant amelioration of radiological scores and clinical outcomes compared to T2DM patients with COVID-19 on another diabetic pharmacotherapy.

CONCLUSIONS

Our findings highlighted that metformin efficiently managed T2DM patients with COVID-19 by reducing inflammatory and oxidative stress with mitigating effects on the radiological scores and clinical outcomes.

Intralesional photodynamic therapy induces apoptosis in basal cell carcinoma and Bowen's disease through caspase 3 and granzyme B

BACKGROUND

Photodynamic therapy (PDT) is used to treat cutaneous cancers. It may induce cell death through direct and indirect means, including apoptosis, inflammation and certain immune mechanisms, with the depth of penetration as a potential modifying factor.

OBJECTIVES

To examine the pathways of apoptosis in the intralesional PDT of basal cell carcinoma (BCC) and intraepidermal squamous cell carcinoma (Bowen's disease).

METHODS

Sixteen patients with superficial or nodular BCC and Bowen's disease were treated with intralesional aminolevulinic acid-PDT. Biopsies were taken at baseline and 24 h post-PDT, and sections were examined by immunohistochemistry for the expression of markers of apoptosis, such as caspase 3, involved in the intrinsic apoptotic pathway, granzyme B, a caspase-independent apoptotic mediator, and the proapoptotic markers BAX and BAK.

RESULTS

Apoptotic cells stained with TUNEL showed statistically significant staining at 24 h post PDT (p < 0.01 in both BCC and Bowen's lesions). Caspase 3 (p < 0.01 in BCC and p < 0.05 in Bowen's) and granzyme B (p < 0.01 in BCC and p < 0.01 in Bowen's) were significantly increased at 24 h post-PDT. BAX expression was apparently increased compared to baseline in Bowen's lesions at 24 h post-PDT, whereas Bak was upregulated both in BCC and Bowen's disease at baseline and at 24 h post-PDT.

CONCLUSION

Intralesional PDT induces apoptosis in BCC and Bowen's disease via common and alternative apoptotic pathways involving granzyme B. Proapoptotic factors Bak in both BCC and Bowen and Bax in Bowen's disease appear to increase by intralesional PDT at 24 h.

Different clinical and pathological profiles of sudden cardiac death victims caused by coronary artery dissection or myocardial infarction with non-obstructed coronary arteries

Background

Spontaneous coronary artery dissection (SCAD) is a potential cause of acute coronary syndrome and sudden cardiac death (SCD). Coronary fibromuscolar dysplasia (FMD) has been correlated to SCAD occurrence.The prevalence of SCAD and FMD among SCD victims are unclear. Myocardial infarction with non-obstructed coronary arteries (MINOCA) could represent a cause of SCD. Since SCAD could clinically manifest as acute myocardial infarction, expert consensus documents have often considered SCAD as a subtype of MINOCA (1,2), but studies which address direct comparison between these two conditions are lacking.

Purpose

To assess characteristics of decedents with SCAD and/or FMD found at autopsy, and to compare their clinical and pathological profile with MINOCA SCD victims.

Methods

We reviewed a database of 5325 consecutive cases of SCDs referred to our cardiac pathology center between 1994 and July 2017.

Results

We identified 21 (0.4%) with SCAD and 37 (0.7%) victims with MINOCA (3), whereas FMD was found only in 2 (0.04%). SCAD decedents were females in 81%, versus 38% of MINOCA (p=0.02).

No signs of coronary FMD were found among SCAD and MINOCA victims. Necrotic myocardium was identified in the totality of MINOCA and only in 8 (38%) of SCAD decedents (p&lt;0.001). Pre-mortem cardiac symptoms were present in 100% of SCAD and 49% of MINOCA victims (p&lt;0.001); illicit drug use was reported in none of SCAD versus 46% of MINOCA decedents (p=0.001).

Conclusions

SCAD is a rare cause of SCD. Compared to MINOCA, SCAD victims are more frequently females, always experienced pre-mortem cardiac symptoms and have no habit of substances abuse. At autopsy coronary FMD is not present among SCAD victims. SCAD and MINOCA shows different clinical and pathological profile. SCAD should not be considered a subtype of MINOCA.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiac Risk in the Young (CRY) and the Charles Wolfson Charitable Trust.

Exercise induced coronary inflammation in masters athletes

Background

Chronic endurance exercise has been linked to increased prevalence of coronary artery disease (CAD) in male master athletes. Data are limited regarding the presence of exercise-induced coronary inflammation and its association with atherosclerosis in master endurance athletes. Human coronary inflammation can be detected non-invasively by imaging pericoronary adipose tissue (PCAT). We tested the hypothesis that chronic endurance exercise leads to increased prevalence of atherosclerosis via coronary inflammation.

Methods

Computed tomography coronary angiogram CTCA scans from 2 cohorts of master athletes and age-matched controls, without known risk factors for CAD, were analysed post-hoc and the PCAT attenuation index was calculated around the proximal right coronary artery (FAIRCA). The athletes and the healthy controls also underwent an electrocardiogram, an echocardiogram, a cardiopulmonary exercise test (CPET), a 24-hour Holter tape and a Cardiac Magnetic Resonance (CMR) scan.

Results

Scans from 243 masters endurance athletes (62% females) and 58 age and Framingham CAD risk score matched healthy controls were analysed. FAIRCA was significantly higher (less negative) in male masters athletes vs female masters athletes [−61.3 Hounsfield Units (HU) vs −62.8 HU, p=0.01], in male athletes vs male controls (−61.3 HU vs −68.6 HU, p&lt;0.001) and in female athletes vs female controls (−62,8 HU vs −67.5 HU, p=0.005). In female masters athletes, peak oxygen consumption during CPET (peak VO2) statistically significantly predicted the FAIRCA, F(1,146) = 22.62, p&lt;0.0001. There was no correlation between the FAIRCA and presence of atherosclerosis in male masters athletes.

Conclusions

Masters athletes show increased markers of coronary inflammation. This effect appears to be greater in male masters athletes and is associated with a higher peak VO2 in female masters athletes. However, we did not identify a link between coronary inflammation and coronary atherosclerosis in this cohort.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Cardiac Risk in the Young, UK

Prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players

Background

Identification of athletes with cardiac inflammation following COVID-19 can prevent exercise fatalities. The efficacy of pre and post COVID-19 infection electrocardiograms (ECGs) for detecting athletes with myopericarditis has never been reported. We aimed to assess the prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players.

Methods

We conducted a multicentre study over a 2-year period involving 5 centres and 34 clubs and compared pre COVID and post COVID ECG changes in 455 consecutive athletes. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were considered abnormal if they were not detected on the pre COVID-19 infection ECG: (a) biphasic T-waves; (b) reduction in T-wave amplitude by 50% in contiguous leads; (c) ST-segment depression; (d) J-point and ST-segment elevation &gt;0.2 mV in the precordial leads and &gt;0.1 mV in the limb leads; (e) tall T-waves ≥1.0 mV (f) low QRS-amplitude in &gt;3 limb leads and (g) complete right bundle branch block. Athletes exhibiting novel ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all 28 (6%) athletes, despite the absence of cardiac symptoms or ECG changes.

Results

Athletes were aged 22±5 years (89% male and 57% white). 65 (14%) athletes reported cardiac symptoms. The mean duration of illness was 3±4 days. The post COVID ECG was performed 14±16 days following a positive PCR. 440 (97%) athletes had an unchanged post COVID-19 ECG. Of these, 3 (0.6%) had cardiac symptoms and CMRs resulted in a diagnosis of pericarditis. 15 (3%) athletes demonstrated novel ECG changes following COVID-19 infection. Among athletes who demonstrated novel ECG changes, 10 (67%) reported cardiac symptoms. 13 (87%) athletes with novel ECG changes were diagnosed with inflammatory cardiac sequelae; pericarditis (n=6), healed myocarditis (n=3), definitive myocarditis (n=2), and possible/probable myocarditis (n=2). The overall prevalence of inflammatory cardiac sequelae based on novel ECG changes was 2.8%. None of the 28 (6%) athletes, who underwent a CMR, in the absence of cardiac symptoms or novel ECG changes revealed any abnormalities. Athletes revealing novel ECG changes, had a higher prevalence of cardiac symptoms (67% v 12% p&lt;0.0001) and longer symptom duration (8±8 days v 2±4 days; p&lt;0.0001) compared with athletes without novel ECG changes. Among athletes without cardiac symptoms, the additional yield of novel ECG changes to detect cardiac inflammation was 20% (n=3).

Conclusions

3% of elite soccer players demonstrated novel ECG changes post COVID-19 infection, of which almost 90% were diagnosed with cardiac inflammation during subsequent investigation. Most athletes with novel ECG changes exhibited cardiac symptoms. Novel ECGs changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.

Funding Acknowledgement

Type of funding sources: None.

Mitral valve abnormalities in decedents of sudden cardiac death due to hypertrophic cardiomyopathy and idiopathic left ventricular hypertrophy

Background

The sole identification of left ventricular hypertrophy (LVH) in a young individual that died suddenly may often lead to an erroneous diagnosis of hypertrophic cardiomyopathy (HCM). Emerging data suggests that idiopathic LVH (ILVH) and HCM may be separate entities.

Aim

We aimed to report on the prevalence and nature of mitral valve (MV) abnormalities, in a cohort of sudden cardiac death (SCD) victims with a post-mortem examination consistent with HCM and ILVH.

Methods

We reviewed 6860 consecutive cases of SCD referred to our specialist cardiac pathology centre between 1994 and 2020. SCD was defined as death from a cardiovascular cause within 12 hours of apparent well-being. HCM was defined by the presence of LVH, in the absence of abnormal loading conditions and characterised by myocyte disarray at histology. ILVH was defined as unexplained LVH (heart weight &gt;500 g in males and &gt;400 g in females) and left ventricular (LV) wall thickness &gt;15mm, in the absence of myocardial disarray or secondary causes of LVH. The MV was examined for patency, circumference, thickening, nodularity, ballooning, bulging between cords, perforation, and the presence of impact lesions in the LV outflow tract (LVOT) and aortic outlet.

Results

Of the total cases of SCD, 264 (4%) were due to HCM (mean age 41±18 years, 78% males, LV maximal wall thickness 19±6 mm) (Figure 1). Ante-mortem symptoms were reported in 44 (17%) cases and for the majority (n=217, 82%) HCM was established at post-mortem. Death was attributed to ILVH in 253 (3%) cases (mean age 43±16 years, 80% males, LV maximal wall thickness 18±4 mm). MV abnormalities were found in 58 (22%) decedents with HCM (mean age 38±17 years; 72% males) and in 13 (5%) decedents with ILVH (mean age 55±15 years; 77% male), p&lt;0.001. Amongst the 58 (22%) cases with HCM and MV abnormalities, 15 (6%) cases had multiple MV abnormalities. These included impact lesions associated with thickening of the anterior leaflet of the MV (n=39) and degenerative changes (n=34) such as bulging and ballooning; and thickening and nodularity. Decedents with HCM exhibiting MV abnormalities were younger than decedents with a normal MV (38±17 versus 45±19 years; p=0.08). Among the 253 decedents with ILVH, 13 (5%) cases exhibited MV abnormalities, which largely included degenerative changes (n=12). Among decedents with HCM and ILVH exhibiting MV abnormalities, the former was significantly younger (38±17 versus 55±15; p=0.001). Myocardial fibrosis was observed in 162 (61%) cases of HCM and 99 (39%) cases of ILVH, p&lt;0.001.

Conclusions

MV abnormalities are over four-fold more common in individuals with HCM than those with ILVH and may be considered as additional macroscopic features to differentiate between these two entities. Furthermore, the inherent descriptive terminologies used when assessing the MV, support a greater emphasis on the standardisation and quantification of MV abnormalities as part of the autopsy in victims of SCD.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Acknowledgements: We thank the charitable organisation, Cardiac Risk in the Young (CRY) who fund and support the CRY Cardiovascular Pathology Unit and CRY database.

Sudden cardiac death during exercise in young individuals with hypertrophic cardiomyopathy

Background

Sudden cardiac death (SCD) in young individuals and athletes is generally caused by hereditary cardiac conditions, including cardiomyopathies such as hypertrophic cardiomyopathy (HCM). Although historically HCM has been reported as the predominant cause of SCD in young athletes, it is unclear as to what degree exercise is a trigger for possible fatal arrhythmias.

Aim

We aimed to report on the circumstances of SCD in a cohort of young individuals aged ≥10 and &lt;30 whose autopsy was consistent with HCM.

Methods

We reviewed 6860 consecutive cases of SCD referred to our specialist cardiac pathology centre 1994 and 2020. SCD was defined as death from a cardiovascular cause within 12 hours of apparent well-being. All cases underwent detailed autopsy evaluation of the heart, including histological analysis, by expert cardiac pathologists. A minimum of 10 blocks of tissue were taken for histological analysis. HCM was defined by the presence of increased heart weight or increased wall thickness and significant myocyte disarray at histological examination.

Results

Of the total cases of SCD, 264 (4%) were due to HCM. Our cohort of young decedents comprised of 66 individuals (average age 21±5 years, males 76%). For the majority (n=52, 79%) SCD was the first manifestation of HCM. The average heart weight was 507±152 grams and left ventricular (LV) fibrosis was found in 28 (42%) cases (Figure 1A). Death was more common between 16 and 20 years of age (n=24) (Figure 1B). Death occurred during exertion in 25 (38%) individuals and at rest or during daily activities in the remaining 41 (62%), including 5 individuals who died during sleep. Male sex was more represented among decedents who died during exertion (88% compared with 68% in the group that died at rest, p=0.07); LV fibrosis was more commonly observed in individuals who died during exertion (56% compared with 34% in the group who died at rest, p=0.08). Younger individuals between 10–15 years of age died mostly during exercise (80%), in other age groups death occurred mainly at rest (33% in age group 16–20 years, 30% in age group 21–25 years, 33% in age group 26–30 years) (Figure 1B).

Conclusions

We observed a high age-related variability in terms of circumstances of death. In the context of HCM, our findings suggest that individuals aged 10–15 years are the most vulnerable in terms of exercise-related-SCD. This exemplifies the importance of preventative cardiac screening in young individuals who might be harbouring quiescent cardiac conditions associated with young SCD.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Acknowledgements: We thank the charitable organisation, Cardiac Risk in the Young (CRY) who fund and support the CRY Cardiovascular Pathology Unit and CRY database.

Patterns and clinical significance of non-specific myocardial fibrosis; Evidence from a cohort of young competitive athletes referred to a tertiary referral centre

Funding Acknowledgements

Type of funding sources: None.

Background

Non-specific myocardial fibrosis (NSMF) is a heterogeneous entity whose clinical significance remains unknown.

Purpose

We aimed to evaluate a cohort of young competitive athletes with and without NSMF to establish potentially clinically significance.

Methods

We analysed data from 328 young athletic individuals referred to our dedicated Sports Cardiology service for a variety of reasons. All athletes underwent an evaluation with 12-lead ECG, Holter, cardiopulmonary exercise test (CPET) and cardiac magnetic resonance (CMR). After excluding individuals with NSMF due to a well-defined cardiac condition, we identified 60 athletes with NSMF (80% male, 72% white, 65% endurance sport) and compared them with a similar group of 75 athletes no fibrosis. Athletes with NSMF were further divided into Group 1 (n=32) with minimal (‘minor’) fibrosis and Group 2 (n=28), with more extended/non-focal (‘major’) fibrosis. Athletes were followed-up for adverse events, including supraventricular and ventricular tachycardia (VT), cardiac symptoms leading to A/E presentations and hospital admissions.

Results

Hours of exercise, baseline heart rate, cardiac volumes, function and CPET performance were similar between the two groups. Athletes with NSMF demonstrated a higher prevalence of lateral T-wave inversion (48 vs. 17%, p&lt;0.001) and ventricular arrhythmias (VEs&gt;500/24h 13.1 vs 2.6%, p=0.046; non-sustained ventricular tachycardia 5.2% vs 0%) compared to athletes without NSMF. Regarding fibrosis localization, 28.6% of the NSMF group had mid-wall, 16.1% subepicardial and 7.1% subendocardial patterns respectively. Athletes of black ethnicity were more likely to have a subepicardial pattern (OR: 5, CI; 1.45-16.67, p=0.004) and those with lateral T-wave inversion (OR: 5.40, CI; 1.70-17.10, p=0.004) were more likely to exhibit major NSMF. In contrast, athletes with minor NSMF had higher right ventricular end diastolic (RVEDV) volumes (104.2±3.6 vs 86.9±5.3 mL/m2, p=0.008) and demonstrated higher values of maximum heart rate (182±13 vs 171±15 bpm, p=0.016), maximum Watts (328.5±18.5 vs 259.2±8.2, p=0.017) and maximum oxygen uptake (V02) (p=0.003), compared to athletes with major NSMF. After adjustment for confounders, the presence of lateral T-wave inversion (p=0.026) and a maximum &lt;44 mL/min/Kg (p=0.040) remained the only significant predictors for presence of major NSMF. During 45.5±25.1 months of follow up, 20 adverse events occurred. No athlete exhibited cardiac arrest or death. Cox regression analysis revealed athletes with major fibrosis were 9.1 more likely to exhibit an adverse event (CI; 1.1-76.3, p=0.041).

Conclusions

The presence of lateral T-wave inversions is associated with increased risk of myocardial fibrosis and should prompt comprehensive evaluation with a cardiac MRI. Major fibrosis was associated with increased prevalence of arrhythmias and adverse events, highlighting the importance of close monitoring and long-term follow-up.

Prevalence and outcomes of WPW pattern in the young: a report from a nationwide cardiac screening programme

Funding Acknowledgements

Type of funding sources: None.

Background

Individuals with accessory pathways, also referred as the Wolff-Parkinson-White pattern (WPWp), are usually asymptomatic and fatal arrhythmias may be the first presentation. Risk stratification is recommended, with electrophysiological study (EPS) being the gold standard. Catheter ablation offers a widely available, curative option, and provides incentive for screening, particularly in high-risk populations such as athletes.

Purpose

We sought to assess the prevalence, real-world clinical practice and outcomes of WPWp in young individuals identified through a nationwide cardiac screening programme.

Method

Between 2008 and 2018, 113,209 consecutive individuals (14 to 35 years old, 38% female) underwent cardiac screening with a health questionnaire, 12-lead electrocardiogram (ECG) and cardiology consultation. Individuals with suspected cardiac disease were referred for further investigations as necessary. Clinical outcomes were obtained via an online questionnaire and matched de-identified records from the Office of National Statistics database. Individuals were classified as elite athletes, non-elite athletes and non-athletes.

Results

A total of 214 (0.2%) individuals were referred for secondary evaluation with a suspected WPWp (Figure 1). Clinical outcomes were unavailable for 30 (14%) individuals. Follow-up confirmed an additional 13 individuals with a WPWp who were deemed to have normal investigations at screening, of which 8 (61%) had reported cardiovascular symptoms on their HQ and, in retrospect, 4 (30%) demonstrated subtle WPWp on their ECG. A WPWp was confirmed in 187 individuals (0.2%), of which 149 (80%) individuals were considered non-athletes, 114 (61%) reported cardiovascular symptoms, 116 (62%) underwent risk stratification with an EPS and 95 (43%) underwent catheter ablation. Report of palpitation was significantly greater in non-athletes than athletes (p=0.034). In asymptomatic individuals, those engaging in sports at elite level were more likely to be referred for an EPS (p=0.04). Four adverse cardiac events were reported over a follow up period of 7.4 years (IQR 4.9 to 9.2), including 3 individuals (16 years, 20 years, 40 years) with life-threatening arrhythmic events (LAE) requiring cardioversion, and 1 individual (20 years) with sudden cardiac death. Of these 4 individuals, only 1 with a LAE had undergone risk stratification with EPS.

Conclusions

The incidence of SCD in this young screened population was 0.72 per 1000 person-years. Clinical practice was variable and EPS was not offered to a significant proportion of patients, despite inadequate non-invasive risk stratification. The indication to EPS was driven by the athletic status in the asymptomatic individuals. The WPW syndrome may manifest with subtle ECG changes, posing a diagnostic challenge to interpreting physicians.

Results of a nationally implemented cardiac screening programme in elite cricket players in England and Wales

OBJECTIVES

We assessed the diagnostic yield and costs of an electrocardiogram-based national screening programme in elite cricket players and the incremental value of transthoracic echocardiography and periodic evaluation.

DESIGN

Cross-sectional study.

METHODS

Between 2008 and 2019, 1208 cricketers underwent screening with a health questionnaire, 12-lead electrocardiogram and cardiology consultation. Athletes with concerning findings underwent on-site transthoracic echocardiography and further investigations as necessary. In addition, despite a normal health questionnaire and electrocardiogram, 342 (28.3%) athletes had a transthoracic echocardiogram and 493 (40.8%) underwent repeat evaluations.

RESULTS

After initial evaluation, 47 (3.9%) athletes underwent on-site transthoracic echocardiography of whom 35 (2.8%) were referred for further evaluation. Four athletes (0.3%) were diagnosed with major cardiac conditions; hypertrophic cardiomyopathy (n = 1), arrhythmogenic cardiomyopathy (n = 1) and Wolff-Parkinson-White pattern (n = 2). Two athletes were identified with minor valvular abnormalities. Repeat evaluation of 493 athletes identified hypertrophic cardiomyopathy in a 22-year-old athlete, two years after his initial normal screening. During a follow-up of 5.8 ± 2.9 years no additional diagnoses or adverse cardiac events were reported. The cost of the electrocardiogram-based programme was £127,844, translating to £106 per athlete and £25,569 per major cardiac condition identified.Routine transthoracic echocardiography in 342 athletes identified two athletes with major cardiac conditions (bicuspid aortic valve with severe aortopathy and aortic regurgitation and an atrial septal defect associated with right ventricular volume overload) and 10 athletes with minor abnormalities.

CONCLUSIONS

An electrocardiogram-based national screening programme identified a major cardiac condition in 0.3% of athletes. Routine transthoracic echocardiography and periodic evaluation increased the diagnostic yield to 0.6%, at an incremental cost.

Yield from family screening in a national adolescent cardiac screening program

Introduction

Cascade family screening in patients with confirmed or suspected inherited cardiac disorders is now well established. This may refute or confirm a familial clinical diagnosis and is particularly relevant in young adolescent individuals as it may be too early to manifest a distinct phenotype.

Objectives

A large cohort of 2708 adolescents aged 14–16 years gave consent to participate in a national cardiac screening program (BEAT-IT). Individuals with suspected inherited cardiac disorders were extensively evaluated. Their relatives were also invited to undergo screening. This study reports the yield of this family cardiac screening program.

Methodology

Family members of probands with suspected or confirmed inherited cardiac conditions were offered cardiac screening. A standard clinical screening protocol for all first-degree family members included a resting 12-lead ECG and echocardiogram. Those with a channelopathy suspicion also underwent postural ECGs and exercise testing. Screening second-degree relatives was also performed in a cascade fashion when clinically indicated. Relatives with a normal baseline screen were offered surveillance if younger than 25 years or a proband clinical diagnosis. Those with an abnormal ECG and/or echocardiogram were referred for further evaluation.

Results

17 probands (63% females) were suspected of harbouring inherited heart disease. Another 2 were diagnosed with a clinical phenotype. The mean age was 15.3±0.58 years. All were Caucasian.

77 family members underwent cardiac screening, with a mean age of 42.5±16.43 at first evaluation. The majority were female (n=44, 57.1%). 12 (15.6%) had an abnormal ECG. 6 (7.8%) had an abnormal echocardiogram, with 2 (2.6%) consistent with cardiomyopathy. 8 (10.4%) were diagnosed with an inherited cardiac condition (n=2 HCM, n=1 DCM, n=5 LQTS). Another 7 (9.1%) are under surveillance because of a pathological ECG in the absence of a clinical phenotype.

The highest clinical yield was in the Long QT group (n=5, 55.6%). Family members (n=25) referred because of proband lateral TWI were the second most likely to require clinical follow-up because of a pathological ECG or a clinical diagnosis (n=7, 28.0%). Relatives referred because of isolated anterior TWI on the proband's ECG had the lowest diagnostic yield (n=17, 0%). After excluding families of probands with isolated anterior TWI (n=18), the overall clinical yield increased to 13.6%. Another 11.9% are under surveillance because of a pathological ECG.

Conclusion

The yield of family screening as part of a national cardiac screening program was 10.4%. This increases to 13.6% when excluding probands with anterior TWI, with 11.9% under surveillance because of a pathological ECG. To our knowledge, this is the first such study of its kind.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Beating Hearts MaltaResearch, Innovation and Development Trust (University of Malta)

Determinants of high-risk coronary artery disease in ostensibly healthy male master endurance athletes

Background

Healthy male master endurance athletes have a greater prevalence of high coronary calcium (CAC) scores compared to healthy sedentary counterparts, and some demonstrate high-risk plaque features. A number of theories have been postulated but reasons remain unclear. Concurrently atherosclerotic coronary artery disease (CAD) is the most common cause of sudden cardiac death in male master athletes drawing much public and scientific interest and making this an important public health issue.

Purpose

To examine the relationship of age, resting systolic blood pressure (SBP), exercise dose and sporting discipline with high-risk CAD markers in male master endurance athletes.

Methods

A prospective study undertaken over 19 months evaluated 214 male master (40–65 years) endurance athletes, free from known cardiovascular risk factors, symptoms or relevant health conditions. Clinical evaluation included cardiopulmonary exercise test, resting blood pressure (BP) and coronary computed tomogram angiography (CCTA). CCTA assessed CAC score, significant stenosis, (&gt;50%) and plaque vulnerability markers. Exercise dose was defined by years of endurance exercise and average MET-hours/week (lifetime exercise volume multiplied by the metabolic equivalent scores). Resting BP was the average of 3 consecutive supine measures after at least 5 minutes rest.

Results

Athletes (mean age 51, SD 70.1) exercised for minimum 6 hours/week (median 8.5) for a median of 15 years (2–26). Almost half (60.2%) were multi-endurance athletes i.e. any combination swimming, cycling and running. The remainder were runners (22.4%) and cyclists (15.4%). Median Framingham risk score 3.2% (1.8–5.8). The mean resting BP was 129/80 mmHg and a quarter (26%) of athletes were hypertensive (≥140/90 mmHg) at rest. A CAC score &gt;100 Agatston units (AU) was present in 16% of athletes. There was a total of 15 stenotic lesions in 11 (5%) athletes. 13% had plaque vulnerability markers.

Logistic regression evaluated whether age, resting SBP, exercise dose measures and sporting discipline were predictive for a CAC score &gt;100 AU, significant stenosis and plaque vulnerability markers (table 1). CAC score was associated with age, years of endurance exercise and resting SBP. A Stenosis &gt;50% and plaque vulnerability markers were associated with resting SBP and cycling compared with all other sporting disciplines.

Conclusion

Despite correcting for age, higher exercise dose (years endurance exercise) is associated with CAC score &gt;100 AU but does not predict significant stenosis or plaque vulnerability markers. Resting SBP and cycling strongly predict high-risk disease. Cycling enables a greater intensity of exercise compared with other endurance sports, which may be associated with prolonged rises in SBP. Resting SBP and cycling are important determinants for high-risk CAD in middle-aged male endurance athletes and should be considered when risk stratifying in pre-participation evaluation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Right ventricular assessment of the adolescent footballers heart: impact of ethnicity

Introduction

Athletic training often results in electrical and structural changes that may mimic phenotypical features of pathological cardiomyopathies. These physiological changes are influenced by age, ethnicity and sporting discipline. The presence of such changes that overlap with diseases implicated in exercise related sudden cardiac death may require comprehensive assessment to confirm or refute the presence of disease. One such potential physiological overlap with pathological change in athletes can occur in arrhythmogenic right ventricular dysplasia (ARVD), with features including chamber dilatation and T-wave inversion (TWI). An erroneous interpretation may have profound consequences ranging from false reassurance in a vulnerable athlete to unfair disqualification in a healthy individual. Therefore, it is important for the clinician to distinguish physiology from pathology.

Purpose

Studies detailing the physiological adaptation to exercise on the right ventricle (RV) of adolescent athletes are fewer compared to the left ventricle, with even fewer reports describing the impact of ethnicity on the RV. We set out to describe the normal dimensions of the RV of academy football players.

Results

ECG and echocardiographic data of 3000 academy male footballers were analysed, aged between 13 and 18 years old (mean age 16.4±0.5 years), who underwent mandatory cardiac screening. Ethnicity was categorised as white (n=1000), black (African/Caribbean; n=1000) and mixed-race (one parent white and one parent black; n=1000). ARVD major criteria for TWI was seen in 6.3% of the cohort. This was more prevalent in black footballers (3.7%) when compared to mixed race footballers (2%) or white footballers (0.6%), p&lt;0.05. In up to 67% of the overall cohort, RV values exceeded those for normal adult reference ranges. There were no differences in RV dimensions between ethnicities (Tables 1 & 2). If ARVD criteria was applied, 13.2% would fulfil major ARVD criteria for right ventricular outflow tract. This was also demonstrated for RVOT dimensions (6.1% - 23.6%; Figure 1). Overall, 0.2% of the cohort would fulfil diagnosis for “definite” ARVD and 2.2% would fulfil diagnosis for “borderline” ARVD. This was seen more frequently in black footballers (9.9%) than mixed race footballers (3.9%) or white footballer (0.6%), P=0.0005. Among athletes meeting definite or borderline ARVD criteria, no cardiomyopathy was identified after comprehensive clinical assessment.

Conclusion

This is the largest study to our knowledge that reports RV dimension data among adolescent footballers of different ethnicities. Right heart sizes in excess of standard adult ranges occurred in as many as one in 22 athletes. It is not unusual to observe values that would overlap with criteria for ARVD. As with LV parameters, variations in terms of ethnicity should be accounted for when considering RV dimensions and ECG changes when performing routine cardiac assessments of adolescent athletes.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): National Institute for Health Research

Characterisation of ventricular premature beats during exercise testing in masters athletes

Background

Exercise induced ventricular premature beats (VPBs) are associated with an adverse outcome in patients with cardiac disease and the general population. The incidence and significance of exercise induced VPBs in masters athletes remains unknown.

Methods

237 masters athletes (54.6±8 years of age, 42% male) and 50 controls of similar age and sex were assessed with a 12-lead ECG, echocardiogram, cardiopulmonary exercise test, 24-hour holter, cardiovascular magnetic resonance imaging and a CT coronary angiogram. Athletes had participated in endurance exercise for a meanof 32±12 years.

Results

Athletes achieved a higher VO2 max (43.2 ml/min/kg vs 28 ml/min/kg) compared with controls and on average weighed 12kg less (63kg vs 75kg).

VPBs were common in master athletes during exercise but are no more common than in age matched sedentary controls (39.3% vs 33.3% &gt;1 VPB, and 8.9% vs 5.9% complex or frequent VPBs). There were no sex differences in terms of VPB number (40% vs 39%) or complex morphology (10% vs 8%) between male and female athletes.

Athletes demonstrating complex ectopy during ETT had similar age (54.8±9 and 54.6±8), years of competition (34±9 and 32±12), VO2 max (40±6 and 43±7ml/min/kg), left ventricular mass (142±36g and 148±35g), end diastolic volume (160±35ml and 157±32ml) and incidence of late gadolinium enhancement (14% and 10%) compared with athletes who did not reveal complex VPBs.

Conclusion

VPBs are common during exercise testing in both masters athletes and sedentary age matched controls. Exercise-induced complex ectopy in an asymptomatic, low risk masters athlete represents a poor marker of significant structural heart disease.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiac Risk in the Young

Race, gender and clinical presentation in apical hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Background

The apical variant of hypertrophic cardiomyopathy (ApHCM) has male predominance and is a relatively rare phenotype in Western population. Characteristics of female and black patients diagnosed with ApHCM are very limited in the existing literature.

Purpose

We aimed to investigate whether gender and race are associated with a different clinical presentation and CMR findings in apical HCM.

Methods

We retrospectively analysed 150 patients (113 males and 37 females) with a diagnosis of apical HCM who have been followed in our inherited cardiac conditions (ICC) clinic between 2010 and 2020. Only patients with a CMR study and apical hypertrophy defined as ≥ 13mm at the time of diagnosis were included.

Demographics and clinical characteristics were obtained from electronic records. Volumetric CMR data were taken from confirmed reports while other parameters were measured by standard protocol. "Pure" ApHCM was defined as isolated apical hypertrophy and "mixed" with both apical and septal hypertrophy but with the apex thickest (1). Apical displacement of papillary muscles (PM) was defined when the base of PM originated from the apical one-third of the left ventricle (LV) in the apical 4- or 2-chamber views. Giant T-wave inversion was defined as T-wave inversion that is equal or greater than 10 mm (1 mV) in any electrocardiogram lead.

Results

Our study population included patients of White (55, 37%), Black (37, 25%), Asian (36, 24%) and Mixed/Others (22, 15%) ethnicity.  Black patients were more likely to have a diagnosis of hypertension at presentation when compared to White (70% vs 40%, p = 0.01) and to Asian and Mixed/Other patients (70% vs 48%, p = 0.03). Similarly, they were more likely to have "mixed" ApHCM than White (49% vs 20%, p = 0.003) and Asian and Mixed/Other (49% vs 26%, p = 0.02) patients.

Females were diagnosed at an older age (63 ± 12 vs 52 ± 14, p &lt; 0.001) and were less likely to have deep T-wave inversion on their ECG at presentation (14% vs 32%, p = 0.03) compared to their male counterparts. Females in this cohort also had higher representation of black ethnicity and were more likely to have hypertension (68% vs 47%, p = 0.03). Apart from the expected gender related differences in volumes and LV mass, there were no differences in cardiomyopathy-specific parameters we investigated.

Conclusions

In our cohort, females with ApHCM presented at an older age and were less likely to have giant T-wave inversion on ECG. Black patients with ApHCM were more likely to have hypertension and the "mixed" type of the disease.

The prevalence of short PR interval in adolescent athletes and non-athletes

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Malta Heart Foundation and Beating Hearts

Background

Little is known about the prevalence and clinical relevance of an isolated short PR interval in young individuals.

Objectives

To explore the PR interval in adolescent athletes and non-athletes and determine possible association with sex, age, ethnicity, athletic ability and sporting discipline.

Methods

Between 2017-2018, school children aged 14-17 years were invited to participate in a National cardiac screening programme comprised of a health questionnaire and a resting 12-lead ECG. An athlete was defined as an individual participating in &gt;4 hours/week of organised sports. Sport disciplines were categorised as skill, power, mixed and endurance. A short PR interval was defined as &lt;120ms.

Results

A total of 1619 (61.0%) non-athletes and 1036 (39.0%) athletes  (median age 15 years, 50.5% females, 93.0% Caucasian) participated in the screening program. Most athletes participated in mixed sports (62.2%).

The mean PR interval was shorter in non-athletes compared to athletes (136.65 ± 19.00ms vs 139.93 ± 19.86ms p &lt; 0.001) and in females compared to males (135.98 ± 18.39ms vs 139.93 ± 20.20ms, p &lt; 0.001). An isolated short PR interval was present in 405 (15.3%) individuals. Associated pre-excitation was present in an additional 5 cases (0.2%). A short PR interval was commoner in females (18.7% vs 11.7%, p &lt; 0.001) and in non-athletes (16.6% vs 13.2%, p = 0.020). Age (p = 0.657) and ethnicity (p = 0.115) did not influence the presence of a short PR interval.

The presence of a short PR interval in adolescent athletes was independent of the sporting discipline category (p = 0.071), in both males (p = 0.400) and females (p = 0.233).  The absolute PR interval did not differ significantly between sporting categories (p = 0.065),  in both genders (males, p = 0.202, females, p = 0.279).

Symptoms that were suggestive of arrhythmias were present in similar proportions of individuals with short and normal PR intervals (18.8% vs 17.1%, p = 0.393). 

Conclusion

An isolated short PR interval was a frequent finding in this cohort, with a predilection for females and non-athletes. The high frequency of short PR in young individuals suggests that in the absence of pre-excitation or symptoms, further evaluation is not warranted. Long-term follow-up studies may further elucidate the clinical relevance of this phenomenon.

Six-month outcomes of a high intensity exercise programme in young patients with hypertrophic cardiomyopathy: The SAFE-HCM trial

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Cardiac Risk in the Young

Background

Moderate intensity exercise training in older patients with hypertrophic cardiomyopathy (HCM) can improve functional capacity, without significant harm. However, younger patients are attracted to high intensity training (HIT) regimes. The SAFE-HCM study demonstrated that an individually tailored, HIT programme in young patients with HCM was feasible, and provided both health and psychological benefits, without an increase in the burden of arrhythmia.

Purpose

To assess whether observed benefits of a HIT programme in young patients with HCM are sustained at 6 months.

Methods

Eighty patients with HCM (45.7y+/-8.6) underwent baseline clinical and psychological assessment. Individuals were randomised to a 12-week HIT programme (n = 40) or usual care (n = 40). Baseline evaluation was repeated at 12 weeks (T12). Feasibility, safety, health and psychological benefits were assessed. At 12-weeks individuals were encouraged to continue with the frequency and intensity of physical activity (PA) achieved at the end of the cardiac rehabilitation programme. Participants in the exercise arm were invited to follow-up at 6 months (T6m).

Results

The majority (83%) of participants completed the 12-week study. At T12 there was no significant difference between groups in the composite arrhythmia safety outcome (p = 0.99). The indices of exercise capacity were significantly improved in the exercise compared to the control group; peak VO2 (+3.7ml/kg/min [CI 1.1,6.3], p = 0.006), VO2/kg at anaerobic threshold (VO2/kgAT) (+2.44ml/kg/min [CI 0.6,4.2], p = 0.009), time to AT (+115s [CI 54.3,175.9], p &lt; 0.001) and exercise time (max ET) (+108s [CI 33.7,182.2], p = 0.005). The exercise group also demonstrated greater reduction in systolic BP (-7.3mmHg [CI -11.7,-2.8], p = 0.002), BMI (-0.8kg/m2 [CI-1.1,-0.4], p &lt; 0.001), anxiety (-2.6 [CI-3.6,-1.6], p= &lt;0.001) and depression (-1.1 [CI -2.0,-0.2], p = 0.015) scores. At T6m patient reported exercise adherence was comparable to baseline PA in 33/34 of the exercise group attending for follow up. Most exercise gains dissipated with the exception of time to AT (p = 0.002), max ET (p = 0.003), VO2/kgAT (p = 0.04) and anxiety score (p &lt; 0.001) (Figure 1). There were no sustained episodes of atrial or ventricular arrhythmias. The incidence of NSVT did not differ between time points (p = 0.09).

Conclusion

A 12-week HIT programme in young patients with HCM offers considerable gains in fitness and psychological outcomes, with no increase in arrhythmic burden. At T6m exercise levels as well as most physiological adaptations and health benefits returned to baseline, as seen in other studies when formal participation in an exercise programme comes to an end. This highlights the importance of the implementation of strategies to encourage ongoing engagement in PA. Potential solutions include identification of barriers to exercise, as well as adoption of novel tele-rehabilation approaches.

Abstract Figure 1 Sustained benefits at T6m

Left ventricular remodelling in masters athletes

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): I have received a research fellowship grant from the UK based charity Cardiac Risk in the Young

Objectives

We investigated the effect of long-term exercise and sex on left ventricular (LV) geometry in a large group of female and male masters athletes.

Background

Studies assessing LV geometry in masters athletes are scarce.

Methods

Different types of LV geometry were identified according to echocardiography-derived relative wall thickness (RWT) and left ventricular mass (LVM) values as per international guidelines. 4 groups were formed: normal (normal LVM/normal RWT), concentric hypertrophy (increased LVM/increased RWT), eccentric hypertrophy (increased LVM/normal RWT), and concentric remodeling (normal LVM/increased RWT).

Results

A total of 277 healthy, elite, caucasian endurance masters athletes (65% female; mean age54.8 ± 7.7 years) were assessed. The athletes were exercising for a mean 32 ± 11.7 years and have completed a median 70 competitions including a median 13 marathon-type competitions. Females exhibited lower absolute LVM (127.7 ± 30.31g vs 196.57 ± 45.0g, p &lt; 0.001), indexed LVM (76.8 ± 18.0 g/m2 vs. 103.6 ± 22.7 g/m2; p &lt; 0.001), RWT (0.36 ± 0.07 vs. 0.42 ± 0.08; p &lt; 0.001) and absolute LV end-diastolic dimension (LVEDD) (46.3 ± 4.1 mm vs 50.1 ± 5.11 mm, p &lt; 0.001) but greater indexed LVEDD (27.7 ± 2.7mm/m2 vs 26.5 ± 2.7 mm/m2, p &lt; 0.001) compared with male athletes. Most female athletes showed normal LV geometry (72% vs 38% in male athletes, P &lt; 0.001) and significantly less concentric remodeling (12% vs 35%, p &lt; 0.001) and concentric hypertrophy (5% vs 13%, p = 0.01) (table & figure).

Conclusions

A sex-specific response to chronic exercise is observed. Male masters athletes exhibit significantly more frequently abnormal LV geometry with concentric LV remodeling and/or concentric hypertrophy.

Cohort characteristics Male masters athletes N = 97 Female masters athletes N = 180 P value Age (years) 55.0 ± 9.0 54.7 ± 6.9 0.68 Years of exercise 32.0 ± 12.8 33.3 ± 11.1 0.14 LV Mass (g) 127.7 ± 30.31 196.57 ± 45.0 &lt;0.001 LV Mass Indexed (g/m2) 76.8 ± 18.0 103.6 ± 22.7 &lt;0.001 LVEDD (mm) 46.3 ± 4.1 50.1 ± 5.11 &lt;0.001 LVEDD Indexed (mm/m2) 27.7 ± 2.7 26.5 ± 2.7 &lt;0.001 Normal Remodeling 36 (37) 130 (72) &lt;0.001 Eccentric Hypertrophy 14 (14) 18 (10) 0.27 Concentric Remodeling 34 (35) 23 (13) &lt;0.001 Concentric Hypertrophy 13 (13) 9 (5) 0.01 LV Left Ventricular, LVEDD: Left Ventricular End Diastolic Dimension Abstract Figure. Patterns of left ventricular remodeling

Speckle illumination SFDI for projector-free optical property mapping

Spatial frequency domain imaging can map tissue scattering and absorption properties over a wide field of view, making it useful for clinical applications such as wound assessment and surgical guidance. This technique has previously required the projection of fully characterized illumination patterns. Here, we show that random and unknown speckle illumination can be used to sample the modulation transfer function of tissues at known spatial frequencies, allowing the quantitative mapping of optical properties with simple laser diode illumination. We compute low- and high-spatial frequency response parameters from the local power spectral density for each pixel and use a lookup table to accurately estimate absorption and scattering coefficients in tissue phantoms, in vivo human hand, and ex vivo swine esophagus. Because speckle patterns can be generated over a large depth of field and field of view with simple coherent illumination, this approach may enable optical property mapping in new form-factors and applications, including endoscopy.

Usefulness of subcutaneous Implantable Loop Recorder in Brugada Syndrome. A single UK centre experience

Background

Experience with implantable loop recorder (ILR) in Brugada Syndrome (BrS) is limited.

Purpose

We sought to evaluate the usefulness of continuous monitoring in BrS patients in a UK based Inherited Cardiac Conditions centre.

Methods

Subjects with BrS were consecutively recruited and demographic, clinical, device and follow-up data acquired.

Results

Of 452 subjects with BrS recruited in our centre, 41 (9%) received an ILR. Twenty-one (51%) were males. Twenty-four subjects (59%) had a high probability of BrS based on the Shanghai score. Mean age at implantation was 45.3±15.5 years. The indications for the implantation were: syncope or pre-syncope in 28 subjects (68%), palpitations in 12 (29%), family history of SADS in 1 case. Sixteen subjects presented with a spontaneous type 1 pattern, of whom 12 (75%) underwent an electrophysiological study for risk stratification which was negative. During a mean follow-up of 82±46 months (range 4.0–182), 5 new diagnoses of atrial fibrillation (AF) or supraventricular tachycardia were made; 3 subjects had symptomatic pathological pauses (in one case associated with fast AF) and underwent permanent pacemaker or ICD implantation; one subject experienced an asymptomatic episode of fast, non-sustained monomorphic ventricular tachycardia. In 2 cases the device was explanted prematurely due to site infection. Patients who received an ECG diagnosis following interrogation of the ILR were older (mean age 55±11 vs 43±16m p=0.04), although there were no differences in sex or Shanghai score.

Conclusions

In a large UK cohort of BrS patients, the use of ILR was low. However, continuous subcutaneous monitoring yielded a diagnosis of tachy- or brady-arrhythmic episodes in 22% of cases, and therefore can be helpful in guiding the management of low/intermediate risk BrS patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Robert Lancaster Memorial Fund

Safety and outcomes of a structured exercise programme in young patients with hypertrophic cardiomyopathy: the SAFE-HCM trial

Background

Contemporary studies in hypertrophic cardiomyopathy (HCM) suggest that moderate intensity exercise can improve cardiorespiratory fitness without raising significant safety concerns. Although low/moderate intensity exercise may be appropriate for older HCM patients, it is unlikely to attract younger, often asymptomatic patients, who wish to engage in higher intensity regimes.

Purpose

To assess the feasibility, safety and outcomes of an individually tailored, high intensity exercise programme in young patients with HCM.

Methods

In this RCT, 80 patients with HCM, aged 16–60 (mean 45.7, [SD8.6]) underwent baseline testing with ECG, echocardiography, blood testing, exercise testing, 48-hour ECG and psychological assessment. Individuals were randomised to a 12-week supervised exercise programme (HRR increased from 70–85%) (n=40) or usual activity (n=40). Baseline investigations were repeated at 12 weeks.

Feasibility was assessed by a) recruitment, adherence and retention rates; b) staffing ratios and logistics; c) acceptability of the intervention/educational materials. Safety was assessed as a composite of 1) cardiovascular death, 2) cardiac arrest, 3) device therapy, 4) exercise induced syncope, 5) sustained/non-sustained (NS) ventricular tachycardia (VT) or 6) sustained atrial arrhythmias. Secondary outcomes included health and psychological benefits.

Results

67 individuals (82.5%) completed the study. Reasons for refusal included travel, work and family commitments. The majority (64.7%) of exercising individuals progressed to 85%HRR. Resource requirements were similar to other programmes. All individuals felt supported, more confident to exercise, and found educational materials clear and informative.

There was no significant difference between groups for the composite safety outcome. One individual experienced exercise induced syncope due to ventricular standstill (exercise) and another sustained VT (control). Both required device implantation. There was no significant difference between groups in episodes of NSVT (p=0.573) or ectopic burden (p=0.729).

At 12 weeks, exercise group participants demonstrated greater activity levels (+1.1 hours [CI 0.2–2.1], p=0.024). The change in peak aerobic capacity (+255.2ml/min [CI 93.2–417.1], p=0.003), time to anaerobic threshold (AT) (+115s [CI 54.2–176.0], p&lt;0.001), total exercise time (+108.1s [CI 33.1–183.0], p=0.005) and oxygen uptake at AT (+2.44ml/kg/min [CI 0.6–4.2], p=0.009) were all significantly greater in the exercise group. HADS anxiety (p&lt;0.001) and depression (p=0.017) scores demonstrated the greatest reduction in the exercise group.

Conclusions

A high intensity exercise programme is feasible in young patients with HCM, with considerable gains in cardiorespiratory fitness and psychological outcomes. Importantly, arrhythmia burden was not increased in the exercise group. Further research is still required to assess the long-term safety of high intensity exercise in the HCM population.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Cardiac Risk in the Young

P890Gene carriers of hypertrophic cardiomyopathy, what to expect over time

Background

Data on the natural history of genotype positive/phenotype negative (G+/P-) hypertrophic cardiomyopathy (HCM) patients identified as a part of genetic cascade screening in different age groups is limited.

Purpose

To describe the rate of conversion to overt HCM phenotype in G+/P- subjects in relation with the age who were identified in a specialized clinic in a single center.

Methods

We retrospectively identified 56 consecutive HCM G+/P− subjects followed in our center specialized clinic between Jan 2012-Jan 2019. Demographics, family history of sudden cardiac death (SCD) and presence of symptoms were collected. All of them underwent baseline investigations including ECG, echocardiogram and/or cardiac magnetic resonance (CMR) and 24 hour monitor at baseline and during follow up. Overt HCM phenotype was defined as left ventricular hypertrophy (LVH) ≥13mm in the echocardiogram or CMR.

Results

We identified 56 HCM G+/P− subjects from 34 different families. 22 subjects were ≤18 years old with a mean age of 11.6±0.9 years (IQR [P25-P75] 9–16 years) and 32 subjects were >18 years old with a mean age of 38.1±2.2 years (IQR [P25-P75] 27–48 years). Mean time of follow up was 35.2±34.4 months (IQR [P25-P75] 4.25–50.25 years). 60.7% (34) of them were female and 82.1% (46) were of Caucasian ethnicity. Most of the subjects with no evidence LVH were asymptomatic but small number had symptoms, 8.9% (5), and 3.6% (2) were treated with betablockers for palpitations. Family history of SCD was present in 57.1% (32) of the subjects and 35.7% (20) had a relative with an implantable cardiac defibrillator (ICD). MYBPC3 gene mutations were identified in 62.5% (35) of subjects, followed by MYH7 gene mutation in 23.2% (13) of the cases.

None of the subjects under 18 year old developed HCM during the period of observation, however 7 subjects (21.9%), mean age 48.6±10.5 years, 71.4% (5) females, showed progression to HCM in the >18 years old group. All of them had pathogenic MYBPC3 gene variants. No differences were found in gender, ethnicity, symptoms or family history of SCD in the G+/P− vs HCM group. There were no differences on the presence of ECG abnormalities and no episodes of NSVT were recorded in any of the groups. Baseline E/e' values of those with new HCM vs G+/P− were higher (8.2±3.3 vs 5.6±1.7, p=0.014).

Conclusions

In our cohort, rate of progression to HCM phenotype was 21.9% of >18 years old HCM G+/P- subjects. The mean age at the time of developing the phenotype was 48.6±10.5 years old and all the patients were asymptomatic for cardiac symptoms. Echocardiographic E/e' values were increased. This data supports the need of life long follow up of this group of patients with ongoing clinical evaluation.

Acknowledgement/Funding

ESC clinical grant

P3683Diagnosis of arrhythmogenic cardiomyopathy and overlap with cardiac adaptation to exercise: insights from a cardiac magnetic resonance study

Background

The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) is often challenging and some structural abnormalities typical of the disease may overlap with changes reflective of cardiac adaptation to exercise.

Purpose

The aim of the study was to assess the performance of the cardiac magnetic resonance (CMR) 2010 Task Force Criteria (TFC) in a cohort of patients with definite diagnosis of ARVC and define the overlap with a cohort of highly trained athletes of similar age and sex.

Methods

We compared the CMR features of 43 patients (mean age 49±17 years, 49% males, 32 (74%) genotyped) with a definite diagnosis of ARVC according to the revised TFC to 97 (mean age 45±16 years, 61% males) highly-trained athletes of similar age and sex, in whom cardiac disease was excluded after comprehensive work-up.

Results

The CMR was abnormal in 37 (86%) patients. The right ventricle (RV) was affected in isolation in 17 (39%) patients, with 18 (42%) patients exhibiting biventricular involvement and 2 (5%) patients showing isolated left ventricular (LV) involvement. The most common RV abnormalities were regional wall motion abnormalities (RWMA) (n=34; 79%), RV dilatation fulfilling a major or minor volume TFC (n=18; 42%), impaired systolic function (RV ejection fraction (EF) ≤45%: n=17; 40%) and myocardial fibrosis (n=13; 30%). The predominant LV abnormality was myocardial fibrosis (n=20; 47%), with a small proportion of patients exhibiting RWMA (n=6; 14%) and impaired systolic function (LVEF <50%: n=6; 14%). Twenty-three (53%) patients fulfilled a major (n=14; 32%) or a minor (n=9; 21%) CMR TFC. Sixteen (16%) athletes exceeded the cut-off values for RV volumes used as a major (n=10; 10%) or a minor (n=6; 6%) TFC with an inverse relationship between age and RV volumes (r=−41, p=0.001). None of the athletes fulfilled the TFC for RV ejection fraction. Applying the CMR TFC to the ARVC patient population showed a sensitivity of 33% for the major and 28% for the minor criteria. Applying the RV volume and systolic function TFC values in the entire study population showed a sensitivity of 53%, a specificity between 83% and an accuracy of 0.68.

Conclusions

The great majority (86%) of patients with ARVC demonstrates structural abnormalities suggestive of cardiomyopathy on CMR but only 53% fulfills any of the CMR TFC. Only a small proportion (16%) of older athletes demonstrate significant RV dilatation that overlaps with the volume criteria for ARVC, in juxtaposition to younger athletes who exhibit a greater degree of overlap. The emergence of ARVC as a biventricular disease provides an opportunity to re-evaluate the diagnostic criteria and include LV involvement in conjunction with RV involvement to improve diagnostic accuracy.

Acknowledgement/Funding

CRY (Cardiac Risk in the Young) charity

Surgery for colorectal cancer in elderly patients: is there such a thing as being too old?

INTRODUCTION

The overall increase in life expectancy causes a rapid increase in number of elderly patients needing colorectal surgery. It remains unclear if there is a significant risk factor in patients over 80 years of age for postoperative morbidity and mortality. For this reason we investigated the perioperative, outcome and long-term survival after surgery for colorectal cancer in our hospital.

MATERIALS AND METHODS

We retrospectively analysed a database containing information about patients who underwent surgery for colorectal cancer from January 2010 to December 2015 at the St. Bernhard Hospital in Kamp-Lintfort, Germany. The last follow-up date was 31th of December 2017.

RESULTS

A total of 232 patients were enrolled and analysed in this study. All patients were separated in tow groups depending in age. The first group was ≥80 years old (n=49). The second group was <80 years old (n=183). High ASA-Scores (≥3) were detectable more often in elderly patients (p<0,05). Elderly and young patients had a similar risk for postoperative anastomosic leakages (p=0,047). Likewise there were no significant differences regarding the Dindo-Clavien-Classification (p=0,13). The mortality within the first 30 days after surgery was significant elevated for elderly patients compared to younger patients (p=0,04). Also the overall 1-year survival was 90% for the younger and 73,5% for the older study group (p<0,05) Conclusion. Both the short-term outcome and long-term survival rate after colorectal surgery for cancer are worse for patients older than 80 years of age. After interpretation of all data it remains unclear if the age itself is still the biggest risk factor. When old patients have a good ASA-Score and no severe comorbidities, colorectal surgery remains safe even for patients older than 80 years.