European Journal of Preventive Cardiology (2022) 29, 1592–1593
https://doi.org/10.1093/eurjpc/zwac117
On the characterization of athlete’s heart
using 3D echocardiography
Andre La Gerche 1, Gianni Pedrizzetti 2, Brigida Ranieri
Antonello D’Andrea 4, and Eduardo Bossone 5*
1
Clinical Research Domain, Baker Heart and Diabetes Institute, 99 Commercial Road, Melbourne, VIC 3004, Australia; 2Department of Engineering and Architecture, University of
Trieste, Via Alfonso Valerio, 6/1, 34127 Trieste, Italy; 3IRCCS SYNLAB SDN, Via Emanuele Gianturco, 113, 80143 Naples, Italy; 4Department of Cardiology, Umberto I Hospital Nocera
Inferiore, Via Alfonso de Nicola, 84014 Nocera Inferiore, SA, Italy; and 5Cardiology Division, Antonio Cardarelli Hospital, Via Antonio Cardarelli, 9 - 80131 Naples, Italy
Online publish-ahead-of-print 7 June 2022
This editorial refers to ‘Biventricular mechanical pattern
of the athlete’s heart: comprehensive characterization
using three-dimensional echocardiography’, by
A. Fábián et al., https://doi.org/10.1093/eurjpc/zwac026.
The structural and functional adaptations of the athlete’s heart facili-
tate the performance related increased blood flow.1,2 These heart
changes comprise increases in cardiac chambers size as well as the
requisite improvements in inotropic and lusitropic function enabling
larger stroke volumes to be ejected from the ventricles during exer-
cise.1,2 The physiological mechanisms of this process are remarkable
and, despite decades of research, remain incompletely understood.
It should be said the majority of investigations about the athlete’s
heart cardiac adaptations have focused on the left ventricle (LV). In
this regard, the principal established changes can be ascribed (at a ba-
sic level) as an increase in LV volumes (both at end-diastole and end-
systole, especially in endurance athletes) and myocardial mass. This
physiological LV dilatation is naturally associated with a reduction
in ejection fraction (EF) at resting conditions, ensuring a higher re-
serve with exercise. However, it should be highlighted that the EF
is the result of longitudinal and circumferential contractions, mea-
sured by global longitudinal and circumferential strain (GLS and
GCS), respectively.3,4 Thus, the reduction of overall contraction—in-
dicated by the EF—must necessarily reflect in a corresponding re-
duction of GLS and/or GCS. However, results about changes of
global strain components in athletes are heterogeneous and appar-
ently dependent on the specific sport category.5
Fábián et al.6 present an interesting evaluation of the mechanical
function of both LV and right ventricle (RV) in an extended popula-
tion of athletes (n = 425) as assesses by three-dimensional (3D)
echocardiography (Figure 1A and B).
They confirm the increase in LV size and mass along with the de-
crease in EF is accompanied by a significant reduction in GCS and, to
The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Preventive Cardiology or of the European Society of Cardiology.
* Corresponding author. Tel: +39 0817473068, Email: eduardo.bossone@aocardarelli.it
© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email:
journals.permissions@oup.com.
INVITED EDITORIAL
3
,
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a smaller extent, in GLS reflecting the relationship between EF and
strain4 [EF = 100 − 100 × (GLS/100 + 1) × (GCS/100 + 1)].2
On the other hand, peculiar geometry and anatomical structure of
the RV correspond to a specific ventricular contraction mechanical
behaviour that likely reflects different adaptation mechanisms.
Global measurements give preliminary indications, and a more care-
ful characterization requires to separate the contribution coming
from different regions of the RV boundary as recently suggested7–9
(Figure 1C and D).
The study of Fábián et al.6 is rich in data. To the authors’ credit and
the benefit of the readers, the study includes a large cohort of highly
trained female athletes.10,11 In this regard, the reported 3D echocar-
diographic data support the premise that the adaptations in men and
women are similar in nature but differ in extent. Right ventricle and
LV volumes are increased in both sexes, whilst deformation and EF
tended to be lower.6 It has been previously well described that over-
all cardiopulmonary fitness (VO2max) is lower in women and this has
been again observed by Fábián et al.6 Furthermore Fabian et al.6 dem-
onstrate that the lower VO2max values are associated with, and
largely proportional to, smaller cardiac volumes and lesser changes
in functional parameters. In short, sports cardiology clinicians may
be reassured that male and female athletes can be considered part
of the same spectrum of cardiac adaptations relative to physical con-
ditioning. This would imply that outliers (e.g. very large cardiac vo-
lumes and reductions in deformation in an athlete of modest
fitness) should be evaluated further for the possibility of underlying
pathology regardless of gender.
Within the findings of Fábián et al.6 potentially important and no-
vel observations are about the cardiac remodeling in adolescent ath-
letes. In the total cohort there is a strong relationship between
cardiopulmonary fitness (VO2max), and chambers enlargement.
However, adolescent athletes were found to have the highest
VO2max and yet cardiac volumes were slightly less than those of
Invited Editorial
Figure 1 Progresses in echocardiography allow improved characterization of right-ventricular mechanical function in athletes: (A) two-
dimensional speckle-tracking echocardiography from apical four-chamber visualization allows measuring right ventricle area and longitudinal strain
limited to that cross section; (B) right ventricle geometry extracted from three-dimensional echocardiography; (C) the contraction can be separated
in wall-specific contributions (credit: Kovács et al.8, under a Creative Commons Attribution 4.0 International License); (D) principal strain analysis
allows to identify direction and entity of contraction.
adult athletes. This raises some very interesting questions regarding
the interaction between healthy athletic cardiac remodeling and
aging. According to the Fick equation, VO2max equates to the prod-
uct of cardiac output and peripheral oxygen utilization in the working
peripheral muscles. Therefore, there are two main possibilities to ex-
plain the observation of greater VO2max with a slightly smaller heart.
The first is that the young athlete has better peripheral oxygen util-
ization. The other possibility is that the young athlete heart can gen-
erate greater outputs with lesser resting volumes. This is an intriguing
proposition, which evokes the suggestion that the heart in the adult-
and middle-aged athletes may compensate by enlarging (and
relying on greater elastic recoil) because it has a lesser capacity to
rely on enhanced lusitropy and contractility. Referring back to
Morganroth’s original simile between athlete’s heart and regurgitant
valvular heart disease, it could be that there is a point in which the
athlete’s heart relies more on structural enlargement than on func-
tional adaptation. Is there a point at which extreme cardiac enlarge-
ment could be considered a failure of functional adaptation? Are
there any clinical consequences? These are all questions that cannot
be addressed in the cross-sectional design of the Fábián et al.6 and
again speak to the need for longitudinal data in highly trained athletes.
The rapid advancement of imaging technology will see an ever-
increasing number of studies about ventricular function based on
3D techniques.12 This technological advancement produces a multi-
tude of information and requires the parallel development of feasible
and reproducible methods capable of providing a realistic picture of
the actual cardiac function and able to synthesize it with a few rep-
resentative parameters. This is a scientific challenge requiring inter-
disciplinary and synergistic collaborations in order to progress
toward a ground-based understanding of cardiac mechanical function
and adaptation. New mechanistic knowledge may shed the light on
the clinical conundrum related to identifying the good athlete’s heart
from the rare case in which the remodeling is bad.
Funding
This research did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors.
1593
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Conflict of interest: None declared.
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