Cardiac Imaging in Athlete’s Heart: The Role of the Radiologist

Abstract

Athlete’s heart (AH) is the result of morphological and functional cardiac modifications due to long-lasting athletic training. Athletes can develop very marked structural myocardial changes, which may simulate or cover unknown cardiomyopathies. The differential diagnosis between AH and cardiomyopathy is necessary to prevent the risk of catastrophic events, such as sudden cardiac death, but it can be a challenging task. The improvement of the imaging modalities and the introduction of the new technologies in cardiac magnetic resonance (CMR) and cardiac computed tomography (CCT) can allow overcoming this challenge. Therefore, the radiologist, specialized in cardiac imaging, could have a pivotal role in the differential diagnosis between structural adaptative changes observed in the AH and pathological anomalies of cardiomyopathies. In this review, we summarize the main CMR and CCT techniques to evaluate the cardiac morphology, function, and tissue characterization, and we analyze the imaging features of the AH and the key differences with the main cardiomyopathies.

The Role of Multimodality Imaging in Athlete’s Heart Diagnosis: Current Status and Future Directions

“…Stress CMR, usually with exercise, can be used to identify a reduced functional reserve and early-stage cardiomyopathy when resting functional assessment is mildly abnormal [ 73 ]. However, further studies are necessary to evaluate the cost-effectiveness of stress CMR imaging in this setting.…”

“…LV functional evaluation by CCT is particularly useful in claustrophobic patients, unable to undergo CMR, or if contraindications to CMR exist (albeit rare among athletes). Otherwise, CCT cannot be recommended as a first-line imaging technique for functional evaluation of the LV in athletes, given the higher radiation exposure required [ 73 , 77 ].…”

“…The use of iodine contrast medium allows the evaluation of ECV and myocardial fibrosis (with the analysis of late iodine enhancement, LIE) by CCT, even if not routinely used in clinical practice, with good agreement with the same evaluations performed by contrast-enhanced CMR [ 73 ].…”

Diagnosis and Treatment of Idiopathic Premature Ventricular Contractions: A Stepwise Approach Based on the Site of Origin

“…LVEF is best measured in the sinus beat after the first post-extrasystolic beat or, in case of bigeminy, by averaging measures taken during PVCs and sinus beats [40,41]. Besides LVEF, echocardiographic assessment should focus on PVCs' presumed SOO, especially is case of a suspected arrhythmogenic right ventricular cardiomyopathy (ARVC): the presence of right ventricular wall motion abnormalities (akinesia, dyskinesia, aneurysm, bulging), together with a disproportionate RVOT dilation, represent diagnostic criteria for ARVC, and help to differentiate it from training-induced RV re-modeling, which is commonly encountered in athletes [42][43][44]. In case of reduced LVEF, symptoms, cardiovascular risk factors, or other elements suggestive of ischemic heart disease (i.e., presence of abnormal q waves, repolarization abnormalities, regional wall motion abnormalities) invasive or computed tomographic (CT), coronary angiography should be considered to rule out a significant coronary artery disease, with the latter reserved for younger patients, with a lower pre-test probability [45,46].…”

“…Nonetheless, CMR carries some limitations in patients with frequent PVCs, including gating difficulties and motion artifacts due to the irregular rhythm [56,57]. Furthermore, identification of fibro-fatty replacement of the right ventricular wall may be problematic due to its thin structure [43]. Besides non-invasive diagnostic modalities, electroanatomical mapping (EAM), which is pivotal during CA procedures as it allows the precise localization of the arrhythmic focus by activation mapping, may also provide important diagnostic and prognostic information [58,59].…”