Geometrical remodeling of the mitral and tricuspid annuli in response to exercise training: a 3-D echocardiographic study in elite athletes

Abstract

Intense exercise exposes the heart to significant hemodynamic demands, resulting in adaptive changes in cardiac morphology and function. Nevertheless, the athletic adaptation of the atrioventricular valves remains to be elucidated. Our study aimed to characterize the geometry of mitral (MA) and tricuspid (TA) annuli in elite athletes using 3D echocardiography. Thirty-four athletes presented with functional mitral regurgitation (FMR) were retrospectively identified and compared to 34 athletes without MR, and 34 healthy, sedentary volunteers. 3DE datasets were used to quantify MA and TA geometry and leaflet tenting by dedicated softwares. MA and TA areas, as well as tenting volumes, were higher in athletes compared to controls. MA area was significantly higher in athletes with MR compared to those without (8.2±1.0 vs. 7.2±1.0cm2/m2, p<0.05). Interestingly, athletes with MR also presented with a significantly higher TA area (7.2±1.1 vs. 6.5±1.1cm2/m2, p<0.05). Non-planar angle describing the MA's saddle shape was less obtuse in athletes without MR, whereas the values of athletes with MR were comparable to controls. The exercise-induced relative increases in left ventricular (35±25%) and left atrial (40±29%) volumes were similar; however, the increment in the MA area was disproportionately higher (63±23%, overall p<0.001). The relative increase in TA area (40±23%) was also higher compared to the increment in right ventricular volume (34±25%, p<0.05). Atrioventricular annuli undergo a disproportionate remodeling in response to regular exercise. Athletic adaptation is characterized by both annular enlargement and increased leaflet tenting of both valves. There are differences in MA geometry in athletes presented with versus without FMR.

Right Ventricular Structure and Function in Adolescent Athletes: A 3D Echocardiographic Study

“…Most recently, using 3D echocardiography, Jone et al provided sex-specific reference values for pediatric RV volumes, EF, and z-score equations from children across five centers in North America [31]. The RV volumes measured in our athletic population are remarkably higher, also pointing to significant remodeling of not only the left heart but also its right counterpart [32]. Importantly, female adolescent athletes are also presented with the above-mentioned phenomena -but with less of a degree.…”

Right ventricular structural and functional adaptation to regular, intense exercise in the young: a 3D echocardiographic study in adolescent athletes

“…26 The RV volumes measured in our athletic population are remarkably higher, also pointing at signi cant remodelling of not just the left heart but its right counterpart. 27 Importantly, female adolescent athletes are also presented with the above-mentioned phenomena -but with less of a degree. As such, we should consider young female athletes as part of the spectrum as well.…”

Mitral and Tricuspid Valve Disease in Athletes

“…Therefore, a balanced adaptation of the cardiac chambers is a characteristic and unmistakable feature of an athlete's heart. However, although ventricular and atrial dilation can significantly affect atrioventricular annular geometry and related valvular competency in various pathological states, less is known about the EICR alterations in the shape and function of the mitral annulus (MA) and tricuspid annulus (TA) in CAs [4,17].…”

“…The MA and TA are elliptical, saddle-shaped, and dynamic structures that connect the leaflets with the ventricular and atrial myocardium. Elite athletes have a significant dilatation of the MA and TA dimensions and an increase in the tenting of both atrioventricular valves compared to non-athlete counterparts, [4] indicating that atrioventricular annuli undergo disproportionate remodeling in response to regular training. [4] Indeed, through a combination of annulus enlargement and tethering of the valve leaflets, functional regurgitation of the MV or TV has been primarily linked to LV or right ventricle (RV) remodeling, respectively [1].…”

“…Primary valvular heart diseases (VHDs) show similar prevalence in athletes and the general population; however, athletes are more likely to experience secondary (functional) mitral regurgitation (MR) and tricuspid regurgitation (TR) [3]. This observation may be partially attributed to the adaptive changes of atrioventricular remodeling in the context of the "athlete's heart" [2,4]. Although many studies have focused on the adaptations of the cardiac chambers to physical exercise, the effects of exercise on MV and TV should be clarified.…”