Potential role of an athlete-focused echocardiogram in sports eligibility

Table 1 Common cardiovascular diseases associated with sudden cardiac deaths in athletes (adapted from[15,21])

Type of pathology	Pathology
Cardiomyopathies	HCM
	DCM
	LVNC
	ARVC
CAD
Myocarditis
Congenital defects	AOCA
	BAV
Valvulopathies	MVP
Aortic diseases	Aortic dissection
	Aortic rupture
	Aortic aneurism
Kawasaki disease
Idiopathic scarring
Conduction defects	WPW
Channelopathies	LQTs
	Brugada syndrome
	CPVT

HCM: Hypertrophic cardiomyopathy; DCM: Dilated cardiomyopathy; LVNC: Left ventricle non compaction; ARVC: Arrhythmogenic right ventricle cardiomyopathy; CAD: Coronary artery disease; AOCA: Anomalous origin of coronary arteries; BAV: Bicuspid aortic valve; MVP: Mitral valve prolapse; WPW: Wolff-Parkinson-White syndrome; LQTs: Long QT syndrome; CPVT: Catecholaminergic polymorphic ventricular tachycardia.

Table 2 Minimum dataset for transthoracic echocardiography (adapted from[33])

Echo views	Structure	Measure
PLAX	LV	IVS
		End diastolic diameter
		Posterior wall
		Wall motion
	Mitral Valve	Leaflets and annulus
		Color
	Aortic Valve	Anulus
		Valsalva Sinus
		STJ
		Color
	Ascending aorta	Size
	RV	RVOT
	LA	Size
PSAX–aortic valve	Aortic Valve	Morphology
	OCA
	RV	RVOT
	Pulmonary valve	Color
		PW
PSAX-base	Mitral Valve	Leaflets and annulus
PSAX–mid/apex	LV	Wall motion
A4C	LV	EF
		Wall motion
		Wall thickness
		End diastolic area/volume
	VSD
	ASD
	LA	LAVI
	Mitral valve	Color
		PW
		TDI
	RV	RVD1
		RVD2
		RVD3
		Wall motion
		TAPSE
	TV	Color
		CW
	Pulmonary veins	PW
A5C	Aortic valve	Color
		CW
A2C	LV	Wall motion
Subcostal	ASD
	Inferior vena cava	Size
		Breath collapsibility
	Pericardium	Pericardial effusion
	Abdominal aorta	Size
Suprasternal	Aortic arch	Size
		Color
		CW

PLAX: Parasternal long axis view; PSAX: Parasternal short axis view; A4C: Apical 4 chambers view; A5C: Apical 5 chambers view; A2C: Apical 2 chambers view; LV: Left ventricle; BSA: Body surface area; EF: Ejection fraction; RVOT: Right ventricle outflow tract; RV: Right ventricle; FAC: Fractional area charge; LAVI: Left atrium ventricle index; LA: Left atrium; IVS: Inter ventricular septum; PW: Power doppler wave; CW: Continuous doppler wave; RA: Right atrium; STJ: Sinotubular junction; OCA: Origin of coronary arteries; PDA: Patent ductus arteriosus; COA: Aortic coarctation; ASD: Atria septum defect; VSD: Ventricular septal defect; RVD: Right ventricle diameter; TAPSE: Tricuspid annular plane excursion.

Table 3 Athlete-focused echo protocols

Ref.	Echo view (parameters assessed)	Estimated exam time
Feinstein et al[51]	PLAX (LV IVS, LV posterior wall, LVOT)	1-2 min
Wyman et al[53]	PLAX (aortic arch size, aortic valve characteristics, mitral valve characteristics, LV wall motion, LV mass); PSAX (aortic valve characteristics, aortic valve morphology, origin of coronary arteries, CW pulmonary valve, LV wall motion, LV wall thickness); A4C (tricuspid valve characteristics, mitral valve characteristics, RV size, RV wall motion, LV size); A5C (CW aortic valve)	Not specified
Weiner et al[52]	PLAX (aortic valve characteristics, mitral valve characteristics, CW tricuspid valve); PSAX (aortic valve characteristics, pulmonary valve characteristics, LV wall motion); A4C (RV size, RV wall motion, LV size, LV wall motion, PW mitral valve, TDI mitral valve, tricuspid valve characteristics); A5C (CW aortic valve); A2C (LV wall motion)	13 min
Yim et al[55]	PLAX (IVS, LV end diastolic diameter, PW, aortic arch size)	Not specified
Fishman et al[54]	LV IVS, LV posterior wall, LV end diastolic diameter, PW, EF, AVR, MVR aortic valve regurgitation, mitral valve regurgitation, aortic valve morphology, aortic root dimension	1 min

PLAX: Parasternal long axis view; PSAX: Parasternal short axis view; A4C: Apical 4 chambers view; A5C: Apical 5 chambers view; A2C: Apical 2 chambers view; IVS: Inter ventricular septum; LVOT: Left ventricle outflow tract; LV: Left ventricle; CW: Continuous wave; RV: Right ventricle; PW: Power doppler wave; TDI: Tissue doppler imaging; EF: Ejection fraction; AVR: Aortic valve regurgitation; MVR: Mitral valve regurgitation.

Table 4 Proposed echocardiographic protocol for athletes

Echo views	Structure	Measure
PLAX	LV	IVS
		End diastolic diameter
		Posterior wall
	Mitral valve	Leaflets
		Color
	Aortic valve	Valsalva sinus
		Color
	Ascending aorta	Size
PSAX–aortic valve	Aortic valve	Morphology
	OCA
	RV	RVOT
	PDA
A4C	LV	Trabeculations
		Wall motion
	VSD
	ASD
	Mitral valve	Color
		PW
	TV	Color
		CW
A5C	Aortic valve	Color
		CW
Subcostal	ASD
	Inferior vena cava	Size
		Breath collapsibility
	Pericardium	Pericardial effusion
Suprasternal	Aortic arch	Size
	COA

PLAX: Parasternal long axis view; PSAX: Parasternal short axis view; A4C: Apical 4 chambers view; A5C: Apical 5 chambers view; A2C: Apical 2 chambers view; LV: Left ventricle; BSA: Body surface area; EF: Ejection fraction; RVOT: Right ventricle outflow tract; RV: Right ventricle; FAC: Fractional area charge; LAVI: Left atrium ventricle index; LA: Left atrium; IVS: Inter ventricular septum; PW: Power doppler wave; CW: Continuous doppler wave; RA: Right atrium; STJ: Sinotubular junction; OCA: Origin of coronary arteries; PDA: Patent ductus arteriosus; COA: Aortic coarctation; ASD: Atria septum defect; VSD: Ventricular septal defect; RVD: Right ventricle diameter; TAPSE: Tricuspid annular plane excursion.

Table 5 Main echo findings of cardiovascular pathologies in athletes

Pathology	What to assess? (echo view)	Cut-off mm (mean mm)	If pathological, what to assess? (echo view)	Cut-off mm (mean mm)
HCM	LV Max end-diastolic wall thickness	M white 15 (10); M Afro-American 16 (11.5); F white 11; F Afro-American 13 (9.5); M/F adolescent 16 (12)	LV wall thickness distribution	Asymmetric (HCM)
			LV end diastolic diameter (A4C)	M 70 (55); F 66 (49); Adolescent 60 (51)
			LV mass/BSA	M 117 mm/m2 (83 mm/m2); F 143 mm/m2 (101 mm/m2)
			LVOT obstruction
			E/A (A4C)	1.3 (1.93)
DCM	LV end diastolic diameter (PLAX)	M 70 (50); F 66 (49); Adolescent 60 (51)	EF (A4C)	55% (64%)
LVNC	LV trabeculation	NC/C layer ratio > 2.0 in systole	EF (A4C)	55% (64%)
			Thickness of compact layer in systole	8
			E/A (A4C)	1.3 (1.93)
ARVC	RVOT/BSA (PSAX)	> 21 mm/m2	RV inflow (A4C)/ LV end diastolic diameter (PLAX)	> 0.9
	RVOVT/BSA (PLAX)	> 19 mm/m2	RV wall motion abnormalities
			RV FAC	33%
Aortic dilatation	Aortic valve max dimension (PLAX)	M 40 (32); F 34 (28)	Other congenital defects (BAV)
	Ascending aorta dimension (PLAX)		Aortic regurgitation
Mitral prolapse	Mitral prolapse (PLAX)	Abnormal systolic bulging of leaflets > 2 mm toward LA	Mitral regurgitation
			PAPS (A4C)	40 mmHg (24 mmHg)
			Pulmonary veins flow	Reverse
			EF (A4C)	55% (64%)
			LV mass/BSA	M 117 mm/m2 (83 mm/m2); F 143 mm/m2 (101 mm/m2)
			LAVI	M 36 mm/m2 (28 mm/m2); F 33 mm/m2 (26.5 mm/m2)
AOCA	Coronary arteries origin (PSAX)
BAV	Aortic morphology (PSAX)		Aortic stenosis
			Aortic regurgitation
			Aortic root max dimension (PLAX)	M 40 (32); F 34 (28)
			Other congenital defects (coarctation of the aorta, interrupted aortic arch, patent ductus arteriosus, coronary anomaly or hypoplastic left heart, as well as Williams or Turner syndrome)
ASD	ASD		RV dimension (A4C)	Basal RV: M 55 (43.5), F 49 (39); Medial RV: M 47 (34), F 43 (32); Longitudinal RV: M 109 (89), F 100 (82)
			RA area/BSA (A4C)	M 28 mm/m2 (19.5 mm/m2); F 24 mm/m2 (15.5 mm/m2)
			PAPS (A4C)	40 mmHg (24 mmHg)
VSD	VSD		LV mass/BSA (PLAX)	M 117 mm/m2 (83 mm/m2); F 143 mm/m2 (101 mm/m2)
			PAPS (A4C)	40 mmHg (24 mmHg)
			Aortic regurgitation
			Other congenital defects (aneurysm of Valsalva sinus, ToF, TGA, DCRV)
PDA	PDA (PSAX)		LA/Aortic root ratio	≥ 1.4
			LV mass/BSA (PLAX)	M 117 mm/m2 (83 mm/m2); F 143 mm/m2 (101 mm/m2)
			PAPS (A4C)	40 mmHg (24 mmHg)
			Pulmonary artery size (PSAX)
			RV dimension (A4C)	Basal RV: M 55 (43.5), F 49 (39); Medial RV: M 47 (34), F 43 (32); Longitudinal RV: M 109 (89), F 100 (82)
			RA area/BSA (A4C)	M 28 mm/m2 (19.5 mm/m2); F 24 mm/m2 (15.5 mm/m2)
			Other congenital defects (COA, pulmonary atresia)
COA	COA (PSAX)		Aortic stenosis
			Mitral stenosis
			LV mass/BSA (PSAX)	M 117 mm/m2 (83 mm/m2); F 143 mm/m2 (101 mm/m2)
			EF (A4C)	55% (64%)
			Other congenital defects (BAV, ascending aortic aneurysm)
Myocarditis	EF (A4C)	55% (64%)
	LV wall motion abnormalities
	Pericardial effusion
	Increased LV wall thickness
Pericarditis	Pericardial effusion
Kawasaki disease	Coronary artery abnormalities
	EF (A4C)	55% (64%)
	LV wall motion abnormalities
	Mitral regurgitation
	Aortic regurgitation
	Pericardial effusion

PLAX: Parasternal long axis view; PSAX: Parasternal short axis view; A4C: Apical 4 chambers view; HCM: Hypertrophic cardiomyopathy; DCM: Dilated cardiomyopathy; LVNC: Left ventricle non compaction; ARVC: Arrhythmogenic right ventricular cardiomyopathy; BAV: Bicuspid aortic valve; AOCA: Anomalous origin of coronary arteries; ASD: Atrial septum defects; VSD: Ventricular septal defects; PDA: Patent ductus arteriosus; CoA: Aortic coarctation; M: Male; F: Female; LV: Left ventricle; BSA: Body surface area; EF: Ejection fraction; LVOT: Left ventricle outflow tract; NC/C: Non-compact/compact; RVOT: Right ventricle outflow tract; RV: Right ventricle; FAC: Fractional area charge; PAPS: Pulmonary artery systolic pressure; LAVI: Left atrium ventricle index; RA: Right atrium; ToF: Tetralogy of fallot; TgA: Transposition of great arteries; DCRV: Double-chambered right ventricle.

Table 6 Differential diagnosis between hypertrophic cardiomyopathy and athlete’s heart, in the grey-zone (adapted from[42])

HCM	Findings	Athlete’s heart
Normal, reduced	LV cavity size	Enlarged, eccentric pattern
Asymmetric and heterogeneous	LV hypertrophy	Symmetric and homogeneous
Present	LVOT obstruction	Absent
Abnormal	LV diastolic function	Normal
Unchanged	LV wall thickness after detraining	Reduced

HCM: Hypertrophic cardiomyopathy; LV: Left ventricle; LVOT: Left ventricle outflow tract.

Table 7 Differential diagnosis between dilated cardiomyopathy and athlete’s heart (adapted from[42])

DCM	Findings	Athlete’s heart
> 60 mm	LV end diastolic diameter	< 60 mm
Reduced	EF	Normal
Abnormal	Diastolic function	Normal

DCM: Dilated cardiomyopathy; LV: Left ventricle; EF: Ejection fraction.

Table 8 Differential diagnosis between left ventricle non compaction and athlete’s heart, in the grey zone (adapted from[42])

LVNC	Findings	Athlete’s heart
Reduced	LV systolic function	Normal
Reduced	Thickness of compact layer	Normal
Abnormal	Diastolic function	Normal

LVNC: Left ventricle non compaction; LV: Left ventricle.

Table 9 Differential diagnosis between arrhythmogenic right ventricular cardiomyopathy and athlete’s heart, in the grey-zone (adapted from[42])

ARVC	Findings	Athlete’s heart
Exceeding major criteria for ARVC	RV size	Not exceeding major criteria for ARVC
Abnormal	Regional RV wall motion	Normal
Abnormal	Global RV function	Normal

ARVC: Arrhythmogenic right ventricular cardiomyopathy; RV: Right ventricle.

Table 10 Echocardiographic criteria for the definition of severe valve regurgitation (adapted from[165])

	AVR	MVR	TVR
Vena contracta width (mm)	> 6	≥ 7	≥ 7
Other	Pressure half-time < 200 ms	TVI mitral/TVI aortic > 1.4	PISA radius > 9 mm
EROA (mm2)	≥ 30	≥ 40	≥ 40
Regurgitant volume (mL/beat)	≥ 60	≥ 60	≥ 45

AVR: Aortic valve regurgitation; EROA: Effective regurgitant orifice area; MVR: Mitral valve regurgitation; PISA: Proximal isovelocity surface area; TVR: Tricuspid valve regurgitation; TVI: Time velocity integral.

Table 11 Echocardiographic parameters indicative of the degree of severity of different valve stenosis (adapted from[111,165])

	AVS			MVS			TVS	PVS
	Low	Moderate	Severe	Low	Moderate	Severe	Clinically significant	Low	Moderate	Severe
V max (m/s)	2.6-2.9	3.0-3.4	≥ 4.0					< 3	3-4	≥ 4
DP mean (mmHg)	< 30	30-40	≥ 40	< 5	5-10	> 10	> 5	< 30	30-50	> 50
Valve orifice area (cm2)	> 1.5	1.0-1.5	< 1.0	> 1.5	1.0-1.5	< 1.0

AVS: Aortic valve stenosis; MVS: Mitral valve stenosis; TVS: Tricuspid valve stenosis; PVS: Pulmonary valve stenosis; PAP: Pulmonary artery pressure.