ΟΜΑΔΑ ΕΡΓΑΣΙΑΣ ΑΠΕΙΚΟΝΙΣΤΙΚΩΝ ΤΕΧΝΙΚΩΝ, ΜΑΓΝΗΤΙΚΟΥ ΣΥΝΤΟΝΙΣΜΟΥ, ΠΥΡΗΝΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ ΚΑΙ ΑΞΟΝΙΚΗΣ ΤΟΜΟΓΡΑΦΙΑΣ ΚΑΡΔΙΑΣ

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1 ΟΜΑΔΑ ΕΡΓΑΣΙΑΣ ΑΠΕΙΚΟΝΙΣΤΙΚΩΝ ΤΕΧΝΙΚΩΝ, ΜΑΓΝΗΤΙΚΟΥ ΣΥΝΤΟΝΙΣΜΟΥ, ΠΥΡΗΝΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ ΚΑΙ ΑΞΟΝΙΚΗΣ ΤΟΜΟΓΡΑΦΙΑΣ ΚΑΡΔΙΑΣ Β Στρογγυλό Τραπέζι Οι απεικονιστικές τεχνικές στη διερεύνηση κλινικών σεναρίων Aθλητής με εκτακτοσυστολική κοιλιακή αρρυθμία ΚΩΝΣΤΑΝΤΙΝΟΣ ΤΣΟΒΟΛΑΣ ΚΑΡΔΙΟΛΟΓΟΣ

2 ΧΟΡΗΓΙΑ BAYER - ELPEN

3 The benefits of exercise Sanjay Sharma et al. Eur Heart J 2015

4 Changes in cardiovascular risk factors in response to marathon training. Jodi L. Zilinski et al. Circ Cardiovasc Imaging 2015

5 ΑΘΛΗΤΙΚΗ ΚΑΡΔΙΑ 1890 Henschen Nordik skiers 1890 Darling Harvard University rowers 1900 Dudley White Boston Marathon runners Δομικές αλλαγές: συχνή άσκηση >3 ώρες/εβδομάδα ~ 50% αθλητών Διάταση καρδιακών κοιλοτήτων Υπερτροφία τοιχωμάτων Βραδυκαρδία Προσαρμογή ΟΧΙ πάθηση

6 Cardiovascular and peripheral adaptation to exercise in athletes. Sanjay Sharma et al. Eur Heart J 2015

7 Incidence and relative risk (RR) of sudden death (SD) among athletes (solid columns) and non-athletes (open columns) from cardiovascular and non-cardiovascular causes. Domenico Corrado, Cristina Basso, Giulio Rizzoli, Maurizio Schiavon, Gaetano Thiene Does sports activity enhance the risk of sudden death in adolescents and young adults? JACC 2003

8 Annual incidence of SCD in young athletes (<35 years) : 0.7 to 3.0 / athletes Harmon KG, Drezner JA, Wilson MG, Sharma S. Heart 2014 In older athletes the incidence is higher Schmied C et al Sudden cardiac death in athletes. J Intern Med 2014

9 ΔΟΜΙΚΕΣ ΔΙΑΤΑΡΑΧΕΣ ΗΛΕΚΤΡΙΚΕΣ ΔΙΑΤΑΡΑΧΕΣ ΤΟΞΙΚΑ Πρώιμη στεφανιαία νόσος σ. μακρού QT διαστήματος Κοκαϊνη, αμφεταμίνες, αλκοόλ Υπερτροφική μυοκαρδιοπάθεια (1:500) σ. Brugada Φάρμακα QT (μακρολίδες / συγχορήγηση ) Διατατική μυοκαρδιοπάθεια (1:2500) Αρρυθμιογόνος μυοκαρδιοπάθεια/δυσπλασία της δεξιάς κοιλίας (1:2000) Ανώμαλη έκφυση στεφανιαίων αγγείων Κατεχολαμινεργική πολύμορφη ΚΤ σ. στενού QT διαστήματος σ. Wolff Parkinson White Οξεία μυοκαρδίτιδα Παθήσεις ερεθισματαγωγού συστήματος Συγγενείς καρδιοπάθειες / στένωση αορτικής βαλβίδας / παθήσεις αορτής

10 Differentiating features between physiological cardiac changes and cardiomyopathy in athletes. Sanjay Sharma et al. Eur Heart J 2015

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13 The definition of an abnormal ECG using the (A) refined criteria, (B) European Society of Cardiology (ESC) recommendations and (C) Seattle criteria Nabeel Sheikh et al. Circulation 2014

14 Flow diagram illustrating the proposed screening protocol for young competitive athletes. Corrado D et al. Eur Heart J 2005

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16 The results of CV evaluation in Olympic athletes. Antonio Pelliccia et al. Br J Sports Med 2017

17 American Journal of Cardiology 2013

18 Premature ventricular contractions (PVCs) - General population - 27% of healthy individuals during exercise testing Their prevalence increases with age and with the presence and severity of heart disease. Exercise-induced and recovery-phase premature ventricular contractions or nonsustained ventricular tachycardia are associated with increased mortality, probably because they are markers for underlying heart disease. Very frequent premature ventricular contractions > 24% of total heart beats / 24 h or incessant repetitive monomorphic ventricular tachycardia occasionally causes depressed ventricular function. Roy M John et al. Lancet 2012

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21 ΑΘΛΗΤΕΣ Καλοήθης ηλεκτροανατομική αναδιαμόρφωση λόγω συστηματικής άθλησης/προπόνησης Ανομοιογενής επαναπόλωση μυοκαρδίου Αυξημένη επίπτωση κοιλιακών αρρυθμιών

22 The definition of an abnormal ECG using the (A) refined criteria, (B) European Society of Cardiology (ESC) recommendations and (C) Seattle criteria Nabeel Sheikh et al. Circulation 2014

23 2 premature ventricular contractions When two PVCs are recorded on a baseline (10 s) ECG, the likelihood is very high that the athlete has >2000 PVCs per 24 h. In athletes with >2000 PVCs per 24 h, underlying structural heart disease which may predispose to more lifethreatening ventricular arrhythmias was found in 30% of cases, compared to only 3% of athletes with PVCs, and 0% of athletes with <100 PVCs on a 24 h Holter. Over half of the athletes with >2000 PVCs also had bursts of non- sustained ventricular tachycardia. Therefore, a structural cardiac abnormality should be ruled out in athletes with >2000 PVCs per 24 h. Documentation of 2 PVCs on baseline ECG should prompt more extensive evaluation to exclude underlying cardiac disease - If the Holter and echocardiogram are normal and the PVCs suppress with exercise, some experts recommend no further evaluation for an asymptomatic athlete. - In cases with >2000 PVCs per 24 h or episodes of non-sustained ventricular tachycardia, and depending on the level of clinical concern, morphology of the PVCs and type of sport, additional evaluation may also include cardiac MRI and more extensive electrophysiological (EP) evaluation with signal averaged ECG, long-term ECG recording, invasive EP study and/or cardiac biopsy. Considerations in high-level endurance athletes with PVCs In high-level adult endurance athletes (such as cyclists, triathlon athletes, marathon runners and rowers), concern has been raised about right ventricular changes that may resemble familial arrhythmogenic right ventricular cardiomyopathy (ARVC), but in the absence of demonstrable desmosomal mutations or a familial history. - exercise-induced ARVC

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27 The discovery of frequent VPCs in otherwise healthy subjects raises many questions: The first is whether common noninvasive examinations (resting and exercise ECG and echocardiography) are sufficient to exclude a heart disease whether, in the apparent absence of a heart disease, VPCs may be an early manifestation of a concealed evolving heart disease whether continuing sports activity can influence the number and complexity of VPCs, thereby increasing the risk of major ventricular arrhythmias

28 Proposed EACVI algorithm for differential diagnosis between athlete's heart and HCM or IDCM. Maurizio Galderisi et al. Eur Heart J Cardiovasc Imaging 2015

29 Proposed EACVI algorithm for differential diagnosis between athlete's heart and ARVC and diagnosis of CAD in athletes. Maurizio Galderisi et al. Eur Heart J Cardiovasc Imaging 2015

30 CMR - μη διαγνωστικές ηχοκαρδιογραφικές εικόνες, κακή τεχνική λήψη - grey zone LVH - εντοπισμένη LVH μη ευκρινής από υπέρηχο (κορυφή) - δεξιά κοιλία - μελέτη των μακροχρόνιων επιπτώσεων της άσκησης στην καρδιά

31 CMR 3D imaging high spatial and temporal resolution image the heart in any plane without ionizing radiation sharp contrast between the interface of darkened myocardium and bright blood pool truly tomographic imaging by acquiring a stack of short-axis images with full ventricular coverage European Heart Journal Cardiovascular Imaging 2015

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33 HCM

34 CMR for HCM diagnosis and phenotypic characterization with management implications. Martin S. Maron, and Barry J. Maron Circulation 2015

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36 DCM

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40 J Cardiovasc Magn Reson 2008

41 Prevalence of Arrhythmias on 24-h Holter ECG With Respect to DE in 177 HCM Patients A. Selcuk Adabag, Barry J. Maron, Evan Appelbaum, Caitlin J. Harrigan, Jacqueline L. Buros, C. Michael Gibson, John R. Lesser, Constance A. Hanna, James E. Udelson, Warren J. Manning, Martin S. Maron Occurrence and Frequency of Arrhythmias in Hypertrophic Cardiomyopathy in Relation to Delayed Enhancement on Cardiovascular Magnetic Resonance Journal of the American College of Cardiology 2008

42 29 studies - 2,948 patients Andrea Di Marco et al. JCHF 2017

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46 42-y-old martial art player presenting with frequent and coupled premature ventricular beats with right bundle branch block/superior axis morphology during exercise testing Alessandro Zorzi et al. Circ Arrhythm Electrophysiol. 2016;9:e004229

47 A 23-y-old soccer player who suffered syncope during a match. Alessandro Zorzi et al. Circ Arrhythm Electrophysiol. 2016

48 A 18-y-old tennis player who underwent contrast-enhancement cardiac magnetic resonance for inferolateral T-wave inversion at baseline 12-lead ECG (A) and frequent ventricular ectopic beats with a right bundle branch block/superior axis at exercise testing (B). Alessandro Zorzi et al. Circ Arrhythm Electrophysiol. 2016

49 A, Kaplan Meier analysis for survival from major arrhythmic events (sudden death, cardiac arrest because of ventricular fibrillation, sustained ventricular tachycardia, or appropriate implantable cardiac defibrillator shock) in athletes with ventricular arrhythmias and late gadolinium enhancement (LGE), in athletes with ventricular arrhythmias and no LGE, and in controls (with or without spotty LGE). Alessandro Zorzi et al. Circ Arrhythm Electrophysiol. 2016

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51 European Cardiology Review 2016

52 MV PROLAPSE

53 Proposed EACVI algorithm for differential diagnosis between athlete's heart and ARVC and diagnosis of CAD in athletes. Maurizio Galderisi et al. Eur Heart J Cardiovasc Imaging 2015

54 Patient with normal coronary morphology, as visualized by 64-slice MDCT. (A) Axial CT image was obtained at level of left main (LM) coronary artery ostium, which arises from left sinus of Valsalva and runs posterior to pulmonary artery (PA). Udo Hoffmann et al. J Nucl Med 2006

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57 myocardial bridging 15 to 85% at autopsy and % at coronary angiography ruling out significant CAD a very low radiation dose by using latest generations scanners Subclinical cases detected with calcium scanning 108 marathon runners with higher calcium scores compared with age- and risk-factor-matched controls.

58 Coronary Atherosclerosis Imaging by Coronary CT Angiography : Current Status, Correlation With Intravascular Interrogation and Meta-Analysis JACC: Cardiovascular Imaging, 2011

59 Current ESC guidelines recommend stress CMR alongside other tests as a gate keeper to invasive angiography in patients with suspected CAD and intermediate pre-test probability.

60 5% - 10% of cases SCD occurs in the absence of CHD or cardiomyopathy long QT syndrome (LQTS) short QT syndrome (SQTS) Brugada syndrome catecholaminergic VT

61 Isolated premature ventricular contractions PVCs may reflect pathological myocardial irritability due to a cardiomyopathy, an underlying systemic disease process, or may be a completely benign normal variant. PVCs are common in athletes with high vagal tone and resting bradycardia and may increase in frequency in parallel with physical fitness. A single PVC captured during a routine 12-lead ECG in an asymptomatic athlete does not require further evaluation, unless the athlete performs a high-intensity endurance sport (mainly cycling, triathlon, rowing or swimming). In this select group of high-intensity endurance athletes, a single PVC, especially if it has an LBBB morphology, may be a hallmark of exercise-induced ARVC, and further evaluation should be considered. The presence of PVCs in an athlete with cardiovascular symptoms or a family history of sudden death or suspected cardiomyopathy should prompt further evaluation. Multiple PVCs (2 or more) during a single ECG tracing (10s), multifocal PVCs or PVCs found in tandem with other abnormal ECG findings should be further evaluated. Drezner JA et al Br J Sports Med 2013 Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy

62 BC#36 ESC Gene carriers without phenotype (HCM, ARVC, DCM, ion channel diseases) All sports Only recreational sports LQTS >0.47 s in male subjects, >0.48 s in female subjects >0.44 s in male subjects, >0.46 s in female subjects Low-intensity competitive sports Only recreational sports Marfan syndrome If aortic root <40 mm, no MR, no familial SD, then low-moderate intensity competitive sports permitted Only recreational sports Asymptomatic WPW EPS not mandatory EPS mandatory All competitive sports (restriction for sports in dangerous environment) All competitive sports (restriction for sports in dangerous environment) Premature ventricular complexes All competitive sports, when no increase in PVCs or symptoms occur with exercise All competitive sports, when no increase in PVCs, couplets, or symptoms occur with exercise Nonsustained ventricular tachycardia If no CV disease, all competitive sports If CV disease, only low-intensity competitive sports If no CV disease, all competitive sports If CV disease, only recreational sports Antonio Pelliccia J Am Coll Cardiol 2008

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64 ΜΑΓΝΗΤΙΚΟΥ ΣΥΝΤΟΝΙΣΜΟΥ ΠΥΡΗΝΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ ΑΞΟΝΙΚΗΣ ΤΟΜΟΓΡΑΦΙΑΣ ΚΑΡΔΙΑΣ ΟΜΑΔΑ ΕΡΓΑΣΙΑΣ ΑΠΕΙΚΟΝΙΣΤΙΚΩΝ ΤΕΧΝΙΚΩΝ