ABSTRACT
Introduction: The cardiovascular effects of COVID-19 in elite athletes is still a matter of intense scientific debate. Hypothesis: We sought to perform a comprehensive echocardiographic characterization of postCOVID athletes by comparing them to a non-COVID athlete cohort. Methods: 107 elite athletes with COVID-19 were prospectively enrolled (P-CA;23±6 years, 23% female) 107 healthy athletes were selected as a control group using propensity score matching (NCA). All athletes underwent 2D and 3D echocardiography. Left (LV) and right ventricular (RV) enddiastolic volumes (EDVi) and ejection fractions (EF) were quantified. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall versus septal longitudinal strain (FWLS/SLS) were also measured. To describe septal flattening (SF-frequently seen in PCA), LV eccentricity index (EI) was calculated.Results: P-CA and N-CA athletes had comparable LV and RVEDVi (P-CA vs N-CA;77±12 vs. 78±13mL/m2;79±16 vs 80±14mL/m2). P-CA had significantly higher LVEF (58±4 vs 56±4%, p<0.001), while LVGLS values did not differ between P-CA and N-CA (-19.0±1.9 vs -18.8±2.2%). EI was significantly higher in P-CA (1.13±0.16 vs 1.01±0.05, p<0.001), which was attributable to a distinct subgroup of P-CA with a prominent SF (n=35, 33%), further provoked by inspiration. In this subgroup, the EI was markedly higher compared to the rest of the P-CA (1.29±0.15 vs 1.04±0.08, p<0.001), LVEDVi was also significantly higher (80±14 vs 75±11 mL/m2, p<0.001), while RVEDVi did not differ (82±16 vs 78±15mL/m2). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (91.7±8.6 vs 97.3±8.2, p<0.01). P-CA with SF experienced symptoms less frequently (1.4±1.3 vs. 2.1±1.5 symptom during the infection, p=0.01). Conclusions: COVID-19 infection might be frequently associated with a constriction-like physiology in elite athletes.
ABSTRACT
The COVID-19 pandemic had a major impact on the sports community as well. Despite the vast majority of athletes experiencing mild symptoms, potential cardiac involvement and complications have to be explored to support a safe return to play. Accordingly, we were aimed at a comprehensive echocardiographic characterization of post-COVID athletes (P-CA) by comparing them to a propensity-matched healthy, non-COVID athlete (NCA) cohort. One hundred and seven elite athletes with COVID-19 were prospectively enrolled after an appropriate quarantine period and formed the P-CA group (23±6 years, 23% female). From our retrospective database comprising 425 elite athletes, 107 age-, gender-, body surface area-, and weekly training hours-matched subjects were selected as a reference group using propensity score matching (N-CA group). All athletes underwent a comprehensive clinical investigation protocol comprising 2D and 3D echocardiography. Left (LV) and right ventricular (RV) end-diastolic volumes (EDVi) and ejection fractions (EF) were quantified using dedicated softwares. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall versus septal longitudinal strain (FWLS/SLS) were also calculated. In order to describe septal flattening (SF-frequently seen in P-CA), LV eccentricity index (EI) was measured. P-CA and N-CA athletes had comparable LV and RV EDVi (P-CA vs NCA;77±12 vs 78±13mL/m2;79±16 vs 80±14mL/m2, respectively). P-CA group had significantly higher LV EF (58±4 vs 56±4%, p<0.001) and GLS (-18.2±1.8 vs -17.6±2.2%, p<0.05). Eccentricity index was significantly lower in P-CA (0.89±0.10 vs 0.99±0.04, p<0.001), which was attributable to a distinct subgroup of P-CA athletes with a prominent SF (n=34, 32%), further provoked by inspiration. In this subgroup, the eccentricity index was markedly lower compared to the rest of the P-CA group (0.79±0.07 vs 0.95±0.07, p<0.001). In the SF subgroup, LV EDVi was significantly higher (80±14 vs 75±11 mL/m2, p<0.001), while RV EDVi did not differ (82±16 vs 78±15mL/m2). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (0.92±0.09 vs 0.97±0.08, p<0.01). Interestingly, P-CA athletes with SF experienced fatigue (17 vs 34%, p<0.05) or chest pain (0 vs 15%, p=) less frequently during the course of the infection;however, the presence of a mild pericardial effusion was more common (41 vs 12%, p<0.01). Elite athletes following COVID-19 showed distinct morphological and functional cardiac changes compared to a propensity score-matched control athlete group. These results are mainly driven by a subgroup, which presented with some echocardiographic features characteristic of constrictive pericarditis (septal flattening, lower FWLS/SLS ratio, pericardial effusion). Follow-up of athletes and further, higher case number studies are warranted to determine the clinical significance and potential effects on exercise capacity of these findings.
ABSTRACT
During the pandemic, several studies were carried out on the short-term effects of acute SARS-CoV-2 infection in athletes. As some cases of young athletes with serious complications like myocarditis or thromboembolism and even sudden death were reported, strict recommendations for return to sport were published. However, we have less data about athletes who have already returned to high-intensity trainings after a SARS-CoV-2 infection. Athletes underwent cardiology screening (personal history, physical examination, 12-lead resting ECG, laboratory tests with necroenzyme levels and echocardiography) 2 to 3 weeks after suffering a SARS-CoV-2 infection. In case of negative results, they were advised to start low intensity trainings and increase training intensity regularly until achieving maximal intensity a minimum of 3 weeks later. A second step of cardiology screening was also carried out after returning to maximal intensity trainings. The above mentioned screening protocol was repeated and was completed with vita maxima cardiopulmonary exercise testing (CPET) on running treadmill. If the previous examinations indicated, 24h Holter ECG recording, 24h ambulatory blood pressure monitoring or cardiac MR imaging were also carried out. Data are presented as mean±SD. Two-step screening after SARS-CoV-2 infection was carried out in 111 athletes (male:74, age:22.4±7.4y, elite athlete:90%, training hours:14.8±5.8 h/w, ice hockey players:31.5%, water polo players:22.5%, wrestlers:18.9%, basketball players:18.0%). Second screenings were carried out 94.5±31.5 days after the first symptoms of the infection. A 5% of the athletes was still complaining of tiredness and decreased exercise capacity. Resting heart rate was 70.3±13.0 b.p.m., During CPET examinations, athletes achieved a maximal heart rate of 187.3±11.6 b.p.m., maximal relative aerobic capacity of 49.2±5.5 ml/kg/min, and maximal ventilation of 138.6±31.2 l/min. The athletes reached their anaerobic threshold at 87.8±6.3% of their maximal aerobic capacity, with a heart rate of 93.3±3.7% of their maximal values. Heart rate recovery was 29.9±9.2/min. During the CPET examinations, short supraventricular runs, repetititve ventricular premature beats + ventricular quadrigeminy and inferior ST depression were found in 1-1 cases. Slightly higher pulmonary pressure was measured on the echocardiography in 4 cases. Hypertension requiring drug treatment was found in 5.4% of the cases. Laboratory examinations revealed decreased vitamin D3 levels in 26 cases, decreased iron storage levels in 18 athletes. No SARS-CoV-2 infection related CMR changes were revealed in our athlete population. Three months after SARS-CoV-2 infection, most of the athletes examined had satisfactory fitness levels. However, some cases of decreased exercise capacity, decreased vitamin D3 or iron storage levels, arrhythmias, hypertension and elevated pulmonary pressure requiring further examinations, treatment or follow-up were revealed.