Cardiac magnetic resonance based deformation imaging: role of feature tracking in athletes with suspected arrhythmogenic right ventricular cardiomyopathy

Csilla Czimbalmos,Ferenc Imre Suhai,Andreas Müssigbrodt,Bela Merkely,Ibolya Csecs,Hajnalka Vago,Orsolya Kiss,Laszlo Geller,Zsofia Dohy,Attila Toth

doi:10.1007/s10554-018-1478-y

Abstract

Both, arrhythmogenic right ventricular cardiomyopathy (ARVC) and regular training are associated with right ventricular (RV) remodelling. Cardiac magnetic resonance (CMR) is given an important role in the diagnosis of ARVC in current task force criteria (TFC), however, they contain no cut-off values for athletes. We aimed to confirm the added value of feature tracking and to provide new cut-off values to differentiate between ARVC and athlete’s heart. Healthy athletes with training of minimal 15 h/week (n = 34), patients with definite ARVC (n = 34) and highly trained athletes with ARVC (n = 8) were examined by CMR. Left and right ventricular volumes and masses were determined. Global right and left ventricular, and regional strain analysis for the RV free wall was performed using feature tracking on balanced steady-state free precession cine images. 94% of healthy athletes showed RV dilatation of the proposed TFC, 14.7% showed RV ejection fraction (RVEF) between 45–50%, none of them had RVEF < 45%. Although RVEF showed the highest accuracy in differentiating between athlete’s heart and ARVC, only 37.5% of athletes with ARVC showed RVEF < 45%. The only parameters falling in the pathological range (based on our established cut-off values: > − 25.6 and > − 1.4, respectively) in all athletes with ARVC were the strain and strain rate of the midventricular RV free wall. Establishing RVEF and RV strain analysis provides an important tool to distinguish ARVC from athlete’s heart. CMR based regional strain and strain rate values may help to identify ARVC even in highly trained athletes with preserved RVEF.

Highlights

Prolonged endurance exercise may lead to pronounced morphological changes of the right ventricle [1]
Certain exercise induced alterations seem to be a benign consequence of athletic performance, occasionally observed overlap between arrhythmogenic right ventricular cardiomyopathy (ARVC) and physiological right ventricular adaptation may lead to clinical challenges
We investigated whether establishing gender-specific cut-off values may influence the diagnostic accuracy, but comparing male and female receiver operating characteristic (ROC) curves for Cardiac magnetic resonance (CMR) parameters with the highest diagnostic accuracy (RVEF, RV mid strain, RV average strain, RV min strain) showed no significant difference

Summary

Introduction

Prolonged endurance exercise may lead to pronounced morphological changes of the right ventricle [1]. Overlapping electrical and structural features of athlete’s heart and ARVC—such as right bundle branch block, T-wave inversion in precordial leads, elevated RV enddiastolic volume (RVEDVi) or slightly decreased EF—may cause diagnostic difficulties. Current TFC require as a major criterion regional RV akinesia or dyskinesia or dyssynchronous RV contraction and RVEDVi ≥ 110 ml/m2 (male) or ≥ 100 ml/m2 (female) or RV ejection fraction ≤ 40%. Morphological features of ARVC require wall motion abnormalities and increased RV volume or decreased RV ejection fraction. As the diagnosis of wall motion abnormalities is based on individual subjective judgement and current TFC contain no athlete-specific criteria adapted for the objective parameters RVEDVi and RVEF [4], misdiagnosis of ARVC in healthy athletes may occur frequently. Improved cut-off values for CMR parameters differentiating ARVC and athlete’s heart are needed

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