Letter by Heidbuchel et al Regarding Article, "Right and Left Ventricular Function and Mass in Male Elite Master Athletes: A Controlled Contrast-Enhanced Cardiovascular Magnetic Resonance Study".

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HomeCirculationVol. 134, No. 16Letter by Heidbuchel et al Regarding Article, “Right and Left Ventricular Function and Mass in Male Elite Master Athletes: A Controlled Contrast-Enhanced Cardiovascular Magnetic Resonance Study” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Heidbuchel et al Regarding Article, “Right and Left Ventricular Function and Mass in Male Elite Master Athletes: A Controlled Contrast-Enhanced Cardiovascular Magnetic Resonance Study” Hein Heidbuchel, MD, PhD, Guido Claessen, MD, PhD and Andre La Gerche, MD, PhD Hein HeidbuchelHein Heidbuchel From University Hospital and University of Antwerp, Antwerp, Belgium (H.H.); Department of Cardiovascular Sciences and University Hospital, University of Leuven, Leuven, Belgium (G.C.); and Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.). Search for more papers by this author , Guido ClaessenGuido Claessen From University Hospital and University of Antwerp, Antwerp, Belgium (H.H.); Department of Cardiovascular Sciences and University Hospital, University of Leuven, Leuven, Belgium (G.C.); and Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.). Search for more papers by this author and Andre La GercheAndre La Gerche From University Hospital and University of Antwerp, Antwerp, Belgium (H.H.); Department of Cardiovascular Sciences and University Hospital, University of Leuven, Leuven, Belgium (G.C.); and Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.). Search for more papers by this author Originally published18 Oct 2016https://doi.org/10.1161/CIRCULATIONAHA.116.024071Circulation. 2016;134:e360–e361To the Editor:We were delighted to read the article by Bohm et al1 addressing the potential deleterious impact of exercise on right ventricular (RV) function. This field definitely needs further study. The work was carried out by a renowned group. However, we were surprised by their conclusion “that the hypothesis of an exercise-induced ARVC needs to be questioned,”1 not only because the small study is underpowered but mainly because the conclusion is not supported by the findings.The authors summed up 4 criteria by which to test the hypothesis. The first concerned the ratio of left ventricular end-diastolic volume/right ventricular end-diastolic volume (LVEDV/RVEDV). This test is indirect at best, only indicating that the athletes were indeed athletes. Prior studies have shown that endurance exercise disproportionately increases RVEDV, as confirmed by Bohm et al (although there appears to be some discrepancy between Figure 2 showing an LVEDV/RVEDV ratio <1 and the text reporting mean left ventricular end-diastolic volume of 139±42 mL and RVEDV of 133±37 mL). If anything, this (indirect) test confirmed the hypothesis.The second evaluation criterion was resting RV ejection fraction (RVEF). However, athletes with exercise-induced RV damage often have only minor RV dysfunction at rest, whereas RV function during exercise (measured by cardiac magnetic resonance imaging or echocardiography) has much better discriminatory potential.2–4 Surprisingly, no exercise evaluation was done. Nonetheless, 5 athletes (15%) had a resting RVEF<45%, and the mean RVEF was much lower than in a previous athletic cohort cardiac magnetic resonance imaging description by the same group (52±8% vs. 63±3%).1,5 If anything, the data confirm the hypothesis. The third criterion concerned delayed gadolinium enhancement, again an inaccurate test for the hypothesis: Few athletes with exercise-induced arrhythmogenic right ventricular cardiomyopathy have delayed gadolinium enhancement. Conversely, delayed gadolinium enhancement presence in other athlete studies was rarely associated with signs of RV dysfunction or damage.2 Also the fourth criterion, assessing N-terminal pro-brain natriuretic peptide (NT-proBNP) and hsTroponin at rest, is not a valid test. It is surprising that the authors did not take the effort to retest the biomarkers after the exercise test, which would have allowed pairwise comparisons and their interpretation in the light of other findings (eg, RVEF). We have shown before that biomarker increase immediately after an endurance race is related to the degree of transient RV dilatation and decrease of RVEF.2Therefore, we agree with Wasfy and Baggish, the editorialists, that this study does not refute prior findings (also from animal work) suggestive of a relationship between endurance exercise and RV damage. We can wonder what this study adds beyond the confirmation of decreased LVEDV/RVEDV ratio in most elite athletes and a borderline low RVEF at rest in a sizable subgroup (15%), both confirming the fact that the RV seems most susceptible to the hemodynamic load of endurance exercise. We started an international prospective large-scale athlete study, [email protected], exactly as suggested by both the authors and editorialists (please see www.proatheart.org). [email protected] will prospectively evaluate the extent and incidence of exercise-induced RV remodeling. We invite all those interested to participate in this study, which may provide more definitive answers and, hence, resolve this intriguing sports cardiology enigma.Hein Heidbuchel, MD, PhDGuido Claessen, MD, PhDAndre La Gerche, MD, PhDDisclosuresNone.FootnotesCirculation is available at http://circ.ahajournals.org.