Stefano Caselli, MD, PhD

Ospedale San Pietro Fatebenefratelli

Rome, Italy

Novel echocardiographic modalities: 3D echo,

speckle tracking and strain rate imaging.

Potential roles in sports cardiology.

Athlete’s HeartDCM

HCM

Other forms of LVH

Differential diagnosis of the athlete’s heart

Up to 15% of athletes may develop left ventricular enlargement

which rises the differential diagnosis with DCM

Up to 2% of athletes show LV wall thickening which rises the

differential diagnosis with HCM

Beyond ECG and conventional Echo

Pelliccia et al NEJM 2008

Abnormal ECG

Normal ECG

McLeod et al JACC 2009

Abnormal

EKG, 94%

Normal

EKG, 6%

HCM patients

The need for new diagnostic tools!

Relative distance

Speckle Tracking Echocardiography

Strain is a measure of deformation.

Strain rate is the velocity of deformation

Strain(%), ε =(L0 – L1)

L0

Strain rate = ε / sec

Components of myocardial strain

S. Caselli, MD

Longitudinal strain: shortening (-)

Transverse strain: thickening (+)

Circumferential strain: shortening (-)

Radial strain: thickening (+)

Longitudinal Strain

Longitudinal Strain Rate

Peak S

Peak E Peak A

Myocardial Strain in Athletes

Nottin S et al J Physiol 2008

Longitudinal Strain

(Negative)

Controls

Athletes

Nottin S et al. Circ Cardiovasc Imaging 2009

Effects of EXTREME EXERCISE on

LV strain in athletes

Lo

ng

itu

din

al S

tra

in (

%)

23 triathlon athletes

participating the Ironman

competition.

STE was performed

before and soon after the

race.

All components of strain

were reduced in systole,

after the race.

Galderisi et al. J Am Soc Echocardiogr 2010

Controls Rowers Hypertension

Longitudinal -21 ± 2 -22 ± 3 -17 ± 3*

Circumferential -18 ± 3 -18 ± 2 -16 ± 4*

Radial 46 ± 16 48 ± 19 46 ± 17

Left Ventricular Strain in pathologic left

ventricular hypertrophy (LVH)

30 Hypertensive pts,

30 Power athletes

48 controlsHypertensive pts had:

Global longitudinal strain

Peak systolic strain rate

Early diastolic strain rate

Saghir M et al J Am Soc Echocardiogr 2007

Left Ventricular Strain in pathologic left

ventricular hypertrophy (LVH)

Hypertrophic Cardiomyopathy

Strain imaging in HCM

0

5

10

15

20

25

30

35

40

Transverse Radial

Serri et al. J Am Coll Cardiol 2006

Controls HCM

Longitudinal Circumferential Transverse Radial

p<0.001 p<0.001 p<0.001 p<0.001

0

2

4

6

8

10

12

14

16

18

20

Transverse Radial

29 Soccer players, 26 nHCM and 17 controls

Circumferential, transverse and radial strain significantly

reduced in HCM patients compared to athletes and controls.

Longitudinal strain reduced in hypertrophied segments.

Richand V, Am J Cardiol 2007

Strain imaging in HCM

Abozguia K et al. Am Heart J 2010

Strain rate in HCM

56 nHCM patients

All strain components

reduced compared to

controls.

All underwent

cardiopulmonary

exercise test.

Peak VO2 was reduced

in nHCM patients.

Longitudinal strain rate

correlated significantly

with peak VO2

Reduced Strain Rate predicts reduced

exercise capacity in nHCM patients.

Live 3D Echocardiography

Volumes & EF

LV Shape

LV Mass

LV regional function /

synchronicity

Quantitative Analysis

3D echo in athletes.

3D echo in athletes.

Upper limits for LV end-diastolic volume and mass

Caselli S et al. Am J Cardiol 2011 (in press)

3D echo in athletes.

LV Mass EDV ESV

Controls Skill Strength Combined Endurance

Caselli S et al. Am J Cardiol 2011 (in press)

LV Mass

End diastolic Volume=

Left Ventricular Remodelling Index

LVRI

Hypertrophic

Cardiomyopathy

Dilated

Cardiomyopathy

Competitive

Athletes

Healthy

Volunteers

De Castro S Caselli S - Heart 2007

End-Diastolic Volume

LV

Ma

ss

LVRI = 2.0

LVRI = 0.5

LV

Ma

ss

Left Ventricular Remodelling Index

Left Ventricular Remodelling Index

End-Diastolic Volume

Caselli S et al. Am J Cardiol 2011 (in press)

Patterns of LV

adaptations are similar

in all athletes,

regardless to the

specific sport discipline

Apical

Medium

Basal

SeptumAnterior

Lateral

Inferior

Myocardial Dispersion Index

68 subjects including controls,

athletes, hypertensive and

HCM.

LV was divided in a 12

segments model.

MDI was calculated as the

mean Standard Deviation at

the basal medium and apical

segments.

Caselli S et al. Am J Cardiol 2008

MDI > 1.13

Sensitivity 93%

Specificity 100%

Caselli S et al. Am J Cardiol 2008

Myocardial Dispersion Index

Left Ventricular Non Compaction

Left Ventricular Non Compaction

Left Ventricular Non Compaction

17 patients with LVNC.

Analysis of Trabecular

Volume by 3D

echocardiography.

No differences between

Athletes and controls

LVNC patients had a

4-fold increase in

Trabecular Volume.

Caselli S et al. Euroecho 2010

Beyond EKG

In the majority of cases the screening of the athletes with

EKG and conventional echocardiography allows the

correct definition of athlete’s heart and differential

diagnosis with cardiomyopathies.

There is however a smaller percentage of young athletes

who fall in the so called “grey zone”.

Speckle tracking echocardiography allows a deeper and

accurate investigation of myocardial mechanics in systole

and diastole.

3-dimensional echo allows a better description of the

anatomy and geometry of the heart chambers.

Thank you

Stefano Caselli