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Physiologic Left Ventricular Cavity Dilatation in Elite Athletes

Antonio Pelliccia, MD; Franco Culasso, PhD; Fernando M. Di Paolo, MD; and Barry J. Maron, MD
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From the Institute of Sports Science, Italian National Olympic Committee, and University La Sapienza, Rome, Italy; and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.

Ann Intern Med. 1999;130(1):23-31. doi:10.7326/0003-4819-130-1-199901050-00005
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Background: Absolute left ventricular cavity dimension may be substantially increased in some highly trained athletes. This raises questions about the differential diagnosis between athlete's heart and dilated cardiomyopathy as well as possible disqualification from competitive sports.

Objective: To evaluate the morphologic characteristics and physiologic limits of left ventricular cavity enlargement associated with intensive, long-term athletic conditioning.

Design: Evaluation of left ventricular cavity dimension in a large sample of highly trained athletes.

Setting: Institute of Sports Science, Rome, Italy.

Participants: 1309 elite Italian athletes (957 men and 352 women), 13 to 59 years of age (mean, 24 years), participating in 38 different sports.

Measurements: Echocardiographic assessment of left ventricular cavity dimension and multivariate statistical analysis of the determinants.

Results: Left ventricular end-diastolic cavity dimensions varied widely (38 to 66 mm [mean, 48 mm] in women and 43 to 70 mm [mean, 55 mm] in men) and was within generally accepted normal limits for most participants (≤ 54 mm in 725 athletes [55%]). According to an arbitrary clinical cut-point of 60 mm, the left ventricular cavity was substantially enlarged in 185 participants (14%). These athletes had global left ventricular systolic function within normal limits and no regional wall-motion abnormalities; participants remained free of cardiac symptoms and impaired performance over 1 to 12 years (mean, 4.7 years). The major determinants of cavity dimension were greater body surface area and participation in certain endurance sports (cycling, cross-country skiing, and canoeing).

Conclusions: In a sample of highly trained athletes, left ventricular cavity dimension varied widely but was strikingly increased to a degree compatible with primary dilated cardiomyopathy in almost 15% of participants. In the absence of systolic dysfunction, this cavity dilatation is most likely an extreme physiologic adaptation to intensive athletic conditioning. The long-term consequences and significance of this marked left ventricular remodeling of the athlete's heart is not known.


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Figure 1.
Distribution of left ventricular end-diastolic cavity dimensions in 1309 highly trained athletes without evidence of structural cardiovascular disease.white barsstriped bars

Data are shown for female ( ) and male ( ) athletes. Fourteen percent of athletes had markedly enlarged left ventricular cavities ranging in size from 60 mm to 70 mm.

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Figure 2.
Relative impact values for different sports on left ventricular (LV) end-diastolic cavity dimension.

The bars show the individual sport regression coefficients and the 95% upper CIs. These impact values were calculated relative to the reference sport (table tennis; regression coefficient, −2.96), which was then set at zero. This figure included the 29 sporting disciplines represented in the study sample with more than 10 participants.

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Figure 3.
Stop-frame two-dimensional and M-mode echocardiograms.ABCLVDVSPW

The parasternal long-axis ( ) and short-axis ( ) views from a 26-year-old elite rower show global dilatation of the left ventricular cavity. The M-mode echocardiogram ( ) shows markedly increased left ventricular end-diastolic cavity dimension ( ) (68 mm), mildly thickened ventricular septum ( ) (13 mm), and normal posterior free-wall thickness ( ) (10 mm).

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