THE ROLE OF CARDIAC MAGNETIC RESONANCE IN COMPETITIVE ATHLETES: PROGNOSTIC VALUE OF MODERN-DAY TECHNIQUES

Background Cardiac magnetic resonance (CMR) is the primary imaging modality for the non- invasive myocardial tissue characterization, and it is considered as the gold standard technique for quantifying cardiac function, myocardial volumes, and mass. Until now, most of the CMR studies in athletes have been based principally on qualitative or semiquantitative techniques for detecting oedema and/or macroscopic fibrosis by T2-weighted or late-gadolinium enhancement (LGE) sequences. Modern-day mapping techniques, allowing for precise, quantitative, and segmental characterization of the myocardial are significantly changing the clinical management in the patients with cardiac involvement. Moreover, in recent years, the development of feature tracking analysis has allowed a better evaluation of heart function. Thus, advanced imaging techniques are aiming to close the gaps in diagnostic accuracy in trained subjects, as there are still various uncertainties in the differential diagnosis of the athlete’s heart with other cardiac diseases. To date, in our knowledge, there is no data regarding the prognostic value of CMR and, in particular, of such advanced techniques. Objectives The aim of the study is to verify the onset or progression of symptoms in competitive athletes one year after the first CMR and correlate them with CMR findings, in order to explore their prognostic value. Materials and methods We evaluated the first 50 competitive athletes consecutively underwent CMR in our Institute for pathological suspects, from September 2021 to May 2022. CMR evaluation included morpho volumetric and functional assessment, perfusion alterations, oedema and late enhancement detection, T1/T2/ECV mapping and strain analysis. One year after CMR examination, all patients were questioned about the occurrence of cardiovascular events and clinical/instrumental (ECG, ECG stress test - EST, Holter) available data were collected, as well as information regarding variations in their sport activity. Correlations between CMR results and follow up data were explored. Results We included 42 (88%) males and 6 (12%) females, mean age 29 years (range 13-69). Among these, no follow up information could be obtained for six patients. All but two subjects showed CMR alterations by traditional and/or advanced techniques. At follow up questionnaire, 43% (n=18) reported experiencing cardiovascular symptoms, and in particular the persistence or appearance of arrhythmias was recorded in 9 subjects. Moreover, 18 subjects underwent a reduction or suspension of sport activity, and 12 did not achieve the eligibility to participate in competitive sports. At instrumental examinations, 9 subjects showed abnormalities in EST/Holter/ECG. A statistically significant correlation was found with T2 mapping evaluation, that showed normal values in most of subjects without follow up instrumental alterations (ECG vs mid septum T2, p=0.012; EST vs T2 global, p=0.018; Holter vs T2 global, p=0.011) and palpitations (p=0.031), and in those who have not undergone changes in their activity (p=0.007 and p=0.005, considering T2 global or segmental values, respectively). Furthermore, also ventricular dilation, associated or not with the presence of enhancement, showed a correlation with EST (p=0.047, and p=0.013, respectively), while kinesis evaluation turned out to be correlated with EST and Holter findings (p=0.033 and p=0.027, respectively). Conclusion Trained subjects represent a challenge population in CMR assessment, considering athlete’s heart variations. Our preliminary results shows that T2 mapping values, as well as kinesis and volumes seem to be positive prognostic factors, if normal. Further evaluations in a larger population are recommended.