R E S E A R C H Open Access
Moderate intensity supine exercise causes
decreased cardiac volumes and increased outer
volume variations: a cardiovascular magnetic
, Robert Jablonowski
, Per M Arvidsson
, Marcus Carlsson
, Bengt Saltin
and Håkan Arheden
Background: The effects on left and right ventricular (LV, RV) volumes during physical exercise remains
controversial. Furthermore, no previous study has investigated the effects of exercise on longitudinal contribution
to stroke volume (SV) and the outer volume variation of the heart. The aim of this study was to determine if LV, RV
and total heart volumes (THV) as well as cardiac pumping mechanisms change during physical exercise compared
to rest using cardiovascular magnetic resonance (CMR).
Methods: 26 healthy volunteers (6 women) underwent CMR at rest and exercise. Exercise was performed using a
custom built ergometer for one-legged exercise in the supine position during breath hold imaging. Cardiac
volumes and atrio-ventricular plane displacement were determined. Heart rate (HR) was obtained from ECG.
Results: HR increased during exercise from 60±2 to 94±2 bpm, (p<0.001). LVEDV remained unchanged (p=0.81)
and LVESV decreased with −9±18% (p<0.05) causing LVSV to increase with 8±3% (p<0.05). RVEDV and RVESV
decreased by −7±10% and −24±14% respectively, (p<0.001) and RVSV increased 5±17% during exercise although
not statistically significant (p=0.18). Longitudinal contribution to RVSV decreased during exercise by −6±15%
(p<0.05) but was unchanged for LVSV (p=0.74). THV decreased during exercise by −4±1%, (p<0.01) and total heart
volume variation (THVV) increased during exercise from 5.9±0.5% to 9.7±0.6% (p<0.001).
Conclusions: Cardiac volumes and function are significantly altered during supine physical exercise. THV becomes
significantly smaller due to decreases in RVEDV whilst LVEDV remains unchanged. THVV and consequently radial
pumping increases during exercise which may improve diastolic suction during the rapid filling phase.
Keywords: Physiology, Total heart volume variation, Ventricle, Cardiac pumping, Cardiovascular magnetic resonance
Total heart volume at rest has a strong correlation to
peak exercise capacity in healthy normal subjects and
athletes [1,2]. When going from rest to exercise the nor-
mal heart in a sedentary individual can increase its cardiac
output from 5 L/min to 20–25 L/min . This change has
been attributed to an increase in heart rate and stroke
volume. In turn, the stroke volume can increase either by
an increase in end-diastolic volume (EDV), decrease in
end-systolic volume (ESV), or both. The effects on left
ventricular (LV) volumes during physical exercise remain
controversial. Previous studies using radionuclide angiog-
raphy or echocardiography have shown both unchanged
and increased LV end-diastolic volumes (LVEDV) during
upright and supine exercise compared to resting values
in the same position [4-12]. Although most studies show
a decrease in ESV during exercise, Sundstedt et al. 
showed unchanged ESV during supine exercise using
echocardiography. Few studies have investigated the
* Correspondence: firstname.lastname@example.org
Department of Clinical Physiology, Lund University, Lund University Hospital
Lund, Lund, Sweden
Full list of author information is available at the end of the article
© 2013 Steding-Ehrenborg et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Steding-Ehrenborg et al. Journal of Cardiovascular Magnetic Resonance 2013, 15:96
effects of exercise on the right ventricle [13,14] and further
studies are needed to understand how physical exercise af-
fects left and right cardiac volumes and subsequently the
stroke volume (SV).
Ventricular stroke volume is ejected by a combination
of longitudinal and radial contraction of the ventricle
[15-18]. At rest the longitudinal contribution to SV has
been shown to be 60% for the LV and 80% for the RV
and radial contribution is 40% and 20% respectively
[15,17,19]. It has been shown that during exercise there
is a significant increase in the mitral valve displacement
during exercise . Longitudinal pumping is calculated
as the atrio-ventricular plane displacement (AVPD) multi-
plied by the short-axis area of the ventricle and an increase
in AVPD may therefore affect the longitudinal contribu-
tion to SV. Several studies have suggested that at higher
heart rates a larger longitudinal contribution may keep the
outer volume variation of the heart to a minimum render-
ing less energy to be wasted on moving surrounding tis-
sues [21-23]. However, this remains to be explored.
Therefore, the aim of this study was to determine left
and right ventricular volumes, left and right atrial vol-
umes and total heart volumes as well as longitudinal and
radial pumping during rest and physical exercise using
cardiovascular magnetic resonance (CMR).
This study was approved by the Regional Ethical Review
Board in Lund, Sweden and follows the Declaration of
Helsinki. All participants provided written informed con-
sent. All CMR examinations were performed at Skane
University Hospital Lund, Sweden.
Study population and experimental setup
Twenty-six healthy volunteers (six women) aged 30±8 years
(mean±SD) (range 19–59) underwent CMR at rest and
during exercise with one-legged knee extensions. A custom
built MR-compatible ergometer provided concentric re-
sistance during knee extension by a rope and pulley sys-
tem which was integrated with a mechanically braked
flywheel. A strap connected to a variable weight system
provided resistance and weight was added to achieve an
exercise level at approximately 40 beats per minute
(bpm) higher than the subjects’resting heart rate. The
subjects were connected at the ankle to the axle of the
flywheel by a rope and the extension phase of the exer-
cise turned the flywheel. Gravity returned the leg to the
starting position and a gearing system on the axle
returned the rope to the starting position at the end of
each duty cycle.
Reproducibility of exercise measurements
Six subjects underwent a total of five CMR scans to in-
vestigate the reproducibility of volumetric measurements
during exercise and the potential effects of different re-
spiratory phases as well as differences in exercising muscle
mass. The scans were divided into two sessions with a
1.5 hour rest outside the scanner between them. Session 1
included a) CMR at rest; b) CMR with 1-legged exercise
at end-expiratory breath hold; and c) CMR with 2-legged
exercise at end-expiratory breath hold. Session 2 in-
cluded a) CMR with 1-legged exercise at end-expiratory
breath hold; and b) CMR with 1-legged exercise at end-
inspiratory breath hold with the instructions to keep an
open glottis and avoid Valsalva-like increases in intra-
Cardiac magnetic resonance imaging
A 1.5T scanner (Philips Achieva, Philips, Best, The
Netherlands) with a 5 channel cardiac coil was used to
scan all subjects in the supine position. A balanced
steady-state free-precession (bSSFP) sequence with
retrospective ECG gating was used to acquire images of
the heart (repetition time typically 3.0 ms, turbo factor
16, echo time 1.5 ms, flip angle 60°, reconstructed to a
spatial resolution of 1.4 × 1.4 mm, acquired temporal
resolution typically 50 ms reconstructed to 30 ms, and
slice thickness 8 mm with no slice gap). After defining
the long-axis orientation of the heart, short-axis images
covering the heart from the base of the atria to the apex
of the ventricles were obtained. Breath-hold during
imaging during exercise was typically 6 s for long-axis
images and 8–10 s for each short-axis slice. An ECG-
triggered phase-contrast sequence was used to measure
blood flow in the aorta (repetition time 8.6 ms, echo
time 6.4 ms, 150 cm/s velocity encoding, slice thickness
8 mm). The measurement plane was positioned perpen-
dicular to the vessel. Heart rate was obtained from the
ECG during image acquisition.
Atrial and ventricular volumes
All measurements were done using the software Segment
1.8 (http://segment.heiberg.se) . Left and right atrial
volumes were measured in short-axis images at the time of
ventricular end-diastole and ventricular end-systole. Left
ventricular mass (LVM), end-diastolic volume (LVEDV),
end-systolic volume (LVESV) and stroke volume (LVSV)
were measured in short-axis images using planimetry, by
manual delineation of endocardial and epicardial borders
of the left ventricle. Papillary muscles were not included in
LVM measurements. Right ventricular end-diastolic vol-
ume (RVEDV), end-systolic volume (RVESV) and stroke
volume (RVSV) were measured in short-axis images by
manual delineation of the right ventricular endocardial and
Total heart volume (THV) was measured in short-axis
images by planimetry  and was defined as the vol-
ume of all structures within the pericardium, including
Steding-Ehrenborg et al. Journal of Cardiovascular Magnetic Resonance 2013, 15:96 Page 2 of 8
myocardium, blood pool, atria, pericardial fluid and the
proximal parts of the great vessels.
Atrio-ventricular plane displacement (AVPD) was deter-
mined from CMR long-axis images as previously de-
scribed . Longitudinal pumping of the left and right
ventricle was calculated as the distance travelled by the
AV-plane multiplied by epicardial short-axis area of the
ventricle . Radial pumping was determined from the
total heart volume variation (THVV) . Longitudinal
and radial contribution to SV (%) was calculated as lon-
gitudinal pumping divided by SV and radial pumping di-
vided by SV.
Statistical analysis was performed using SPSS statistics
20 (IBM, Chicago, IL, USA) and a p-value <0.05 was
considered statistically significant. Paired t-tests were used
to test for changes between rest and exercise. Wilcoxon
non-parametric test was used to test for differences be-
tween rest and exercise in the subgroup of six subjects
who underwent a total of five scans to investigate the re-
producibility of measurements. Results are presented as
mean ±SEM unless stated otherwise. Inter-observer vari-
ability was determined for the left ventricular measure-
ments in ten subjects during rest and exercise.
Subject characteristics are presented in Table 1. All sub-
jects reported to be healthy and none of the subjects
showed any signs of cardiac disease on the CMR scan.
In three subjects the same short-axis slice was imaged
twice due to difficulties in breath holding during exer-
cise. These extra slices were identified and removed be-
fore the images were analysed. Figure 1 and Additional
files 1, 2, 3 and 4 show typical examples of the image
quality during exercise.
Heart rate and cardiac volumes
Heart rate increased significantly during exercise from
60±2 to 94±2 bpm (p<0.001). Left atrial volumes at end-
diastole decreased from 39±3 to 35±3 mL (p<0.05) as did
right atrial end-diastolic volumes from 65±5 to 56±4 mL
(p<0.05). At ventricular end-systole, where the atria reach
their largest volumes, left atrial volumes were unchanged
(84±4 and 85±5 mL, p=0.72) and right atrial volume de-
creased significantly from 124±7 to 103±7 mL (p<0.001)
Left ventricular EDV remained unchanged during ex-
ercise (186±8 to 185±8 mL, p=0.81) and LVESV de-
creased from 82±4 to 74±4 mL (p<0.05) (Figure 2A-B).
Left ventricular SV increased from 104±4 to 111±5 mL
(p<0.05, Figure 2C). For the right ventricle, both RVEDV
and RVESV decreased from 203±9 to 185±10 mL for
RVEDV and from 100±6 to 77±6 mL for RVESV
(p<0.001 for both) (Figure 2D-E) but the increase in
right ventricular SV from 104±4 to 108±5 mL was not
significant (p=0.18) (Figure 2F). Both left and right ven-
tricular ejection fraction (LVEF and RVEF) increased dur-
ing exercise from 56±1 to 60±1% and from 52±1 to 59±1%
respectively (p<0.01 for both). Cardiac output increased
from 6.2±0.3 to 10.4±0.5 L/min (p<0.001) mainly due
ingly, total heart volume decreased significantly during
exercise by −30±8 mL, (p<0.01) corresponding to a 4±1%
decrease of volume (example shown in Figure 4 and in
Additional file 4). As expected, LVM was unchanged from
rest to exercise (115±6 to 114±6 g, p=0.62).
Left and right atrio-ventricular plane displacement
Left ventricular AVPD and RVAVPD remained unchanged
during exercise. Left ventricular AVPD was 14.6±0.3 mm
at rest and 15.3±0.5 mm during exercise (p=0.06) and
the RV AVPD was 20.9±0.6 mm for both rest and ex-
Longitudinal and radial pumping
Left ventricular longitudinal contribution to SV (%)
remained unchanged at approximately 60% (59±1% at
rest and 60±2% at exercise, p=0.74). Right ventricular
longitudinal contribution (%) decreased from 81±2 to
75±2% (p<0.05) (Figure 5A-B) due to the decrease in
RV end-diastolic volume. Total heart volume variation
increased during exercise from 5.9±0.5 to 9.7±0.6%
(p<0.001) (Figure 5C).
Table 1 Subject characteristics and cardiac volumes at
rest for men and women (mean±SD)
Men n=20 Women n=6
Age (years) 30±9 29±8
Weight (kg) 78±12 61±14
Height (m) 1.80±0.07 1.68±0.07
THV (mL) 861±145 586±123
LVEDV (mL) 197±34 148±36
RVEDV (mL) 219±37 149±39
LVSV (mL) 109±19 87±22
RVSV (mL) 110±17 84±23
LVM (g) 126±22 79±17
LAes (mL) 89±19 65±24
RAes (mL) 134±33 90±22
g = gram, kg = kilogram, LAes = left atrial volume measured at ventricular
end-systole, LVEDV = left ventricular end-diastolic volume, LVM = left ventricular
mass, LVSV = left ventricular stroke volume, m = metre, mL = millilitre,
RAes = right atrial volume measured at ventricular end-systole, RVEDV = right
ventricular end-diastolic volume, RVSV = right ventricular stroke volume,
THV = total heart volume, THVV = total heart volume variation.
Steding-Ehrenborg et al. Journal of Cardiovascular Magnetic Resonance 2013, 15:96 Page 3 of 8
Reproducibility of exercise measurements
For the six subjects participating in repeated scans there
were no differences in THV, RVEDV or left and right SV
between the first and second exercise session with one
leg. Left ventricular EDV increased more during the
second exercise session when compared to rest; a 5±5%
increase during the first session and a 11±4% increase
during the second session (p<0.05). When comparing end-
expiratory breath hold with end-inspiratory breath hold,
only LVEDV differed between sessions. When compared
Figure 1 Short-axis images showing the typical image quality during exercise. These images were acquired at a heart rate of 119 bpm. The
top left image shows the most basal short-axis slice showing the roof of the atria and the bottom right image shows the most apical slice of the
ventricles. Ao –aorta, LA –left atrium, LV –left ventricle, Pulm –pulmonary trunk, RA –right atrium, RV –right ventricle.
Figure 2 Left and right ventricular volumes and stroke volumes at rest and exercise. Upper panel shows no changes in left ventricular
end-diastolic volumes (A) and a small but significant decrease in end-systolic volume (B), leading to an increased stroke volume (C). Lower panel
show a significant decrease in right ventricular end-diastolic volume (D) and end-systolic volume (E). Right ventricular stroke volume increased
during exercise, however not statistically significant (F). Error bars denote mean and standard error of the mean (SEM).
Steding-Ehrenborg et al. Journal of Cardiovascular Magnetic Resonance 2013, 15:96 Page 4 of 8
to rest there was a 5±5% increase at end-expiratory
breath hold and a 15±7% increase at end-inspiratory
breath hold (p<0.05). During exercise using two legs,
left and right ventricular EDV did not differ when com-
pared to one-legged exercise. Left ventricular EDV in-
creased by 5±5% and 7±7% respectively (p=0.35), and
RVEDV decreased by −4±6% and −2±7% respectively
(p=0.17). Right ventricular SV, however, increased more
during exercise using two legs. When compared to rest the
increase was 3±10% with one leg and 12±9% with two legs.
Inter-observer variability and validation
Results are presented as mean ±SD. At rest, inter-
observer variability for LVM was 9±5 g, EDV −1±4 mL
and SV −2±5 mL. During exercise imaging was more
difficult and the image quality was lower, which is
reflected by a slightly larger variability; LVM 7±10 g,
EDV −3±16 mL and SV 0±9 mL.
The present study has shown that the total heart vol-
ume decreases in healthy normal subjects during
moderate exercise in the supine position. This de-
crease is caused by reduced right atrial and ventricu-
lar volumes whilst left atrial and ventricular volumes
remain unchanged during exercise. With regards to
pumping function there is an increase in outer vol-
ume changes during exercise and thus, an increased
radial contribution to stroke volume. AV-plane move-
ment is unchanged during exercise but a smaller
short-axis area of the right ventricle causes the lower
longitudinal contribution to RVSV. Left ventricular
longitudinal contribution to SV is unchanged during
exercise. Total left and right ventricular SV were only
slightly increased (LVSV) or unchanged (RVSV) dur-
is best explained by the rise in heart rate.
Figure 3 Heart rate and cardiac output at rest and exercise. Heart rate (A) and cardiac output (B) increased significantly from rest to
exercise. Error bars denote mean and standard error of the mean (SEM).
Figure 4 Mid-ventricular short axis slices in end-diastole (ED) and end-systole (ES) during rest and exercise with the corresponding
4-chamber (4 ch) view to illustrate the location of the slice. The solid line indicates delineations for total heart volume. In the exercise
images, the dashed line shows the total heart volume delineation copied from the corresponding resting image. The right ventricular volume is
decreased whereas the left ventricle remains unchanged.
Steding-Ehrenborg et al. Journal of Cardiovascular Magnetic Resonance 2013, 15:96 Page 5 of 8
Ventricular volumes and stroke volume
The inconsistent results of previous studies [4-7,11,12,14,26]
may be explained by differences in imaging modalities
and, perhaps most important, body position. The results
of this study are in line with other studies of supine exer-
cise showing unchanged LVEDV [5,9,10,27,28]. The sig-
nificant decrease in RVEDV differs from previous studies
of RV volumes during supine exercise using radionuclide
ventriculography  and CMR [14,28] where RVEDV
remained unchanged during moderate intensity exercise
(mean HR in these studies were 112,120 and 100 bpm re-
spectively). However, in line with our results the study by
Mols et al.  used radionuclide ventriculography and
showed a decreased RVEDV at workloads at a HR of
127 bpm and above. The differences between the present
study and previous CMR studies may be explained by dif-
ferences in exercise protocol where we acquired breath-
hold images during leg exercise whilst Holverda et al. 
used non-breath hold imaging and Roest et al. 
allowed the subjects to rest for the short period of image
acquisition. Free-breathing may decrease image quality
and rest during image acquisition will allow HR to de-
crease making interpretation of results more difficult.
In line with studies by Bevegård et al.  the present
study showed that CO increased significantly due to in-
creased HR whilst SV only increased by 8%. During the
early stages of exercise in healthy subjects, the increase in
HR is primarily caused by a decreased parasympathetic
tone whereas the sympathetic effects are not seen until
later stages . As the exercise bouts of the study were
short, the increased HR with only a small increase in SV is
likely caused by parasympathetic withdrawal. Further-
more, the increased venous return caused by the supine
position lead to maximal filling of the ventricles already at
rest, which would explain the discrepancy between our
study and exercise studies performed in the upright pos-
ition. Our study would then be more representative of ex-
ercise in the supine position such as swimming or perhaps
in micro gravitational environments such as space flight.
Longitudinal and radial contribution to stroke volume
In contrast to a previous study of upright exercise on an
ergometer cycle where the left ventricular valve displace-
ment was significantly increased during exercise ,
our results showed unchanged LV AVPD and longitudinal
contribution to LVSV. Right ventricular valve displace-
ment (RV AVPD) remained unchanged but together with
the decreased volume of the right ventricle, the right ven-
tricular longitudinal contribution to SV was significantly
decreased. Furthermore, total cardiac pumping became
significantly more radial during exercise as shown by the
increased THVV when exercising both with one and two
legs, as well as during end-expiratory and end-inspiratory
breath hold. This is in contrast to a hypothesis previously
suggested by our group  where we expected cardiac
longitudinal pumping to increase and radial pumping to
decrease. Increased radial pumping as seen in the present
study may theoretically increase the amount of energy
spent on moving surrounding tissues and thus decrease
the energy efficiency of the heart. However, for the left
ventricle, Riordan and Kovács  showed that radial
pumping may actually be important for diastolic suction
during the rapid filling phase. Exercise requires rapid mass
transfer from the atria to the ventricle, and it is possible
that the increased radial pumping seen in the right ven-
tricle may actually improve cardiac pumping efficiency
due to enhanced diastolic suction.
It is possible that our findings of increased THVV only
relates to exercise in the supine position such as swim-
ming, and it would be of interest to perform similar
studies during upright exercise.
Reproducibility of exercise measurements
Ventricular volumes and THV were reproducible between
the first and second exercise session, and also when im-
aging was performed at end-inspiratory breath hold as
well as during exercise with two legs. The differences seen
in LVEDV between the first and second exercise session
with one leg as well as between end-expiratory and end-
Figure 5 Longitudinal and radial contribution to stroke volume at rest and exercise. Left ventricular longitudinal contribution increased
(A) whereas the right ventricular contribution decreased (B). Total radial contribution calculated as total heart volume variation THVV (C) increased
significantly indicating an overall increase in radial pumping of the heart during exercise. Error bars denotes mean and standard error of the
Steding-Ehrenborg et al. Journal of Cardiovascular Magnetic Resonance 2013, 15:96 Page 6 of 8
inspiratory breath hold is probably best explained by indi-
vidual variations that are more distinguishable in the small
population. As shown in Figure 2 there is some variability
between individuals for all variables and when only asses-
sing six subjects results may fall out as statistically signifi-
cant although not physiologically relevant.
Heart failure is a complex syndrome and diagnosis can
be especially challenging at early stages. Cardiac MR
during physical exercise may become useful for assessing
patients with normal ejection fraction and suspected
heart failure to investigate if cardiac function and filling
are affected during low and medium intensity exercise.
Furthermore, exercise CMR may also be used to asses
patients with congenital heart disease such as Tetralogy
of Fallot before and after surgery.
Exercise heart rate in our healthy volunteers only in-
creased by approximately 40 bpm over resting HR and it
is possible that a higher exercise HR may yield different
results. The study population included to test for repro-
ducibility of exercise measurements was small (n=6) and
the results of the statistical tests of this subpopulation
on reproducibility should be interpreted with caution.
Furthermore, the study was performed in the supine
position limiting the interpretation of our results to su-
pine exercise such as swimming, but it may also be ap-
plicable for conditions of microgravity, such as space
Moderate intensity exercise in the supine position sig-
nificantly decreases the total heart volume. This is due
to decreases in right atrial and ventricular volumes at
end-diastole whilst the LVEDV remains unchanged. The
contribution of longitudinal pumping to stroke volume
is unchanged in the left ventricle but decreased in the
right ventricle in exchange for an increase in radial
pumping. In contrast to previous belief, THVV and con-
sequently radial pumping increases which may improve
diastolic suction of the ventricles.
Additional file 1: Short-axis image of a healthy heart during
exercise at a heart rate of 108 bpm.
Additional file 2: Two-chamber long-axis view of a healthy heart
during exercise at a heart rate of 102 bpm.
Additional file 3: Three-chamber long-axis view of a healthy heart
during exercise at a heart rate of 117 bpm.
Additional file 4: Four-chamber long-axis view of a healthy heart
during exercise at a heart rate of 124 bpm.
The authors declared that they have no competing interest.
KSE: Conception of study, data inclusion and analysis, interpretation of data,
drafting and revising the manuscript. RJ: Data inclusion and critical revision
of the manuscript. PMA: Data inclusion and analysis, critical revision of the
manuscript. MC: Conception of study, data inclusion and critical revision of
the manuscript. BS: Conception of study, construction of MR ergometer,
critical revision of manuscript. HA: Conception of study, critical revision of
manuscript. All authors read and approved the final manuscript.
The authors wish to thank FlemmingJessen at the Copenhagen Muscle
Research Centre for design and construction of the ergometer and Ance
Kreslin for help with data collection and analysis. This study was supported
by the Swedish Research Council, the Swedish Heart and Lung Foundation,
Region of Scania, the Medical Faculty at Lund University, Sweden, the
Swedish Heart Association and Novo Nordisk Foundation, Denmark.
Copenhagen Muscle Research Centre, Copenhagen, Denmark.
Research Centre for Magnetic Resonance, Hvidovre Hospital, Copenhagen,
Department of Clinical Physiology, Lund University, Lund
University Hospital Lund, Lund, Sweden.
Received: 26 April 2013 Accepted: 1 October 2013
Published: 24 October 2013
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Cite this article as: Steding-Ehrenborg et al.:Moderate intensity supine
exercise causes decreased cardiac volumes and increased outer volume
variations: a cardiovascular magnetic resonance study. Journal of
Cardiovascular Magnetic Resonance 2013 15:96.
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