Dilatation and Dysfunction of the Right Ventricle Immediately After Ultraendurance Exercise Exploratory Insights From Conventional Two-Dimensional and Speckle Tracking Echocardiography

Article (PDF Available)inCirculation Cardiovascular Imaging 4(3):253-63 · March 2011with55 Reads
DOI: 10.1161/CIRCIMAGING.110.961938 · Source: PubMed
Abstract
Running an ultramarathon has been shown to have a transient negative effect on right ventricular (RV) and left ventricular (LV) function. Additionally, recent findings suggested that ultraendurance athletes may be more at risk of developing a RV cardiomyopathy. The standard echocardiographic assessment of RV function is problematic; however, the introduction of ultrasonic speckle tracking technology has the potential to yield a comprehensive evaluation of RV longitudinal function, providing new insights into this phenomenon. Thus, the primary aim of this exploratory study was to evaluate comprehensively RV structure and function after a 161-km ultramarathon and establish whether changes in the RV are associated with alterations in LV function. Myocardial speckle tracking echocardiograms of the RV and LV were obtained before and immediately after a 161-km ultramarathon in 16 healthy adults. Standard echocardiography was used to determine RV size and function and LV eccentricity index. Speckle tracking was used to determine the temporal evaluation of indices of RV and LV function. RV size was significantly increased postrace (RV outflow, 32 to 35 mm, P=0.002; RV inflow, 42 to 45 mm, P=0.027) with an increase in LV eccentricity index (1.03 to 1.13, P=0.006). RV strain (ε) was significantly reduced postrace (-27% to -24%, P=0.004), but there was no change in the rates of ε. Peak ε in all planes of LV motion were reduced postrace (longitudinal, -18.3 to -16.3%, P=0.012; circumferential, -20.2% to -15.7%, P=0.001; radial, 53.4% to 40.3%, P=0.009). Changes in RV size and function correlated with diastolic strain rates in the LV. This exploratory study demonstrates RV dilatation and reduction in function after an ultramarathon. Further research is warranted to elucidate the mechanisms responsible for these findings. It is not clear what clinical impact might result from consecutive bouts of postexercise RV dysfunction.

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Circulation: Cardiovascular Imaging is published by the American Heart Association. 7272 Greenville
DOI: 10.1161/CIRCIMAGING.110.961938
2011;4;253-263; originally published online March 18, 2011;Circ Cardiovasc Imaging
Sarah Charlesworth, Heather Foulds, Martin D. Hoffman, Karen Birch and Keith George
David Oxborough, Robert Shave, Darren Warburton, Karen Williams, Adele Oxborough,
Tracking Echocardiography
Exercise : Exploratory Insights From Conventional Two-Dimensional and Speckle
Dilatation and Dysfunction of the Right Ventricle Immediately After Ultraendurance
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Dilatation and Dysfunction of the Right Ventricle
Immediately After Ultraendurance Exercise
Exploratory Insights From Conventional Two-Dimensional and Speckle
Tracking Echocardiography
David Oxborough, MSc; Robert Shave, PhD; Darren Warburton, PhD; Karen Williams, MSc;
Adele Oxborough, BSc; Sarah Charlesworth, PhD; Heather Foulds, MSc; Martin D. Hoffman, MD;
Karen Birch, PhD; Keith George, PhD
Background—Running an ultramarathon has been shown to have a transient negative effect on right ventricular (RV) and
left ventricular (LV) function. Additionally, recent findings suggested that ultraendurance athletes may be more at risk
of developing a RV cardiomyopathy. The standard echocardiographic assessment of RV function is problematic;
however, the introduction of ultrasonic speckle tracking technology has the potential to yield a comprehensive
evaluation of RV longitudinal function, providing new insights into this phenomenon. Thus, the primary aim of this
exploratory study was to evaluate comprehensively RV structure and function after a 161-km ultramarathon and
establish whether changes in the RV are associated with alterations in LV function.
Methods and Results—Myocardial speckle tracking echocardiograms of the RV and LV were obtained before and immediately
after a 161-km ultramarathon in 16 healthy adults. Standard echocardiography was used to determine RV size and function
and LV eccentricity index. Speckle tracking was used to determine the temporal evaluation of indices of RV and LV function.
RV size was significantly increased postrace (RV outflow, 32 to 35 mm, P0.002; RV inflow, 42 to 45 mm, P0.027) with
an increase in LV eccentricity index (1.03 to 1.13, P0.006). RV strain () was significantly reduced postrace (27% to
24%, P0.004), but there was no change in the rates of . Peak in all planes of LV motion were reduced postrace
(longitudinal, 18.3 to 16.3%, P0.012; circumferential, 20.2% to 15.7%, P0.001; radial, 53.4% to 40.3%,
P0.009). Changes in RV size and function correlated with diastolic strain rates in the LV.
Conclusions—This exploratory study demonstrates RV dilatation and reduction in function after an ultramarathon. Further
research is warranted to elucidate the mechanisms responsible for these findings. It is not clear what clinical impact
might result from consecutive bouts of postexercise RV dysfunction. (Circ Cardiovasc Imaging. 2011;4:253-263.)
Key Words: ventricles
echocardiography
imaging
exercise
cardiac output
fatigue
T
he effects of prolonged strenuous exercise on cardiac function
during the early stages of recovery have been relatively well
explored, with substantive descriptive evidence supporting a tran-
sient reduction in left ventricular (LV) systolic and diastolic func-
tion.
1
Interest in the impact of prolonged exercise on right ventric-
ular (RV) function was likely stimulated by case reports of 2
athletes presenting with pulmonary edema and right-side heart
failure after a 90-km ultramarathon race.
2
Subsequently, a small
number of exercise studies (using conventional 2D echocardio-
graphic indices) have shown a reduction in RV function during the
recovery period.
3–7
Using tissue Doppler echocardiography-derived
strain () technology, Neilan and colleagues
8
described a reduction
in RV free wall deformation in athletes after completion of the
Boston Marathon. In a recent study by our group, a transient
depression in both LV and left atrial (LA) function was reported in
athletes after running a marathon, with a link postulated between a
postrace reduction in LA deformation and RV function.
9
This study
Clinical Perspective on p 263
demonstrated reduced RV function using echocardiographic-
derived RV fractional area change (RVFAC), which may well
have had a consequent impact on LA preload and subsequent
distension. Taken together, these previous reports suggest RV
involvement after prolonged exercise; however, at present, a
Received November 4, 2010; accepted March 2, 2011.
From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales,
UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and
Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia,
Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research Institute for Sport and Exercise Sciences, Liverpool John Moores University,
Liverpool, UK (K.W., K.G.); Spire Hospital, Leeds, UK (A.O.); Department of Physical Medicine and Rehabilitation, Department of Veterans Affairs,
Northern California Health Care System, and University of California Davis Medical Center, Sacramento, CA (M.D.H.); and Multidisciplinary
Cardiovascular Research Centre, University of Leeds, Leeds, UK (K.B.).
Correspondence to David Oxborough, University of Leeds, Woodhouse Ln, Leeds LS2 9JT, UK. E-mail d.oxborough@leeds.ac.uk
© 2011 American Heart Association, Inc.
Circ Cardiovasc Imaging is available at http://circimaging.ahajournals.org DOI: 10.1161/CIRCIMAGING.110.961938
253
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comprehensive evaluation of RV structure and function
before and after prolonged exercise has not been attempted.
The significance of RV impairment after prolonged strenuous
exercise is the subject of some speculation. Exercise-induced
RV damage has been proposed as a potential mechanism for RV
arrhythmias in some ultraendurance athletes,
10
and a recent
study by La Gerche and colleagues
11
highlighted the potential
for developing an arrhythmogenic RV cardiomyopathy pheno-
type through prolonged bouts of intense endurance exercise. In
view of this, it is tempting to speculate that acute changes to RV
structure and function after a bout of intense endurance exercise
may contribute to this chronic phenomenon.
The assessment of RV systolic function with 2D echocar-
diography, particularly the calculation of volumes and, thus,
Figure 1. Myocardial speckle tracking dem-
onstrating region of interest along the right
ventricular lateral wall and subsequent
offline analysis of right ventricular strain and
strain rate. AVC, aortic valve closure.
254 Circ Cardiovasc Imaging May 2011
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function, is extremely problematic because of the geometry,
location, and excess trabeculation of the RV.
12
Myocardial
speckle tracking (MST) is a relatively new technique that has
been applied to the assessment of LV
13
and, more recently,
LA function.
14
Unlike other techniques, such as tissue Dopp-
ler echocardiographic imaging of velocities or ,
8
MST-
derived is free from angle dependency
15
and has been
shown to be reliable and valid in providing circumferential,
radial, and longitudinal deformation indices.
16
Because of the
advantages of the technique in overcoming some of the
geometric ultrasound limitations, MST recently has been
applied successfully to the assessment of the RV.
17
In view of the development in ultrasound technology and
the possible clinical significance of RV dysfunction after
intense exercise, we sought to provide in this exploratory
study a comprehensive evaluation of RV structure and func-
tion after a 161-km ultraendurance trail run and to establish
whether any changes are associated with alterations in LV
function. We proposed the following hypothesis: A 161-km
ultramarathon will negatively affect RV function, and postex-
ercise changes in LV filling will be related to altered RV
function.
Methods
Participants
Sixteen (12 male) competitors in the 161-km 2009 Western States
Endurance Run (Squaw Valley, CA, to Auburn, CA) aged 428
years (range, 25 to 60 years) volunteered to participate in the study.
All participants were healthy and free from known cardiovascular
disease, had no early family history of cardiovascular disease, and
were not currently taking any form of prescribed medication. All
were endurance runners with a broad range of experience demon-
strated by the number of previously completed ultramarathon races
(mean, 69117 races; range, 7 to 500 races) and years training
(1512 years; range, 2 to 46 years). Also documented was the
training status of the cohort in terms of miles per week (mean,
6522 miles/week; range, 40 to 120 miles/week) and hours per
week (mean, 144 hour/week; range, 8 to 24 hours/week). All
subjects provided written informed consent to participate, and the
study was granted approval by the ethics committee at Brunel
University as well as complied with the Declaration of Helsinki.
Experimental Procedures
Echocardiograms were performed 24 hours before starting the
race, and postrace echocardiograms were completed within 1 hour of
race completion. Body mass was measured with the same scale
preceding each echocardiogram. All subjects refrained from vigor-
ous training for 24 hours and avoided alcohol and caffeine for 4
hours before the prerace assessment. During the race, participants
were permitted to consume food and fluid ad libitum. On the day of
the race, the event started at 0500 hours. Over the race period (30
hours), temperature recorded at course temperature stations ranged
from 4°C to 37°C.
Figure 2. Temporal graphical representation of RV strain before
and after an ultramarathon competition. PVC indicates pulmo-
nary valve closure; RV, right ventricular.
Table 1. RV Indices Before and After the Ultramarathon Competition
Prerace Postrace
Parameter MeanSE Range MeanSE Range P
RV end-diastolic area, cm
2
230.8 16 to 28 250.9 20 to 30 0.010
RV end-systolic area, cm
2
130.6 7to17 150.7 12 to 22 0.007
RVFAC, % 430.02 30 to 60 380.02 26 to 48 0.028
RV outflow, mm 321.0 27 to 40 351.1 25 to 41 0.002
RV inflow, mm 421.1 36 to 50 451.2 38 to 53 0.027
RV acceleration time, cm/s 1.60.24 0.6 to 3.1 1.70.27 0.6 to 3.1 0.677
RV IVCT, ms 774.7 60 to 100 805.8 60 to 110 0.496
RV IVRT, ms 477.0 20 to 80 578.0 30 to 110 0.049
LVEI 1.030.01 0.91 to 1.18 1.130.03 0.92 to 1.50 0.006
RA volume, mL 654.9 38 to 114 675.6 32 to 110 0.535
RV ,% 271.5 17 to 36 241.8 12 to 37 0.004
RV SRs⬘⫺1.660.09 1.14 to 2.38 1.670.13 1.06 to 3.19 0.948
RV SRe 2.140.19 0.94 to 3.48 1.940.21 0.29 to 3.41 0.381
RV SRa 1.580.14 0.72 to 2.55 1.500.15 0.72 to 2.40 0.580
RV SRe/SRa 1.480.15 0.49 to 2.62 1.460.19 0.32 to 2.94 0.930
indicates strain; IVCT, isovolumic contraction time; IVRT, isovolumic relaxation time; LV, left ventricular; LVEI, LV
eccentricity index; RA, right atrial; RV, right ventricular; RVFAC, RV fractional area change; SRa, strain rate late
ventricular diastole; SRe, strain rate early ventricular diastole; SRs, strain rate during ventricular systole.
Oxborough et al Right Ventricular Function After an Ultramarathon 255
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Echocardiographic Assessments
After a full explanation of procedures, participants lay supine for 5
minutes before