Echocardiography. 2018;35:767–768. wileyonlinelibrary.com/journal/echo
© 2018 Wiley Periodicals, Inc.
Changes in right ventricular morphology and function in
Athletes performing isotonic as well as isometric exercise activities
show changes in morphology and function of cardiac chambers. The
endurance athletes largely perform isotonic exercises, whereas the
strength- strained (static) athletes perform more isometric exercises.
Changes in cardiac structure and function seem to be related to the
hemodynamic changes that are seen with these types of exercises.
The article by Mirea O et al
in this issue of the journal primarily
describes the changes in right heart in athletes and its association
with increase in pulmonary arterial pressure.
1 | MORPHOLOGICAL AND FUNCTIONAL
CHANGES IN RIGHT VENTRICLE IN
Alterations of right ventricular (RV) function in competitive athletes
with left ventricular (LV) hypertrophy have been described previ-
The endurance athletes, due to the increased blood flow,
have larger LV and RV chamber sizes in diastole. The strength- trained
athletes, on the other hand, are seen to have more often normal cav-
ity sizes although they have increased LV wall thickness.
function plays an important role in exercise performance. The early
diastolic RV myocardial function was found to be an independent
determinant of the LV stroke volume and exercise performance.
is not known whether the alteration in RV chamber size and function
is related to changes in pulmonary pressure and subsequent increase
in RV afterload or it is purely related to increased blood flow. In
Olympic level athletes who involve in both static and dynamic com-
ponents, although both LV and RV were enlarged, the RV enlarges to
a greater extent than LV with intense training.
However, there are
conflicting reports of association of RV enlargement with RV systolic
or diastolic dysfunction in athletes. It is unclear whether this differ-
ence is related to the type of training the athletes undergo. In the
study that included primarily athletes who involve both static and
dynamic intense training, RV enlargement does not accompany RV
systolic or diastolic dysfunction.
On the other hand, in the study
that involved athletes undergoing endurance training, RV dilatation
was accompanied by RV regional deformation and deformation rates
suggesting reduced systolic function mostly in basal segments.
left ventricle seems to be relatively spared from systolic and dias-
tolic dysfunction in endurance athletes even in the presence of LV
Right ventricular enlargement is more prevalent in endurance
athletes compared to strength- trained athletes. The type and
duration of training, pulmonary artery systolic pressure, and LV
stroke volume are independent predictors of RV end- diastolic vol-
The important clinical implication of this RV dilatation would
be the risk for arrhythmia in athletes with such RV remodeling. An
association between endurance sports and arrhythmogenic RV
remodeling has been described.
Also, athletes who have had
ventricular arrhythmias had high prevalence of right ventricular
involvement. Reduced RV systolic function is also associated with
ventricular arrhythmias in endurance athletes,
and hence, there
is a concern that endurance exercise may act as trigger for these
arrhythmias as well as act as a promoter of morphological and func-
tional changes in RV.
2 | CAUSES OF RIGHT VENTRICULAR
STRUCTURE AND FUNCTION IN ATHLETES
There seems to be multifactorial causation for RV morphological
and functional changes in prolonged exercise. The systemic circu-
lation, by peripheral vasodilation, accommodates threefold to five-
fold increase in cardiac output during prolonged strenuous exercise.
However, this massive increase in blood flow has to be accommo-
dated by the pulmonary circulation that has a limited capacity for
recruitment and vasodilation; and this increases the pulmonary
Higher relative increase in afterload is seen in
pulmonary circulation compared to systemic circulation. Although
RV adequately handles the increased blood flow and the pulmonary
artery pressure during exercise, prolonged strenuous exercise is
also known to cause cardiac injury that disproportionately affects
Right bundle branch block and incomplete right bundle
branch block in electrocardiogram are associated with exercise-
induced RV remodeling in athletes.
3 | CLINICAL IMPLICATIONS OF RIGHT
VENTRICULAR DILATATION IN ATHLETES
The clinical importance of RV remodeling depends on various char-
acteristics of the individual athlete. In some, the changes may be re-
lated to the presence of subclinical arrhythmogenic right ventricular
dysplasia (ARVD). Benign RV dilatation, which is seen frequently in
endurance athletes, should be differentiated from the pathologic RV
dilatation found in ARVD.
The current diagnostic criteria for RV
dilatation cannot be applied to athletes because there is a potential