Abstract
Left atrial (LA) fibrosis with increased stiffness has been assumed to be the substrates for occurrence of atrial arrhythmias in athletes. However, this hypothesis has not yet been confirmed in humans. Aim of this study was, therefore, to assess LA remodeling and stiffness in competitive athletes. 150 competitive athletes and 90 age and sex-matched sedentary subjects were analyzed by speckle-tracking echocardiography to measure peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS). LA stiffness was determined using E/e’ ratio in conjunction with PALS. Left ventricular (LV) stiffness was also calculated. LA volume index was greater in athletes as compared with controls (24.6 ± 7.3 vs. 18.4 ± 7.8 mL/m2, p < .0001). LA PALS, LA PACS, and E/e’ ratio were lower in athletes in comparison with controls (p < .05, p ≤ .001, and p < .0001, respectively). Despite greater LA size, competitive athletes had lower LA stiffness as compared with controls (0.13 ± 0.04 vs. 0.16 ± 0.06, p ≤ .001). In addition, LV stiffness was lower in athletes (0.84 ± 0.27 vs. 1.07 ± 0.46, p ≤ .001). The only independent predictor of LA stiffness was LV stiffness (β = 0.46, p < .0001), while the only independent predictor of LA volume index was LV end-systolic volume index (β = 0.25, p = .002). Competitive athletes showed greater LA size associated with lower stiffness as compared with controls. Thus, LA remodeling in the context of the athlete’s heart is not associated with increased LA stiffness. These findings support the benign nature of LA remodeling in athletes, occurring as a physiological adaptation to exercise conditioning.
Similar content being viewed by others
References
Pelliccia A, Maron BJ, Di Paolo FM, Biffi A, Quattrini FM, Pisicchio C, Roselli A, Caselli S, Culasso F (2005) Prevalence and clinical significance of left atrial remodeling in competitive athletes. J Am Coll Cardiol 46:690–696
D’Andrea A, Riegler L, Cocchia R, Scarafile R, Salerno G, Gravino R, Golia E, Vriz O, Citro R, Limongelli G, Calabrò P, Di Salvo G, Caso P, Russo MG, Bossone E, Calabrò R (2010) Left atrial volume index in highly trained athletes. Am Heart J 159:1155–1161
Nistri S, Galderisi M, Ballo P, Olivotto I, D’Andrea A, Pagliani L, Santoro A, Papesso B, Innelli P, Cecchi F, Mondillo S (2011) Determinants of echocardiographic left atrial volume: implications for normalcy. Eur J Echocardiogr 12:826–833
D’Ascenzi F, Cameli M, Lisi M, Zacà V, Natali B, Malandrino A, Benincasa S, Catanese S, Causarano A, Mondillo S (2012) Left atrial remodelling in competitive adolescent soccer players. Int J Sports Med 33:795–801
D’Ascenzi F, Pelliccia A, Natali BM, Zacà V, Cameli M, Alvino F, Malandrino A, Palmitesta P, Zorzi A, Corrado D, Bonifazi M, Mondillo S (2014) Morphological and functional adaptation of left and right atria induced by training in highly trained female athletes. Cir Cardiovasc Imaging 7:222–229
D’Ascenzi F, Cameli M, Zacà V, Lisi M, Santoro A, Causarano A, Mondillo S (2011) Supernormal diastolic function and role of left atrial myocardial deformation analysis by 2D speckle tracking echocardiography in elite soccer players. Echocardiography 28:320–326
Calvo N, Brugada J, Sitges M, Mont L (2012) Atrial fibrillation and atrial flutter in athletes. Br J Sports Med 46(Suppl):i37–i43
Mascia G, Perrotta L, Galanti G, Padeletti L (2013) Atrial fibrillation in athletes. Int J Sports Med 34:379–384
Ofman P, Khawaja O, Rahilly-Tierney CR, Peralta A, Hoffmeister P, Reynolds MR, Gaziano JM, Djousse L (2013) Regular physical activity and risk of atrial fibrillation: a systematic review and meta-analysis. Circ Arrhythm Electrophysiol 6:252–256
Inama G, Pedrinazzi C, Durin O, Inama L, Furlanello F (2010) Atrial fibrillation and flutter in athletes. G Ital Cardiol (Rome) 11(10 Suppl 1):102S–106S
Benito B, Gay-Jordi G, Serrano-Mollar A, Guasch E, Shi Y, Tardif JC, Brugada J, Nattel S, Mont L (2011) Cardiac arrhythmogenic remodeling in a rat model of long-term intensive exercise training. Circulation 123:13–22
Gabrielli L, Enríquez A, Córdova S, Yáñez F, Godoy I, Corbalán R (2012) Assessment of left atrial function in hypertrophic cardiomyopathy and athlete’s heart: a left atrial myocardial deformation study. Echocardiography 29:943–949
Machino-Ohtsuka T, Seo Y, Tada H, Ishizu T, Machino T, Yamasaki H, Igarashi M, Xu D, Sekiguchi Y, Aonuma K (2011) Left atrial stiffness relates to left ventricular diastolic dysfunction and recurrence after pulmonary vein isolation for atrial fibrillation. J Cardiovasc Electrophysiol 22:999–1006
Kurt M, Wang J, Torre-Amione G, Nagueh SF (2009) Left atrial function in diastolic heart failure. Circ Cardiovasc Imaging 2:10–15
Her AY, Choi EY, Shim CY, Song BW, Lee S, Ha JW, Rim SJ, Hwang KC, Chang BC, Chung N (2012) Prediction of left atrial fibrosis with speckle tracking echocardiography in mitral valve disease: a comparative study with histopathology. Korean Circ J 42:311–318
Du Bois D, Du Bois EF (1916) A formula to estimate the approximate body surface area if height and weight be known. Arch Intern Med 17:863–871
Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise J, Solomon S, Spencer KT, St John Sutton M, Stewart W (2006) Recommendations for chamber quantification. Eur J Echocardiogr 7:79–108
Eshoo S, Ross DL, Thomas L (2009) Impact of mild hypertension on left atrial size and function. Circ Cardiovasc Imaging 2:93–99
Thomas L, Levett K, Boyd A, Leung DY, Schiller NB, Ross DL (2002) Compensatory changes in atrial volumes with normal aging: is atrial enlargement inevitable? J Am Coll Cardiol 40:1630–1635
Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA, Evangelisa A (2009) Recommendations of evalutation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr 10:165–193
Yu CM, Sanderson JE, Marwick OhJK (2007) Tissue Doppler imaging a new prognosticator for cardiovascular disease. J Am Coll Cardiol 49:1903–1914
Kasner M, Westermann D, Steendijk P, Gaub R, Wilkenshoff U, Weitmann K, Hoffmann W, Poller W, Schultheiss HP, Pauschinger M, Tschöpe C (2007) Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction: a comparative Doppler-conductance catheterization study. Circulation 116:637–647
Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfiled MM, Tajik AJ (2000) Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation 102:1788–1794
King GJ, Murphy RT, Almuntaser I, Bennett K, Ho E, Brown AS (2008) Alterations in myocardial stiffness in elite athletes assessed by a new Doppler index. Heart 94:1323–1325
Popovic D, Ostojic MC, Petrovic M, Vujisic-Tesic B, Popovic B, Nedeljkovic I, Arandjelovic A, Jakovljevic B, Stojanov V, Damjanovic S (2011) Assessment of the left ventricular chamber stiffness in athletes. Echocardiography 28:276–287
Shaikh AY, Maan A, Khan UA, Aurigemma GP, Hill JC, Kane JL, Tighe DA, Mick E, McManus DD (2012) Speckle echocardiographic left atrial strain and stiffness index as predictors of maintenance of sinus rhythm after cardioversion for atrial fibrillation: a prospective study. Cardiovasc ultrasound 10:48
Yoon YEY, Kim HJ, Kim SA, Kim SH, Park JH, Park KH, Choi S, Kim MK, Kim HS, Cho GY (2012) Left atrial mechanical function and stiffness in patients with paroxysmal atrial fibrillation. J Cardiovasc Ultrasound 20:140–145
Mont L, Elosua R, Brugada J (2009) Endurance sport practice as a risk factor for atrial fibrillation and flutter. Europace 11:11–17
Wilhelm M (2013) Atrial fibrillation in endurance athletes. Eur J Prev Cardiol 21:1040–1048
Guasch H, Benito B, Qi X, Cifelli C, Naud P, Shi Y, Mighiu A, Tardif JC, Tadevosyan A, Chen Y, Gillis MA, Iwasaki YK, Dobrev D, Mont L, Heximer S, Nattel S (2013) Atrial fibrillation promotion by endurance exercise: demonstration and mechanistic exploration in an animal model. J Am Coll Cardiol 62:68–77
Marrouche NF, Wilber D, Hindricks G, Jais P, Akoum N, Marchlinski F, Kholmovski E, Burgon N, Hu N, Mont L, Deneke T, Duytschaever M, Neumann T, Mansour M, Mahnkopf C, Herweg B, Daoud E, Wissner E, Bansmann P, Brachmann J (2014) Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA 311:498–506
Kuppahally SS, Akoum N, Burgon NS, Badger TJ, Kholmovski EG, Vijayakumar S, Rao SN, Blauer J, Fish EN, Dibella EV, Macleod RS, McGann C, Litwin SE, Marrouche NF (2010) Left atrial strain and strain rate in patients with paroxysmal and persistent atrial fibrillation. Relationship to left atrial structural remodeling detected by delayed-enhancement MRI. Circ Cardiovasc Inmaging 3:231–239
Suga H (1974) Importance of atrial compliance in cardiac performance. Circ Res 35:39–43
Hoit BD, Walsh RA (1992) Regional atrial distensibility. Am J Physiol 262:H1356–H1360
White CW, Kerber RE, Weiss HR, Marcus ML (1986) The effects of atrial fibrillation on atrial pressure-volume and flow relationships. Circ Res 51:205–215
Grant C, Bunnell IL, Greene DG (1964) The reservoir function of the left atrium during ventricular systole. Am J Med 37:36–43
Eshoo S, Semsarian C, Ross DL, Thomas L (2010) Left atrial phasic volumes are modulated by the type rather than the extent of left ventricular hypertrophy. J Am Soc Echocardiogr 23:538–544
Boyd AC, Ng AC, da Tran T, Chia EM, French JK, Leung DY, Thomas L (2010) Left atrial enlargement and phasic function in patients following non-ST elevation myocardial infarction. J Am Soc Echocardiogr 23:1251–1258
Abhayaratna WP, Fatema K, Barnes ME, Seward JB, Gersh BJ, Bailey KR, Casaclang-Verzosa G, Tsang TS (2008) Left atrial reservoir function as a potent marker for first atrial fibrillation or flutter in persons > or = 65 years of age. Am J Cardiol 101:1626–1629
Acknowledgments
The work has been awarded at EuroPrevent 2014 in Amsterdam as Best Poster in the field of Sports Cardiology. The authors wish to thank managers, athletes, medical and technical staff of the Teams involved in this project. A special thank to Italian Volleyball Federation and to Marco Mencarelli and Marco Paglialunga for their support.
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
D’Ascenzi, F., Pelliccia, A., Natali, B.M. et al. Increased left atrial size is associated with reduced atrial stiffness and preserved reservoir function in athlete’s heart. Int J Cardiovasc Imaging 31, 699–705 (2015). https://doi.org/10.1007/s10554-015-0600-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10554-015-0600-7