title: Subepicardial delayed gadolinium enhancement in asymptomatic athletes: let sleeping dogs lie?
abstract: BACKGROUND
  Subepicardial delayed gadolinium enhancement (DGE) patches without underlying cardiomyopathy is poorly understood. It is often reported as the result of prior silent myocarditis. Its prognostic relevance in asymptomatic athletes is unknown; therefore, medical clearance for competitive sports participation is debated. This case series aims to relate this pattern of DGE in athletes to outcome.
  
  
  METHODS
  We report on seven young asymptomatic athletes with isolated subepicardial DGE detected during workup of abnormalities on their regular screening examination, that is, pathological T-wave inversions on ECG (n=4) or ventricular arrhythmias on exercise test (n=3). All underwent a comprehensive initial investigation in order to assess left ventricular (LV) function at rest and exercise (exercise cardiac MRI and/or exercise echocardiography) and occurrence of arrhythmias (exercise test, 24 h-ECG Holter, electrophysiological study). All underwent a careful follow-up with biannual evaluation.
  
  
  RESULTS
  All athletes had extensive subepicardial DGE (12.0±4.8% of LV mass), predominantly in the lateral wall. Three athletes had non-sustained ventricular arrhythmias, whereas two of them had LV ejection fraction <50% at rest with no contractile reserve at exercise. During a follow-up of 3.0±1.5 years in the four remaining athletes, two had symptomatic ventricular tachycardia and one demonstrated progressive LV dysfunction. Hence, six of seven athletes had to be excluded from competitive sports participation.
  
  
  CONCLUSIONS
  Isolated large areas of subepicardial DGE in an asymptomatic athlete are not benign and require a careful evaluation at exercise and a strict follow-up. These findings question whether extreme exercise during silent myocarditis may facilitate fibrosis generation and adverse remodelling.
authors.affiliation: Department of Sport Medicine, University Hospital Pontchaillou, Rennes, France Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium.
authors.forename: Frédéric
authors.initials: F
authors.lastname: Schnell
authors.affiliation: Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium.
authors.forename: Guido
authors.initials: G
authors.lastname: Claessen
authors.affiliation: Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.
authors.forename: André
authors.initials: A
authors.lastname: La Gerche
authors.affiliation: Department of Radiology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium.
authors.forename: Jan
authors.initials: J
authors.lastname: Bogaert
authors.affiliation: Department of Radiology, University Hospital Pontchaillou, Rennes, France.
authors.forename: Pierre-Axel
authors.initials: PA
authors.lastname: Lentz
authors.affiliation: Department of Cardiovascular Imaging and Dynamics, University of Leuven, Leuven, Belgium.
authors.forename: Piet
authors.initials: P
authors.lastname: Claus
authors.affiliation: Department of Cardiology, University Hospital Pontchaillou, Rennes, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Mabo
authors.affiliation: Department of Sport Medicine, University Hospital Pontchaillou, Rennes, France.
authors.forename: François
authors.initials: F
authors.lastname: Carré
authors.affiliation: Hasselt University and Heart Center, Jessa Hospital, Hasselt, Belgium.
authors.forename: Hein
authors.initials: H
authors.lastname: Heidbuchel
mesh_terms: D000328:Adult; D001145:Arrhythmias, Cardiac / Q000175:diagnosis / Q000503:physiopathology; D053840:Brugada Syndrome / Q000473:pathology / Q000503:physiopathology; D000075224:Cardiac Conduction System Disease; D003287:Contrast Media; D042241:Early Diagnosis; D004562:Electrocardiography; D005260:Female; D005682:Gadolinium; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D009205:Myocarditis / Q000473:pathology* / Q000503:physiopathology; D013177:Sports / Q000502:physiology*; D016277:Ventricular Function, Left / Q000502:physiology; D020257:Ventricular Remodeling / Q000502:physiology; D055815:Young Adult
chemical_list: D003287:Contrast Media; D005682:Gadolinium
keywords: Athlete; Cardiology; MRI