CMR Findings in Competitive Athletes Recovering From COVID-19

Quick Takes

  • This an observational study on CMR findings in collegiate athletes recently recovered from COVID-19 infection.
  • Without comparative control groups, the high-risk nature of the CMR abnormalities is difficult to interpret.
  • Nevertheless, this is a unique report and underscores the need to collect more data on the potential effects of COVID-19 on the heart.

Study Questions:

Does cardiac magnetic resonance imaging (CMR) in competitive collegiate athletes recovered from coronavirus disease 2019 (COVID-19) infection identify athletes at higher risk for return to play?

Methods:

The study cohort was comprised of all competitive athletes referred to Ohio State University’s sports medicine clinic between June and August 2020 after testing polymerase chain reaction (PCR) positive for COVID-19. All underwent CMR with cine, T1 and T2 mapping, extracellular volume (ECV) fraction calculation, and late gadolinium enhancement (LGE). Institutional normatives for T1, T2, and ECV were given in the Table. T2 and LGE were significant only if seen in two orthogonal planes. CMR was performed after a prescribed quarantine period. An electrocardiogram (ECG), serum troponin I, and transthoracic echocardiogram were performed on the day of the CMR.

Results:

Twenty-six athletes, 15 (58%) of which were male, representing football, soccer, lacrosse, basketball, and track and field, underwent CMR. Quarantined time was variable, between 11-53 days. Twelve athletes (27%) had mild symptoms (defined as shortness of breath, myalgias, fever); the rest had no symptoms. No athletes required hospitalization. There were no ECG or troponin I abnormalities. Left ventricular function was normal in all, although one patient (without myocarditis) had an ejection fraction of 33% by CMR, shown in the Table. Four athletes (15%; all male, two had symptoms), had elevated T2 signal and LGE, consistent with myocarditis by updated Lake Louise Criteria; two also had pericardial effusions. Another eight (31%) had LGE without T2 elevation, suggestive of prior myocarditis. In all, 42% (12/26) had LGE.

Conclusions:

CMR may be used for risk stratification in patients with COVID-19 related myocarditis; larger and longer studies with control groups are needed on CMR findings in competitive athletes.

Perspective:

This is a unique observational report of CMR findings in collegiate athletes recovered from COVID-19 infection. The high rate of LGE (42%) is similar to the 38% seen in a recent study of 93 healthy triathletes (Domenech-Ximenos B, et al., J Cardiovasc Magn Reason 2020;Sep 3:[Epub ahead of print]).

A major limitation of this study is the lack of controls, acknowledged by the authors. While the findings of LGE are concerning, and along with T2 changes are potentially suggestive of myocarditis, it is hard to conclude these are indeed high-risk findings without pre-COVID-19 CMRs (self controls) and without comparative groups such as matched healthy athletes and/or matched athletes with another type of viral infection. In addition, the Lake Louise Criteria are meant for evaluating those with suspected myocardial inflammation; however, the athletes in this study had minimal or no symptoms, normal troponin I, and normal echocardiograms. The authors acknowledged that physiologic adaptation could be responsible for the CMR findings but concluded that the four with elevated T2 signal were most likely pathologic. The wide range of quarantine times might have also affected the degree of inflammation detected. Additionally, follow-up data (e.g., repeat CMR, exercise stress testing, ambulatory ECG monitoring) are not provided.

While this study adds to emerging data, it does not imply that CMR should be performed in all COVID-19 positive patients to screen for myocardial inflammation. A large longitudinal study with proper control groups is needed to guide evolution of recommendations for resumption of sport after COVID-19 infection.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pericardial Disease, Prevention, Sports and Exercise Cardiology, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Sports and Exercise and Imaging

Keywords: Athletes, Coronavirus, Contrast Media, COVID-19, Diagnostic Imaging, Echocardiography, Electrocardiography, Gadolinium, Magnetic Resonance Imaging, Myalgia, Myocarditis, Pericardial Effusion, Primary Prevention, Quarantine, Sports, Troponin I, Ventricular Function, Left


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