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ORIGINAL ARTICLE
Year : 2015  |  Volume : 15  |  Issue : 1  |  Page : 74-81

Functional and structural changes in soccer players' heart and the risk for sudden cardiac death


1 Department of Cardiac Technology, College of Applied Medical Sciences, University of Dammam, Dammam, Saudi Arabia
2 Department of Physiotherapy, College of Applied Medical Sciences, University of Dammam, Dammam, Saudi Arabia
3 Department of Health Information Management, College of Applied Medical Sciences, University of Dammam, Dammam, Saudi Arabia

Date of Web Publication19-Jan-2015

Correspondence Address:
Ayman M Azoz
University of Dammam, P.O BOX 2435, Dammam - 31451
Saudi Arabia
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DOI: 10.4103/1319-6308.146352

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  Abstract 

Background: Regular exercise in athletes is associated with cardiac acclimation in the form of functional and structural changes. Its effect on the cardiac functions still debated. Objective: The objective was to detect the impact of long-term regular physical exercise on the cardiac systolic and diastolic function of soccer players. Materials and Methods: Thirty professional soccer players were examined twice, the first examination was made during the passive resting period before the beginning of the season (measurement I) and the second during the peak of the season (measurement II). At both examinations, players underwent electrocardiogram (ECG), conventional Echo-Doppler, pulsed tissue Doppler imaging on both septal and lateral sides of the mitral annulus and lateral tricuspid annulus. The (propagation velocity [Vp]) values were measured. Paired t-test was used for comparison. Results: The following changes between measurement I and measurement II were found: ECG Changes; 80% of the entire group showed early repolarization, 93% had left ventricular hypertrophy (LVH) by voltage criteria, 20% showed right atrial abnormalities, 20% left atrial abnormalities, 40% showed inverted T-wave in leads V1-V4, 5% showed mobitz type I second degree heart block, and 5% showed incomplete right bundle branch block. Echo changes; The mitral E/E` ratio increased from 6.18 ± 1.27 to 6.91 ± 1.18; the Vp decreased from 56.3 ± 9.23 to 50.67 ± 8.6; the tricuspid valve Ratio between the early and late peak pulsed Doppler velocities on tricuspid valve decreased from 1.67 ± 0.23 to 1.54 ± 0.23 while the E`/A` ratio decreased from 1.67 ± 0.53 to 1.28 ± 0.49; the (isovolumetric relaxation time) of the right ventricle increased from 52.4 ± 11.33 to 58.17 ± 10.73; the (isovolumetric contraction time) decreased from 70.47 ± 9.9 to 65.2 ± 7.9. All changes were statistically significant at P < 0.001. Conclusions: Long-term regular exercise in soccer players is associated with cardiac alterations in the form of bradycardia, early repolarization, inverted T-wave, concentric LVH, and a tendency toward diastolic impairment of both ventricles.

  Abstract in Arabic 

الخلفية: ممارسة الرياضة البدنية بإنتظام ولفترات طويلة قد تؤدي الي حدوث تغيرات شكلية ووظيفية في عضلة القلب ... هذه التغيرات قد تكون حميدة وقد تؤدي الي خطورة الاصابة بالموت المفاجئ وظل تفسير هذه التغيرات محور خلاف بين العلماء والاطباء علي مر السنوات الماضية ، وفي الاونة الاخيرة انتشرت حالات الموت المفاجئ بين لاعبي كرة القدم اثناء المباريات مما ادي الي زيادة الاهتمام بدراسة الاسباب المؤدية الي ذلك. الاهداف: دراسة تأثير ممارسة الرياضة البدنية المنتظمة لفترات طويلة على كفاءة القلب الانقباضية والانبساطية في لاعبي كرة القدم. المواد وطرق البحث: اجريت الدراسة علي عدد 30 لاعب كرة قدم من المحترفين بالاندية السعودية بالمنطقة الشرقية وتم فحص اللاعبين مرتين ، الفحص الاول اثناء الراحة السلبية قبل بداية الموسم الرياضي والفحص الثاني في منتصف الموسم الرياضي بعد بلوغ اللاعبين ذروة اللياقة البدنية . وفي كلا الفحصين تم عمل تخطيط للقلب وموجات فوق صوتية علي القلب (ايكو) وقياس الدوبلار النسيجي علي الصمام الميترالي والصمام ذو الثلاث شرفات . وتم استخدام اختبار "تي" (paired t test) لمقارنة. النتائج: النتائج: اشارت نتائج الدراسة لحدوث التغيرات الاتية:- بالنسبة لتخطيط القلب وجد ان 93% من اللاعبين حدث عندهم تضخم في عضلة القلب خاصة البطين الايسر ، 20% عانوا من تضخم الاذين الايسر بينما 20% عانوا من تضخم الاذين الايمن ، 40% من اللاعبين عانوا من انعكاس في قطبية الموجة تي "T wave Inversion" 5% عانوا من سدة كهربائية درجة ثانية " Mobitz type I second degree heart block " و5% عانوا من انسداد غير كامل بالضفيرة الكهربائية اليمني للقلب "incomplete RBBB " .بعض هذه التغيرات قد تؤدي الي زيادة فرصة حدوث الموت المفاجئ بين هؤولاء اللاعبين بالنسبة للموجات الصوتية اوضحت الدراسة وجود تغيرفي كفاءة القلب الانبساطية لكلا من البطين الايسر والايمن وتغير في الكفاءة الانقباضية للبطين الايسر ، مع وجود اتجاه نحو اختلال الكفاءة الانبساطية لكلا البطينين وهو مما يزيد من مخاوف الاصابة بالموت المفاجئ لبعض اللاعبين. التوصيات: اوصت الدراسة بضرورة عمل فحوصات دورية لقلب اللاعبين قبل المشاركة في الالعاب التنافسية وضرورة وضع الية واستراتيجية لعمل فحص ومسح طبي للاعبين علي جميع المستويات طبقا لما اقرته التوصيات الدولية في هذا المجال




Keywords: Athletes, football players, left ventricle dysfunction, right ventricle dysfunction, sudden cardiac death


How to cite this article:
Azoz AM, Alshehri AM, Shaheen HA, Farrag YA, Muaidi QI, Youssef AA. Functional and structural changes in soccer players' heart and the risk for sudden cardiac death. Saudi J Sports Med 2015;15:74-81

How to cite this URL:
Azoz AM, Alshehri AM, Shaheen HA, Farrag YA, Muaidi QI, Youssef AA. Functional and structural changes in soccer players' heart and the risk for sudden cardiac death. Saudi J Sports Med [serial online] 2015 [cited 2019 Aug 20];15:74-81. Available from: http://www.sjosm.org/text.asp?2015/15/1/74/146352


  Introduction Top


In the last few years, the sports world specially the International Olympic Committee and the Fèderation Internationale de Football Association were shocked due to repeated attacks of sudden cardiac death (SCD) among athletes. These increased incidents of SCD led the researchers to focus their attention regarding the causes of sudden deaths in trained young athletes. Hypertrophic cardiomyopathy (HCM) constitutes about 36% of cardiac causes of death in athletes; while the left ventricular hypertrophy (LVH) associated with increased cardiac mass without signs of HCM constitutes about ten percent. [1] Regular exercise training induced LVH was found to be a benign adaptation and its effect on the ventricular diastolic function is different from that induced by pathological hypertrophy. [1],[2] Previous study demonstrated that status post prolonged exercise; the left ventricle (LV) may suffer a reduction in its systolic and/or diastolic function. [3] On the other hand, the effect of exercise on the right ventricle (RV) function is controversial; some studies suggested that the RV may show earlier and obvious signs of cardiac dysfunction, [4],[5],[6] while other studies underestimated this effect due to difficulties in obtaining efficient and precise data from the RV. [3] In the last few years, the dependence on the tissue Doppler imaging (TDI) and propagation velocity (Vp) in evaluation of the myocardial function was increased. This is because the TDI is more accurate than the traditional Doppler in evaluation of myocardial velocities. [7] The advantage of the Vp in assessment of the LV function is because it does not pseudo-normalize and not affected by the preload and correlates well with the time constant of isovolumetric relaxation and peak negative dp/dt. [8] Although the TDI and Vp have a superior sensitivity in the detection of ventricular dysfunction in clinical practice, their application in athletes and sports medicine is still scarce. [7] The purpose of the current study was to detect the impact of long-term regular physical exercise on both the RV and LV systolic and diastolic function of soccer players, to assess cardiac structural adaptation in response to exercise training in this specific type of sports setting and to detect the impact of long-term regular exercise on the electrocardiogram (ECG) changes, and detect abnormalities that increase the risk for SCD.


  Materials and methods Top


Methods

This research project was approved by the deanship of scientific research at the University of Dammam as a grant number 2011054.

Subjects

We enrolled 30 full-time male soccer players from two Saudi sports clubs in the Eastern region. The training protocol included both isotonic dynamic exercise (3 h/day, 6 days a week) and isometric static exercise (maximum 2 h/week). The players had been training for more than 15 h/week for at least 5 years. Written consent and legal approval had been taken from both the soccer players and the sports clubs. These players were screened twice, first during the passive resting period between two seasons and we referred to this as (measurement I) and the second during the summit of fitness before the end of the seasons and we referred to this as (measurement II). The players underwent general and local clinical exanimation in the form of pulse, temperature, blood pressure, body weight, height, body mass index, and body surface area (BSA). Furthermore, they underwent:

Resting electrocardiogram

With special emphasis on the T-wave changes, early repolarization patterns, and conduction abnormalities.

Traditional echocardiography

Two dimensional echocardiography was performed. Gain, depth, and frequency were adjusted to provide optimal endocardial delineation. Two dimensional images were obtained in the parasternal long and short axis views and apical two and four chamber views. LV diameters and area were measured according to the criteria provided by the American Society of Echocardiography. [9] The LV ejection fraction was estimated according to the LV volumes evaluated by the biplane method of disks (modified Simpson's rule) and the left ventricular mass (LV mass) was calculated using the Deveraux formula. [10] LV mass = 0.8 × (1.04 [Left ventricular end diastolic pressure [LVEDd] + posterior wall thickness [PWTD] + septal wall thickness] 3 - (LVEDd) 3 ]) +0.6 g and the left ventricular mass index (LVMI) was calculated by dividing LV mass by BSA. In order to define/classify the type of hypertrophy, relative wall thickness dimension (RWTd) was calculated according the following formula: RWTd = 2 × PWTD/LVEDd. LV geometry was classified into four patterns based on an upper normal limit for LVMI of 124 g/m 2 and RWTd of 0.44. [11]

  • Concentric hypertrophy (increased LVMI and RWTd)
  • Eccentric hypertrophy (increased LVMI and normal RWTd)
  • Concentric remodeling (normal LVMI and increased RWTd)
  • Normal geometry (normal LVMI and normal RWTd).


Traditional Doppler echocardiography

In the apical four chamber view, a 3 mm sample gate was positioned at the tips of the mitral and tricuspid valves. All measurements were made at the end of expiration. The following pulsed Doppler trans-mitral and trans-tricuspid flow velocity parameters were evaluated: peak E, peak A, the Ratio between the early and late peak pulsed Doppler velocities on tricuspid valve (E/A) ratio, and these were averaged over three consecutive cardiac cycles. [12]

Pulsed wave tissue Doppler imaging

Pulsed wave TDI was performed by bypassing the high-pass filter while setting the gains to a minimal value to obtain best signal to noise ratio. In the apical two and four chamber views, the 2 mm pulsed Doppler sample volume was placed in two regions of the mitral annulus (lateral and septal) and also within the lateral aspect of the tricuspid annulus, ensuring best alignment between wall motion and the ultrasound beam. The following measurement were taken: Peak systolic velocity (s), peak early diastolic (E`), peak late diastolic (A`), and the E`/A` ration. Further, pulsed Doppler and TDI data were combined in the calculation of the E/E` ratio.

Color M-mode Doppler study

Recordings were obtained by placing the M mode cursor through the center of the mitral inflow region in the apical four-chamber view and the Doppler color scale was adjusted for aliasing. The VP value was obtained by measuring the slope delineated by the first aliasing velocity from the mitral tips toward the apex. [12] The LV filling pressure (LVFvp) was calculated according to the formula LVFvp = 5.9 (E/Vp) + 2.5 mmHg. [13]

Statistical analysis

All clinical and echocardiographic parameters were analyzed as continuous variables and presented as mean and standard deviation. Paired t-test was used to compare these parameters during the two study periods. A P < 0.001 was considered to be statistically significant to adjust for multiple comparisons.


  Results Top


Baseline and mid-season clinical characteristics of the study measurements are shown in [Table 1]. Our study group consisted of young players with a mean age of 23 ± 3 years. Duration of playing soccer was 15 ± 4 years.
Table 1: Baseline and mid‑season clinical characteristics of the study measurements

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Electrocardiogram characteristics

The basic rhythm of the entire study group was sinus rhythm with a main heart rate of 59 ± 4 versus 55 ± 5 in measurements I and II, respectively. Five percent of the cases showed mobitz type I second degree heart block and 5% show incomplete right bundle branch block (RBBB). Ninety-three percent of the entire study group showed LVH by voltage criteria and 80% showed early repolarization; while only 40% showed inverted T-wave in leads V1-V4 and 20% showed right arterial abnormalities and 20% left atrial abnormalities. The main QTc was 423.5 ± 15.4 while the PR interval was 170 ± 24.6.

Echocardiography results

Baseline and mid-season M-mode and two-dimensional echocardiographic data are shown in [Table 2]. The Doppler measurements over both the mitral and tricuspid valves are presented in [Table 3] and [Table 4]. The LV geometry in both measurements I and II is presented in [Figure 1] while [Figure 2] and [Figure 3] present the percent of changes in echo-Doppler parameters in both the LV and RV functions. The LV ejection fractions were within normal limits.

Our study revealed that after regular exercise, the LVMI measurement significantly increased from 134.46 ± 29.9 to 172.66 ± 29.8 (P < 0.001) and the percent of change was + 28.4%, while the R-wave detection increase by 9.3% from 0.43 ± 0.08 to 0.47 ± 0.08 (P < 0.001) and the main LV geometry changes was concentric LVH.
Figure 1: Left ventricle geometry in measurement I and II

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Figure 2: Percent changes in the left ventricular function from the baseline (LVMI*: Left ventricular mass index; RWTD†: Relative wall thickness; E/A Ratio Mitral‡: Ratio between the early and late peak pulsed Doppler velocities on mitral valve; E' septal§: Early peak tissue velocity of the septal part of
mitral annulus; E/E' ǀǀ: Ratio between pulsed Doppler mitral flow in early diastole and early diastolic mitral annulus velocity; A' septal¶: Late peak tissue velocity of the septal part of the mitral annulus; E'/A'#: The ratio of early to late peak tissue velocity of the mitral annulus; E'Lateral**: Early peak tissue velocity of the lateral side of the mitral annulus; Vp††: Propagation velocity; LVF Vp ‡‡: LV filling pressure. Values in the table are mean ± standard deviation)


Click here to view
Figure 3: Percent changes in the right ventricular function from the baseline (E/A tricuspid*: Ratio between the early and late peak pulsed Doppler velocities on tricuspid valve; E'†: Early peak tissue velocity of the tricuspid annulus; A'‡: Late peak tissue velocity of the tricuspid annulus; E'/A'§: The
ratio of early to late peak tissue velocity of the tricuspid annulus; IVRTǀǀ: Isovolumetric relaxation time; IVCT¶: Isovolumetric contraction time; Sa#: Peak systolic tricuspid annular velocity. Values in the table are mean ± standard deviation)


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Table 2: Baseline and mid‑season M‑mode and two dimensional echocardiographic of the LV

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Table 3: Echocardiographic results in the study group on the mitral valve

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Table 4: Echocardiographic results in the study group on the tricuspid valve

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Table 5: Common physiological and pathological ECG changes in athletes

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Doppler finding of the mitral valve

We observed a significant reduction in the trans-mitral E/A ratio in measurement II compared to measurement I after reaching the peak of exercise fitness 2.01 ± 0.49 versus 1.85 ± 0.046 (P < 0.001) with percentage change of − 8%.

Tissue Doppler finding on the mitral valve

In our study, the E` septal significantly increased from 0.1.3 ± 0.02 in measurement I to 0.14 ± 0.02 in measurement II (P < 0.001) with percent of change 7.7%. While the A` significantly increased by 14.3% from 0.07 ± 0.01 in measurement I to 0.08 ± 0.01 in measurement II (P < 0.001) which is reflected on the E`/A` septal ratio which showed a reduction from 2.08 ± 0.61 in measurement I to 1.83 ± 0.45 in measurement II, percentage reduction of 12% (P = 0.005). The E/E` ratio which is a predictor of LVFvps is significantly increased by 11.8% from 6.18 ± 1.27 to 6.91 ± 1.18 in measurement II (significant at P < 0.001).

Color M-mode propagation velocity

In our study, the Vp is decreased by 10% from 56.3 ± 9.23 in measurement I to 50.67 ± 8.6 in measurement II (P < 0.001) and about 26.7% of measurement II their Vp decreased below 45 cm/s with a P ≤ 0.001.

Right ventricle changes

In our study, we observed a significant reduction in the E/A ratio of the tricuspid valve by 7.8% from 1.67 ± 0.23 in measurement I to 1.54 ± 0.23 in measurement II (
P < 0.001).

Tissue Doppler finding on the tricuspid valve

The E` decreased by 14.3% from 0.14 ± 0.02 in measurement I to 0.12 ± 0.02 in measurement II (P = 0.004). Meanwhile, the A` significantly increased by 11.1% from 0.09 ± 0.02 in measurement I to 0.10 ± 0.02 in measurement II (P < 0.001) which was reflected in the E`/A` ratio which also showed a significant reduction by 23.4% from 1.67 ± 0.53 in measurement I to 1.28 ± 0.49 in measurement II (P < 0.001). In our study, the Sa is obviously decreased from 0.13 ± 0.02 in measurement I to 0.12 ± 0.03 measurement II (P < 0.001) with percentage reduction of 7.7%.

Isovolumetric relaxation time

In our study, the isovolumetric relaxation time (IVRT) of the RV significantly increased from 52.4 ± 11.33 in measurement I to 58.17 ± 10.73 in measurement II (P < 0.001) with a percentage increase of 11%. The isovolumetric contraction time (IVCT) of the RV significantly decreased by 7.5% from 70.47 ± 9.85 in measurement I to 65.2 ± 7.92 in measurement II (P < 0.001).


  Discussions Top


The results of our study showed that long-term regular exercise in soccer player is associated with physiological changes expressed in the ECG as sinus bradycardia, isolated LVH by voltage criteria, incomplete RBBB, and early repolarization and pathological ECG changes in the form of Inverted T-wave more than 5 mm depth from V1 to V4 and atrial abnormalities. Our study also showed morphological cardiac changes by echocardiography in the form of concentric LVH, and alteration of the RV and LV diastolic function toward impaired relaxation. Although the Doppler changes were not extensive enough to be graded as grade I diastolic dysfunction, but the Vp clearly demonstrated a diastolic dysfunction of the LV after exercise. It was clear that the RV systolic function shows significant changes without changes of the LV systolic function.

Effects of long term exercise on the electrocardiogram of athletes

Electrocardiogram changes in athletes are common and usually reflect the physiological and pathological changes which associated with prolonged exercise. These changes are summarized in [Table 5]. [14] Early repolarization is a common ECG finding that sought to be a benign condition, but recent studies [15],[16] suggested that early repolarization particularly in the inferior leads is associated with increased risk of SCD. In our study, about 80% of the entire group showed early repolarization. Pelliccia et al. [17] followed-up 81 athletes with remarkable early repolarization and normal echocardiography for nine years; they reported two cardiac arrests, one of which was fatal. On the other hand, Haοssaguerre et al. [18] reviewed the prevalence of early repolarization in 206 cases who survived SCD due to idiopathic ventricular fibrillation (VF), they found that early repolarization was more common in patients suffered from idiopathic VF than the control group. Non-voltage ECG criteria for LV hypertrophy (Estes criteria) are not usually seen in athletes and the presence of these ECG abnormalities raise the suspicion for underlying cardiac pathology, e.g. HCM, aortic valve disease, hypertension. On the other hand, an isolated LVH is a very uncommon finding in HCM patients. [14] Our study revealed that about 93% had LVH by voltage criteria (Sokolow-Lyon criteria) [19] and 20% had left atrial abnormalities and 20% had right atrial abnormalities. T-wave inversions in leads V1-V3 in young athletes <16 years are relatively common and may represent the juvenile pattern while T-wave inversions in adult athletes >16 years in the inferior/lateral leads or beyond V2 is relatively rare [20] and constitute only about 3-4% [21] and it raise the suspicious of HCM [22] and arrhythmogenic right ventricular cardiomyopathy (ARVC) and more investigation is needed to confirm it. [23] Our study revealed that about 40% of measurement II showed an inverted T-wave in the right chest leads (VI-V3); this is consistent with two large Italian prospective observational studies [24],[25] which showed that young athletes frequently have inverted T-wave in the right chest leads (V1-V4), similar to ARVC. Pelliccia et al. [17] followed-up 81 athletes who showed ECG changes in the form of inverted T-waves without obvious structural heart disease, they found five cases having cardiomyopathy, three of them proved to have HCM.{Table 5}

Effects of long-term exercise on the left ventricle function of athletes

Asymptomatic diastolic dysfunction may be an early marker of an increased risk of symptomatic heart failure and subsequent death while patients with obvious diastolic dysfunction are more prone to ventricular arrhythmias and SCD. [26] According to the American society of echocardiography guidelines, [12] there is a significant association between E` and LV relaxation and a Vp >50 cm/s is associated with normal diastolic function, while E/Vp ≥2.5 predicts pulmonary capillary wedge pressure (PCWP) >15 mm Hg. Our study revealed that there is morphologic alteration in the LV in the form concentric LVH (63% of the cases) and 30% eccentric LVH. The E/E` ratio has been reported to be an excellent noninvasive assessment of PCWP, and thus an indirect assessment of the preload and LV diastolic function, an E/E` <8 indicates normal LV mean diastolic pressure while E/E` >15 indicates increased LV pressure. [12] Our study showed increases in the E' and A' velocities of the mitral valve and a significant increase of the E/E' ratio by 11.8% which in spite of being within the normal range they indicated a tendency toward impaired LV relaxation. Recently, the color M-mode Vp has emerged as a relatively preload independent tool for studying the LV diastolic function and its normal value in adult person should be >50 cm/s. [27] Our study revealed that overall Vp measurement was markedly reduced by 10% from 56.3 ± 9.23 in measurement I to 50.67 ± 8.6 in measurement II, furthermore, 26.7% of the players in measurement II showed a decrease in the Vp measurement below 45 cm/s indicating LV diastolic dysfunction according to the American Society of Echocardiography Guidelines. [12] Aaron et al. [28] studied the cardiac change in organized team athletes and they found that the endurance athlete group had dilatation in both atria and ventricles associated with increment in biventricular function, while the strength athlete group experienced concentric LVH with reduction in the LV diastolic function without changes in the atrial dimension or RV function and structure. In contrast, Tumuklu et al. [29] studied 24 professional soccer players and twenty healthy male controls. They concluded that in spite of morphological changes that happened in both the LV and LA, there was improvement in the left ventricular diastolic function that detected by TDI and Vp.

Effects of long-term exercise on the right ventricle function of athletes

Our study revealed that endurance exercise in professional soccer players is associated with RV diastolic impairment expressed as a reduction in the E/A ratio of the tricuspid valve, reduction of the E' velocity, elevated A' velocity, and marked reduction of the E'/A' ratio, these results are consistent with other published studies [4],[5],[6] which suggested that the RV may show earlier or more evident signs of exercise-induced cardiac dysfunction in well-trained athletes after opposition. The Sa is a simple parameter to evaluate the RV basal free wall and it advised to be used in the assessment of the RV systolic function, especially in a younger adult. [30] In our study, the Sa is significantly decreased by 7.7% and this strongly correlates with tendency toward impaired RV systolic function. Oxborough et al. [31] examined 35 marathon runners and they found obvious diastolic dysfunction in both ventricles without significant changes in the systolic function after a marathon race. Impaired RV relaxation leads to prolongation of the IVRT with subsequent delay in the tricuspid valve opening and prolongation of the deceleration time of early filling. [30] In our study, the IVRT of the RV is significantly increased from 52.4 ± 11.33 in measurement I to 58.17 ± 10.73 in measurement II with a percentage increase of 11%. The IVCT of the RV is significantly decreased by 7.5% from 70.47 ± 9.85 in measurement I to 65.2 ± 7.92 in measurement II. In the other hand, Erol and Karakelleoglu. [32] studied 36 highly trained male athletes and 16 normally active age-matched control subjects. They concluded that athletes with or/without LVH have similar RV systolic and diastolic parameters, for which they suggested that these LVH changes are normal physiological adaptation to prolonged training.


  Conclusions Top


Our study revealed that long-term regular exercise in professional soccer players is associated with physiological and morphological changes in the form bradycardia, early repolarization, LVH, Rt, and Lt atrial abnormalities and inverted T-wave in the ECG, concentric LVH, and alteration of both systolic and diastolic function of the RV and only diastolic function of the LV by echocardiography. These changes could increase the risk of SCD and long-term follow-up is recommended.


  Recommendation Top


Although our study group was relatively small, our results have demonstrated the importance of pre-participation screening for athletes and the advantage of the new echocardiographic modalities of interpretation. We recommend the use of tissue Doppler and color M-mode Vp as a standard examination in echocardiography to assess the cardiac diastolic functions.


  Acknowledgment Top


The authors would like to thank Al-Qadesia and Al-Etifaq sports clubs for their cooperation. We would also like to thank the Saudi Federation of Sports Medicine for their support. We are grateful for Mr. Omar Al-Omar and Mr. Ahmed Mansy for their assistance in the project. The authors greatly appreciate the continuous support of the Deanship of Scientific Research at the University of Dammam.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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