Right ventricular assessment of the adolescent footballers heart: impact of ethnicity
Authors: Sivalokanathan S , Augustine D X , Sharma A , Willis J , Pearce K , Papadakis M , Sharma S , Malhotra A 
Published: October 2021

Abstract

Introduction
Athletic training often results in electrical and structural changes that may mimic phenotypical features of pathological cardiomyopathies. These physiological changes are influenced by age, ethnicity and sporting discipline. The presence of such changes that overlap with diseases implicated in exercise related sudden cardiac death may require comprehensive assessment to confirm or refute the presence of disease. One such potential physiological overlap with pathological change in athletes can occur in arrhythmogenic right ventricular dysplasia (ARVD), with features including chamber dilatation and T-wave inversion (TWI). An erroneous interpretation may have profound consequences ranging from false reassurance in a vulnerable athlete to unfair disqualification in a healthy individual. Therefore, it is important for the clinician to distinguish physiology from pathology.

Purpose
Studies detailing the physiological adaptation to exercise on the right ventricle (RV) of adolescent athletes are fewer compared to the left ventricle, with even fewer reports describing the impact of ethnicity on the RV. We set out to describe the normal dimensions of the RV of academy football players.

Results
ECG and echocardiographic data of 3000 academy male footballers were analysed, aged between 13 and 18 years old (mean age 16.4±0.5 years), who underwent mandatory cardiac screening. Ethnicity was categorised as white (n=1000), black (African/Caribbean; n=1000) and mixed-race (one parent white and one parent black; n=1000). ARVD major criteria for TWI was seen in 6.3% of the cohort. This was more prevalent in black footballers (3.7%) when compared to mixed race footballers (2%) or white footballers (0.6%), p&lt;0.05. In up to 67% of the overall cohort, RV values exceeded those for normal adult reference ranges. There were no differences in RV dimensions between ethnicities (Tables 1 & 2). If ARVD criteria was applied, 13.2% would fulfil major ARVD criteria for right ventricular outflow tract. This was also demonstrated for RVOT dimensions (6.1% - 23.6%; Figure 1). Overall, 0.2% of the cohort would fulfil diagnosis for “definite” ARVD and 2.2% would fulfil diagnosis for “borderline” ARVD. This was seen more frequently in black footballers (9.9%) than mixed race footballers (3.9%) or white footballer (0.6%), P=0.0005. Among athletes meeting definite or borderline ARVD criteria, no cardiomyopathy was identified after comprehensive clinical assessment.

Conclusion
This is the largest study to our knowledge that reports RV dimension data among adolescent footballers of different ethnicities. Right heart sizes in excess of standard adult ranges occurred in as many as one in 22 athletes. It is not unusual to observe values that would overlap with criteria for ARVD. As with LV parameters, variations in terms of ethnicity should be accounted for when considering RV dimensions and ECG changes when performing routine cardiac assessments of adolescent athletes.

Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): National Institute for Health Research