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Funding Acknowledgements Type of funding sources: None. Background Several determinants affect cardiac remodelling in athletes, including sport discipline, body size and sex. Recently, interest in myocardial deformation (MD) imaging as reliable functional index is growing. Available MD data are usually derived by echocardiography and mostly related to the evaluation of the left ventricle. Data on right ventricle (RV) deformation assessed by CMR are lacking and, currently, specific reference values in athletes have not been explored. Purpose To assess RV deformation in a cohort of Olympic athletes and to evaluate possible inter-individual differences related to type of sport and sex. Methods A cohort of Olympic athletes with unremarkable cardiovascular pre-participation screening tests was enrolled. A group of sedentary individuals was also enrolled for comparison. All subjects underwent CMR without contrast. Cine-images were post-processed to assess RV volume, ejection fraction (EF) and MD by computing global longitudinal strain (GLS) by feature-tracking software. Athletes were divided in subgroups based on sex, ESC sport classification and RV enlargement (RVEDV/LVEDV>1 or ≤1). Results 265 Olympic athletes (15% skill, 19% power, 25% mixed, 41% endurance; 58% male) and 21 sedentary controls were enrolled. Endurance athletes showed the greatest RV remodeling in terms of volumes (Table). No differences in RV-EF were found comparing athletes of different sport categories, but between athletes and sedentary controls. Median value of RV-GLS of the whole athletic cohort was -23 (-21, -25). There were no significant differences among the different sport disciplines other than endurance vs. sedentary controls for RV-GLS. Female athletes showed higher values of RV-GLS when compared with males. When examined with regard to presence of RV enlargement, no differences were observed (Figure). Conclusion Endurance athletes showed the greatest right ventricle remodelling in terms of RV volumes and function. Specifically, they showed the highest values of RV volumes and the lowest values of RV-GLS of the entire athlete’s population, but still within the normal range. Female athletes had higher RV-GLS values when compared with males. No difference was observed between athletes with dilated RV compared to non-dilated RV.

Funding Acknowledgements Type of funding sources: None. Background Athlete’s heart is associated with a physiological electrical and structural remodelling induced by training. While several data have been published in male athletes, data on female competitive athletes, and their comparison with male counterparts or sedentary women, are still inconclusive. Objectives This study aimed to analyze the electrical, structural, and functional cardiac remodelling in female and male competitive athletes and sedentary controls. Methods Competitive athletes were evaluated by 12-lead resting ECG and echocardiography and compared to the sedentary controls. Results The study population was composed of 1,096 individuals (360 female Olympic athletes, 410 male Olympic athletes, 130 sedentary women and 196 sedentary men). Female athletes had lower resting heart rate, longer PR interval, higher voltage of P, R, and T waves and more frequently incomplete RBBB, left ventricular (LV) hypertrophy, early repolarization, and anterior T-wave inversion as compared with non-athletes. Biventricular dimensions and LV wall thickness were greater in female athletes as compared to non-athletes. However, women showed a lower degree of training-induced structural remodelling than men. A progressive increase in biventricular dimensions and LV wall thickness was observed from athletes engaged in skill and power to those practicing mixed and endurance disciplines. However, in women, but not in men, the type of sport did not significantly influence ECG remodelling. Conclusions Highly-trained women demonstrate a relevant training-induced electrical and structural remodelling. However, the type of sport did not influence ECG parameters in women while it impacted on biventricular remodelling, with female endurance athletes showing the greatest degree of adaptation.

Funding Acknowledgements Type of funding sources: None. Background Cardiac Magnetic Resonance (CMR) represents the gold standard for morpho-functional assessment and for myocardial tissue characterization. Although Mapping technique provided added value to tissue characterization, data on Mapping in athletes are still scarce and differences between sport disciplines have not been evaluated. Purpose To compare T1 and T2 Mapping values between Olympic Athletes engaged in different types of sport and a control group of sedentary subjects. Methods A group of Olympic athletes with unremarkable cardiovascular pre-participation screening prior the Olympic games underwent CMR without contrast administration. A group of sedentary subjects was enrolled as a control group. Cine, native T1 and T2 Mapping were analyzed. Athletes were divided in different sports categories according to the ESC classification. Results 265 Olympic athletes (15% skill, 19% power, 25% mixed, 41% endurance - 58% male) and 21 controls were enrolled. Comparing athletes of different sport categories and sedentary controls, endurance presented the lowest value of T1 Mapping. T2 Mapping was slightly higher in endurance athletes but were within normal limits (referred to local normal range) (Table). Compared with males, female athletes had higher values of T1 native myocardial Mapping [956 (934-981) vs 941 (926-963); p=0,004], while there were no significant differences regarding T2 Mapping values (p=0,874) (Figure). Conclusion T1 was lower and T2 Mapping slightly higher athletes engaged in endurance compared to other sport disciplines and sedentary controls. Female athletes showed higher T1 native myocardial Mapping compared with males, while T2 Mapping did not show differences.

Funding Acknowledgements Type of funding sources: None. Background Intense and prolonged exercise training induces morpho-functional cardiac changes, known as "athlete’s heart". The physiologic nature of this cardiac remodeling has been questioned and data on reversibility of cardiac remodeling, especially of the right ventricle (RV), after the suspension of high intensity training are scarce. Purpose To describe cardiac morpho-functional changes by echocardiography in a group of Olympic athletes prior the Olympic games (T1) and years after cessation of their competitive athletic career (T2). Methods Endurance athletes evaluated prior their participation to the Olympic games (edition 2004-2008-2012) and after cessation of their athletic career (> 3 years of cessation of intensive exercise training) were invited to be evaluated at our Institute. 12-lead ECG, exercise ECG test and echocardiogram were performed. Echocardiogram parameters at T1 and T2 were compared including left ventricle (LV) and RV dimension, systolic and diastolic function. Results 25 athletes were enrolled (mean age 47±2 years). The mean time from the end of their agonistic activity was 12 ± 7 years. No differences in terms of LV dimensions and function were observed (Table). Veterans showed a significant decrease in RV dimensions and improvement in function at T2 compared to T1. Conclusion After suspension of competitive training, Veteran athletes showed reverse remodeling of the right ventricle compared with the evaluation during the peak training by echocardiography.

Funding Acknowledgements Type of funding sources: None. Background Athletes of endurance disciplines present the highest level of cardiac remodelling often generating concerns for differential diagnosis with cardiomyopathies. In addition to standard morpho-functional evaluation, left ventricle (LV) myocardial deformation (MD) and estimated intra-ventricular hemodynamic forces (HDFs) are emerging diagnostic tools, particularly in heart failure patients. In the athletic population MD data are scarce while HDFs are lacking. Purpose To describe MD and HDFs evaluated by CMR feature-tracking in a cohort of endurance Olympic athletes and to evaluate the possible relationship with LV geometry. Methods A group of endurance Olympic athletes evaluated prior the Olympic games and with unremarkable cardiac pre-participation screening tests was enrolled. All athletes underwent CMR without contrast administration. Cine images were post-processed to evaluate end-diastolic and end-systolic LV volumes, ejection fraction (LVEF), global longitudinal and circumferential strain (GLS and GCS) and estimated HDFs by a dedicated feature-tracking software. HDFs were measured in apex-base (AB) and latero-septal (LS) directions, over the entire cardiac cycle, in systole and diastole. LS/AB ratio was also derived to determine forces distribution. Athletes were divided in subgroups according to the 3D sphericity index (< 40% or 40%). A group of sedentary subjects was enrolled as a control group. Results 109 endurance Olympic athletes (62% male; mean age 26 ± 5 years) and 21 sedentary subjects were enrolled. Athletes with increased sphericity index (≥40%) were 61 (56%) and presented with greater EDV, ESV and lower LVEF compared to those without increased sphericity and controls (Table). No significant differences were found between athletes and controls regarding LV-GLS and GCS. HDFs distribution was not different between groups and even athletes with a more spherical LV shape showed an HDFs diastolic ratio comparable to those of athletes with lower sphericity index and control. Conclusion Although more than half of endurance athletes presented with altered geometry (increased sphericity index), strain parameters and hemodynamic forces were not different from sedentary controls and those athletes without increased sphericity. The use of advanced parameters to evaluate cardiac function could be used as a tool to confirm the benign nature of cardiac adaptation due to intense exercise training.

Funding Acknowledgements Type of funding sources: None. Background Cardiac magnetic resonance (CMR) provides an effective contribution for the prevention of sudden cardiac death with its ability to provide accurate information on morpho-functional abnormalities and on myocardial tissue characterization. However, data on its utility in clinical scenario in the competitive athletes are limited to selected cohort of patients with complex arrhythmias. Objective To retrospectively analyze all the CMR performed at our center for evaluating the predictors of positive CMR findings in a large cohort of competitive and non-competitive athletes presenting with different clinical indications. Methods Over a period of 30 months all the CMR performed on athletes aged > 14 years and training for at least 5 hours per week at our Institutes were retrospectively recruited. The following data were also collected: medical history, ECG, echocardiography, exercise testing. CMR were categorized as "positive" or "negative" based on the presence or absence of late gadolinium enhancement (LGE, excluding RV insertion point) and/or morphological and/or functional abnormalities. Predictors of "positive" CMR were explored. Results 503 CMR were recruited and the most frequent indications for CMR were: ventricular arrythmias (n= 213, 42%), ECG abnormalities (n= 140, 28%) followed by echocardiogram abnormalities, symptoms and family history (Figure A). 308 (61%) CMR were "negative" and 195 (39%) "positive" (Figure B). Uncommon ventricular arrythmias did not result associated with positive CMR (p= 0.43), while polymorphic ventricular beats are associated with positive CMR (p= 0.02). Among ECG abnormalities only T-waves inversion, particularly on lateral and infero-lateral leads, were associated with positive CMR (p= 0.04). Conclusion Ventricular arrhythmias represented the most common indication for require a CMR but in almost half the cases, the CMR was negative. Excises induced ventricular arrhythmias is not significantly associated with pathological findings on CMR, while the polymorphic morphology of arrhythmias and the presence of lateral and infero-lateral repolarization abnormalities on ECG were associated with positive CMR.

Funding Acknowledgements Type of funding sources: None. Background Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in the athletic population. However, data are limited to the approached based on Troponine, ECG and echocardiogram while the data on exercise test are scarce. Purpose Aim of the study was to evaluate the prevalence of cardiac involvement after COVID-19 in competitive athletes for the RTP applying a comprehensive cardiovascular evaluation. Methods Since October 2020, all consecutive competitive athletes (age≥14 years) presented to our Institute after COVID-19 prior RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-hours ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was performed based on clinical indication. Results 219 competitive athletes were enrolled (59% male), age 23 years (19,27): 20% asymptomatic, 77% mildly asymptomatic, 2% had pneumonia. The evaluation was performed after a median of 10 days (6-17 days) from negative SARS-CoV-2 swab. All athletes had a good performance at CPET. Uncommon premature ventricular contractions (PVCs) were found in 10% (n=21) and were detected by CPET. Two athletes (1%) were finally diagnosed with acute myocarditis (confirmed by CMR) and another had newly diagnosed mild pericardial effusion (Figure). All the three athletes were temporally refrain from sport participation. Conclusions Cardiac abnormalities in competitive athletes screened after COVID-19 resolution were detected in a minority of the cases (1.4%). No one of the remaining athletes had abnormalities by imaging or laboratory test neither reduction in cardiopulmonary fitness. Our data are in line with those reporting low prevalence of cardiovascular complication in mildly symptomatic or symptomatic athletes.

Funding Acknowledgements Type of funding sources: None. Background Sport induces structural and functional cardiac adaptation with different entity related to several factors including type of training and gender. Cardiovascular Magnetic Resonance (CMR) is the gold standard for morpho-functional evaluation of athletes’ heart and commonly relies on ventricular volume, wall thickness and ejection fraction (EF) assessment. Data on myocardial deformation (MD) are limited to echocardiography and are scarce. Purpose To assess MD in Olympic athletes and to evaluate the possible influence of sport categories and gender. Methods A group of Olympic athletes evaluated prior the Olympic games with unremarkable cardiovascular pre-participation screening tests underwent CMR without contrast administration. A group of sedentary subjects was enrolled as a control group. Cine-images were post-processed for volume and function evaluation and to assess global longitudinal strain (GLS) and global circumferential strain (GCS) by feature-tracking software. Athletes were divided in subgroups according to ESC sport classification. Male and female athletes were compared. Athletes were also divided based on EF (≤53% or >53%). Results 93 elite athletes (33% power, 33% mixed, 33% endurance) and 18 controls were enrolled. No differences in terms of EF were observed, while endurance athletes showed the greater LV remodeling (Table). GLS and GCS values of the entire population were -22.5±2.7% and -30.7±3.4%, respectively. No significant differences were found comparing athletes of different sport categories and sedentary controls for GLS (p= 0.940) and GCS (p=0.072). Female athletes showed higher GLS compared to male (-23.5±2.8% vs-21.9±2.8%, p=0.002) but not differences in terms of GCS (-31.5±3.1% vs-30.2±3.5%, p=0.076). Athletes with EF≤53% had lower GLS values compared with those with >53% but within normal limits (Figure). Conclusion No differences were observed in MD assessed by CMR between different sport categories and controls. Female athletes showed higher longitudinal but not circumferential strain compared with male. Athletes with lower EF presented lower values of strain but within normal range with the potentiality to be used as a tool for differential diagnosis between normal adaptation and disease.

Funding Acknowledgements Type of funding sources: None. Background Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in the athletic population. However, these data are mainly based on Troponin and imaging findings. Purpose Aim of the study was to evaluate the prevalence of cardiac involvement after COVID-19 in Olympic athletes, who had previously been screened in our pre-participation program. Methods Since November 2020, all consecutive Olympic athletes presented to our Institute after COVID-19 prior RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-hours ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was also performed. All Athletes were previously screened in our Institute as part of their periodical pre-participation evaluation. Results Forty-seven Italian Olympic athletes were enrolled: 83% asymptomatic, 13% mildly asymptomatic, 4% had pneumonia. The evaluation was performed after a median of 9 days from negative SARS-CoV-2 swab. Uncommon premature ventricular contractions (PVCs) were found in 13% athletes, however, only 6% (n=3) were newly detected. All newly diagnosed uncommon PVCs were detected by CPET. One of these three athletes had evidence for acute myocarditis by CMR, along with Troponin raise; another had mild pericardial effusion. No one of the remaining athletes had abnormalities detected by CMR (Figure). Conclusions Cardiac abnormalities in Olympic athletes screened after COVID-19 resolution were detected in a minority and were associated with new ventricular arrhythmias. Only one had evidence for acute myocarditis (in presence of symptoms and elevated biomarkers). No one of the remaining athletes had abnormalities by imaging or laboratory test. Our data support the efficacy of the clinical assessment including exercise-ECG to raise suspicion for cardiovascular abnormalities after COVID-19. Instead, the routine use of CMR as a screening tool appears not justified.

Funding Acknowledgements Type of funding sources: None. Background Non-invasive evaluation of left ventricular hemodynamic forces (HDFs) by Cardiac Magnetic Resonance (CMR) is a promising tool to improve systolic and diastolic evaluation. No data are available on athletic population. Purpose To provide the range of normal values of HDFs in Olympic athletes and to evaluate the possible influence of different sport categories. Methods A group of Olympic athletes evaluated prior the Olympic games with unremarkable cardiovascular pre-participation screening tests underwent CMR without contrast administration. A group of sedentary subjects was enrolled as a control group. Cine-images were post-processed by a feature-tracking based software to estimate HDFs. HDFs were measured in apex-base (AB) and latero-septal (LS) directions, over the entire heartbeat, in systole and diastole. Athletes were divided in subgroups according to ESC sport classification for comparison. They were also divided according to the ejection fraction (EF ≤ or >53%). Results 93 elite athletes (33% power, 33% mixed, 33% endurance) were enrolled. HDFs in AB and LS direction were 20.5%± 4.3 and 2.9%± 0.7 in the entire heartbeat, 32.6% ± 7 and 3.6%± 1 in systole, 11%± 4.1 and 2.3%± 0.8 in diastole. Comparing athletes of different sport category and sedentary controls no significant differences were found between groups (Table). Comparing athletes with ejection fraction (EF) £ 53% and > 53%, the former showed lower values of AB-HDFs assessed in the entire heartbeat and in systole (18.9 ± 4.6 % vs 20.9 ± 4.1; p= 0.024 and 29.6 ± 6.3 vs 33.3 ± 7; p= 0.024, respectively), but within the normal range. Conclusion We provide normal range for HDFs assessed by CMR in elite athletes and no differences were observed between sedentary controls and athletes involved in different sport categories. Comparing athletes with low-normal and normal ejection fraction, the former showed lower values of AB-HDFs but within the normal range.

Background The pattern of premature ventricular beats, as a clue to site of origin, may help identify underlying cardiac diseases. Aim To assess the value of premature ventricular beat patterns in managing athletes with ventricular arrhythmias. Methods Athletes with 50 or more isolated premature ventricular beats/24 hours, and/or multifocal and/or repetitive premature ventricular beats at baseline, and/or exercise, and/or 24-hour electrocardiograms were selected for this analysis. Premature ventricular beats were defined as ‘common’ (outflow tract or fascicular origin), or ‘uncommon’ (other morphologies and/or multifocal or repetitive). Results From 4595 athletes consecutively examined, 205 (4%, 24.6 ± 6.9 years, 67% men) were included, 118 (58%) with uncommon and 87 (42%) with common premature ventricular beats. In particular, 81 (39%) showed complex patterns; 63 (31%) right/left ventricular outflow tract origin; 24 (12%) fascicular origin; 20 (10%) right bundle branch block pattern, intermediate/superior axis, wide QRS; and 17 (8%) left bundle branch block pattern, intermediate/superior axis. Uncommon premature ventricular beat patterns were predominant among men (62% vs. 38%; P Conclusions Evaluation of premature ventricular beat patterns in Olympic athletes identified cardiac diseases, requiring disqualification and/or follow-up, in 12% with uncommon versus 1% with common patterns. This result suggests that athletes with uncommon premature ventricular beat patterns should undergo comprehensive cardiac evaluation and/or serial follow-up, irrespective of gender or sporting discipline.