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Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Amsterdam Movement Sciences and the Dutch Olympic Committee. Background Cardiac magnetic resonance imaging (CMR) T1 mapping is an established tool for tissue characterisation. This is of particular interest in athletes as differentiation of the ‘grey zone’ between physiological adaptation to sports and pathology can be highly challenging. To correctly interpret individual T1 times, T1 times are conventionally compared to normal values derived from healthy controls. However, whether these values can be applied to elite athletes with different types of cardiac adaptation is unknown. Purpose To determine differences in native T1 times between elite athletes and healthy non-athletic controls and to determine differences in athletes with different types of cardiac remodelling. Methods This is a cross-sectional analysis of elite athletes included in the ELITE cohort. ELITE collects the preparticipation cardiovascular screenings data from all athletes that perform at the highest national, international and/or Olympic level in the Netherlands. All athletes were sixteen years or older. The screening includes cardiovascular magnetic resonance imaging on a Siemens Avanto fit 1.5T machine with cine-imaging, delayed hyperenhancement and a three-pulse shortened modified look-locker inversion recovery 5(3)3 sequence. For this analysis, all athletes with a history of cardiovascular disease or pathological late gadolinium enhancement were excluded. Athletes were classified according to the Mitchell Sports Classification based on the intensity (low (L) / moderate (M) / high (H)) of the dynamic (D) and static components (S). Native- and post-contrast T1 mapping times were calculated by manually tracing the endocardial- and epicardial contours. Results A total of 117 elite athletes (44% women; mean age 26±6.5; Mitchell sports classification: 47 HS/HD, 8 HS/LD, 5 HS/MD, 36 LS/HD, 16 MS/HD, 3 MS/MD, 3 missing) and 48 healthy non-athletic controls (54% women; mean age 39±15.1). Men had lower t1 times compared to women, both in athletes (949ms vs 964ms, p Conclusion Men demonstrate markedly shorter T1 times compared to women in both athletes and controls. Moreover, native T1 times were associated with markers for cardiac remodelling. Sex- and athlete-specific characteristics should be taken into account when interpreting T1 times in athletes.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Amsterdam Movement Sciences (AMS); Dutch National Olympic Committee & National Sports Federation (NOC*NSF); Heart To Handle. Background Differentiating between exercise-induced cardiac remodelling (EICR) and pathology constitutes a central challenge in sports cardiology. To facilitate this differentiation, reference ranges for cardiovascular magnetic resonance imaging (CMR) are needed. However, female athletes, and especially, female elite athletes with potentially the most outspoken adaptation, are severely underrepresented. Moreover, no large studies including CMR data in female, elite athletes are currently available. Purpose To quantify EICR on CMR in a large cohort of female, elite athletes, compared with currently available reference values of the general female, and female athlete population. Methods We performed a cross-sectional CMR analysis in female elite athletes aged ≥16 years, included in the ELITE cohort. We excluded athletes with known cardiovascular disease. The primary outcome was EICR quantification as BSA indexed RV and LV end-diastolic volume (EDVi), LV wall mass (LVMi), LV remodelling index (LVMi/LVEDVi), and LV/RV ratio (LVEDi/RVEDVi). Second, we compared our parameters with reference ranges (1,2). CMR was performed according to a uniform protocol, and included cine-imaging and delayed hyperenhancement, preferentially on 1.5T. A dedicated core-lab analysed all CMRs in Circle Cardiovascular Imaging. Results We included 102 female elite athletes, 97% caucasian, mean age of 26.3 ±5.0, BSA 1.79 ±0.14 m2, and mean professional athlete years of 10.3 ±5. Main athlete disciplines (≥10 hours/week) were field hockey (15%), rowing (13%), road cycling (12%), and European style football (10%). Female elite athletes had marked EICR as compared with general population reference values, with higher LVEDVi (108 ±13.9 vs 69 ±12 ml/m2, p Conclusion EICR on CMR in female, elite athletes is mainly characterised by isolated increased volumes, with a considerable proportion (11%) demonstrating no EICR. Compared with the general population, female athletes have larger cardiac ventricular volumes and wall mass; compared with available elite athlete reference ranges comparable ventricular volumes, but a larger spread in cardiac wall mass. Our results constitute a first step towards sex-specific CMR reference ranges for female athletes.

Background/Introduction Specific athlete reference values for cardiac volumes and function using cardiac magnetic resonance (CMR) parameters have been reported and are used in clinical practice. Elite athletes are conventionally thought to demonstrate the highest levels of physiological adaptation to sports and therefore dictate the upper limit of normal for biventricular size and function in the athlete population. Purpose To compare volumetric parameters in a cohort of both male and female elite-level athletes to previously published reference values. Methods We used data from the prospective ELITE-cohort, which collects pre-participation data of elite athletes (national-, international-, Olympic-, Paralympic-level), including CMR imaging. Athletes suspected of pathology based on comprehensively investigated electrocardiograph, exercise test, echocardiogram and late gadolinium enhancement were excluded. Biventricular volumes were derived from short-axis cine images using Cvi42 (v5.1.2.) and indexed for body surface area (BSA). Volumetric parameters were compared to the previously reported gender- and Mitchell sports classification specific cardiac 95th percentile (95%tile) reference values, as reported by Luijkx et al.: left-ventricle (LV) end-diastolic volume (EDV) / BSA for high-static and high-dynamic sports (HS/HD; ♀ 142 ♂ 158); low-static and high-dynamic (LS/HD; ♀ 127 ♂ 149); high-static and low-dynamic (HS/LD; ♀ 114 ♂ 140); right ventricle (RV) EDV / BSA HS/HD (♀ 154 ♂ 184), LS/HD (♀ 136 ♂ 163), and HS/LD (♀ 120 ♂ 157). Results We analysed a total of 221 athletes (38% female), with a median age (IQR) of 26.0 (22.5–29.8) years, and mean ±SD BSA of 1.96±0.22 m2. Athletes were classified according to the Mitchell sports classification: HS/HD 116 (54%); LS/HD 61 (29%); moderate-static and high-dynamic (MS/HD) 20 (9.4%); HS/LD 16 (7.5%) (Table). We found smaller mean ±SD (95%tile) RV EDV/BSA in athletes participating in HS/HD sports (♀: 117±20 (148) and ♂: 133±20 (160)) and LS/HD sports (♀: 109±11 (129) and ♂: 119±15 (142)) and smaller LV EDV/BSA in male athletes in LS/HD sports (116±15 (138)) compared to reference values, (Figure). When using conventional cut-offs in our population we found 10 (4.5%) and 2 (0.9%) athletes above 95%tile for LVEDV/BSA and RVEDV/BSA, respectively (Figure). Conclusion In a cohort consisting of healthy, elite athletes, volumetric adaptations were less outspoken as compared with current reference ranges, specifically in the RV. Only 1 percent of our athletes exceeded conventional 95%tile references for the RV. Potentially, current athlete reference values could overestimate healthy upper limits of cardiac volumes in elite athletes. Our study could indicate that a stricter definition of volumetric reference values, including 95%tile, might be of added value in the specific group of elite athletes to help differentiate between pathology and sports adaptation. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Amsterdam Movement Sciences (P1A210AMC2018)

Background/Introduction In the general population, cardiac magnetic resonance imaging (CMR) T1 mapping is an established tool used for cardiac tissue characterisation. Such characterisation is of particular interest in athletes, as differentiation of the “grey zone” between physiological adaptation to sports and myocardial pathology can be highly challenging. To correctly interpret individual T1 times, T1 times are conventionally compared with normal values derived from healthy controls. However, whether these normative T1 values can be applied to elite athletes, who commonly demonstrate the most extreme cardiac adaptation, is unknown. Purpose To determine whether there are gender-specific differences in normative T1 times between elite athletes and healthy controls. Methods This study is a cross-sectional assessment of healthy athletes included the ELITE-cohort. ELITE includes athletes at national, international, and Olympic level in the Netherlands, aged sixteen years or older and without a history of cardiovascular disease. All athletes undergo standard periodic preparticipation screening with cardiovascular magnetic resonance imaging (Phillips 1.5 Tesla), including native T1 mapping. For the current study, we compared athletes to healthy controls per gender group. T1 inversion times were calculated in Circle Cardiovascular software (v5.12); means for global and segmented myocardium, according to the AHA 16-segment model, were determined using R (v4.1.4). Results A total of 81 elite athletes (35 women, 43.2%) with a median (IQR) age of 26 (22.0–29.55) years and 55 healthy controls (27 women, 49.1%), with a mean age of 38.4±15 years were included (Table 1). Overall, mean global T1 times were markedly shorter in athletes compared with controls (959±21.1ms vs. 984±26.6ms, P Conclusion(s) Athletes demonstrate markedly shorter T1 times as compared with healthy controls, both in women and men. Sex-specific, athlete-normative T1 times should be taken into account when interpreting T1 times in athletes undergoing cardiac evaluation. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Amsterdam Movement Sciences and the Dutch Olympic Committee*Dutch Sports Federation

Background/Introduction SARS-CoV-2 (subclinical) myocarditis has been demonstrated in up to 5% in athletes, and is currently a topic being intensively investigated. However, more subtle changes in function and volumetric parameters have been less well documented, especially in elite athletes, who perform at the highest levels of sports, with potentially the most outspoken adaptation. Purpose To determine differences in cardiac function and volumetric parameters using cardiac magnetic resonance imaging (CMR) in elite athletes recovered from a SARS-CoV-2 infection as compared to non-infected elite athletes (controls). Methods We included elite athletes from the ELITE (Evaluation of Lifetime Intensive Top-level sports and Exercise) cohort, who voluntary undergo cardiovascular pre-participation screenings, which includes cardiac magnetic resonance imaging (CMR). SARS-CoV-2 infection was diagnosed with a positive-PCR or antibody test (if unvaccinated). The primary outcome was the incidence of structural cardiac changes on CMR, defined as LV/RV BSA indexed-EDV (EDVi), LV/RV BSA indexed-ESV (ESVi), LV/RV EF, presence of pathological late gadolinium enhancement (LGE) (excluding hinge point fibrosis), and T1 times. Results We included 234 elite athletes, mean age 27 (±7), 39% female, with main athletic disciplines (≥10 hours/week) of cycling (24%), field hockey (13%), and water polo (12%). In total 69 elite athletes had documented SARS-CoV-2 infection, and 165 were documented as not exposed to SARS-CoV-2. The majority reported mild symptoms 61/69 (88%), 1/69 (1%) severe symptoms, and 7/69 (11%) no symptoms. Mean time between infection and CMR was 2.8 (±2) months. CMR showed no significant difference between elite athletes with SARS-CoV-2 and without (Table) in mean LVEDVi (117±19 vs 120±19 ml/m2, p=0.29), LVESVi (50.6±11 vs 53.2±11 ml/m2, p=0.12), LVEF (56.9% ±5 vs 55.8% ±5, p=0.14), RVEDVi (120±20 vs 122±19 ml/m2, p=0.56), RVESVi (54.5±11 vs 56.2±11 ml/m2, p=0.29), and RVEF (54.6% ±4 vs 53.9% ±5, p=0.23). In 4/69 (4.7%) vs 1/165 (1.3%) pathological non-ischemic pattern of myocardial LGE was present (≤20% of total LV mass), of which one athlete (1.2%) showed increased T1 time, all with no deterioration in right and left ventricle function and volumetric parameters (Figure) after SARS-CoV-2 infection. All athletes made a full recovery and returned to elite competitive sports. Conclusion(s) This cross-sectional study of elite athletes demonstrates that infection with SARS-CoV-2 is not associated with deterioration in cardiac function and volumetric parameters on CMR compared with non-infected athletes, also in the small subset of athletes with pathological LGE patterns after SARS-CoV-2 infection. Prospective studies with long-term follow-up are needed to establish whether intensive sports is associated with long-term cardiac deleterious effects in elite athletes exposed to SARS-CoV-2. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Dutch Heart FoundationDutch National Olympic Committee & National Sports Federation (NOC*NSF)

ObjectivesQuantification of pericardial/myocardial involvement and risks of sudden cardiac arrest/sudden cardiac death (SCA/SCD) after SARS-CoV-2 infection in athletes who return to sports.DesignSystematic review on post-SARS-CoV-2 infection pericardial/myocardial manifestations in athletes.Data sourcesCombinations of key terms in Medline, Embase and Scopus (through 2 June 2021).Eligibility criteria for selecting studiesInclusion: athletes, with cardiovascular magnetic resonance (CMR) or echocardiography after recovery from SARS-CoV-2 infection, including arrhythmia outcomes. Exclusion: study population ≥1 individual comorbidity and mean age 64 years. Quality assessment was performed using Joanna Briggs Institute Critical Appraisal tools checklists.ResultsIn total, 12 manuscripts (1650 papers reviewed) comprising 3131 athletes (2198 college/student athletes, 879 professional athletes and 54 elite athletes) were included. The prevalence of myocarditis on echocardiography and/or CMR was 0%–15%, pericardial effusion 0%–58% and late gadolinium enhancement (LGE) 0%–46%. Weighted means of diagnosed myocarditis were 2.1% in college/student athletes and 0% in elite athletes. The prevalence of LGE was markedly lower in studies with high-quality assessment scores (3%–4%) versus low scores (38%–42%). A single study reported reversibility of myocardial involvement in 40.7%. No important arrhythmias were reported. Ten studies (n=4171) reporting postrecovery troponin T/I found no clear relationship with cardiac abnormalities.Summary/conclusionAthletes have an overall low risk of SARS-CoV-2 pericardial/myocardial involvement, arrhythmias and SCA/SCD. Rates of pericardial/myocardial abnormalities in athletes are highly variable and dependent on study quality. Troponin screenings seem unreliable to identify athletes at risk for myocardial involvement. Prospective athlete studies, with pre-SARS-CoV-2 imaging (CMR), including structured follow-up and arrhythmia monitoring, are urgently needed.

Background: Genetic variants associated with cardiomyopathies (CMPs) are prevalent in the general population. In young athletes, CMPs account for roughly a quarter of sudden cardiac death, with further unexplained clustering in specific sports. Consequently, most CMPs form a contraindication for competitive sports. We hypothesized that genetic variants might (paradoxically) improve physical performance early in life while impairing cardiac function later in life. Methods: Systematic PubMed search was done to investigate whether genetic variants in genes associated with CMPs could be related to beneficial performance phenotypes. Summary: In a limited number of studies (n = 6), 2,860 individuals/subjects with genetic variants were able to outperform those without said variants, as measured by running speed (∼38 m/min in heterozygous [HET] mice, n = 6, vs. ∼32 m/min in wild type [WT] mice, n = 7, p = 0.004) and distance (966 ± 169 km HET mice vs. 561 ± 144 km WT mice, p = 0.0035, n = 10), elite athlete status in endurance athletes (n = 1,672, p = 1.43 × 10−8), maximal oxygen uptake in elite athletes (absolute difference not provided, n = 32, p = 0.005), maximal oxygen uptake in unrelated individuals (n = 473, p = 0.0025), personal records in highly trained marathon runners (2:26:28 ± 0:06:23 min HET, n = 32, vs. 2:28:53 ± 0:05:50 min without polymorphism, n = 108, p = 0.020), and peripheral muscle force contraction in patients following a cardiac rehabilitation program (absolute values not provided, n = 260). Key Message: Beneficial effects in genetic variants associated with CMPs could hypothetically play a role in the selection of young athletes, consequently explaining the prevalence of such genetic variants in athletes and the general population.

Background/Introduction Transthoracic echocardiography (TTE) is often the first diagnostic imaging modality of choice in athlete care to differentiate between physiological adaptation to sports and pathology. Mechanical strain as outcome measure, i.e. left ventricular (LV) global longitudinal strain (GLS), has been suggested as a tool to detect early signs of myocardial diseases in athletes. However, low or very low rates of myocardial deformation can also be associated with cardiac adaptation to sports. We hypothesize that observing decreased cardiac deformation in elite athletes may be a sign of an outspoken relaxed cardiac state, rather than pathology. Therefore, we investigated whether a short exercise bout can normalize strain values in elite athletes with abnormal resting GLS. Methods We prospectively enrolled elite athletes who participated in the ELITE (Evaluation of Lifetime Participation in Intensive Top-level Sports and Exercise) cohort. In short, ELITE is a prospective athlete cohort, which collects medical history, ECG, TTE and cardiac magnetic resonance (CMR) data in elite athletes (Olympic/Paralympic level or comparable). For this analysis, we analysed TTEs of asymptomatic athletes without cardiovascular disease and with a structurally normal heart on CMR. TTE (Vivid, GE) was performed in each athlete according to guidelines at rest. After a short exercise bout, consisting of 20 squats, additional measurements were performed when heart-rate (HR) was comparable to HR during pre-exercise measurements. TTE data was assessed using EchoPAC (GE). Paired t-tests were calculated for functional parameters; boxplots for pre- and post-exercise measurements; and GLS delta (pre- to post-exercise) for each athlete was calculated were plotted; using R. GLS ≥−16% was considered decreased and −16% ≥ GLS >−18% borderline. Results Our population comprised 51 athletes (35% women), with a mean age (±SD) of 26.4±5.2 years, and mean BSA of 2±0.3m2. Athletic disciplines consisted of road cycling (n=25), hockey (n=7), swimming (n=5), and 7 miscellaneous sports (n=14). We observed an increase of myocardial deformation after a short bout of exercise: mean GLS delta of 2.6±2% (pre- vs post-exercise GLS: −18.2±2.1% vs −20.8±1.9%; P≤0.001; Figure, A). Furthermore, mean LV stroke volumes were 94±19ml vs 103±23ml (P=0.020), ejection fractions (EF) 57±4% vs 60±4% (P≤0.001), and HR 55±10bpm vs 54±13bpm (P=0.8). Finally, we found a decreased strain in 8 athletes (16%), in 7 of which increased to normal values. Mean delta GLS was 4.5±2.2 (pre- vs post-exercise GLS: −14.9±1.1% vs −19.4±2.7%, P=0.002, Figure, B). The athlete who did not show an increase to normal GLS levels had a decreased LV EF (42%), but showed no other signs of cardiac pathology (MRI, biomarkers, complaints). Conclusion In athletes with abnormal GLS at rest, performing a short exercise bout may provide a pragmatic method to separate decreased GLS due to true pathology from sports adaptation. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Amsterdam Movement Sciences

Background/Introduction The prognosis of peri- and myocarditis can be negatively influenced by intensive exercise and sports. Therefore sustained cardiac involvement after recovery from COVID-19 in athletes is of particular relevance for the prevention of sudden cardiac arrest/sudden cardiac death (SCA/SCD). To date, only small sample-size studies are available, or studies predominantly focusing on hospitalized and severely ill patients. We aimed to address this knowledge gap in a comprehensive, systematic review of peri-/myocardial involvement after SARS-CoV-2 infection in athletes versus healthy non-athletes. Purpose Quantification of peri-/myocardial involvement and risks of SCA/SCD after SARS-CoV-2 infection in athletes as compared with healthy non-athletes. Methods We performed a systematic search with a combination of key terms in Medline (Ovid), Embase (Ovid) and Scopus (through March 8th 2021). To capture potential non- peer-reviewed COVID-19 SCA/SCD reports we performed monthly scoping internet searches. Inclusion criteria: athletes/non-athletes, with cardiovascular magnetic resonance (CMR) or echocardiography after recovery from SARS-CoV-2 infection, including arrhythmia outcomes. Exclusion criteria: study population ≥1 individual comorbidity and mean age 64 years. Results We included 16 manuscripts (933 papers reviewed) comprising 1129 athletes (284 college/student-, 807 professional- and 38 elite athletes) and 382 healthy non-athletes. Athletes vs non-athletes reported myocarditis on echocardiography and/or CMR in 0–15% vs 45–60%, LGE in 0–46% vs 0–74% (Figure 1), and pericardial effusion in 8–58% vs 0–47% (Figure 2). Weighted means of diagnosed myocarditis were 3% in athletes (3.5% college/student-, and 0% elite athletes) and 56.6% in non-athletes. No important arrhythmias were reported. Systematic internet query identified 2 collapsed post-COVID-19 athletes during exercise, 1 lethal. Ten studies (n=1301) reporting post-recovery troponin T/I found no clear relationship with cardiac abnormalities. Summary/Conclusions Rates of peri-/myocardial abnormalities in athletes/healthy non-athletes after SARS-CoV-2 infection are variable, ranging from 0–74%, and predominantly seen on CMR. Athletes have a lower risk of peri-/myocardial involvement, and myocarditis (0–3.5% vs 56.5%) than non-athletes after SARS-CoV-2 infection. Risks of SCA/SCD appear low, but data are lacking. Troponin screenings seems unreliable to identify athletes at risk for myocardial involvement. Prospective studies, with pre-COVID-19 imaging (CMR), in athletes, including follow-up and arrhythmia monitoring, are urgently needed. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Dutch Olympic Committee*Dutch Sports Federation (NOC*NSF)Amsterdam Movement Sciences (AMS) Figure 1. Total peri-/myocardial LGE (%)Figure 2. Total pericardial effusion (%)

Background/Introduction Multidisciplinary teams (MDT) are an integral part of cardiology. In sports cardiology wide area of expertise is required to differentiate between extraordinary pathophysiological adaption and pathology. In Addition, expertise-based sports advice should be prescribed with great care considering the great impact on (professional) sports careers. Specific guidelines for the composition of MDT's for sports cardiology are currently lacking. We established a sports cardiology MDT in April 2020 (Amsterdam UMC), consisting of experts in the fields of sports medicine, cardiogenetics and paediatric cardiology, cardiovascular imaging and electrophysiology, with bi-monthly meetings. Cases were contributed from cardiologists or referred nationally for expertise with patients/athletes varying from recreational to elite-level sports. Purpose To describe our infrastructure and utilization of a sports cardiology MDT, and to justify the need for a sports cardiology MDT. Methods We retrospectively analysed all MDT reviewed cases (from April 2020 to April 2021), and collected follow-up data 1 year after initial MDT review. Data were classified according to type/level of sports. We compared diagnosis and/or reason for referral and sports advice at initial MDT application and after panel review. In addition we abstracted data on occurrence of cardiac symptoms and/or cardiac events, and adherence to sports advice. Results 112 cases underwent MDT review, with a mean age of 32 (SD 16.0) years. In total 12% were women, 38% professional athletes, and 30% engaged in high dynamic/low static sports. Reasons for referral were personalised sports advice in 48%, expert opinion in 28%, and abnormal ECG/CMR/CPX in 24%. The diagnosis was revised in 55% (n=61), main groups; 1) suspicion of (non-specified) cardiomyopathy (CMP) to no cardiac pathology in 20% (n=12), and 2) “cardiac abnormalities with no clear diagnosis” to “no cardiac pathology” in 36% (n=22) (Figure 1). Sports advice was revised to more personalized sports advice in 30% (n=34) (Figure 2), main groups; no restriction to no peak load/specific maximum load in 38% (n=13), and no restrictions to no competitive sports in 26% (n=9). At 1 year follow-up, the (sports) advice was adhered in 99,98% (n=111), and cases with no sports restrictions reported no cardiac symptoms in 99% (n=72/73), and no major acute cardiovascular events in 100% (73/73). No further revisions of diagnoses were found to have taken place. Conclusion Our experience with a comprehensive, sports cardiology MDT demonstrates that such an approach is feasible, and leads to more personalised treatment- and sports advice in athletes. Medium-term adherence to sports advice given is high. A team-based approach also leads to a higher percentage definitive diagnoses. Our findings serve as a proof-of-concept of the added value of the sports cardiology team in care for athletes and patients who wish to engage in sports and exercise. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Dutch Olympic Committee*Dutch Sports Federation (NOC*NSF)Amsterdam Movement Sciences (AMS) Figure 1. Revised diagnosis before and after panel review (N=61)Figure 2. Revised sports advice before and after panel review (N=34)

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Dutch Olympic Committee*Dutch Sports Federation (NOC*NSF) Amsterdam Movement Sciences (AMS) Most studies investigating the cardiotropic effects of SARS-CoV-2 focus on cardiac complications in severely ill patients. Little is known about eventual sustained cardiac involvement after recovery from COVID-19, especially in patients with a moderate or mild course of illness. Furthermore, as physical exercise can potentially worsen the prognosis of patients with COVID-19 peri- or myocarditis, cardiac involvement in athletes or in the physically active population warrants investigation. Finally, the risk of arrhythmias in such individuals remains largely unknown. We aim to provide a comprehensive overview of myocardial and pericardial involvement after SARS-CoV-2 infection, long-term cardiac sequelae after infection, and risks of SCD/SCD in a predominantly healthy/physical active population, including athletes. We performed a systematic PubMed and MedRxiv search through December 19th, 2020, with the combined terms or synonyms for: COVID-19, SARS-CoV-2, cardiovascular imaging, cardiac MRI, athletes. Exclusion criteria were: no CMR investigations reported, ≥1 comorbidities, age ≤16 years, and reviews. Two investigators independently screened and assessed all identified manuscripts, and additionally searched for reported arrhythmia outcomes. The initial search yielded 127 papers; after extensive review, we included a total of nine papers comprising 607 recovered post-COVID patients/athletes. The table summarises the main CMR findings. No study reported arrhythmias except for Ho et al. who found 18% undefined arrhythmias at baseline. In 5 studies in 201 patients, the weighted mean for the prevalence of elevated T1 was 55%, elevated T2 48%, myocardial LGE 35%, and pericardial LGE 17%. One study (Knight et al.) did not report T1 and T2 measurements. Ho et al. and Ming-Yen et al. found respectively 40% and 19% of patients to meet the Lake Louise Criteria (LLC) for myocarditis; Puntmann et al. reported that 60% had active myocardial inflammation. Second, in 1 study in 139 healthcare workers, the mean for the prevalence of elevated T1 was 42%, T2 4%, LGE 30%, and 5% met LCC for myocarditis. Third, in 3 studies in 96 athletes, the weighted mean for the prevalence of elevated T1 was 21%, T2 24%, myocardial LGE 4%, and pericardial LGE 29%. Brito et al., Clark et al. and Rajpal et al. reported that respectively 0%, 5% and 15% met the LCC for myocarditis. Studies investigating peri- and myocardial sequelae after SARS-CoV-2 infection report varying prevalences of cardiac abnormalities. Such studies are limited in numbers, generally include a low number of individuals, and report no follow-up; only 1 study reported non-specified arrhythmia outcomes. Based on the available studies, the short-term risk for post-COVID-19 SCD due to arrhythmias caused by myocardial inflammation appears to be low. Prospective investigations in larger, well-defined populations, including longer-term follow up and arrhythmia monitoring, are urgently needed. Abstract Figure.

Sports cardiology is a rapidly evolving subspecialty of cardiology, with a growing demand for expertise. To improve patient care, clinicians, patients, and athletes (recreational to elite) should be able to easily identify specialised care pathways, expertise centres and clinicians with sports cardiology expertise. To this purpose, several international societies and organisations recommend establishing a local and national sports cardiology infrastructure. We therefore aimed to establish The Netherlands Sports Cardiology Map. We conducted a web-based survey, which was published on the Netherlands Society of Cardiology home page (2019–2020) and in which each cardiology department or clinic was asked to provide information on sports cardiology expertise and the current infrastructure. Of the 46 respondent centres, 28 (61%) reported that they had expertise in sports cardiology, of which 22 (79%) had specific expertise in one or more specific types of sports. Integrated multidisciplinary meetings were reported by 43% of the centres (n = 12/28). Only two centres reported ongoing research projects that had been approved by an institutional review board. The Netherlands Sports Cardiology Map is an important step towards improving the existing infrastructure and developing network medicine for sports cardiology.

Background/Introduction The grey zone between cardiac adaptation to sports and exercise and (early stages of) cardiac pathology constitutes one of the greatest challenges for clinicians involved in the care for (elite level) athletes. Cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE) is a central diagnostic tool to help differentiate between physiological adaptation and pathology. LGE as seen in myocardial fibrosis has been shown to be a strong predictor for cardiac events. While general (ie. dynamic, static sports) levels of physiological adaptation in athletes have been described, sports-specific CMR findings are essentially lacking, and a systematic sport-specific investigation of LGE is absent. Purpose To establish a sports-specific baseline for CMR indices in apparently healthy, male elite water polo players. Methods We performed a cross-sectional study in Olympic-level male water polo players. All athletes were asymptomatic and were examined during pre-participation screening. The athletes underwent a comprehensive CMR protocol consisting of long- and short-axis cine imaging, LGE and was performed on two 3 Tesla MRI-scanners (Philips). CMR data were analysed using Circle Cardiovascular Imaging software, and statistical analyses were performed in R. Results We screened 24 athletes with a mean age (±SD) of 24.2±3.6 years and body surface area (BSA) of 2.23±0.2 m2. The athletes had indexed end-diastolic volumes of 101.87±33.01 ml and 104.51±43.24 ml, stroke volumes of 140.70±33.23 and 139.44±29.93 ml, and ejection fractions of 56.68±9.07% and 52.98±8.18%, in the left- and right ventricle, respectively. Thirteen athletes (54.2%) had LGE consistent with hinge point fibrosis (HPF+) (one case example presented in the figure). Another two athletes had other patterns of LGE (LGE+). There was a trend towards having a smaller BSA in the LGE+ and HPF+ groups (2.18±0.17 m2 in LGE+ vs 2.31±0.10 m2 in LGE−, p=0.056, and 2.18±0.18 m2 in HPF+ vs 2.29±0.10 m2 in HPF−, p=0.072). Conclusion Myocardial fibrosis is present in more than 50% of asymptomatic elite water polo players, with a predilection for the inferior hinge point. Our findings in asymptomatic elite athletes suggest that HPF could be a normal finding in athletes instead of an early sign of pathology. Further studies are warranted to investigate if the HPF is associated with long-term cardiac changes or the development of cardiac pathology. Figure 1. Late gadolinium enhanced short axis image (left) combined with a polar map of cardiac segmentation (right) depicting the fibrosis pattern in a case of an elite male water polo player alongside the inferior hinge point - as expressed in the percentage of myocardium exceeding the mean signal intensity of reference myocardium plus six-times standard deviation. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Harald Jørstad has received funding from the Amsterdam Movement Sciences and the National Olympic Committee & National Sports Federation