British Journal of Sports Medicinear
Head-to-head Comparison Between Echocardiography and Cardiac MRI in the Evaluation of the
Athlete's Heart
Niek H J Prakken, Arco J Teske, Maarten J Cramer, Arend Mosterd, Annieke C Bosker, Willem P Mali,
Pieter A Doevendans, Birgitta K Velthuis
Br J Sports Med. 2012;46(5):348-354.
Abstract and Introduction
Abstract
Objective Echocardiographic cut-off values are often used for cardiac MRI in athletic persons. This study
investigates the difference between echocardiographic and cardiac MRI measurements of ventricular and
atrial dimensions and ventricular wall thickness, and its effect on volume and wall mass prediction in
athletic subjects compared with non-athletic controls.
Methods Healthy non-athletic (59), regular athletic (59) and elite athletic (63) persons, aged 18–39 years
and training 2.5±1.9, 13.0±3.0 and 25.0±5.4 h/week, respectively (p<0.001), underwent echocardiography
and cardiac MRI consecutively. Left ventricular (LV) and right ventricular (RV) dimensions were
measured on both modalities. LV and RV end-diastolic and end-systolic volumes and LV wall mass were
determined on cardiac MRI. Echocardiographic M-mode LV volumes (Teichholz formula) and LV wall
mass (American Society of Echocardiography formula) were calculated.
Results LV and RV dimensions were smaller on echocardiography (p<0.001), and although the
correlation with the cardiac MRI volume was good (p<0.01), the difference in volume was large (LV enddiastolic volume difference 93±32 g, p<0.001). LV wall thickness and calculated wall mass were
significantly (p<0.001) larger on echocardiography (wall mass difference −101±34 g, p<0.001).
Differences in absolute dimensions did not change significantly between non-athletic and athletic persons;
however, the difference in echocardiographic estimations of LV volumes and wall mass did increase
significantly with the larger athlete's heart, requiring possible correction of the standard
echocardiographic formulas.
Conclusions Echocardiography shows systematically smaller atrial and ventricular dimensions and
volumes, and larger wall thickness and mass, compared with cardiac MRI. Correction for the
echocardiographic formulas can facilitate better intertechnique comparability. These findings should be
taken into account in the interpretation of cardiac MRI findings in athletic subjects in whom
cardiomyopathy is suspected on echocardiography.
Introduction
Preparticipation screening of endurance athletes has gained interest during the past decade. Its main focus
is to prevent sudden cardiac death (SCD) from unrecognised cardiac pathology, including hypertrophic
cardiomyopathy (HCM) and arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) in
individuals <40 years, and predominantly coronary artery disease in ≥40 years of age.[1–3]
If the results of clinical evaluation or preparticipation screening (including medical history, assessment of
symptoms and signs and ECG) of athletes warrant further investigation, non-invasive imaging is typically
used to identify the presence of structural heart disease.[4,5] The most frequently used imaging modality is
echocardiography, which can accurately assess cardiac function and morphology, while being
inexpensive, rapid and widely available.
Unfortunately, physiological changes due to long-term remodelling in response to the increased volume
load during endurance training (the athletes' heart) can resemble relevant cardiac disorders, associated
with SCD in athletes,[6,7] especially when left ventricular (LV) wall thickness is increased to an extent to
fulfil HCM criteria, or when the right ventricle (RV) becomes enlarged, a hallmark feature of ARVD/C
on echocardiography.[7–12] This distinction is relevant when a potentially career changing decision must be
made for the individual athlete with already suspect findings on the ECG.[5,7,13] If echocardiographic
results remain inconclusive or warrant further investigations, cardiac MRI can be considered.[14] Wellestablished cut-off values to identify cardiomyopathy have almost exclusively resulted from studies using
echocardiography as the non-invasive research tool.[14,15]
Although numerous papers have studied the difference between echocardiography and cardiac MRI in
healthy controls and patients, the effect of this difference in athletes is still unclear, as few studies have
included athletes.[6,9,16,17] This is a relevant issue in athletes, as differences between echocardiography and
cardiac MRI may place them in different risk categories.
Our aim was to establish the difference between echocardiographic and cardiac MRI measurements of
ventricular and atrial dimensions as well as ventricular wall thickness in the athlete's heart in a head-tohead fashion using state-of-the-art imaging techniques. We investigated the degree of difference in
athletic persons as compared with non-athletic controls and calculated how many athletes would qualify
for cardiac pathology using echocardiographic cut-offs for both modalities. Using cardiac MRI
ventricular volumes and wall mass as reference, we also studied if the conventionally measured
dimensions on echocardiography and cardiac MRI are a reliable prediction of cardiac MRI volume and
wall mass.
Results
Study Population
The baseline characteristics of the study population have been described previously and are summarised
in Table 1 .[8,10,11] More men than women were included in this study; however, the distribution among the
groups was equal. Of all athletes, 37% were rowers (58% men), 29% were triathletes (54% men), 20%
were cyclists (92% men), 10% were runners (58% men), and 4.2% participated in other endurance sports
(20% men).
Echocardiographic and cardiac MRI dimensions per group are summarised in Table 2 . All mean values
are significantly larger in athletic than in non-athletic persons. Although not significant, all mean values
were also higher in elite than in regular athletic subjects. This has been reported in detail previously.[8,10,11]
Echocardiography versus Cardiac MRI
The mean differences between echocardiography and cardiac MRI are shown in Table 3 . Absolute values
on echocardiography compared with cardiac MRI were significantly smaller for ventricular and atrial
dimensions, while wall thickness values were significantly larger. The high and significant correlations
between the modalities indicate that the observed difference is a systematic over-/underestimation. For
distribution analysis, absolute differences were plotted in a histogram (figure 2A,B) and showed a normal
Gaussian distribution for all parameters. The regression coefficients, ranging from 0.7 to 1.1, signify that
all reported differences in Table 3 apply to the entire range of absolute values and did not change
significantly when the absolute measurements were larger, as seen in athletes. A subgroup analysis based
on the amount of athletic activity in the three groups revealed no significant variance in difference.
(Enlarge Image)
Figure 2.
Comparison between echocardiographic and cardiac MRI measurements and calculated
echocardiographic left ventricle (LV) volume and wall mass versus cardiac MRI. (1) Echocardiograpic
measurements plotted against cardiac MRI. Solid line indicates the linear regression, dashed line the 95%
CI; (2) Bland–Altman plot, solid line indicates the bias and the dashed lines the 1.96 SD; LV long-axis
internal diameter at end-diastole (LVIDd) (A), RVIT, right ventricle inflow tract diameter at end-diastole
(B) and the septal and wall thickness (IVSd) (C) are shown. Stars, non-athletic; open circles, regular
athletic; solid circles, elite athletic subjects. (3) LV end-diastolic volume (LVEDV) (A), end-systolic
volume (LVESV) (B), and LV mass (C) calculated for the parasternal long-axis view on
echocardiography plotted against the calculated volumes and wall mass on cardiac MRI. Note the
increase in bias with larger volumes/mass. ASE, American Society of Echocardiography.
Echocardiographic and cardiac MRI dimensions were correlated to cardiac MRI volumes and wall mass
as a reference value, and the correlations are presented as a result of the pooled data of all participants in
Table 4 .
The Teichholz formulas for calculation of LV volume resulted in much smaller echocardiographic
estimates compared with cardiac MRI volumes for both the LVEDV (125±27 on echocardiography vs
218±53 ml on cardiac MRI, difference 93±32, p<0.001) and the LVESV (31±7.8 vs 94±28 ml, difference
64±23, p<0.001). On the other hand, calculation of LV wall mass using the ASE formula resulted in
twofold higher values on echocardiography (205±53 vs 104±33 g, difference −101±34, p<0.001).
The correlations (r) between the techniques were relatively good (LVEDV 0.8, LVESV 0.7 and LV wall
mass 0.8). Difference (regression slope b) increased with higher values using these formulas (LVEDV
1.5, LVESV 2.4 and LV wall mass 0.5), which resulted in a significantly higher difference for these
parameters in regular and elite athletic as compared with non-athletic subjects.
Correction Factor
In order to achieve a 1:1 relation between cardiac MRI and M-mode estimation of LV wall mass, the ASE
value has to be divided by approximately 2 to obtain cardiac MRI values (LV wall mass (g): cardiac
MRI=(0.49ASE)+3.2). For LVEDV (ml) this would be cardiac MRI=(1.53Teichholz)+26.3 and for the
LVESV: cardiac MRI=(2.38Teichholz)+21.6.
Cut-off Values
The echocardiographically measured absolute IVSd exceeded a 12 mm threshold in one (3%) nonathletic, four (12%) regular athletic and 11 (26%) elite athletic men, whereas cardiac MRI exceeded 12
mm in two (6%) regular athletic and 10 (23%) elite athletic men. No one exceeded a IVSd threshold of 15
mm on either imaging modality. The echocardiographically measured absolute LVPWd exceeded a 10
mm threshold in five (15%) non-athletic, 15 (46%) regular athletic and 26 (61%) elite athletic men.
Cardiac MRI exceeded 10 mm in five (15%) regular athletic and six (14%) elite athletic men. In none of
the women did IVSd exceed 12 mm or LVPWd 12 mm on either imaging modality.
The echocardiographically measured absolute LVIDd exceeded a 60 mm threshold in one (3%) regular
athletic and three (7%) elite athletic men, but in none of the women. Cardiac MRI exceeded 60 mm in
five (15%)/2 (8%) non-athletic, 13 (39%)/2 (8%) regular athletic and 23 (54%)/3 (15%) elite athletic
men/women. The echocardiographically measured absolute LVIT exceeded a 60 mm threshold only in
one (2%) elite athletic man, and in none of the women. Cardiac MRI exceeded 60 mm in two (6%) nonathletic, 10 (30%) regular athletic and 24 (56%) elite athletic men and three (15%) elite athletic women.
The echocardiographically measured absolute RVIT exceeded a 50 mm threshold only in two (5%) elite
athletic men and in none of the women. Cardiac MRI exceeded 50 mm in 15 (44%)/two (8%) nonathletic, 21 (64%)/five (19%) regular athletic and 35 (81%)/two (10%) elite athletic men/women.
Discussion
The present study shows that compared with echocardiography, cardiac MRI ventricular and atrial
dimensions and ventricular volumes are larger, and wall thickness and wall mass are smaller.
Although there was a good linear correlation of obtained dimensions with the actual volume on cardiac
MRI, the difference in volume and wall mass measurements between echocardiography and cardiac MRI
was large. We have provided a possible correction factor on the echocardiographic formulas to facilitate
better intertechnique comparability.
Comparison to Previous Literature
Although echocardiographic image quality has improved greatly in recent years, cardiac MRI still
provides a higher LV and RV volume and wall mass measurement reproducibility and accuracy owing to
its high spatial resolution.[16,17,20,22–36] Several studies confirm that RV and LV volumes and dimensions on
2D echocardiography are significantly lower, and LV wall mass and wall thickness higher as compared
with cardiac MRI measurements, with moderate agreement per measurement in healthy subjects, as well
as in patients.[16,17,20,22–27,31–36] In particular, the large differences between LV volumes and wall mass on
cardiac MRI compared with those derived from M-mode echocardiography show the limited accuracy of
the ASE and Teichholz formulas.[16,27]
To our knowledge, this is the first paper using a large cohort of healthy athletic and non-athletic persons,
containing both men and women, to compare echocardiographic and cardiac MRI data in a head-to-head
fashion. Previous studies comparing echocardiography results with cardiac MRI in athletic subjects
included only a small group of either athletic males or females and allowed for much larger time windows
between the two examinations.[17,28]
Even though we minimised the methodological difference for individual variations by performing both
examinations consecutively during one session, our results showed larger mean differences between
echocardiographic measurements and cardiac MRI than mostly reported in the literature.[22,23,25,29,30] One
explanation is that the ventricular trabecularisation is recognised better on cardiac MRI and is therefore
included in the ventricular volume diameter instead of inclusion in the LV wall thickness as partly occurs
on echocardiography (figure 1).[23] Another explanation is the use of different cardiac MRI contour
tracing protocols, including or excluding the papillary muscles and trabecularisations as ventricular wall
mass, as well as the option to include the RVOT or LVOT in the blood volume on cardiac MRI or
not.[16,17,21,23]
Clinical Relevance
A reliable assessment of ventricular dimensions by non-invasive imaging is paramount to rule out
potentially lethal cardiomyopathies.[4,5] To this end, a large body of evidence has been published
producing specific cut-off values specifically for echocardiography.[7,37,38] Using these echocardiographic
cut-off values for cardiac MRI is unjustified without establishing the difference between the modalities.
Our results suggest that unmodified implementation of echocardiographic absolute reference values and
cut-off values for cardiac pathology on cardiac MRI measurements is not recommended. In athletic
persons, there is additional concern because of the sport-heart-related larger ventricular volumes and wall
mass, especially in elite athletic men.[11,12]
For example, in elite athletic men, the absolute RVIT exceeded a 50 mm threshold, sometimes used for
arrhythmogenic RV cardiomyopathy more frequently on cardiac MRI (81%) compared with
echocardiography (5%).[38,39] The absolute LVIDd exceeded a 60 mm threshold, a commonly used
echocardiographic cut-off for dilated cardiomyopathy more frequently in cardiac MRI (54%) versus
echocardiography (7%).[7] These differences suggest that the cut-off value should be adjusted for cardiac
MRI (using the 95th percentile).[11] A septal wall thickness of >12 mm on echocardiography has generally
been regarded as a cut-off value to indicate LV hypertrophy.[7,15] The difficulty in recognising the
trabecularisation border on echocardiography is illustrated by the similar measurements between
echocardiography and cardiac MRI in septal wall thickness (26% vs 23% above 12 mm cut-off) and large
variation in PWd (61% vs 14% above 10 mm cut-off).
In clinical practice, a single dimension is often used to get an impression of a three-dimensional
parameter. Our results indicate that most of these commonly applied measurements do provide a good
insight into the volume and wall mass as calculated on cardiac MRI in both echocardiography and cardiac
MRI. The difference between these two modalities seems to be systematic, not influenced by the value of
the measure itself, as indicated by the comparable difference in the controls (normal dimensions and LV
wall thickness) and athletic persons (ventricular enlargement and LV hypertrophy). Echocardiographic
estimation of the LV wall mass and LV volumes using commonly applied formulas do, however, show an
increasing difference as the absolute values increased. Although this is to be expected owing to the
exponential contributions of the 2D measurements in the different formulas, the relationship was linear
(figure 2C). This problem might be overcome using 3D echocardiography, which is free from geometrical
assumptions.[20,33,35,36,40]
Limitations
Several factors, other than the dissimilarity in spatial resolution, could have provided additional variation
to the observed difference between the two techniques. First, the measurements were performed by two
different observers. Although we checked all measurements for overall consistency with the guidelines,
this could have resulted in a systematic difference in the application of the ASE guidelines, and explain
the variation in difference between RA (−1.9 mm) and LA (+10.1 mm) where the exclusion of the
pulmonary vein ostia could have been performed differently. Second, some reference points used for
echocardiographic measurements were less clear on cardiac MRI, such as the tips of the atrio-ventricular
valves. This could have resulted in a slightly different measurement location within the heart, which was
the case for the LVIT and RVIT. Third, image planes were probably not identical during acquisition.
While cardiac MRI follows a protocolised image acquisition sequence, echocardiography is a more userdependent method, where different cardiac compartments could be recorded separately to obtain the
optimal image.[30,41] Nevertheless, the observed differences between echocardiography and cardiac MRI
are too large to be solely attributed to these limitations and showed a typical systematic difference with a
Gaussian distribution, suggesting a relevant clinical difference.
Conclusion
In healthy non-athletic and athletic persons, echocardiography shows systematically smaller atrial and
ventricular dimensions and volumes, and a larger wall thickness and wall mass, compared with cardiac
MRI. While the differences in absolute dimensions do not change significantly between non-athletic and
athletic subjects, the difference in echocardiographic estimations of LV volumes and wall mass does
increase significantly with the larger athletic heart, requiring possible correction of the standard
echocardiographic formulas. It is important that these findings be taken into account in the interpretation
of cardiac MRI findings in athletic persons in whom cardiomyopathy is suspected on echocardiography.
References
1. Corrado D, Basso C, Schiavon M, et al. Preparticipation screening of young competitive athletes
for prevention of sudden cardiac death. J Am Coll Cardiol 2008;52:1981–9
2. Maron BJ. Sudden death in young athletes. N Engl J Med 2003;349:1064–75
3. Maron BJ, Doerer JJ, Haas TS, et al. Sudden deaths in young competitive athletes: analysis of
1866 deaths in the United States, 1980–2006. Circulation 2009;119:1085–92
4. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to
preparticipation screening for cardiovascular a bnormalities in competitive athletes: 2007 update:
a scientifi c statement from the American Heart Association Council on Nutrition, Physical
Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
Circulation 2007;115:1643–55
5. Corrado D, Pelliccia A, Bjornstad HH, et al. Cardiovascular preparticipation screening of young
competitive athletes for prevention of sudden death: proposal for a common European protocol.
Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac
Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial
Diseases of the European Society of Cardiology. Eur Heart J 2005;26:516–24
6. Pluim BM, Zwinderman AH, van der Laarse A, et al. The athlete's heart. A meta-analysis of
cardiac structure and function. Circulation 2000;101:336–44
7. Maron BJ, Pelliccia A. The heart of trained athletes: cardiac remodeling and the risks of sports,
including sudden death. Circulation 2006;114:1633–44
8. Teske AJ, Prakken NH, De Boeck BW, et al. Echocardiographic deformation imaging reveals
preserved regional systolic function in endurance athletes with left ventricular hypertrophy. Br J
Sports Med 2010;44:872–8
9. Pluim BM, Beyerbacht HP, Chin JC, et al. Comparison of echocardiography with magnetic
resonance imaging in the assessment of the athlete's heart. Eur Heart J 1997;18:1505–13
10. Teske AJ, Prakken NH, De Boeck BW, et al. Echocardiographic tissue deformation imaging of
right ventricular systolic function in endurance athletes. Eur Heart J 2009;30:969–77
11. Prakken NH, Velthuis BK, Teske AJ, et al. Cardiac MRI reference values for athletes and nonathletes corrected for body surface area, training hours/week and sex. Eur J Cardiovasc Prev
Rehabil 2010;17:198–203
12. Prakken NH, Cramer MJ, Teske AJ, et al. The effect of age in the cardiac MRI evaluation of the
athlete's heart. Int J Cardiol 2011;149:68–73
13. Maron BJ, Douglas PS, Graham TP, et al. Task Force 1: preparticipation screening and diagnosis
of cardiovascular disease in athletes. J Am Coll Cardiol 2005;45:1322–6
14. McKenna WJ, Thiene G, Nava A, et al. Diagnosis of arrhythmogenic right ventricular
dysplasia/cardiomyopathy. Task Force of the Working Group Myocardial and Pericardial Disease
of the European Society of Cardiology and of the Scientifi c Council on Cardiomyopathies of the
International Society and Federation of Cardiology. Br Heart J 1994;71:215–18
15. Maron BJ. Hypertrophic cardiomyopathy: a systematic review. JAMA 2002;287:1308–20
16. Scharhag J, Urhausen A, Schneider G, et al. Left ventricular mass in enduranceathletes with
athlete's heart and untrained subjects– comparison between different echocardiographic methods
and MRI. Z Kardiol 2003;92:309–18
17. Scharhag J, Thünenkötter T, Urhausen A, et al. Echocardiography of the right ventricle in
athlete's heart and hearts of normal size compared to magnetic resonance imaging: which
measurements should be applied in athletes? Int J Sports Med 2010;31:58–64
18. Lang RM, Bierig M, Devereux RB, et al. Recommendations for Chamber Quantifi cation: A
Report from the American Society of Echocardiography's Guidelines and Standards Committee
and the Chamber Quantifi cation Writing Group, Developed in Conjunction with the European
Association of Echocardiography, a Branch of the European Society of Cardiology. J Am Soc
Echocardiogr 2005;18:1440–63
19. Hergan K, Schuster A, Frühwald J, et al. Comparison of left and right ventricular volume
measurement using the Simpson's method and the area length method. Eur J Radiol
2008;65:270–8
20. Khoo NS, Young A, Occleshaw C, et al. Assessments of right ventricular volume and function
using three-dimensional echocardiography in older children and adults with congenital heart
disease: comparison with cardiac magnetic resonance imaging. J Am Soc Echocardiogr
2009;22:1279–88
21. Prakken N H, Velthuis BK, Vonken EJ, et al. C ardiac MRI: standardized right and left
ventricular quantifi cation by briefl y coaching inexperienced personnel. J Open Magn Reson
2008;1:104–11
22. Lai W W, Gauvreau K, Rivera ES, et al. A ccuracy of guideline recommendations for twodimensional quantifi cation of the right ventricle by echocardiography. Int J Cardiovasc Imaging
2008;24:691–8
23. Guo Y K, Yang ZG, Ning G, et al. Sixty-four-slice multidetector computed tomography for
preoperative evaluation of left ventricular function and mass in patients with mitral regurgitation:
comparison with magnetic resonance imaging and echocardiography. Eur Radiol 2009;19:2107–
16
24. Wernstedt P, Sjöstedt C, Ekman I, e t al. A daptation of cardiac morphology and function to
endurance and strength training. A comparative study using MR imaging and echocardiography
in males and females. Scand J Med Sci Sports 2002;12:17–25
25. Grothues F, Smith GC, Moon JC, et al. Comparison of interstudy reproducibility of
cardiovascular magnetic resonance with two-dimensional echocardiography in normal subjects
and in patients with heart failure or left ventricular hypertrophy. Am J Cardiol 2002;90:29–34
26. Turpeinen A K, Kuikka JT, Vanninen E, et al. A thletic heart: a metabolic, anatomical, and
functional study. Med Sci Sports Exerc 1996;28:33–40
27. Missouris C G, Forbat SM, Singer DR, et al. Echocardiography overestimates left ventricular
mass: a comparative study with magnetic resonance imaging in patients with hypertension. J
Hypertens 1996;14:1005–10
28. Riley-Hagan M, Peshock RM, Stray-Gundersen J, e t al. Left ventricular dimensions and mass
using magnetic resonance imaging in female endurance athletes. Am J Cardiol 1992;69:1067–74
29. Selton-Suty C, Juillière Y. Non-invasive investigations of the right heart: how and why? Arch
Cardiovasc Dis 2009;102:219–32
30. Steen H, Nasir K, Flynn E, et al. Is magnetic resonance imaging the 'reference standard' for
cardiac functional assessment? Factors infl uencing measurement of left ventricular mass and
volumes. Clin Res Cardiol 2007;96:743–51
31. Thuny F, Jacquier A, Jop B, et al. Assessment of left ventricular non-compaction in adults: sideby-side comparison of cardiac magnetic resonance imaging with echocardiography. Arch
Cardiovasc Dis 2010;103:150–9
32. Margossian R, Schwartz ML, Prakash A, e t al. Comparison of echocardiographic and cardiac
magnetic resonance imaging measurements of functional single ventricular volumes, mass, and
ejection fraction (from the Pediatric Heart Network Fontan Cross-Sectional Study). Am J Cardiol
2009;104:419–28
33. Leibundgut G, Rohner A, Grize L, e t al. D ynamic assessment of right ventricular volumes and
function by real-time three-dimensional echocardiography: a comparison study with magnetic
resonance imaging in 100 adult patients. J Am Soc Echocardiogr 2010;23:116–26
34. Sugeng L, Mor-Avi V, Weinert L, et al. M ultimodality comparison of quantitative volumetric
analysis of the right ventricle. JACC Cardiovasc Imaging 2010;3:10–18
35. Nesser HJ, Mor-Avi V, Gorissen W, et al. Quantifi cation of left ventricular volumes using threedimensional echocardiographic speckle tracking: comparison with MRI. Eur Heart J
2009;30:1565–73
36. Jenkins C, Marwick TH. Baseline and follow-up assessment of regional left ventricular volume
using 3-dimensional echocardiography: comparison with cardiac magnetic resonance. Cardiovasc
Ultrasound 2009;1:7–55
37. Firoozi S, Sharma S, Hamid MS, et al. Sudden death in young athletes: HCM or ARVC?
Cardiovasc Drugs Ther 2002;16:11–17
38. Tandri H, Macedo R, Calkins H, et al. Role of magnetic resonance imaging in arrhythmogenic
right ventricular dysplasia: insights from the North American arrhythmogenic right ventricular
dysplasia (ARVD/C) study. Am Heart J 2008;155:147–53
39. Marcus FI, McKenna WJ, Sherrill D, et al. Diagnosis of arrhythmogenic right ventricular
cardiomyopathy/dysplasia: proposed modifi cation of the task force criteria. Circulation
2010;121:1533–41
40. De Castro S, Pelliccia A, Caselli S, e t al. R emodelling of the left ventricle in athlete's heart: a
three-dimensional echocardiographic and magnetic resonance imaging study. Heart
2006;92:975–6
41. Keenan NG, Pennell DJ. CMR of ventricular function. Echocardiography 2007;24:185–93.
Sidebar
What is already known on this topic
Previous studies show that ventricular volumes and dimensions on two-dimensional echocardiography are
significantly lower, and left ventricular wall mass and wall thickness higher as compared with cardiac
MRI measurements in healthy subjects and patients.
What this study adds
The linear difference between echocardiographic and cardiac MRI values for physiological enlargement
of the athlete's heart and pathological left ventricular (LV) hypertrophy has been established using a headto-head comparison. Correction factors are offered in order to achieve a 1:1 relation between
echocardiographic and cardiac MRI estimation of LV volumes and wall mass.
NHJP and AJT have joint first authorship.