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"Sport Medicine Journal" No.5 - 2006

Right ventricular dysfunction – a possible limiting factor of the exercise capacity in top athletes

Pufulete Elisabeta, Georgescu Mariana, Stoian I1, Carp C 2
1 National Institute of Sports Medicine Bucharest
2 Institute of Cardiovascular diseases ,, C.C. ILIESCU “ Bucharest
Abstract. We studied a group of 18 top athletes (A) presenting the alteration of ventricular repolarization in right ventricular area ( mean age of 18 years + 5, mean stage in sport of 6 years +>3,  12 females and 6 males). They practiced long endurance exercise (14) or the resistance sports (4). We performed ECG at rest and during maximal exercise (exercise stress testing) by cycloergometer (2,5 – 3 watts / kg body weight), two-dimensional echocardiographic investigation at rest and immediately after exercise. We also studied a witness group of 15 top athletes (B). Group A presented some signs of R.V. dysfunction: the increased diastolic and systolic area (p<0,01) modified shape, the decreased RV descent (p<0,01). VO We studied a group of 18 top athletes (A) presenting the alteration of ventricular repolarization in right ventricular area ( mean age of 18 years + 5, mean stage in sport of 6 years +2 max. was decreased . We found also an opposite effect of the maximal exercise on the right and the left ventricles: R.V. area increased while the left one decreased. This disproportionate effect was higher in long endurance athletes as compared with the resistance athletes. The explanation could be a disproportionate increase in R.V. afterload and an inadequate R.V. preload reserve caused by the decreased venous return. The changes of the R.V. shape and function during maximal endurance exercise seem to be a possible limiting factor of the effort capacity.
Key Words: Right Ventricle (R.V.), Left Ventricle (L.V.), Electrocardiogram (ECG) , Right Atrium (R.A.), Left Atrium (L.A.), Afterload, Preload, Ejection Fraction (E.F.).

In recent years, we found a particular electrocardiographic aspect in top athletes: inverted “T” waves in right precordial area (V1 to V3 and sometimes V4). Starting from this unexpected aspect , we extended the cardiological research on the R.V., knowing that the effects of the maximal exercise are less well studied on the right than on the left side of the heart (1,2). In fact, the right heart response to extreme or prolonged exercise is practically unknown. Confronted with this particular aspect, we asked ourselves: is it a disadaptive functional state caused by overtraining, or is it a silent myocardial ischemia – not quite impossible in young people over 25 years old, or is it a sign of an isolated R.V. hypertrophic cardiomyopathy – not rare in people younger than 25 years? Also we had to conclude whether it is advisable for these athletes to engage in top sport.

Study subjects: we studied periodically about 18000 elite or high level athletes. Out of them, only 18 subjects presented resting ECG alterations in R.V. area. This group (A) had the following characteristics: mean age of 18 years (range 12 to 31), mean stage in sports activity of 6 years (range 2 to 16), 67% were females and 33% were males. Distribution on sports showed the greatest prevalence in swimming and kayak. We did supplementary investigations: clinical and laboratory biochemical exam (including electrolytes), heart radiological exams concerning dimensions, configuration and pulmonary circulation, the aerobic capacity tested by cycloergometer (2,5 – 3 watts / kg body weight) ECG at rest and during exercise. All athletes underwent two echocardiographic studies, at rest and immediately after exercise. Two- dimensional echocardiograms were recorded from apical four chambers view.
This view allows imaging all cardiac chambers, atrio – ventricular flow and assessment of the right and left ventricular systolic function.The echocardiographic parameters have been corrected according to age and body weight.
There were studied right and left end- diastolic and end- systolic cavities, partly the tricuspid and mitral regurgitation and R.V. descent: the difference in length on a perpendicular chord between the endocardium of the R.V. apex and the tricuspid annulus in end-diastole and end-systole(3).We preferred to study this parameter knowing that the systolic shortening from apex to base has been found to correlate with global R.V. function (4),while the tricuspid annular plane systolic excursion (TAPSE) is closely correlated with R.V.E.F.(5).We also studied a witness group (B) of athletes (swimmers) having the normal resting ECG.
Statistical analysis: Data are presented as mean values +/-standard deviation (SD).A <0,05 was considered statistically significant.

The study subjects were clinicaly asymptomatic, biochemical tests and radiological investigations were also normal .ECG became normal during exercise on cycloergometer. The aerobic capacity (VO2 max)was smaller as compared with thewitness group.In the study group, the echocardiographic investigation showed the resting mean values of the R.V.area bigger than the same mean values found in witness group.The mean values of the L.V.,L.A.,and R.A.areas were similar (Table1)


Mean value± DS
Mean value± DS


R.V. end diastolic
22.5 ± 4.2 18.7 ± 3.62.75<0.01
R.V. end systolic
15.1 ± 5.2 11.2 ± 2.92.58<0.01
L.V. end diastolic
38.1 ± 7.137.0 ± 5.1 0.50 >0.05
L.V. end systolic
26.3 ± 7.1 25.8 ± 6.80.20>0.05
R.A. end diastolic
11.9 ± 2.811.3 ± 2.8 0.61 >0.05
R.A. end systolic
19.1 ± 3.0 18.8 ± 3.00.28>0.05
L.A. end diastolic
11.6 ± 4.011.8 ± 4.0 0.14 >0.05
L.A. end systolic
20.1 ± 4.8 20.0 ± 4.40.06>0.05

R.V. descent was significant smaller. (Table 2)



Mean value ± DS

Mean value ± DS

t p
1,7 + 0,2
2,0 + 0,24,29 <0,01

Immediately after exercise both groups presented the mean values of the R.V. area bigger, while the L.V. area was smaller (Table 3).


Mean value± DS
Mean value± DS
t p
R.V. end diastolic

R.V. end systolic

L.V. end diastolic

L.V. end systolic

R.A. end diastolic

R.A. end diastolic

L.A. end diastolic

L.A. end diastolic

25,1 + 5,2

17,1 + 5,2

36,3 + 6,3

25,1 + 5,9

12,0 + 3,0

18,8 + 3,4

11,2 + 3,1

16,9 + 3,8

19,9 + 4,8

14,1 + 3,8

36,4 + 6,1

24,8 + 5,8

11,5 + 2,8

17,9 + 3,0

11,3 + 3,0

17,2 + 3,9















This fact is conform to the other studies (6), but we did not find anyone concerning the possible correlation between the echocardiographic and electrocardiographic patterns. The dynamic of the altered ECG was as follows: normalization in 74% cases after a various period of time without extreme exercise;one case was stationary; one case presented diffused troubles of ventricular repolarization; one athlete presented an ectopic ventricular activity (as left bundle branch block configuration) being the possibility of an arrhythmogenic R.V.dysplasia. We have to mention three facts:all study subjects with modified ventricular repolarization in R.V. area had had the previous normal ECG; this particular aspect was discovered especially in the precompetitional period, after the long endurance trainings; 15 of them (83%) had had a long stage in sport. Though we could not study the atrio-ventricular regurgitations, we noted that tricuspid regurgitation was nearly unchanged, while the mitral one was severely decreased.

The absence of any clinical symptoms and the normal ECG during the exercise stress testing seem to exclude a coronarian substrata. Echocardiographic study does not identify the signs of a hypertrophic cardiomyopathy.The resting big R.V.area and the decreased R.V.descent could indicate a possible R.V. dysfunction.In clinical practice the multivariate analysis revealed that R.V.descent as a marker of the R.V.dysfunction, was an independent predictor of adverse outcome in active myocarditis(4.)R.V.dysfunction in associated with worse L.V.function;it is a possible sign of the depressed biventricular function.In elite athletes practicing long endurance exercise ,R.V.dysfunction could be a sign, a signal that the heart’s physiological adaptive mechanisms are exceeded.In our study, normalized ECG after deconditioning period pleads for the functional transient disadaptive cause.The echocardiographic aspect found immediately after exercise requires a serious analysis. R.V. as well as the L.V. must modify its performance according to the increased circulatory demands of the extreme exercise. It is possible in certain top athletes that exercise determines the opposite effects on the right and left ventricles. We found that R.V. enlarges while the L.V. becomes smaller. The cause of this different response may be a disproportionate increase of the right and left ventricular afterload during and immediately after exercise. This fact was demonstrated by hemodynamic studies, (7,2) which showed that after extreme exercise the pulmonary pressure increases by 50% to 70% while the systemic pressure increases by only 11% to 45%. If the increased afterload is maintained for a period of time,the R.V.dysfunction can manifest as dilation (8). Another possible explanation could be a different preload reserve or venous return. In top athletes, an inadequate venous return(caused by hyperpnoea) could be compensated by a sudden,transient R.V. dilation (9).L.V.function may be negatively affected through a positional shift of the interventricular septum and abnormal wal motion(10, 11).

Limitation of the study
1.It is difficult to assess R.V.sizes because its geometry does not conform to a mathematic model.
2.After extreme exercise,the time for data recording is very limited.
3.We studied only a particular ECG aspect found in top athletes and its certain accompanying echocardiographic parameters
4.The low numer of cases studied does not allow to forward firm conclusions.

1. Inverted “T’’waves in R.V.area is a rare and unexpected ECG aspect in top athletes. It could be a sign of a R.V.dysfunction.
2. This aspect is more frequent in females (67%); also it appears late in the sport career, especially after training in long endurance and high intensity efforts.
3. Altered ECG patterns disappear or are attenuated in the deconditioning period.
4. In study subjects, the echocardiographic investigatins showed an increase of the R.V.area at rest and after exercise bigger than in the witness group.R.V.descent was smaller.
5. The increased R.V.area and the possible changes of its shape and compliance,also the decreased R.V.descent suggest a certain R.V.dysfunction, as a possible consequence of the inadequate R.V.preload reserve.
6. The possibility that the R.V. dysfunction can be a significant limiting factor of the effort capacity begin to have more relevance.
7. The opposite effects of the exercise on the right and left ventricles remain a problem to study in a large numer of top athletes practicing different efforts.The understanding of this problem could be important both in sports cardiology and in clinical cardiological practice.

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  10. Perrault H, Peronnet F, Lebeu R, Nadeau RA (1986), Echocardiographic assessment of left ventricular performance before and after marathon running. Am. Heart. J.; 112: pp 1026-31.
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