Noninvasive biventricular pressure-strain-volume loop-derived myocardial work analysis in competitive athletes

Intense exercise imposes hemodynamic load on the heart, and while morphological remodeling is well-characterized, assessment of exercise-induced functional changes, like enhanced contractility, remains challenging. We aimed to introduce a novel 3D echocardiography (3DE)-derived method for noninvasive quantification of biventricular systolic function, less dependent on loading conditions in competitive athletes, and to explore the relationship with peak exercise capacity. We enrolled 260 athletes and 24 sedentary volunteers. All subjects underwent 3DE to measure left (LV) and right ventricular (RV) volumes and ejection fractions (EF). Biventricular global longitudinal strain (GLS) tracings and noninvasively estimated pressure curves were concatenated and further adjusted to instantaneous volumes to create pressure-strain-volume loops and derive volume-adjusted myocardial work (MW) indices (LV GWIV and RV GWIV). Athletes had lower biventricular EF and LV GLS, but significantly higher LV GWIV (10273 ± 2929 vs. 7387 ± 2050 mmHg%·mL, p < 0.001) and RV GWIV (3422 ± 1339 vs. 2436 ± 796 mmHg%·mL, p < 0.001) compared to controls. Among the functional echocardiographic parameters, RV GWIV showed the strongest correlation (r = 0.30, p < 0.001) and was an independent predictor of exercise capacity. Our novel metrics captured enhanced biventricular function in athletes at rest, and RV GWIV was independently associated with higher peak exercise capacity.