Cardiac Magnetic Resonance Findings in Patients Recovered From COVID-19: Initial Experiences in Elite Athletes.

A new study by Puntmann et al. (1) investigating an unselected group of 100 middle-aged patients who had recently recovered from coronavirus disease-2019 (COVID-19) without cardiac symptoms, suggests that an overwhelming 78% of the cases had cardiovascular involvement detectable by cardiovascular magnetic resonance (CMR) imaging. However, it is unknown if there is a cardiac involvement in otherwise healthy young patients after their recovery from COVID-19, especially in elite athletes who gradually return to vigorous exercise after the infection. Our aim was to describe the CMR results of elite athletes recently recovered from COVID-19 with mild to moderate symptoms to provide further insight into this currently very relevant topic (Figure 1 ).

Figure 1

Example of an Athlete Recovered From Coronavirus Disease 2019

Cardiac magnetic resonance imaging showed normal T2 mapping (43 ms) (A) and T1 mapping (938 ms) (B) values and there was no pathological late gadolinium enhancement (C).

A total of 12 professional, elite (>10 training h/week, participating in mixed sports) athletes (10 females and 2 males; median age: 23 years; interquartile range [IQR]: 20 to 23 years) after recovering from severe acute respiratory syndrome coronavirus 2 infection diagnosed by polymerase chain reaction on swab test, were referred to our center for CMR examination before returning to high levels of athletic performance. Patients underwent laboratory testing on the day of the CMR examination (n = 11). CMR examinations were performed on a 1.5-T MR scanner (Magnetom Aera Siemens, Malvern, Pennsylvania). The protocol contained the following sequences: balanced steady-state free precession cine movie, T2-weighted spectral presaturation with inversion recovery, late gadolinium enhancement images, T1 mapping using long-T1 5(3)3 modified look locker inversion recovery, and T2 mapping using T2-prepared balanced steady-state free precession T2 mapping. Myocardial T1 and T2 relaxation times were measured conservatively in the septal midventricular myocardium using motion-corrected images. The study was approved by the Medical Research Council of Hungary. All participants gave their written informed consent for data collection and research purposes.

The median time from positive polymerase chain reaction to CMR was 17 (IQR: 17 to 19) days in 10 female athletes, and 67 and 90 days in 2 male athletes, respectively. Two athletes were asymptomatic during infection, 10 athletes had mild/moderate symptoms (e.g., taste and/or smell disturbance) (n = 7), weakness (n = 5), fever (n = 4), and sore throat and/or coughing (n = 4). Only 1 athlete had palpitation, and none had chest pain during infection. Nobody had significantly elevated C-reactive protein, N-terminal pro–B-type natriuretic protein, or high-sensitivity troponin T levels. None of the athletes showed myocardial or pericardial edema or pathological late gadolinium enhancement. We compared CMR parameters of the female athletes with age- and sex-matched healthy elite athletes (n = 15) and healthy controls (n = 15) using Kruskal-Wallis tests. There was no difference among the 3 groups (athletes recovered from COVID-19 vs. healthy athletes vs. healthy controls) regarding their left ventricular ejection fraction (58% [IQR: 55% to 61%] vs. 57% [IQR: 54% to 60%] vs. 60% [IQR: 58% to 63%]), and T2 mapping parameters (44 ms [IQR: 44 to 45 ms] vs. 44 ms [IQR: 44 to 45 ms] vs. 46 ms [IQR: 44 to 47 ms]). Left ventricular volumes (left ventricular end-diastolic volume index: 100 ml/m2 [IQR: 95 to 110 ml/m2] vs. 102 ml/m2 [IQR: 98 to 109 ml/m2] vs. 85 ml/m2 [IQR: 80 to 89 ml/m2]; p < 0.001) were elevated and T1 mapping (957 ms [IQR: 943 to 972 ms] vs. 957 ms [IQR: 951 to 976 ms] vs. 981 ms [IQR: 966 to 990 ms]; p = 0.002) values were lower in both groups of athletes compared to healthy controls, showing signs of cardiac remodeling in athletes, as described previously (2).

Our initial findings in a small group of elite athletes without comorbidities who recently recovered from COVID-19 showed no signs of cardiac involvement on CMR. Puntmann et al. (1) reported that CMR performed with median 71 days after COVID-19 diagnosis revealed cardiac involvement in 78% of the cases, with ongoing myocardial inflammation in 60% of patients. In their study, T1 mapping showed excellent discriminative value between COVID-19 patients and risk factor–matched controls, and a significant difference between home- and hospital-recovered patients. However, the publication by Huang et al. (3) found in a smaller sample of 26 COVID-19 patients with cardiac symptoms that patients with conventional CMR findings had higher T1 mapping compared to patients without conventional CMR findings and healthy controls, whereas there was no difference between the latter 2 groups.

As there are uncertainties regarding the cardiovascular consequences of COVID-19, our results do not support the use of routine CMR in troponin-negative, asymptomatic, or mildly symptomatic athletes who recover from this illness.

Our study is limited by the following factors: this small group of patients was younger compared to groups in previous studies and had mild symptoms. Additionally, for 2 male athletes the time from illness to CMR imaging was longer.