Working Diagnosis:
Post-COVID-19 Cardiomyopathy versus Athletic Heart
True: Mild COVID-19 Infection with Initial Elevated hsTnT and reduced RV EF on cMRI
True: Changes largely consistent with Athletic Heart and resolution of any ”grey-zone” abnormalities with final cMRI

Treatment:
Initial cMRI was concerning for Post COVID-19 Cardiomyopathy due to low ventricular ejection fractions and wall dyskinesia. The student-athlete was withheld from all physical activity for 3 months. Repeat cMRI with worsening right ventricular ejection fraction. We continued restriction from sport and did specialty referral to the Mayo Clinic in Rochester, MN. cMRI performed at the Mayo Clinic demonstrated resolution of abnormalities and was interpreted as normal. Cardiac stress transthoracic echocardiogram, 24-hour Holter monitoring, and hsTnT were also normal.

Outcome:
The treatment of this student athlete involved a multi-disciplinary collaboration between: team physicians, cardiology consultants, Mayo Clinic cardiology teams, team athletic trainers, the patient and his parents. At the resolution, we agreed on clearance for return to sport with a gradual and monitored increase in activity. Currently he is targeting a return for the fall 2021 Cross Country season

Author's Comments:
Exercise during COVID-19 myocardial infection could precipitate a malignant ventricular arrhythmia, thus cardiopulmonary clearance is mandatory in athletes before returning to play. Evaluation generally includes: history and physical exam, ECG, Transthoracic Echocardiogram, and hsTnT. If any of these are abnormal, Cardiac MRI is advised to identify the primary arrhythmogenic post-infection cardiac sequelae: Cardiomyopathy, Myocarditis, or Silent Cardiac Inflammation. Results of cardiac MRI are important to understand as athletes are infected by COVID-19 and then require cardiac clearance before return to activity. An athletically conditioned heart may show decreased right ventricular ejection fraction consistent with strain on cardiac MRI. RV end diastolic volume may increase by 25%. RV mass may increase by 37%. Increased end diastolic volume will then decrease RV ejection fraction. Regular and intensive endurance training often results in a balanced enlarged heart. This is consistent with the diagnosis of athletic heart which was the ultimate diagnosis for our student-athlete

Editor's Comments:
Athletic heart is a result of the heart’s response to the conditioning that happens during exercise. These changes can often be confused for pathology and given the unknown cardiac effects of COVID-19, it is imperative that one does their due diligence in differentiating an athletic heart from a cardiac pathology. This due diligence is reflected in the NCAA Management Algorithm on Post-COVID RTP.

References:
Baggish A, Drezner JA, Kim J, Martinez M, Prutkin JM. Resurgence of sport in the wake of COVID-19: cardiac considerations in competitive athletes. Br J Sports Med. 2020; 54(19):1130–1131. https://doi.org/10.1136/bjsports-2020-102516.
Brosnan MJ, Rakhit D. Differentiating Athlete's Heart From Cardiomyopathies - The Left Side. Heart Lung Circ. 2018;27(9):1052-1062. doi:10.1016/j.hlc.2018.04.297
Clerkin KJ, Fried JA, et al. COVID-19 and cardiovascular disease. Circulation. 2020;141(20):1648–1655. https://doi.org/10.1161/CIRCULATIONAHA.120.046941.
Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic. J Am Coll Cardiol. 2020;75(18):2352–2371. https://doi.org/10.1016/j.jacc.2020.03.031.
Maron BJ, Udelson JE, Bonow RO, et al. (2015). Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis: A scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e273-280. https://doi.org/Recovering from COVID-19: An Expert Consensus Statement. JACC: Cardiovascular Imaging, 0(0). https://doi.org/10.1016/j.jcmg.2020.10.005/10.1161/CIR.0000000000000239.
NCAA-COVID-19-Algorithm-12-AUG-2020.pdf. (n.d.). Retrieved March 5, 2021, from https://www.amssm.org/Content/pdf-files/COVID19/NCAA-COVID-19-Algorithm-12-AUG-2020.pdf
Phelan D, Kim JH, Chung EH. A game plan for the resumption of sport and exercise after Coronavirus disease 2019 (COVID-19) infection. JAMA Cardiol. 2020;5(10):1085. https://doi.org/10.1001/jamacardio.2020.2136.
Phelan D, Kim JH, Elliott MD, et al. Screening of potential cardiac involvement in competitive athletes recovering from COVID-19: An expert consensus statement. JACC: Cardiovasc Imaging. December 2020;13(10):2635-2652. https://doi.org/10.1016/j.jcmg.2020.10.005.

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