Echocardiographic Reporting of the Aorta in Young Competitive Athletes

Aortic dissection is a well-established cause of sudden cardiac death (SCD) in young competitive athletes.¹ Unlike most causes of SCD (e.g., cardiomyopathy, channelopathy), which are readily detectable By 12-lead electrocardiography,² aortopathies are typically electrically silent. Therefore, transthoracic echocardiography (TTE) performed during preparticipation screening or individualized clinical evaluation offers an important opportunity to assess for aortic pathology.³ To date, however, the consistency of reporting aortic dimensions among young competitive athletes undergoing TTE has not been previously examined.

This prospective observational cohort study included colleges from the National Collegiate Athletic Association that participated in the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) Study from September 1, 2020, through May 21, 2021.⁴ Deidentified reports of cardiovascular testing performed following SARS-CoV-2 infection were requested for each athlete. The inclusion criterion for this study was at least 1 TTE report from an echocardiography laboratory. All available TTE reports were reviewed by the study investigators to assess for reporting of the aortic root and ascending aorta. A TTE report was deemed to have reported on a specific aortic location if 1 of the following was present: (1) an aortic measurement at the defined location or (2) interpretation of the aorta at the defined location (e.g., “ascending aorta normal”). The diameter of the aortic root or ascending aorta was considered abnormal if it was ≥40 mm in male and ≥34 mm in female athletes.³ “Consistent reporters” were defined as laboratories reporting on the aorta in ≥75% of cases, “variable reporters” as those reporting on the aorta in 25% to 74% of cases, and “infrequent reporters” as those reporting on the aorta in <25% of cases. All aspects of this study were approved by the Massachusetts General Brigham Institutional Review Board (protocol no. 2020P002667).

Complete TTE reports were available for 1,523 athletes (age = 20 ± 3 years, 32% female, 27% Black) who underwent preparticipation cardiac screening, representing 26 unique sporting disciplines, 35 colleges/universities, and 56 distinct echocardiography laboratories (median, 5; interquartile range, [1, 33] echo reports per lab). Laboratory performance for reporting of the aortic root and ascending aorta is presented in Figure 1. All 56 laboratories (100%) were consistent reporters of the aortic root, whereas only 27/56 (48%) were consistent reporters of the ascending aorta. When limiting inclusion to laboratories that submitted ≥5 reports, only 11/29 (38%) were consistent reporters of the ascending aorta. A total of 13/930 (1.4%) male and 3/440 (0.7%) female athletes had abnormal aortic root dimensions among reports with available measurements. Of the 504 athletes who had the ascending aorta reported, 0/348 (0%) male and 3/156 (1.9%) female athletes had abnormal ascending aortic dimensions. Bicuspid aortic valve (BAV) was identified in 5/1,523 (0.3%) athletes, among whom all had concomitant reporting of the aortic root but only 3/5 (60%) had reporting of the ascending aorta.

Figure 1.

Overview of echocardiography reporting of the aorta among 1,523 collegiate athletes. (A) Prevalence of echocardiographic reporting of the aortic root. (B) Prevalence of echocardiographic reporting of the ascending aorta. “Consistent” means echo laboratories reporting on the aorta in ≥75% of cases; “Variable,” echo laboratories reporting on the aorta in 25%–74% of cases; “Infrequent,” echo laboratories reporting on the aorta in <25% of cases.

This study examined reporting of the aorta during TTE imaging of young competitive athletes, with several key findings. First, 100% of the laboratories were consistent reporters of the aortic root, whereas only 48% were consistent reporters of the ascending aorta. This is an important finding as aortopathies may preferentially affect the ascending aorta, leading to missed pathology if only the root is imaged and/or reported. Second, among athletes diagnosed with BAV, the ascending aorta was assessed in only 60% of reports. As ascending aortic dilatation is common among patients with BAV, the ascending aorta should always be assessed in this population.

Several limitations of this study are noteworthy. First, TTEs in this cohort were ordered to detect cardiac involvement following SARS-CoV-2 infection and therefore may have deprioritized assessment of the aorta. However, current imaging guidelines recommend comprehensive aortic assessment irrespective of the indication for TTE. Second, there is heterogeneity nationally as to aortic measurement protocols across different TTE laboratories (i.e., inner edge-to-inner edge vs leading edge-to-leading edge), and we lack data regarding the use of each measurement technique, which may have led to slight over- or underestimation of true pathology. However, similar prevalence estimates of abnormal aortic measurements have been previously reported.⁵

In summary, this study of TTE utilization among young competitive athletes demonstrates that fewer than 50% of echocardiography labs consistently report the size of the ascending aorta and, notably, the ascending aorta is not universally assessed among those with BAV. These key findings represent areas for future quality improvement among echocardiography laboratories and should be considered in future echocardiography and aortic disease guidelines.