Utilization of cardiovascular magnetic resonance (CMR) imaging for resumption of athletic activities following COVID-19 infection: an expert consensus document on behalf of the American Heart Association Council on Cardiovascular Radiology and Intervention (CVRI) Leadership and endorsed by the Society for Cardiovascular Magnetic Resonance (SCMR)

Frederick L. Ruberg, Aaron L. Baggish, Allison G. Hays, Michael Jerosch-Herold, Jiwon Kim, Karen G. Ordovas, Gautham Reddy, Chetan Shenoy, Jonathan W. Weinsaft, Pamela K. Woodard

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Abstract

The global pandemic of coronavirus disease 2019 (COVID-19) caused by infection with severe acute respiratory suyndrome coronavirus 2 (SARS-CoV-2) is now entering its 4th year with little evidence of abatement. As of December 2022, the World Health Organization Coronavirus (COVID-19) Dashboard reported 643 million cumulative confirmed cases of COVID-19 worldwide and 98 million in the United States alone as the country with the highest number of cases. While pneumonia with lung injury has been the manifestation of COVID-19 principally responsible for morbidity and mortality, myocardial inflammation and systolic dysfunction though uncommon are well-recognized features that also associate with adverse prognosis. Given the broad swath of the population infected with COVID-19, the large number of affected professional, collegiate, and amateur athletes raises concern regarding the safe resumption of athletic activity (return to play, RTP) following resolution of infection. A variety of different testing combinations that leverage the electrocardiogram, echocardiography, circulating cardiac biomarkers, and cardiovascular magnetic resonance (CMR) imaging have been proposed and implemented to mitigate risk. CMR in particular affords high sensitivity for myocarditis but has been employed and interpreted non-uniformly in the context of COVID-19 thereby raising uncertainty as to the generalizability and clinical relevance of findings with respect to RTP. This consensus document synthesizes available evidence to contextualize the appropriate utilization of CMR in the RTP assessment of athletes with prior COVID-19 infection to facilitate informed, evidence-based decisions, while identifying knowledge gaps that merit further investigation.

Original languageEnglish (US)
Article number73
JournalJournal of Cardiovascular Magnetic Resonance
Volume24
Issue number1
DOIs
StatePublished - Jan 2022

Bibliographical note

Funding Information:
This effort to consolidate expert opinions in this statement was motived by the observed variability in utilization and interpretation of CMR in the clinical practice of the RTP assessment. With the exception of the larger registry studies, recommendations put forth here are drawn largely upon presently available case series and cohorts that do not in themselves confer sufficient evidence on which to base definitive recommendations. Furthermore, there is considerable overlap in the CMR imaging applications of the RTP recommendation with assessment of non-athletes with symptoms of PASC []. For this reason, investigations funded by the significant $1.1 billon investment committed by the National Institutes of Health (NIH) to address PASC will likely inform the interpretation of testing results, including CMR, in the RTP assessment. Similarly, CMR features of myocarditis following mRNA COVID-19 vaccine is another area of overlap. A more thorough discussion of CMR in the assessment of PASC or post-mRNA vaccine myocarditis is beyond the scope of this document. Table reflects important knowledge gaps relevant to CMR in the RTP (and PASC) assessment which will be addressed through future investigations leveraging various study designs, registries, and multi-center observational studies.

Funding Information:
ALB: Dr. Baggish has received funding from the National Institute of Health/ National Heart, Lung, and Blood Institute, the National Football Players Association, and the American Heart Association to study issues relevant to this manuscript and receives compensation for his role as team cardiologist from the US Olympic Committee / US Olympic Training Centers, US Soccer, US Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University.

Funding Information:
Research grant from American College of Radiology Fund for Collaborative Research in Imaging (FCRI) titled: Transcatheter Aortic Valve Replacement (TAVR) Registry.

Funding Information:
JK: Research grant support from NIH/NHLBI (R01HL159055).

Funding Information:
AGH: Research grant support from NIH/NHLBI (1R01HL147660).

Funding Information:
MJH: Research grant support from NIH/NIA (1R01AG052282).

Publisher Copyright:
© 2022, The Author(s).

Keywords

  • Athlete
  • COVID-19
  • Magnetic resonance imaging
  • Myocarditis

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