Solitary papillary muscle hypertrophy in young athletes: a rationale for inverted T-waves on ECG?

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The underlying mechanisms of inverted T-waves on ECGs in athletes are constantly under investigation.1,2 Two white male soccer players, aged 19 (athlete A) and 17 (athlete B) years, respectively, were referred to our cardiology unit for preparticipation screening. Both of them presented with inverted T-waves on resting ECG, in inferior and/or precordial V1–V4 leads (Fig. 1), likely suggesting left ventricular hypertrophy. High-resolution transthoracic echocardiography demonstrated normal left ventricular end-diastolic volume index (A = 26 and B = 25 ml/m2), normal left ventricular wall thickness (<12 mm), normal left ventricular mass index (A = 82 and B = 92 g/m2), ejection fraction of 0.70 and 0.75, respectively, normal left atrial volume index (A = 22 and B = 24 ml/m2), regular myocardial performance index (A = 0.32 and B = 0.34), normal mitral E/A ratio (A = 1.83 and B = 1.74) and lateral annulus E/E’ ratio (A = 4.5 and B = 5.6). Global left ventricular longitudinal strain was also normal (A = −22.8% and B = −25.2%) and no right ventricular anomalies were assessed. We also measured end-diastolic diameters of the anterolateral and posteromedial papillary muscles from short-axis view as suggested by Kobashi et al.3 Interestingly, solitary papillary muscle hypertrophy (SPMH) with a thickness ranging 13 to 16 mm was disclosed in both athletes (Fig. 1), really higher than the mean value (10.8 ± 0.4 mm) achieved by same-aged athletes in our laboratory. On these grounds, athletes were also requested to perform cardiopulmonary testing. Peak VO2 consumption was 55 and 52 ml/kg/min, respectively, and almost complete normalization of negative T-waves was observed on exercise.

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