The authors report the case of a 16-year-old boy who practices karate, who underwent medical evaluation because of atypical chest discomfort, related to strenuous effort. The ECG and echocardiogram findings were normal. The young boy did a treadmill stress test which was positive for myocardial ischemia. Late during the investigation, he underwent treadmill stress echocardiography, during which he developed intraventricular gradient of over 130 mmHg with end-systolic peak and systolic anterior movement (SAM) of the mitral valve. These echocardiographic findings were not present at rest and disappeared shortly after termination of exercise. The authors discuss the significance of this event. This leads us to advise withdrawal from participation in competitive sport according to the recomendations of the European Society of Cardiology. A possible role of exercise stress echo for intraventricular pressure gradient assessment in symptomatic athletes with structurally normal hearts is suggested

Ana G Almeida

B Maron

C Cotrim

Carlos Cotrim

D Corrado

F Bueno

J Peteiro

K Lau

M Paz

Manuel Carrageta

R Grose

R Yotti

S Almeida

S Firoozi

English

PubMed

© 2007 Cotrim et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.The authors report the case of a 16-year-old boy who practices karate, who underwent medical evaluation because of atypical chest discomfort, related to strenuous effort. The ECG and echocardiogram findings were normal. The young boy did a treadmill stress test which was positive for myocardial ischemia. Late during the investigation, he underwent treadmill stress echocardiography, during which he developed intraventricular gradient of over 130 mmHg with end-systolic peak and systolic anterior movement (SAM) of the mitral valve. These echocardiographic findings were not present at rest and disappeared shortly after termination of exercise. The authors discuss the significance of this event. This leads us to advise withdrawal from participation in competitive sport according to the recomendations of the European Society of Cardiology. A possible role of exercise stress echo for intraventricular pressure gradient assessment in symptomatic athletes with structurally normal hearts is suggested.info:eu-repo/semantics/publishedVersio

Cotrim, Carlos

Almeida, Ana G.

Carrageta, Manuel

Universidade de Lisboa: Repositório.UL

BioMed CentralCardiovascular UltrasoundssOpen AcceCase reportClinical significance of intraventricular gradient during effort in an adolescent karate playerCarlos Cotrim*1,3, Ana G Almeida2,3 and Manuel Carrageta1,3Address: 1Cardiology department, Garcia de Orta Hospital, Almada, Portugal, 2Cardiology department, Santa Maria Hospital, Lisboa, Portugal and 3Lisboa University Medical School, Lisboa, PortugalEmail: Carlos Cotrim* - carlosadcotrim@hotmail.com; Ana G Almeida - anagalmeida@hotmail.com; Manuel Carrageta - mcarrageta@mail.telepac.pt* Corresponding author    AbstractThe authors report the case of a 16-year-old boy who practices karate, who underwent medicalevaluation because of atypical chest discomfort, related to strenuous effort. The ECG andechocardiogram findings were normal. The young boy did a treadmill stress test which was positivefor myocardial ischemia. Late during the investigation, he underwent treadmill stressechocardiography, during which he developed intraventricular gradient of over 130 mmHg withend-systolic peak and systolic anterior movement (SAM) of the mitral valve. Theseechocardiographic findings were not present at rest and disappeared shortly after termination ofexercise. The authors discuss the significance of this event. This leads us to advise withdrawal fromparticipation in competitive sport according to the recomendations of the European Society ofCardiology. A possible role of exercise stress echo for intraventricular pressure gradientassessment in symptomatic athletes with structurally normal hearts is suggested.BackgroundThe development of significant intraventricular gradientsduring exercise is rare, usually in association with left ven-tricular hypertrophy [1,2]. In 23-year-old athlete [3], in an20-year-old professional soccer player [4], and in a 79year-old man we performed exercise echocardiography[5], and during the exercise [6] we unespectedly detectedsignificant (greater than 50 mmHg) intraventricular gradi-ent and systolic anterior movement of the mitral valve. Inthe case presented here, we describe an adolescent karateplayer that developed the same phenomenon.Case reportWe describe the case of a 16 year-old caucasian male, witha four-hour weekly training schedule, who complained ofoccasional chest disconfort on strenuous exercise. Therewas no relevant personal history and no family history ofsudden death or heart disease were reported.Physical examination revealed normal cardiac ausculta-tion and normal radial, carotid and femoral pulses. Thetwelve lead electrocardiogram was normal (Figure 1). Theechocardiogram was also normal (Figure 2, see Additionalfile 1), with no left ventricular hypertrophy; left ventricu-lar end-diastolic diameter was 41 mm, septum and poste-rior wall were 7 and 6 mm respectively, and the leftventricular outflow tract was 17 mm. No abnormalitieswere found in the mitral valve of subvalvular apparatus.Treadmill exercise test was performed following the Bruceprotocol that was considered positive for to myocardialischemia (Figure 3).Published: 19 November 2007Cardiovascular Ultrasound 2007, 5:39 doi:10.1186/1476-7120-5-39Received: 20 October 2007Accepted: 19 November 2007This article is available from: http://www.cardiovascularultrasound.com/content/5/1/39© 2007 Cotrim et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5(page number not for citation purposes)Cardiovascular Ultrasound 2007, 5:39 http://www.cardiovascularultrasound.com/content/5/1/39Page 2 of 5(page number not for citation purposes)Normal echocardiogram without left ventricular hypertrophyFigure 2Normal echocardiogram without left ventricular hypertrophy.Normal ECGFigure 1Normal ECG.Cardiovascular Ultrasound 2007, 5:39 http://www.cardiovascularultrasound.com/content/5/1/39The patient underwent an exercise stress echocardi-ograpgy, and during the exam developed a significantintraventricular gradient of 130 mmHg with an end-systo-lic peak and systolic anterior motion of the mitral valve(Figure 4, see Additional file 2), which disappeared in thefirst minute of recovery period. There was no fall in bloodpressure at the end of the test. The exercise stress echocar-diogram was negative for myocardial ischemia.Discussion and conclusionIt has long been know that small intraventricular gradi-ents are a commom phenomenon. Three mechanismshave been proposed [7] for them increasing significantlyduring exercise: 1) increase in non-obstructive physiolo-gycal gradients; 2) end-systolic obstruction secondary toventricular cavitary obliteration; and 3) mid-systolicobstruction caused by SAM of the mitral valve restrictingejection. However for SAM to occur, there must be somealteration of the geometry of the ventricular chamber or ofthe mitral valve apparatus. This was not the case in ouradolescent, although it has been demonstrated that intra-ventricular gradients can be caused by maneuvers thatchange loading conditions in structurally normal hearts[8], and it is know that participating in sports can bringabout elicit such changes.Sudden death in young athlets has been thoroughly stud-ied, and there is an agreement that the usual causes arehereditary or congenital [9]. However, in some series [10]around 30% of autopsy studies show no abnormalities,which suggests that the standard screening programs arefailing to prevent sudden death.In the case we report the fact that the patient had normalechocardiogram means that morphological study of thisheart would probably reveal no abnormalities. The phe-nomenom that we detected during exercise testing – mitralvalve SAM and intraventricular gradient associated withExercise test with alteration in ST segment in DII, DIII and avFFigure 3Exercise test with alteration in ST segment in DII, DIII and avF.Page 3 of 5(page number not for citation purposes)Cardiovascular Ultrasound 2007, 5:39 http://www.cardiovascularultrasound.com/content/5/1/39ST alterations – could well have been responsible for hissymptoms.The medical examination of this athlete was carried outbecause of symptoms arising from intense effort; wedid'nt reproduced the symptoms during exercise test butwe detected an anomaly in cardiac function [2-5], that inour opinion may explain them. The abnormality detectedis, however, only detectable during effort, and is notamong the diagnosis that contraindicate participation incompetitive sport according to recommendations of the36th Bethesda conference [11] and the European Society ofCardiology [12]. It is possible tht the phenomenondescribed in this adolescent could be among the causes ofsudden death in cases where anatomopathological exam-ination reveals no abnormalities, and we accordinglyadvised the athlete to suspend sports practice and referredhim for assessment to a sports medicine center. In ouropinion, the case described, in which significant abnor-malities in cardiac function were found only during exer-cise, suggests that this methodology should be applied toother adolescents that have symptoms related to exercisebut no structural abnormalities. We should note that thisphenomenon has been almost excluded to be a normalresponse to exercise in young healthy adults [13]. In faceof this, the symptomatic athletes in which the findingswhich we described is detected, should also be subjectedof long term follow-up to obtain an accurate assessmentof its clinical significance.Additional materialAdditional file 1Apical 4 chamber view before exercise. Two-dimensional 4 chamber view, before exercise, showing normal morphology and funtion of left ventricle and mitral valve.Click here for file[http://www.biomedcentral.com/content/supplementary/1476-7120-5-39-S1.avi]At peak exercise systolic anterior movement of mitral valve and significant intraventricular gradient was detectedFigure 4At peak exercise systolic anterior movement of mitral valve and significant intraventricular gradient was detected.Page 4 of 5(page number not for citation purposes)Cardiovascular Ultrasound 2007, 5:39 http://www.cardiovascularultrasound.com/content/5/1/39Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralReferences1. Peteiro J, Monserrat L, Castro Beiras A: Lábil subaortic obstruc-tion during exercise stress echocardiography.  Am J Cardiol1999, 84:1119-23.2. Lau K, Navarijo J, Stainback F: Pseudo-False-Positive ExerciseTreadmill Testing.  Tex Heart Inst J 2001, 28:308-11.3. Cotrim C, João I, Fazendas P, Cordeiro P, Sequeira A, Henriksson I,Oliveira L, Carrageta M: Exercise induced ventricular gradientin a young patient with a positive treadmill test and normalcoronary arteries.  Rev Port Cardiol 2002, 21:331-5.4. Cotrim C, Loureiro M, Simões O, Cordeiro P, Henriksson I, VinhasH, Almeida A, Carrageta M: Intraventricular gradient duringeffort in a professional soccer player. Clinical significance.Rev Port Cardiol 2005, 24:1395-1401.5. Almeida S, Cotrim C, Brandão L, Miranda R, Loureiro M, Simões O,Lopes L, Carrageta M: Exercise-Induced left ventricular outflowtract obstruction. A potential cause of symptoms in the eld-erly.  Rev Port Cardiol 2007, 26:257-262.6. Cotrim C, Carrageta M: Ecocardiografia de Sobrecarga –Esforço.  Rev Port Cardiol 2000, 19:345-350.7. Yotti R: Qué significado tiene un gradiente de presión intra-ventricular sistólico durante el ejercicio?  Rev Esp Cardiol 2004,57:1139-42.8. Grose R, Maskin C, Spindola-Franco H, Yipintsoi T: Production ofleft ventricular cavitary obliteration in normal man.  Circula-tion 1981, 64:448-55.9. Firoozi S, Sharma S, McKenna W: Risk of competitive sport inyoung athletes with heart disease.  Heart 2003, 89:710-714.10. Paz M, Aguilera B: Causes of Sudden Death During SportsActivities in Spain.  Rev Esp Cardiol 2002, 55:347-58.11. Maron B, Zipes D: 36th Bethesda Conference. Introduction: Eli-gibility recomendations for competitive athletes with cardi-ovascular abnormalities – general considerations.  J Am CollCardiol 2005, 45:1318-21.12. Corrado D, Pelliccia A, Bjørnstad H, Vanhees L, Biffi A, Borjesson M,Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mell-wig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Hei-dbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E,Blomstrom-Lundqvist C, McKenna WJ, Thiene G, Study Group ofSport Cardiology of the Working Group of Cardiac Rehabilitation andExercise Physiology and the Working Group of Myocardial and Peri-cardial Diseases of the European Society of Cardiology: Cardiovas-cular pre-participation screening of young competitiveathletes for prevention of sudden death: proposal for a com-mon European protocol. Consensus statement of StudyGroup of Sport Cardiology of the Working Group of CardiacReabilitation and Exercise Physiology and Working Group ofMyocardial and Pericardial Diseases of European Society ofCardiology.  Eur Heart J 2005, 26:516-524.13. Bueno F, Isabel R, Salguero R, Doblas J, Pinilla J, Galván E: Effect ofexercise on systolic left ventricular outflow velocity inhealthy adults.  Rev Esp Cardiol 2006, 59:180-2.Additional file 2Apical 4 chamber view at 13 minutes before end of exercise. Two-dimen-sional 4 chamber view, near peak exercise, showing clearly, systolic ante-rior movement of the mitral valve.Click here for file[http://www.biomedcentral.com/content/supplementary/1476-7120-5-39-S2.avi]Page 5 of 5(page number not for citation purposes)

Cardiovascular Ultrasound

Clinical significance of intraventricular gradient during effort in an adolescent karate player

Springer - Publisher Connector

Carlos  Cotrim

Crossref

Abstract The authors report the case of a 16-year-old boy who practices karate, who underwent medical evaluation because of atypical chest discomfort, related to strenuous effort. The ECG and echocardiogram findings were normal. The young boy did a treadmill stress test which was positive for myocardial ischemia. Late during the investigation, he underwent treadmill stress echocardiography, during which he developed intraventricular gradient of over 130 mmHg with end-systolic peak and systolic anterior movement (SAM) of the mitral valve. These echocardiographic findings were not present at rest and disappeared shortly after termination of exercise. The authors discuss the significance of this event. This leads us to advise withdrawal from participation in competitive sport according to the recomendations of the European Society of Cardiology. A possible role of exercise stress echo for intraventricular pressure gradient assessment in symptomatic athletes with structurally normal hearts is suggested.</p

Almeida Ana G

Cotrim Carlos

Carrageta Manuel

Directory of Open Access Journals

BioMed CentralCardiovascular Ultrasound
ssOpen AcceCase report
Clinical significance of intraventricular gradient during effort in an 
adolescent karate player
Carlos Cotrim*1,3, Ana G Almeida2,3 and Manuel Carrageta1,3
Address: 1Cardiology department, Garcia de Orta Hospital, Almada, Portugal, 2Cardiology department, Santa Maria Hospital, Lisboa, Portugal and 
3Lisboa University Medical School, Lisboa, Portugal
Email: Carlos Cotrim* - carlosadcotrim@hotmail.com; Ana G Almeida - anagalmeida@hotmail.com; 
Manuel Carrageta - mcarrageta@mail.telepac.pt
* Corresponding author    
Abstract
The authors report the case of a 16-year-old boy who practices karate, who underwent medical
evaluation because of atypical chest discomfort, related to strenuous effort. The ECG and
echocardiogram findings were normal. The young boy did a treadmill stress test which was positive
for myocardial ischemia. Late during the investigation, he underwent treadmill stress
echocardiography, during which he developed intraventricular gradient of over 130 mmHg with
end-systolic peak and systolic anterior movement (SAM) of the mitral valve. These
echocardiographic findings were not present at rest and disappeared shortly after termination of
exercise. The authors discuss the significance of this event. This leads us to advise withdrawal from
participation in competitive sport according to the recomendations of the European Society of
Cardiology. A possible role of exercise stress echo for intraventricular pressure gradient
assessment in symptomatic athletes with structurally normal hearts is suggested.
Background
The development of significant intraventricular gradients
during exercise is rare, usually in association with left ven-
tricular hypertrophy [1,2]. In 23-year-old athlete [3], in an
20-year-old professional soccer player [4], and in a 79
year-old man we performed exercise echocardiography
[5], and during the exercise [6] we unespectedly detected
significant (greater than 50 mmHg) intraventricular gradi-
ent and systolic anterior movement of the mitral valve. In
the case presented here, we describe an adolescent karate
player that developed the same phenomenon.
Case report
We describe the case of a 16 year-old caucasian male, with
a four-hour weekly training schedule, who complained of
occasional chest disconfort on strenuous exercise. There
was no relevant personal history and no family history of
sudden death or heart disease were reported.
Physical examination revealed normal cardiac ausculta-
tion and normal radial, carotid and femoral pulses. The
twelve lead electrocardiogram was normal (Figure 1). The
echocardiogram was also normal (Figure 2, see Additional
file 1), with no left ventricular hypertrophy; left ventricu-
lar end-diastolic diameter was 41 mm, septum and poste-
rior wall were 7 and 6 mm respectively, and the left
ventricular outflow tract was 17 mm. No abnormalities
were found in the mitral valve of subvalvular apparatus.
Treadmill exercise test was performed following the Bruce
protocol that was considered positive for to myocardial
ischemia (Figure 3).
Published: 19 November 2007
Cardiovascular Ultrasound 2007, 5:39 doi:10.1186/1476-7120-5-39
Received: 20 October 2007
Accepted: 19 November 2007
This article is available from: http://www.cardiovascularultrasound.com/content/5/1/39
© 2007 Cotrim et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
Cardiovascular Ultrasound 2007, 5:39 http://www.cardiovascularultrasound.com/content/5/1/39
Page 2 of 5
(page number not for citation purposes)
Normal echocardiogram without left ventricular hypertrophyFigure 2
Normal echocardiogram without left ventricular hypertrophy.
Normal ECGFigure 1
Normal ECG.
Cardiovascular Ultrasound 2007, 5:39 http://www.cardiovascularultrasound.com/content/5/1/39The patient underwent an exercise stress echocardi-
ograpgy, and during the exam developed a significant
intraventricular gradient of 130 mmHg with an end-systo-
lic peak and systolic anterior motion of the mitral valve
(Figure 4, see Additional file 2), which disappeared in the
first minute of recovery period. There was no fall in blood
pressure at the end of the test. The exercise stress echocar-
diogram was negative for myocardial ischemia.
Discussion and conclusion
It has long been know that small intraventricular gradi-
ents are a commom phenomenon. Three mechanisms
have been proposed [7] for them increasing significantly
during exercise: 1) increase in non-obstructive physiolo-
gycal gradients; 2) end-systolic obstruction secondary to
ventricular cavitary obliteration; and 3) mid-systolic
obstruction caused by SAM of the mitral valve restricting
ejection. However for SAM to occur, there must be some
alteration of the geometry of the ventricular chamber or of
the mitral valve apparatus. This was not the case in our
adolescent, although it has been demonstrated that intra-
ventricular gradients can be caused by maneuvers that
change loading conditions in structurally normal hearts
[8], and it is know that participating in sports can bring
about elicit such changes.
Sudden death in young athlets has been thoroughly stud-
ied, and there is an agreement that the usual causes are
hereditary or congenital [9]. However, in some series [10]
around 30% of autopsy studies show no abnormalities,
which suggests that the standard screening programs are
failing to prevent sudden death.
In the case we report the fact that the patient had normal
echocardiogram means that morphological study of this
heart would probably reveal no abnormalities. The phe-
nomenom that we detected during exercise testing – mitral
valve SAM and intraventricular gradient associated with
Exercise test with alteration in ST segment in DII, DIII and avFFigure 3
Exercise test with alteration in ST segment in DII, DIII and avF.Page 3 of 5
(page number not for citation purposes)
Cardiovascular Ultrasound 2007, 5:39 http://www.cardiovascularultrasound.com/content/5/1/39ST alterations – could well have been responsible for his
symptoms.
The medical examination of this athlete was carried out
because of symptoms arising from intense effort; we
did'nt reproduced the symptoms during exercise test but
we detected an anomaly in cardiac function [2-5], that in
our opinion may explain them. The abnormality detected
is, however, only detectable during effort, and is not
among the diagnosis that contraindicate participation in
competitive sport according to recommendations of the
36th Bethesda conference [11] and the European Society of
Cardiology [12]. It is possible tht the phenomenon
described in this adolescent could be among the causes of
sudden death in cases where anatomopathological exam-
ination reveals no abnormalities, and we accordingly
advised the athlete to suspend sports practice and referred
him for assessment to a sports medicine center. In our
opinion, the case described, in which significant abnor-
malities in cardiac function were found only during exer-
cise, suggests that this methodology should be applied to
other adolescents that have symptoms related to exercise
but no structural abnormalities. We should note that this
phenomenon has been almost excluded to be a normal
response to exercise in young healthy adults [13]. In face
of this, the symptomatic athletes in which the findings
which we described is detected, should also be subjected
of long term follow-up to obtain an accurate assessment
of its clinical significance.
Additional material
Additional file 1
Apical 4 chamber view before exercise. Two-dimensional 4 chamber view, 
before exercise, showing normal morphology and funtion of left ventricle 
and mitral valve.
Click here for file
[http://www.biomedcentral.com/content/supplementary/1476-
7120-5-39-S1.avi]
At peak exercise systolic anterior movement of mitral valve and significant intraventricular gradient was detectedFigure 4
At peak exercise systolic anterior movement of mitral valve and significant intraventricular gradient was detected.Page 4 of 5
(page number not for citation purposes)
Cardiovascular Ultrasound 2007, 5:39 http://www.cardiovascularultrasound.com/content/5/1/39Publish with BioMed Central   and  every 
scientist can read your work free of charge
"BioMed Central will be the most significant development for 
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central 
yours — you keep the copyright
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http://www.biomedcentral.com/info/publishing_adv.asp
BioMedcentral
References
1. Peteiro J, Monserrat L, Castro Beiras A: Lábil subaortic obstruc-
tion during exercise stress echocardiography.  Am J Cardiol
1999, 84:1119-23.
2. Lau K, Navarijo J, Stainback F: Pseudo-False-Positive Exercise
Treadmill Testing.  Tex Heart Inst J 2001, 28:308-11.
3. Cotrim C, João I, Fazendas P, Cordeiro P, Sequeira A, Henriksson I,
Oliveira L, Carrageta M: Exercise induced ventricular gradient
in a young patient with a positive treadmill test and normal
coronary arteries.  Rev Port Cardiol 2002, 21:331-5.
4. Cotrim C, Loureiro M, Simões O, Cordeiro P, Henriksson I, Vinhas
H, Almeida A, Carrageta M: Intraventricular gradient during
effort in a professional soccer player. Clinical significance.
Rev Port Cardiol 2005, 24:1395-1401.
5. Almeida S, Cotrim C, Brandão L, Miranda R, Loureiro M, Simões O,
Lopes L, Carrageta M: Exercise-Induced left ventricular outflow
tract obstruction. A potential cause of symptoms in the eld-
erly.  Rev Port Cardiol 2007, 26:257-262.
6. Cotrim C, Carrageta M: Ecocardiografia de Sobrecarga –
Esforço.  Rev Port Cardiol 2000, 19:345-350.
7. Yotti R: Qué significado tiene un gradiente de presión intra-
ventricular sistólico durante el ejercicio?  Rev Esp Cardiol 2004,
57:1139-42.
8. Grose R, Maskin C, Spindola-Franco H, Yipintsoi T: Production of
left ventricular cavitary obliteration in normal man.  Circula-
tion 1981, 64:448-55.
9. Firoozi S, Sharma S, McKenna W: Risk of competitive sport in
young athletes with heart disease.  Heart 2003, 89:710-714.
10. Paz M, Aguilera B: Causes of Sudden Death During Sports
Activities in Spain.  Rev Esp Cardiol 2002, 55:347-58.
11. Maron B, Zipes D: 36th Bethesda Conference. Introduction: Eli-
gibility recomendations for competitive athletes with cardi-
ovascular abnormalities – general considerations.  J Am Coll
Cardiol 2005, 45:1318-21.
12. Corrado D, Pelliccia A, Bjørnstad H, Vanhees L, Biffi A, Borjesson M,
Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mell-
wig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Hei-
dbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E,
Blomstrom-Lundqvist C, McKenna WJ, Thiene G, Study Group of
Sport Cardiology of the Working Group of Cardiac Rehabilitation and
Exercise Physiology and the Working Group of Myocardial and Peri-
cardial Diseases of the European Society of Cardiology: Cardiovas-
cular pre-participation screening of young competitive
athletes for prevention of sudden death: proposal for a com-
mon European protocol. Consensus statement of Study
Group of Sport Cardiology of the Working Group of Cardiac
Reabilitation and Exercise Physiology and Working Group of
Myocardial and Pericardial Diseases of European Society of
Cardiology.  Eur Heart J 2005, 26:516-524.
13. Bueno F, Isabel R, Salguero R, Doblas J, Pinilla J, Galván E: Effect of
exercise on systolic left ventricular outflow velocity in
healthy adults.  Rev Esp Cardiol 2006, 59:180-2.
Additional file 2
Apical 4 chamber view at 13 minutes before end of exercise. Two-dimen-
sional 4 chamber view, near peak exercise, showing clearly, systolic ante-
rior movement of the mitral valve.
Click here for file
[http://www.biomedcentral.com/content/supplementary/1476-
7120-5-39-S2.avi]Page 5 of 5
(page number not for citation purposes)


Repositório da Universidade de Lisboa

Aguilera B: Causes of Sudden Death During Sports Activities in Spain. Rev Esp Cardiol

Carrageta M: Intraventricular gradient during effort in a professional soccer player. Clinical significance. Rev Port Cardiol

Castro Beiras A: Lábil subaortic obstruction during exercise stress echocardiography.

E: Effect of exercise on systolic left ventricular outflow velocity in healthy adults. Rev Esp Cardiol

Ecocardiografia de Sobrecarga – Esforço. Rev Port Cardiol

Exercise induced ventricular gradient in a young patient with a positive treadmill test and normal coronary arteries. Rev Port Cardiol

Exercise-Induced left ventricular outflow tract obstruction. A potential cause of symptoms in the elderly. Rev Port Cardiol

Pseudo-False-Positive Exercise Treadmill Testing. Tex Heart Inst J

Qué significado tiene un gradiente de presión intraventricular sistólico durante el ejercicio? Rev Esp Cardiol

Risk of competitive sport in young athletes with heart disease. Heart

Yipintsoi T: Production of left ventricular cavitary obliteration in normal man. Circulation

Zipes D: 36th Bethesda Conference. Introduction: Eligibility recomendations for competitive athletes with cardiovascular abnormalities – general considerations.

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Clinical significance of intraventricular gradient during effort in an adolescent karate player

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