The surprising role of the heart's right ventricle: What endurance athletes need to know

Cardiologists who manage athletes should pay greater attention to the right side of the heart

In the realm of sports science, understanding the intricacies of the heart is crucial, especially when it comes to enhancing athletic performance and ensuring the health of athletes. One area that has garnered significant attention is the right ventricle. Routine assessments of those with suspected arrhythmias often focus on the left ventricle. However, the right ventricle plays a critical role in the cardiovascular system, particularly in athletes. The right ventricle is subjected to much greater stresses during exertion than the left ventricle, and prolonged exercise is associated with temporary damage to the right ventricle.

Furthermore, approaches to the assessment of athletes with heartbeat irregularities (arrhythmias) have typically focused on the heart while it is resting. Yet, as Melbourne-based, world-renowned sports cardiologist, Professor André La Gerche, remarks:

"You do not test a racing car while it is sitting in the garage. Similarly, you can’t assess an athlete’s heart until you assess it under the stress of exercise.”

Dynamic methods for measuring right ventricular function are relatively simple and can be easily integrated into clinical routine. If you are an athlete with heartbeat irregularities, you just might want to discuss this approach with your own cardiologist.

Here, I delve into the relevance of the right ventricle in athletic hearts, shedding light on its functions, adaptations, and the implications for athletic performance and health.

Understanding the Right Ventricle

The heart comprises four chambers: two atria and two ventricles. The right ventricle is responsible for pumping deoxygenated blood to the lungs for oxygenation, a process known as pulmonary circulation. While the left ventricle pumps oxygenated blood to the rest of the body, the right ventricle's function is equally vital in maintaining a balanced and efficient circulatory system.

Right Ventricle Adaptations in Athletes

Athletic training induces various cardiovascular adaptations to meet the increased demands of intense physical activity. One significant adaptation is the remodelling of the heart, including the right ventricle. Athletes, particularly those engaged in endurance sports, often exhibit increased ventricular size and mass. This phenomenon, known as "athlete's heart," enables the ventricles to handle larger volumes of blood and maintain optimal (oxygenated) performance during prolonged exertion.

Research by Dr. André La Gerche and his team has highlighted the importance of these adaptations. Their pioneering studies have utilised novel imaging techniques including exercise cardiac magnetic resonance imaging (MRI) and contrast echocardiography (ECG) to reveal that the right ventricle, being more compliant and capable of greater volume changes, is crucial in sustaining high cardiac output during endurance activities. This adaptation not only enhances performance but also underscores the importance of monitoring right ventricular function in athletes.

The Right Ventricle and Athletic Performance

The efficiency of the right ventricle directly impacts athletic performance. A well-adapted right ventricle ensures effective pulmonary circulation, allowing for better oxygenation of blood and, consequently, improved oxygen delivery to muscles. This is particularly important in endurance sports like long-distance running, cycling, and swimming, where sustained oxygen delivery is paramount.

Furthermore, the right ventricle's ability to handle increased preload (the volume of blood returning to the heart) without significant changes in pressure helps maintain a stable and efficient cardiovascular system. This stability is crucial for athletes to perform at their peak without experiencing undue cardiovascular stress.

Implications for Health and Training

While right ventricular adaptations are beneficial for athletic performance, they also carry potential health implications. Excessive right ventricular remodelling and stress can lead to conditions such as arrhythmogenic right ventricular cardiomyopathy (ARVC). This condition, characterised by abnormal heart rhythms and structural changes, poses a significant risk to athletes if not monitored and managed properly.

Regular cardiovascular assessments are essential for athletes

Assessments, including imaging techniques like echocardiography and cardiac MRI, help in detecting any abnormal changes in right ventricular structure and function. These assessments, which are relatively straightforward to perform, allow for timely interventions and modifications in training regimens to prevent adverse outcomes.

Conclusion

The right ventricle, often overlooked in discussions about athletic hearts, plays a pivotal role in maintaining cardiovascular efficiency and performance. Understanding the adaptations and functions of the right ventricle is crucial for optimising athletic performance and ensuring the health and safety of athletes. With continued research and advanced diagnostic tools, sports scientists and medical professionals can better support athletes in achieving their full potential while safeguarding their cardiovascular health.

The practical implications for athletes of the role of the right ventricle in athletic performance and monitoring of their own health during training will be fleshed out in forthcoming articles on HH4A ePress. Watch this space.

---

References

Elliott AD, La Gerche A, 2015. The right ventricle following prolonged endurance exercise: are we overlooking the more important side of the heart? A meta-analysis. British Journal of Sports Medicine, 49(11):724-9. doi: 10.1136/bjsports-2014-093895. https://pubmed.ncbi.nlm.nih.gov/25281542/

Franklin et al., 2020. Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks into Perspective–An Update: A Scientific Statement From the American Heart Association. Circulation, 141(13): https://doi.org/10.1161/CIR.0000000000000749

La Gerche A, 2015. Mysteries of the right ventricle in sports and exercise. Expert analysis. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2015/10/29/13/26/mysteries-of-the-right-ventricle-in-sports-and-exercise

La Gerche A, 2021. Exercise-Induced Arrhythmogenic (Right Ventricular) Cardiomyopathy Is Real…if you Consider it^∗. Journal of American College of Cardiology and Imaging. 2021 Jan, 14 (1) 159–161.  https://doi.org/10.1016/j.jcmg.2020.09.014

La Gerche A, Rakhit DJ, Claessen G, 2017. Exercise and the right ventricle: a potential Achilles' heel. Cardiovascular Research, 113(12):1499-1508. doi: 10.1093/cvr/cvx156. PMID: 28957535. https://pubmed.ncbi.nlm.nih.gov/28957535/

Prior D, La Gerche A, 2020. Exercise and arrhythmogenic right ventricular cardiomyopathy. Heart and Lung Circulation, 29:547-55.

---

First published in 2018. Updated in June 2024.