Vascular abnormalities in athletes, although less common than musculoskeletal injuries, present a significant diagnostic challenge due to overlapping manifestations. These conditions range from subtle exertional discomfort to potentially limb-threatening ischemia and life-threatening complications such as pulmonary embolism or sudden cardiac death. In this comprehensive review, the authors highlight the spectrum of vascular abnormalities encountered in athletes, emphasizing the pivotal role of multimodality imaging, including US, CT angiography, MR angiography, and conventional angiography in their accurate diagnosis and effective management. They discuss upper extremity conditions such as Paget-Schroetter syndrome, quadrilateral space syndrome, palmar arch injury, and digital ischemia. Lower extremity conditions discussed include arterial thromboembolism, external iliac artery endofibrosis and dissection, adductor canal syndrome, chronic exertional compartment syndrome, popliteal entrapment syndromes, venous insufficiency, and cystic adventitial disease. Other conditions discussed include venous thromboembolism, median arcuate ligament compression, aortopathies, pulmonary hypertension, Bezold-Jarisch reflex, coronary artery disease, coronary anomalies, and high-flow priapism. The authors aim to equip radiologists with essential knowledge to promptly recognize these conditions, thereby facilitating early intervention and improved outcomes. ©RSNA, 2026 Supplemental material is available for this article. See the invited commentary by Nagpal and Bluemke in this issue.

Syncope and presyncope during graded exercise testing (GXT) are uncommon but clinically important events that may reflect hemodynamic, autonomic, conductionrelated, or arrhythmic mechanisms. We reviewed all clinically significant syncope and presyncope occurring during non-imaging GXTs performed at Mayo Clinic between January 2006 and December 2010. All clinically significant events underwent detailed chart review incorporating exercise findings, clinical documentation, and longitudinal follow-up to systematically adjudicate the most likely mechanism. Among 40,715 GXTs performed in 33,885 unique patients, eight episodes of syncope (0.20 per 1000 tests) and five episodes of hemodynamically significant presyncope (0.12 per 1000 tests) required test termination. Five additional patients with transient lightheadedness without exercise-induced hypotension or clinically significant arrhythmia and five mechanical treadmill events without hemodynamic compromise were excluded from the primary analysis. Only two events were attributed to a documented arrhythmic mechanism. Most episodes were adjudicated as hemodynamic, autonomic/neurocardiogenic, or indeterminate. Syncope occurred predominantly in younger women and was generally associated with sinus rhythm and hypotensive or autonomic mechanisms, whereas presyncope occurred predominantly in older men with underlying cardiovascular disease, atrial arrhythmias, bradycardia, or chronotropic incompetence. Clinically significant syncope and presyncope during supervised GXT were exceedingly uncommon and were rarely associated with a documented arrhythmic mechanism. These findings support the safety of supervised exercise testing in appropriately monitored settings and improve understanding of the mechanisms underlying these uncommon exercise laboratory events.

Rationale: Cardiopulmonary exercise testing is a unique tool for simultaneously assessing cardiopulmonary and metabolic responses at peak exercise, making it invaluable for diagnosing unexplained dyspnea and fatigue, common issues in cardiovascular and pulmonary clinics. However, its use is often limited by complex guidelines, restricted lab access, technical demands, and high costs. The Veterans Specific Activity Questionnaire (VSAQ), developed by Meyers et al., offers a practical way to estimate metabolic equivalents and maximum oxygen consumption to assess exercise capacity. While primarily validated in a male population, the VSAQ lacks sufficient research in diverse ethnic and gender groups. Broader validation could enhance personalized cardiopulmonary testing, support equitable healthcare resource allocation, and help lower costs. Methods: In this prospective observational study, participants were included if they were 18 years or older and capable of completing a cardiopulmonary exercise test. Participants were excluded if they had known abnormal breathing patterns at baseline and if they had any contraindication for cardiopulmonary exercise and pulmonary function testing. A total of 17 patients without known cardiopulmonary disease provided informed consent and completed the brief self-administered VSAQ following the cardiopulmonary exercise test. The VSAQ was used to estimate maximal exercise capacity in metabolic equivalents, which was then compared to the actual maximal exercise capacity achieved on a bike ergometer, as recorded in the electronic medical records. Results: A linear regression analysis indicated a marginal association between VSAQ results (METS) and CPET METS, accounting for 22.2% of the variance in CPET METS (p=0.056). This finding suggests a potential, though not statistically significant, positive relationship between VSAQ METS scores and CPET MET. A linear regression analysis indicated a marginal association between VSAQ calculated Peak VO₂ and observed CPET Peak VO₂ (o₂/kg/min), explaining 21.6% of the variance in CPET Peak VO₂ (p=0.060). This suggests a potential positive relationship between VSAQ calculated Peak VO₂ and CPET Peak VO₂, though the association did not reach statistical significance. Conclusion: In this preliminary sample of patients without known cardiopulmonary disease, the VSAQ demonstrated accuracy in predicting maximum oxygen consumption at peak exercise. With further validation and larger sample size, the VSAQ could become a valuable adjunctive tool for assessing patients with unexplained dyspnea and fatigue, supporting more efficient diagnostic evaluations. Additionally, the VSAQ may serve as a practical follow-up measure to track clinical improvement after therapeutic interventions in this specific population.

Background Patients with single-ventricle physiology are often palliated with the Fontan operation, which may involve the creation of a fenestration. We aimed to evaluate differences in cardiopulmonary exercise test (CPET) performance between patients with fenestrated and non-fenestrated Fontan circulation.Methods Patients with a Fontan circulation referred to CPET between 2006 and 2024 were included and were categorised based on their fenestration status at the time of CPET. Logistic regression analyses were performed to assess the impact of fenestration on peak oxygen consumption (VO2), and Cox proportional hazard to evaluate the impact of fenestration on cardiovascular outcomes (death, heart transplant and Fontan-related hospitalisation).Results Of the 184 patients, 141 were classified as non-fenestrated and 43 as fenestrated. The minute ventilation-carbon dioxide production (VE/VCO2 slope) was higher in the fenestrated (36.9±7.9) versus (33.2±6.2; p=0.009) in the non-fenestrated group. There was no significant difference in predicted VO2 between groups (non-fenestrated 51.9%±14.4 vs 51.3%±15.6; p=0.7). Resting oxygen saturation was higher in the non-fenestrated group (93%±4.7 compared with fenestrated group 90.1%±5; p<0.001). Fontan fenestration was not significantly associated with the composite outcome; older patient age at the time of the CPET, cirrhosis and ventricular ejection fraction <40% were significantly associated with higher risk, while higher resting systolic blood pressure, left ventricular morphology and higher predicted peak VO2 were protective.Conclusions The increased hypoxia and reduced ventilatory efficiency associated with Fontan fenestration offset any potential benefits, resulting in similar exercise performance between the groups. Fontan fenestration was not significantly associated with cardiovascular outcomes.

Pilots face significant occupational risks affecting cardiometabolic health and are subject to regulatory health screenings. Cardiometabolic risk factors, cardiac screening findings and outcomes among pilots have not been well reported. This study aimed to investigate cardiac evaluations of asymptomatic aircraft pilots and the association between clinical risk factors and outcomes. Asymptomatic aircraft pilots referred for cardiac assessment between January 1991 and May 2023 were studied. Baseline characteristics, cardiac test findings and outcomes were evaluated. Major adverse clinical event (MACE) was defined as death, myocardial infarction, stroke, major arrhythmia, heart failure event or cardiac-related hospitalisation and estimated using Kaplan-Meier methods. Significant valvular disease by echocardiography was defined as stenosis, regurgitation or prolapse of moderate severity or greater. Aortic dilation by transthoracic echocardiogram (TTE) was defined as measuring ≥40 mm in diameter. 212 pilots met eligibility criteria for the study. The majority were white (92.9%) and male (91%) with a mean age of 58.5±10.9 years. Mean body mass index was 27.8±4.8 with comorbid hyperlipidaemia (48%), hypertension (32%), prior cancer (27%), sleep apnoea (15%), arrhythmia (12%) and known coronary artery disease (6%). Imaging revealed significant valvular disease (2.4%) and dilated aortas (16%) based on TTEs. Functional cardiac testing performed showed mean functional aerobic capacity of 109±24.6% reaching 11.89±2.65 metabolic equivalents with <8% showing positive findings per EKG or wall motion abnormalities on exercise TTE. Six patients received coronary angiography based on clinical evaluation, with two undergoing percutaneous coronary intervention. Over a 32-year period with a median (range) follow-up of 5.15 (0.1, 31.82) years, MACE incidence was 15%. Asymptomatic aircraft pilots have underlying cardiovascular risk factors but good overall functional capacity, long-term outcomes and life expectancy. Prevalence of cardiac structural findings like aortic dilatation warrants increased attention during examination of these patients.

Reverse Potts shunt (rPS) is a surgical procedure that creates an anastomosis between the left pulmonary artery and descending aorta to decompress the right ventricle in suprasystemic pulmonary arterial hypertension (PAH). In this paper, we introduce a unique procedure combining cardiopulmonary exercise testing with forehead and popliteal oximetry to evaluate the efficacy of the rPS. Our study involved tests on 4 patients with PAH who had the shunt in place. We found that the level of oxygen saturation in the popliteal artery decreased during exercise and correlated with the rPS efficacy and the overall clinical outcome. In conclusion, we demonstrate a simple, noninvasive technique for evaluating patency and function of rPS in patients with suprasystemic PAH.

Sports cardiologists specialize in the care of competitive athletes and highly active people by detecting and managing cardiovascular diseases that can impact sports participation and counseling on return to sports after cardiovascular events. Preparticipation evaluation of athletes includes history, physical examination, and electrocardiography (ECG), with exercise ECG added when screening master athletes. If the findings are abnormal or inconclusive, echocardiography is used for further evaluation. Further imaging with MRI, CT, or stress test is performed for establishing a diagnosis when echocardiography is indeterminate or discordant with clinical features and for risk stratification if echocardiography provides a definitive diagnosis. MRI can help distinguish athlete's heart from similar-appearing pathologic entities when echocardiography is inconclusive. Athlete's heart can manifest as left ventricular hypertrophy (LVH), left ventricle (LV) dilatation, prominent LV trabeculations, and right ventricular (RV) dilatation. Adaptive LVH in athletes is concentric and typically measures less than 16 mm, which distinguishes it from pathologic LV thickening of hypertrophic cardiomyopathy, hypertension, valvular disease, and infiltrative cardiomyopathies. Adaptive LV dilatation with normal or mildly reduced ejection fraction can be seen in endurance athletes. LV ejection fraction greater than 40%, augmentation of LV ejection fraction with exercise, and normal or supranormal diastolic function distinguishes it from dilated cardiomyopathy. Physiologic RV dilatation in athletes is distinguished from arrhythmogenic cardiomyopathy (RV type) by global involvement and absence of major regional wall motion abnormalities or late gadolinium enhancement. MRI is also useful in diagnosis and risk stratification of athletes with cardiovascular symptoms and after major cardiovascular events such as arrhythmias, myocardial infarction, and resuscitated sudden cardiac death or arrest. CT angiography provides accurate evaluation of coronary artery anomalies and coronary artery disease. ©RSNA, 2025 Supplemental material is available for this article.

BACKGROUND:Optimum timing for surgery in asymptomatic/mildly symptomatic adult patients with Ebstein anomaly remains uncertain. This study assessed the association between preoperative cardiopulmonary exercise testing (CPET) and mortality, and longitudinal changes in CPET. METHODS:A retrospective review was conducted of consecutive adult patients with Ebstein anomaly who had tricuspid surgery between 2007 and 2018 with preoperative CPET. Primary outcome was all-cause mortality and secondary outcomes included changes in CPET. RESULTS:The cohort included 116 patient, of whom 94 (81.1%) were New York Heart Association Functional Class I/II. Median age was 39.6 years, and 75 (64.7%) were women. There were 44 (37.9%) with ≥1 prior sternotomies, 58 (50%) underwent Cone repair, and 55 (47.5%) had tricuspid replacement. Median percentage predicted peak oxygen consumption (Vo2) was 62%, and ventilatory efficiency was 30 L/min/min. Fifteen (12.9%) had severe right ventricle dysfunction, and median left ventricular ejection fraction was 58%. At a median follow-up of 9.8 years, there were 8 deaths. Ventilatory efficiency trended to be associated with mortality (P = .075) on univariate analysis and was the largest contributor to prediction of mortality in machine learning random forest models. Thirty-three patients had CPET at a median of 2.9 years after surgery. There was significant improvement in ventilatory efficiency (30 L/min/L/min preoperatively vs 27 L/min/L/min postoperatively, P = .015). CONCLUSIONS:In those with minimal or no symptoms, ventilatory efficiency is one of the most important variables in predicting mortality after surgery. Patients may have improved ventilatory efficiency after tricuspid surgery for Ebstein anomaly. These findings highlight the role of CPET in optimizing timing of surgery.

Studies have shown a correlation between greater cardiorespiratory fitness (CRF) and lower risk of incident and recurrent atrial fibrillation (AF). Transthoracic echocardiographic (TTE) parameters correlate to CRF and risk of AF. However, there is scarce data regarding the interplay of CRF, echocardiographic parameters, and AF ablation outcomes. Our study sought to investigate how CRF and echocardiographic parameters impact AF ablation outcomes. We evaluated the Mayo Clinic Cardiorespiratory Exercise database from January 1, 2013, through December 31, 2017, to include all patients who underwent cardiopulmonary exercise testing and an AF ablation in temporal proximity. A total of 205 patients (mean age 61.2 years, 74

Inability to reach age-predicted peak heart rate (APPHR) on treadmill exercise testing (TMET) is associated with lower fitness and increased mortality. The significance of a "supramaximal" heart rate (≥105% of APPHR) is poorly understood; as such, we sought to investigate this relationship. We queried the Mayo Stress database from 1993 to 2010 for patients >30 years old without cardiovascular disease and not on antichronotropic therapy. Patients were stratified into groups based on APPHR: <75%, 75% to 84%, 85% to 94%, 95% to 104%, and ≥105%, with 105% to 114% and ≥115% subgroups. Functional aerobic capacity (FAC) was assessed by ANOVA and all-cause mortality by cox hazard regression; we adjusted for confounders. In total, 18,961 patients were included; 1150 (6.1%) died. 2,144 (11.3%) of patients achieved submaximal APPHR (<85%), 2,917 achieved supramaximal APPHR (≥105%). Patients with submaximal APPHR had significantly lower FAC: 76.4% (p <0.0001) [<75%], 83.5% (p <0.0001) [≥75% to <85%]. Those with supramaximal APPHR had significantly higher FAC: 102.0% (p <0.0001). Patients with submaximal APPHR had significantly higher mortality risks: <75% (adjusted HR 2.36 [1.83 to 3.04], p <0.0001) and ≥75 to <85% (adjusted HR 1.93 [1.62 to 2.31], p <0.0001). Those with supramaximal APPHR, after adjustment for cardiac risk factors and resting heart rate, had significantly lower mortality risk (adjusted HR 0.83 [0.70 to 0.99], p = 0.0414). In conclusion, supramaximal heart rate on TMET was associated with significantly higher FAC and lower all-cause mortality risk.