Guerra E; Carlo Poma Hospital, Mantova, Italy.
Segreti A; Carpenito M; Ciancio M; Guarino L; Ricciardi D; Fossati C; Suma S; Gaibazzi N;
Rosiello R; Lettieri C; Papalia R; Pigozzi F; Boriani G; Grigioni F

Echocardiography. 43(5):e70505, 2026 May.

PURPOSE: This study investigated standard and advanced echocardiographic
parameters in endurance athletes with different training profiles, and
their association with exercise performance.

METHODS: Consecutive endurance athletes undergoing cardiological
screening or orthopedic evaluation for knee injuries at Campus Bio-Medico
University Hospital underwent advanced echocardiography and
cardiopulmonary exercise testing. Athletes were categorized into three
groups: (1) Long-Distance (marathon and ultramarathon runners, n = 30);
(2) Mid-Distance (middle-distance runners, n = 27); and (3) Detrained (>=
6 months training interruption, n = 31).

RESULTS: Left ventricular ejection fraction did not differ among groups.
The Long-Distance group had the highest stroke volume index, followed by
the Mid-Distance and Detrained groups (p <0.001). Long-Distance athletes
showed lower left ventricular global longitudinal strain (p = 0.003) and
left atrial reservoir strain (p = 0.003) compared to the other groups,
with no differences in right ventricular free wall strain. Myocardial work
analysis showed higher work index and constructive work, and lower wasted
work, leading to greater global work efficiency in the Long-Distance group
(p <0.001). In multivariable linear regression analysis, stroke volume
index (beta = 1.02, p < 0.001) and global work efficiency (beta = 1.00, p
= 0.001) were independently associated with Peak VO2, whereas global
longitudinal strain was not.

CONCLUSION: Advanced echocardiography provides additional insights into
the athlete’s heart. Myocardial work indices reflect training-related
cardiac adaptations, and left atrial reservoir strain is influenced by
training status. These findings, together with the association of stroke
volume index and global work efficiency with Peak VO2, support the
integration of advanced echocardiographic parameters into athlete
evaluation and monitoring.