Geert Kleinnibbelink

General Discussion 10 209 this topic, we are currently performing a systematic review regarding sex differences in the elite athlete’s heart titled: ‘The elite athlete’s heart – do men and women demonstrate different cardiac adaptations?’ . With this overview, we aim to pave the way for conduction of large studies addressing sex differences in cardiac remodelling to exercise training. Novel methods to assess cardiac remodelling Over the years novel imaging techniques have been introduced to measure cardiac structure and function. One such technique is the novel strain-area loop which has the ability for comprehensive analysis of cardiac function, including mechanics. 55, 56 In this thesis, we applied this strain-area loop to assess cardiac remodelling to exercise training for the first time. In Chapter 3 , we showed that exercise training induced a rightward shift (increased end-diastolic area), lessening of the systolic slope and reduced uncoupling of the RV strain-area loop. These changes suggest that with an increased RV size following exercise training, the contribution of longitudinal strain to systolic volume ejection lowers. Thereby, the longitudinal contribution to diastolic filling compared to systolic volume ejection will be more dominant. In contrast to these changes, we did not observe any changes in the RV after a 9-month increase in training volume inOlympic rowers; neither in the strain-area loop nor in conventional structural echocardiographic measurements ( Chapter 4 ). This might indicate that a change in mechanics, measured with the strain-area loop, is not an isolated process but merely a consequence of cardiac structural remodelling due to exercise training and may be influenced by baseline training status. These novel insights with the strain-area loop in cardiac remodelling to exercise training substantiates its use to gain greater insight into the (patho)physiological process of cardiac remodelling to exercise training. 10.4 – Strain-area loop and exercise-based cardiac rehabilitation in cardiovascular disease Monitoring patients with PH is predominantly based on subjective rather than objective parameters. The echocardiographic RV strain-area loop may be a suitable technique to incorporate in daily clinical practice and contribute to personalised medicine for the PH patient. It is also relevant to say that exercise-based cardiac rehabilitation (CR) may be beneficial inpatientswith cardiovascular disease and could also contribute topersonalised medicine.