"Athlete's heart" or pathology?

[djd1990]

I have suffered from extreme faintness/lightheadedness and palpitations ever since I was a child. The symptoms come and go in waves, almost a relapsing-remitting pattern, but even during relatively asymptomatic periods there are still individual days or weeks with substantial episodes. I have also fainted a few times. Back in 2012 my symptoms were pretty severe so I saw some cardiologists. I had EKG's, an echo, 24 hour and 30 day Holter monitors, and stress testing. At the time, they didn't find much, aside from some PVC's/PAC's and couplets that corresponded with some of my palpitations. They also found that during sleep I experience relatively prolonged sinus pauses of 3-4+s. Since there were no overt structural or electrical abnormalities I tried to move on and just live with my relatively debilitating symptoms.
         This past year I've been in a horrible wave of symptoms. It's gotten far more severe than anything I'd ever before experienced. I now feel so faint so much of the time. I become extremely faint whenever I eat, shower, have to sit or stand somewhere longer than a few minutes, as well as when I run. I have always been a runner. I currrently run anywhere from 40-65 miles per week. Back in 2012 I was running for my university in cross country and track.
        So, I'd recently gone back to a cardiologist and this time they ordered a cardiac MRI. The results are very concerning to me.  All four chambers are dilated, most especially the left atrium. My LV walls and the septum have thinned quite a bit. There is now tricuspid and pulmonary valve regurgitation. They found pericardial and pleural effusion (fluid in the sacs around the heart and lungs respectively). Yet, systolic function is normal, there was no late gandolium enhancement (meaning there is no evidence of scar tissue/fibrosis), wall motion was normal, and resting perfusion was normal (meaning no ischemia, at least at rest).
        Still, it is concerning to me that so much dilation has developed. My LVEDD went from 46mm to 60mm. My LV walls went from 1.1cm to 0.5cm. The heart appears to be stretching and thinning and filling up with way more blood (LVEDV went from 117mL to 200mL). My stroke volume is now 123.5mL, whereas before it was 60.8mL. To be clear, I ran more back then than I do now, my symptoms are worse now.
        I should also mention that recently a series of other symptoms have developed, which prompted blood test which revealed elevated liver enzymes, which subsequently led to a liver ultrasound that found evidence of liver swelling/damage (I don't drink or smoke, testing negative for hepatitis, am not on medications, am not overweight, have normal glucose and cholesterol, and am only 27). I'm not sure if that is related, because I have read that there is this phenomenon known as "high output heart failure" in which cardiac output actually goes way up in response to various conditions, including chronic liver disease (i.e. the body needs to pump out more oxygenated blood because more blood gets swelled up in the liver/spleen....which may make sense for me, since I get so lightheaded whenever I eat and blood must go down to the digestive tract), or other issues such as anemia (i.e. low oxygen content in the blood requires more be pumped out to meet oxygen demands....and anemia is a potential secondary impact of liver issues).
         Anyways, I just want to know if people have opinions as to whether or not these structural changes in my heart seem more indicative of early compensatory dilated cardiomyopathy (i.e. the heart is stretching/thinning to achieve a higher stroke volume as it becomes harder to meet oxygen demand, which will eventually lead to enough wall thinning and stress (via volume overload and increased filling pressures) that it leads to systolic deterioration....or if somehow this is all a normal adaptation to the fact I run so much (even though it never caused such adaptations before, and one would tend to think that wall dilation and thickness would increase proportionally, rather than dilation being accompanied by thinning walls). I have an appointment with my cardiologist on the 31st, but I just thought I would float this out here for advice and thoughts heading into my appointment. Thank you.

[2210485]

For the tl;dr version of the above

Chambers getting bigger + walls thinner is in fact kind of concerning.

Theres a crap load of things from a whole lot of medical specialties that can be linked to all this stuff.

Probably treat symptomatically and begin a mad scramble to find the right dude that can figure out an underlying pathology. Likely a medical geneticist or some really old school internist that's been around the block... I'd be impressed if you got a conclusive answer in 1 appointment.

[2210485]

P.s. Probability of winding up with Pacemaker: 50/50

That much I'm confident in.

If you're dilated and fainting and they can't figure out why in a reasonable time, Implant.

You have 3 indications of different classes: Syncope, Dilated CM AND Documented Pauses

Any one of those on their own is justification to implant.

[2210485]

Oh golly, sorry I'm late.

Athletes heart = Dilation + Thickening of walls

So yes, those numbers indicate dilated cardiomyopathy.

Yes, fluid overload is a cause and yes the liver is often a culprit in such overload. It could be possible that this is the source of your echo problems.


BUTTT

Your fainting is entirely different. Nothing about anything you said about the tests run points directly to the syncope or vice versa. Sooo... What's causing that?

I have no idea.

I would look at the electrical aspects again maybe? Pauses can cause it, especially at that length but if it only happends at night we can rule that out. I didn't see any mention of any trends like it only happends when you stand up or bend over etc... That just makes the whole thing pretty ambiguous. If you were LQTS that would likely show up on a stress test..

More importantly I would wanna consult with Neurology...

If a young lad has fainting issues and neuro can't solve it they send em to cards and vice versa. This may be such a case..

Theres also the chance that theres something genetic going on with the Liver and Heart situation.. No clue what that would be... I passed everything involving genetics with like.. Coin tosses. There's someone out there who knows alot about that kind of stuff though that could offer some insight, find that guy and ask him for his thoughts as well.

Alot of these inhereted/genetic type of problems effect multiple organ systems. Its not entirely out of the realm of possibility that the same condition is impacting both your ability to appropriately remodel the ventricles and your liver being jacked up. This is where that guy that knows all about genetic stuff comes in handy because he would know alot more about how a genetic issue would effect multiple organ systems as opposed to just being locked in to how it may impact the heart.

Good news is, you still have incredible exercise tolerance! So you're probably not dieing! You got plenty of time to figure this out!

[purple1234567]

I'm not a doctor, so don't really have an opinion on if it's normal or a warning sign for things to come, but just wanted to wish you well at your appointment on the 31st- let us know how you are doing, it seems like you have a lot going on!