Should NFL Teams Still Be Worried About Star Lotulelei's Heart?

Dave Siebert, M.D.@DaveMSiebertFeatured ColumnistApril 8, 2013

Good news about athlete health seems to come around very rarely. For a while, the discovery of Star Lotulelei's heart condition—one that drew the attention of the football and medical communities alike—continued that trend.

The saga started in February when ESPN's Chris Mortensen reported Lotulelei would not participate in NFL Scouting Combine workouts after doctors discovered his heart was underperforming. Specifically, echocardiography demonstrated an ejection fraction (EF) of only 44 percent. In other words, an ultrasound of Lotulelei's heart showed it to be pumping out a mere 44 percent of the blood within it with each beat. A normal EF is 55-70 percent.

The causes of a low EF are numerous, and the complications potentially deadly. Chronic, progressive genetic diseases can be to blame, but so can minor, temporary conditions. Fortunately, with last week's news that Lotulelei's heart now shows "no evidence of dysfunction," according to University of Utah team physician Dr. Dave Petron (h/t Lya Wodraska, Salt Lake Tribune), it's time to close the book on his heart condition once and for all—well, almost.

For starters, Dr. Petron's report is promising. "There was no reason why (Lotulelei) couldn’t continue on in an athletic career," he told Wodraska.

In other words, it's safe to assume Lotulelei's heart condition came about due to one of many possible transient causes. For example, a simple viral infection—similar to those that cause the common cold—could have produced inflammation within the heart, impairing its ability to squeeze.

Abnormal salt levels in the blood can also affect the heart's pumping ability. An earlier report by USA Today's Mike Garafolo suggested dehydration and weight loss—both of which can alter salt ion concentrations in the blood—could be at fault.

The overwhelming likelihood is that Lotulelei's heart will never again prove an issue. Nevertheless, without determining the precise cause of his temporarily decreased EF, complete certainty will continue to evade teams heading up to April's NFL draft.

What is certain, however, is the fact that the frightening possibility of an incurable, irreversible disease is off the table.

Dr. Petron states Lotulelei's heart is performing "consistently with that of highly trained athletes," implying the condition completely reversed itself during the several weeks since the combine. In fact, though typically not as low as 44 percent, the hearts of highly trained athletes can have slightly lower EFs at baseline.

If that is the case, one may wonder why news of Lotulelei's low EF surfaced to begin with. Did his weight loss and dehydration prior to the combine prompt further testing?

Actually, probably not.

According to a report out of the Indiana University School of Medicine, all players receive heart testing at the combine in the form of both electrocardiography and echocardiograms. The former analyzes the heart's electrical activity, and the latter measures its squeezing ability.

In short, the discovery of a heart condition like Lotulelei's at the combine is inevitable.

Regrettably, so are the consequences, and the much larger debate over the appropriateness of screening asymptomatic patients for medical conditions is a fascinating one.

On the one hand, if Lotulelei did not have and never developed symptoms—as appears to be the case—the condition may have gone entirely unnoticed if combine medical evaluations didn't go looking for it. Without such a finding, the doubt surrounding the defensive standout's health status never surfaces, and a team calls him to the podium within the first few picks of the NFL draft.

Then again, health screening is arguably the most important part of the combine, and cases like Lotulelei may represent a sort of necessary collateral damage. Without screening, a top draft pick's undiscovered, silent heart condition could progress without teams knowing, one day effectively ruining the team's decision to draft that player so highly—not to mention wasting its multimillion-dollar investment.

Luckily, that did not turn out to be the case with Lotulelei, and his skill on the field is unquestioned.

However, the aftermath of discovering an EF of 44 percent continues to linger. Is it an insignificant, incidental finding? Probably, but no one can know with certainty.

Sure, the decline proved temporary and completely rebounded. Lotulelei is even working out in full—and turning heads, at that (h/t Dour Farrar, Yahoo! Sports). What's more, according to Wodraska, Lotulelei's heart function picked up soon after the combine:

A repeat of the echocardiogram test administered to Lotulelei in Utah shortly after the combine showed the efficiency was improving, leaving most to believe the abnormality might have been caused by a virus.

It should also be emphasized that the current concern over Lotulelei's heart pales in comparison to what it once was. Following the combine, a diagnosis of an irreversible condition would have likely ended Lotulelei's professional career before it even started.

All of that said, there is no way to know if and when the drop in EF will happen again, and questions remain: Is Lotulelei predisposed to further temporary decreases? If the first episode indeed produced no symptoms, how will teams know if Lotulelei is suffering from another? Does it even matter?

Hopefully, medical reports provided to teams will help clear up those issues by including the findings of the repeat echocardiogram—or  echocardiograms—that followed the combine. Results of any blood tests, such as vitamin levels, electrolyte concentrations and blood counts, will be similarly important.

Images from the cardiac MRI mentioned in Wodraska's column—one that showed no signs of disease—will also strengthen Lotulelei's case. Cardiac MRI is a relatively new, state-of-the-art imaging procedure that shows a heart's squeezing ability in breathtaking detail, much more so than echocardiography.

Unfortunately, reassuring tests only mean so much, as the cause of a low EF remains unknown in a large percentage of cases. As such, the most important testimony comes from Dr. Petron.

"None of the tests performed showed anything that concerned Petron in regards to Lotulelei’s future," Wodraska writes.

In all probability, the mountain of evidence in Lotulelei's favor should be enough to assuage any fears still carried by some NFL teams in regard to his health status and draft stock. Matt Miller—Bleacher Report's NFL draft lead writer—explains:

Lotulelei has top-five potential. With a clean bill of health, most teams will once again be considering him early in Round 1. There are still teams that may keep him off their top-15, but that's where he should be drafted.

In short, Lotulelei should be drafted early, and concern surrounding his heart continues to diminish, if it isn't gone altogether. Assuming the February episode does not repeat itself, the number 44 will soon lose its significance when it comes to the budding NFL star.

Dave is a medical writer for Bleacher Report who will join the University of Washington as a Family Medicine resident physician in June. Medical information discussed above is based on his own knowledge, and quotes were obtained firsthand unless otherwise noted.


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