Skip to main content

Advertisement

SpringerLink
Log in

Valvular Heart Disease in Athletes

  • Valvular Heart Disease (J Dal-Bianco, Section Editor)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Abstract

Purpose of Review

Valvular heart disease is prevalent in older athletes with primarily degenerative valvular disorders and younger athletes with congenital or genetic syndromes. Limited data exist on the risks and benefits of exercise for athletes with underlying valvular disorders, so current guidelines are primarily based upon expert consensus. This review focuses on the current data, guideline recommendations, and emerging clinical conundrums for athletes with common valvular heart conditions including aortic stenosis, bicuspid aortic valve (BAV), mitral regurgitation (MR), mitral valve prolapse (MVP), and thoracic aortic aneurysms.

Recent Findings

Aortic growth appears similar in athletes compared to non-athletes with BAV. Return to exercise following mitral valve repair for primary MR does not seem to lead to significant valve deterioration or adverse outcomes in short-term follow-up. Longitudinal cohort studies of athletes with MVP have suggested that ventricular arrhythmias can be common, but sudden cardiac death is rare. Aortic dilation is uncommon in young otherwise healthy athletes, but can commonly be found in older endurance and strength athletes.

Summary

Valvular heart conditions in athletes are prevalent in clinical practice; however, there are limited data on the outcomes in these patients to drive guideline development and clinical decision-making. Future research should focus on defining the risks of continual exercise on outcomes in patients with known valvular disease, the optimal time for valve repair/replacement, and the risks of returning to exercise following valvular intervention.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. Baggish AL, Battle RW, Beckerman JG, Bove AA, Lampert RJ, Levine BD, et al. Sports cardiology: core curriculum for providing cardiovascular care to competitive athletes and highly active people. J Am Coll Cardiol. 2017;70(15):1902–18.

    Article  PubMed  Google Scholar 

  2. Bonow RO, Nishimura RA, Thompson PD, Udelson JE. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 5: valvular heart disease. Circulation. 2015;132(22):e292–7. https://doi.org/10.1161/CIR.0000000000000241.

    Article  PubMed  Google Scholar 

  3. •• Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S et al. ESC guidelines on sports cardiology and exercise in patients with cardiovascular disease: the task force on sports cardiology and exercise in patients with cardiovascular disease of the European Society of Cardiology (ESC). European Heart Journal. 2020;42(1):17–96.https://doi.org/10.1093/eurheartj/ehaa605. These guidelines provide concise recommendations for sports and exercise for athletes with underlying cardiovascular pathology.

  4. Arbab-Zadeh A, Perhonen M, Howden E, Peshock RM, Zhang R, Adams-Huet B, et al. Cardiac remodeling in response to 1 year of intensive endurance training. Circulation. 2014;130(24):2152–61.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Baggish AL, Wang F, Weiner RB, Elinoff JM, Tournoux F, Boland A, et al. Training-specific changes in cardiac structure and function: a prospective and longitudinal assessment of competitive athletes. J Appl Physiol. 2008;104(4):1121–8.

    Article  PubMed  Google Scholar 

  6. Dawes TJ, Corden B, Cotter S, de Marvao A, Walsh R, Ware JS et al. Moderate physical activity in healthy adults is associated with cardiac remodeling. Circulation: Cardiovascular Imaging. 2016;9(8):e004712.

  7. George K, Whyte GP, Green DJ, Oxborough D, Shave RE, Gaze D, et al. The endurance athletes heart: acute stress and chronic adaptation. Br J Sports Med. 2012;46(Suppl 1):i29–36.

    Article  PubMed  Google Scholar 

  8. Howden EJ, Perhonen M, Peshock RM, Zhang R, Arbab-Zadeh A, Adams-Huet B, et al. Females have a blunted cardiovascular response to one year of intensive supervised endurance training. J Appl Physiol. 2015;119(1):37–46.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Pelliccia A, Culasso F, Di Paolo FM, Maron BJ. Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med. 1999;130(1):23–31.

    Article  CAS  PubMed  Google Scholar 

  10. Pelliccia A, Kinoshita N, Pisicchio C, Quattrini F, DiPaolo FM, Ciardo R, et al. Long-term clinical consequences of intense, uninterrupted endurance training in Olympic athletes. J Am Coll Cardiol. 2010;55(15):1619–25.

    Article  PubMed  Google Scholar 

  11. Pelliccia A, Maron BJ, Di Paolo FM, Biffi A, Quattrini FM, Pisicchio C, et al. Prevalence and clinical significance of left atrial remodeling in competitive athletes. J Am Coll Cardiol. 2005;46(4):690–6.

    Article  PubMed  Google Scholar 

  12. Spence AL, Naylor LH, Carter HH, Buck CL, Dembo L, Murray CP, et al. A prospective randomised longitudinal MRI study of left ventricular adaptation to endurance and resistance exercise training in humans. J Physiol. 2011;589(22):5443–52.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Weiner RB, DeLuca JR, Wang F, Lin J, Wasfy MM, Berkstresser B et al. Exercise-induced left ventricular remodeling among competitive athletes: a phasic phenomenon. Circulation: Cardiovascular Imaging. 2015;8(12):e003651.

  14. Zilinski JL, Contursi ME, Isaacs SK, Deluca JR, Lewis GD, Weiner RB et al. Myocardial adaptations to recreational marathon training among middle-aged men. Circulation: Cardiovascular Imaging. 2015;8(2):e002487.

  15. Wasfy MM, Weiner RB, Wang F, Berkstresser B, Lewis GD, DeLuca JR, et al. Endurance exercise-induced cardiac remodeling: not all sports are created equal. J Am Soc Echocardiogr. 2015;28(12):1434–40. https://doi.org/10.1016/j.echo.2015.08.002.

    Article  PubMed  Google Scholar 

  16. Baggish AL, Battle RW, Beaver TA, Border WL, Douglas PS, Kramer CM, et al. Recommendations on the use of multimodality cardiovascular imaging in young adult competitive athletes: a report from the American Society of Echocardiography in collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2020;33(5):523–49. https://doi.org/10.1016/j.echo.2020.02.009.

    Article  PubMed  Google Scholar 

  17. Douglas PS, Berman GO, O’Toole ML, Hiller WDB, Reichek N. Prevalence of multivalvular regurgitation in athletes. Am J Cardiol. 1989;64(3):209–12. https://doi.org/10.1016/0002-9149(89)90459-1.

    Article  CAS  PubMed  Google Scholar 

  18. Eveborn GW, Schirmer H, Heggelund G, Lunde P, Rasmussen K. The evolving epidemiology of valvular aortic stenosis. The Tromsø study Heart. 2013;99(6):396–400. https://doi.org/10.1136/heartjnl-2012-302265.

    Article  PubMed  Google Scholar 

  19. Osnabrugge RLJ, Mylotte D, Head SJ, Van Mieghem NM, Nkomo VT, LeReun CM, et al. Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling study. J Am Coll Cardiol. 2013;62(11):1002–12. https://doi.org/10.1016/j.jacc.2013.05.015.

    Article  PubMed  Google Scholar 

  20. Yadgir S, Johnson CO, Aboyans V, Adebayo OM, Adedoyin RA, Afarideh M, et al. Global, regional, and national burden of calcific aortic valve and degenerative mitral valve diseases, 1990–2017. Circulation. 2020;141(21):1670–80. https://doi.org/10.1161/CIRCULATIONAHA.119.043391.

    Article  PubMed  Google Scholar 

  21. •• CM Otto RA Nishimura RO Bonow BA Carabello JP Erwin F Gentile et al. ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Circulation. 2021 2020; 143(5):e72 e227. https://doi.org/10.1161/CIR.0000000000000923. This comprehensive guideline document provides thorough recommendations forpatients who present with valvular heart disease.

  22. Sarajlic P, Wolk A, Bäck M, Larsson SC. Physical activity does not reduce aortic valve stenosis incidence. Circ J. 2018;82(9):2372–4. https://doi.org/10.1253/circj.CJ-18-0598.

    Article  PubMed  Google Scholar 

  23. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739–91. https://doi.org/10.1093/eurheartj/ehx391.

    Article  PubMed  Google Scholar 

  24. Berkowitz JN, Moll S. Athletes and blood clots: individualized, intermittent anticoagulation management. J Thromb Haemost. 2017;15(6):1051–4. https://doi.org/10.1111/jth.13676.

    Article  CAS  PubMed  Google Scholar 

  25. Nilsson H, Nylander E, Borg S, Tamás É, Hedman K. Cardiopulmonary exercise testing for evaluation of a randomized exercise training intervention following aortic valve replacement. Clin Physiol Funct Imaging. 2019;39(1):103–10. https://doi.org/10.1111/cpf.12545.

    Article  CAS  PubMed  Google Scholar 

  26. Pressler A, Christle JW, Lechner B, Grabs V, Haller B, Hettich I, et al. Exercise training improves exercise capacity and quality of life after transcatheter aortic valve implantation: a randomized pilot trial. Am Heart J. 2016;182:44–53. https://doi.org/10.1016/j.ahj.2016.08.007.

    Article  PubMed  Google Scholar 

  27. Pressler A, Förschner L, Hummel J, Haller B, Christle JW, Halle M. Long-term effect of exercise training in patients after transcatheter aortic valve implantation: follow-up of the SPORT:TAVI randomised pilot study. Eur J Prev Cardiol. 2020;25(8):794–801. https://doi.org/10.1177/2047487318765233.

    Article  Google Scholar 

  28. Siu SC, Silversides CK. Bicuspid aortic valve disease. J Am Coll Cardiol. 2010;55(25):2789–800. https://doi.org/10.1016/j.jacc.2009.12.068.

    Article  PubMed  Google Scholar 

  29. Sievers H-H, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg. 2007;133(5):1226–33. https://doi.org/10.1016/j.jtcvs.2007.01.039.

    Article  PubMed  Google Scholar 

  30. Miller MJ, Geffner ME, Lippe BM, Itami RM, Kaplan SA, DiSessa TG, et al. Echocardiography reveals a high incidence of bicuspid aortic valve in Turner syndrome. J Pediatr. 1983;102(1):47–50. https://doi.org/10.1016/S0022-3476(83)80284-4.

    Article  CAS  PubMed  Google Scholar 

  31. Nistri S, Porciani MC, Attanasio M, Abbate R, Gensini GF, Pepe G. Association of Marfan syndrome and bicuspid aortic valve: frequency and outcome. Int J Cardiol. 2012;155(2):324–5. https://doi.org/10.1016/j.ijcard.2011.12.009.

    Article  PubMed  Google Scholar 

  32. Patel ND, Crawford T, Magruder JT, Alejo DE, Hibino N, Black J, et al. Cardiovascular operations for Loeys-Dietz syndrome: intermediate-term results. J Thorac Cardiovasc Surg. 2017;153(2):406–12. https://doi.org/10.1016/j.jtcvs.2016.10.088.

    Article  PubMed  Google Scholar 

  33. Duran AC, Frescura C, Sans-Coma V, Angelini A, Basso C, Thiene G. Bicuspid aortic valves in hearts with other congenital heart disease. J Heart Valve Dis. 1995;4(6):581–90.

    CAS  PubMed  Google Scholar 

  34. Forrest JK, Ramlawi B, Deeb GM, Zahr F, Song HK, Kleiman NS, et al. Transcatheter aortic valve replacement in low-risk patients with bicuspid aortic valve stenosis. JAMA Cardiology. 2021;6(1):50–7. https://doi.org/10.1001/jamacardio.2020.4738.

    Article  PubMed  Google Scholar 

  35. Halim SA, Edwards FH, Dai D, Li Z, Mack MJ, Holmes DR, et al. Outcomes of transcatheter aortic valve replacement in patients with bicuspid aortic valve disease. Circulation. 2020;141(13):1071–9. https://doi.org/10.1161/CIRCULATIONAHA.119.040333.

    Article  PubMed  Google Scholar 

  36. Boraita A, Morales-Acuna F, Marina-Breysse M, Heras M-E, Canda A, Fuentes M-E, et al. Bicuspid aortic valve behaviour in elite athletes. European Heart Journal - Cardiovascular Imaging. 2019;20(7):772–80. https://doi.org/10.1093/ehjci/jez001.

    Article  PubMed  Google Scholar 

  37. Stefani L, Galanti G, Innocenti G, Mercuri R, Maffulli N. Exercise training in athletes with bicuspid aortic valve does not result in increased dimensions and impaired performance of the left ventricle. Cardiol Res Pract. 2014;2014:238694-. https://doi.org/10.1155/2014/238694.

  38. Spataro A, Pelliccia A, Rizzo M, Biffi A, Masazza G, Pigozzi F. The natural course of bicuspid aortic valve in athletes. Int J Sports Med. 2008;29(01):81–5.

    Article  CAS  PubMed  Google Scholar 

  39. Braverman AC, Harris KM, Kovacs RJ, Maron BJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 7: aortic diseases, including Marfan syndrome. Circulation. 2015;132(22):e303–9. https://doi.org/10.1161/CIR.0000000000000243.

    Article  PubMed  Google Scholar 

  40. Baleilevuka-Hart M, Teng BJ, Carson KA, Ravekes WJ, Holmes KW. Sports participation and exercise restriction in children with isolated bicuspid aortic valve. Am J Cardiol. 2020;125(11):1673–7. https://doi.org/10.1016/j.amjcard.2020.02.039.

    Article  PubMed  Google Scholar 

  41. Blanc A, Lairez O, Cariou E, Fournier P, Poenar AM, Marcheix B et al. Participating in sports after mitral valve repair for primary mitral regurgitation: a retrospective cohort study. Clinical Journal of Sport Medicine. 2020;Publish Ahead of Print.https://doi.org/10.1097/jsm.0000000000000769.

  42. Langer C, Butz T, Mellwig KP, Oepangat E, Fruend A, Faber L, et al. Elite athletes with mitral or aortic regurgitation and their cardiopulmonary capability. Acta Cardiol. 2013;68(5):475–80. https://doi.org/10.1080/ac.68.5.2994470.

    Article  PubMed  Google Scholar 

  43. Freed LA, Levy D, Levine RA, Larson MG, Evans JC, Fuller DL, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med. 1999;341(1):1–7. https://doi.org/10.1056/nejm199907013410101.

    Article  CAS  PubMed  Google Scholar 

  44. Essayagh B, Sabbag A, Antoine C, Benfari G, Yang L-T, Maalouf J, et al. Presentation and outcome of arrhythmic mitral valve prolapse. J Am Coll Cardiol. 2020;76(6):637–49. https://doi.org/10.1016/j.jacc.2020.06.029.

    Article  PubMed  Google Scholar 

  45. Basso C, Marra MP, Rizzo S, Lazzari MD, Giorgi B, Cipriani A, et al. Arrhythmic mitral valve prolapse and sudden cardiac death. Circulation. 2015;132(7):556–66. https://doi.org/10.1161/CIRCULATIONAHA.115.016291.

    Article  PubMed  Google Scholar 

  46. Muthukumar L, Rahman F, Jan MF, Shaikh A, Kalvin L, Dhala A et al. The Pickelhaube sign: novel echocardiographic risk marker for malignant mitral valve prolapse syndrome. JACC: Cardiovascular Imaging. 2017;10(9):1078–80. https://doi.org/10.1016/j.jcmg.2016.09.016.

  47. Miller MA, Dukkipati SR, Turagam M, Liao SL, Adams DH, Reddy VY. Arrhythmic mitral valve prolapse. Journal of the American College of Cardiology. 2018;72(23_Part_A):2904–14. https://doi.org/10.1016/j.jacc.2018.09.048.

  48. Bui AH, Roujol S, Foppa M, Kissinger KV, Goddu B, Hauser TH, et al. Diffuse myocardial fibrosis in patients with mitral valve prolapse and ventricular arrhythmia. Heart. 2017;103(3):204–9. https://doi.org/10.1136/heartjnl-2016-309303.

    Article  PubMed  Google Scholar 

  49. Fulton BL, Liang JJ, Enriquez A, Garcia FC, Supple GE, Riley MP, et al. Imaging characteristics of papillary muscle site of origin of ventricular arrhythmias in patients with mitral valve prolapse. J Cardiovasc Electrophysiol. 2018;29(1):146–53. https://doi.org/10.1111/jce.13374.

    Article  PubMed  Google Scholar 

  50. Nordhues BD, Siontis KC, Scott CG, Nkomo VT, Ackerman MJ, Asirvatham SJ, et al. Bileaflet mitral valve prolapse and risk of ventricular dysrhythmias and death. J Cardiovasc Electrophysiol. 2016;27(4):463–8. https://doi.org/10.1111/jce.12914.

    Article  PubMed  Google Scholar 

  51. Perazzolo Marra M, Basso C, De Lazzari M, Rizzo S, Cipriani A, Giorgi B et al. Morphofunctional abnormalities of mitral annulus and arrhythmic mitral valve prolapse. Circulation: Cardiovascular Imaging. 2016;9(8):e005030.

  52. Caselli S, Mango F, Clark J, Pandian NG, Corrado D, Autore C, et al. Prevalence and clinical outcome of athletes with mitral valve prolapse. Circulation. 2018;137(19):2080–2. https://doi.org/10.1161/CIRCULATIONAHA.117.033395.

    Article  PubMed  Google Scholar 

  53. Hepner AD, Morrell H, Greaves S, Greaves J, Movahed MR. Prevalence of mitral valvar prolapse in young athletes. Cardiol Young. 2008;18(4):402–4. https://doi.org/10.1017/s104795110800245x.

    Article  PubMed  Google Scholar 

  54. Maron BJ, Haas TS, Murphy CJ, Ahluwalia A, Rutten-Ramos S. Incidence and causes of sudden death in US college athletes. J Am Coll Cardiol. 2014;63(16):1636–43.

    Article  PubMed  Google Scholar 

  55. Pape LA, Tsai TT, Isselbacher EM, Oh JK, O’Gara PT, Evangelista A et al. Aortic diameter ≥5.5 cm is not a good predictor of type A aortic dissection. Circulation. 2007;116(10):1120–7. https://doi.org/10.1161/CIRCULATIONAHA.107.702720.

  56. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation. 2010;121(13):e266–369. https://doi.org/10.1161/CIR.0b013e3181d4739e.

    Article  PubMed  Google Scholar 

  57. Boraita A, Heras M-E, Morales F, Marina-Breysse M, Canda A, Rabadan M et al. Reference values of aortic root in male and female white elite athletes according to sport. Circulation: Cardiovascular Imaging. 2016;9(10):e005292. https://doi.org/10.1161/CIRCIMAGING.116.005292.

  58. Pelliccia A, Paolo FMD, Blasiis ED, Quattrini FM, Pisicchio C, Guerra E, et al. Prevalence and clinical significance of aortic root dilation in highly trained competitive athletes. Circulation. 2010;122(7):698–706. https://doi.org/10.1161/CIRCULATIONAHA.109.901074.

    Article  PubMed  Google Scholar 

  59. Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, et al. Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association athletes: a decade in review. Circulation. 2015;132(1):10–9.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Gentry JL, Carruthers D, Joshi PH, Maroules CD, Ayers CR, Lemos JAd et al. Ascending aortic dimensions in former National Football League athletes. Circulation: Cardiovascular Imaging. 2017;10(11):e006852. https://doi.org/10.1161/CIRCIMAGING.117.006852.

  61. Churchill TW, Groezinger E, Kim JH, Loomer G, Guseh JS, Wasfy MM, et al. Association of ascending aortic dilatation and long-term endurance exercise among older masters-level athletes. JAMA Cardiology. 2020;5(5):522–31. https://doi.org/10.1001/jamacardio.2020.0054.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA

    Bradley J. Petek MD

  2. Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA, 02114, USA

    Aaron L. Baggish MD

Authors
  1. Bradley J. Petek MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Aaron L. Baggish MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Aaron L. Baggish MD.

Ethics declarations

Conflict of Interest

Dr. Petek declares that he has no conflict of interest. Dr. Baggish has received funding from the National Institute of Health/National Heart, Lung, and Blood Institute, the National Football Players Association, and the American Heart Association and receives compensation for his role as team cardiologist from the US Olympic Committee/US Olympic Training Centers, US Soccer, US Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Valvular Heart Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Petek, B.J., Baggish, A.L. Valvular Heart Disease in Athletes. Curr Treat Options Cardio Med 23, 69 (2021). https://doi.org/10.1007/s11936-021-00950-1

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11936-021-00950-1

Keywords

Search

Navigation