Aortic root changes in elite athletes with a tricuspid aortic valve: a longitudinal study

Abstract Introduction Extended periods of intense training may increase the aortic root diameter. To check for a possible thoracic aorta aneurysm, aortic sizes are routinely measured during each ECHO exam. Currently, no universally accepted upper limits for aortic root dimensions in elite athletes have been established, and existing guidelines vary. Purpose This research aimed to evaluate aortic root dimensions in elite athletes and to examine their changes over time. Methods Athletes were included if they were between 18 and 34 years old, had competed in their sport for at least 5 years, trained for a minimum of 10 hours per week, and had undergone two or more ECHO exams. Data from a total of 1,531 healthy elite athletes (71% male, 29% female), aged 24.6 (±4.51) years, with an average of 18.3 (±5.92) training hours per week, were analyzed. Athletes were categorized into four sports disciplines: skill (8%), power (18%), mixed (66%), and endurance (8%). The average follow-up period was 3.47 (±1.98) years (range 2 to 13 years). The aortic root was measured at the sinuses of Valsalva (at end-diastole, leading-to-leading edge). Dimensions were analyzed as a function of training history, sport category, and sex using a linear mixed-effects model with random slopes for individuals. Results Aortic root dimensions in males were 33.5±3.06 mm (range, 26 to 46; 99th percentile≥41 mm), and in females, 28.7±2.56 mm (range, 23 to 37; 99th percentile≥36 mm). Aortic root baseline diameters were larger in mixed (Δ1.21 mm, 95% CI 0.18–2.25, p=0.022) and endurance athletes (Δ2.15 mm, 95% CI 0.75–3.55, p0.001) compared with skill athletes, and smaller in females than males (Δ-4.61 mm, 95% CI -6.20 to -3.02, p0.001). Training-related changes across sport × sex combinations showed slopes in males ranging from 0.17 mm/year (95% CI 0.10–0.23) in skill athletes to 0.24 mm/year (95% CI 0.13–0.36) in power athletes. Slopes in females ranged from 0.04 mm/year (95% CI -0.01–0.09) in power athletes to 0.22 mm/year (95% CI 0.10–0.33) in skill athletes. A total of 17 (1.6%) males and 7 (1.6%) females exhibited increased aortic root dimensions (at or above the 99th percentile), with no adverse events reported during follow-up. Linear mixed-effects modeling of aortic root z-scores: in male athletes, slopes were 0.053 (95% CI -0.002–0.108) for skill, 0.063 (95% CI 0.009–0.116) for power, 0.072 (95% CI 0.017–0.127) for mixed, and 0.019 (95% CI -0.010–0.048) for endurance. In female athletes, slopes were slightly lower: 0.027 (95% CI -0.018–0.072) for skill, 0.007 (95% CI -0.049–0.063) for power, 0.028 (95% CI -0.017–0.073) for mixed, and -0.022 (95% CI -0.069–0.025) for endurance. Conclusion These findings suggest that extended training is linked to a small yet statistically significant increase in aortic root size, with minor sex- and sport-specific variations. This underscores the importance of ongoing monitoring of aortic dimensions using z-score calculations in athletes.Changes in aortic root dimensionsFor image description, please refer to the figure legend and surrounding text. Distribution of aortic root dimensionsFor image description, please refer to the figure legend and surrounding text.