Aortic root diameter and left ventricular end diastolic diameter ratio: a new diagnostic tool

Abstract Background Assessing aortic dimensions in competitive athletes remains challenging, as no universally accepted absolute cut-offs exist to define aortic dilatation in this population. Indexing to body surface area (BSA) may be misleading in athletes, particularly those with extreme body size, where training-induced increases in both cardiac and anthropometric measures may mask true pathology1. Because exercise-induced cardiac remodelling is typically harmonic, preserving proportionality between ventricular and vascular structures, the aortic root diameter–to–left ventricular end-diastolic diameter ratio (AoD/LVEDD) has been proposed as a physiologically grounded tool to help clinicians distinguish pathological aortic enlargement from adaptive, sport-related remodelling2,3. Aims To evaluate the diagnostic performance of the AoD/LVEDD ratio in distinguishing physiological adaptation from pathological aortic dilatation in competitive athletes. Methods We conducted a retrospective study including 1,392 competitive athletes: 933 with normal aortic dimensions and 399 with aortic root dilatation (AoD 40 mm in males and 34 mm in females4). All subjects underwent 2D echocardiography following ASE/EACVI standards.The AoD/LVEDD ratio was calculated. Subgroup analyses were performed according to sport classification (skill, mixed, power, endurance). Results Atheltes with normal AoD showed a greater degree of LV remodelling with greater systolic and diastolic LV diameters, even when indexing for BSA, and greater interventricular thickness. The AoD/LVEDD ratio was significantly lower in athletes without aortic dilatation (0.59±0.05 vs 0.80±0.05, p0.001), with no sex-related differences. A cut-off value of 0.71 yielded a sensitivity of 98.7%, specificity of 98.8%, and a negative predictive value of 99.5%. The majority of the athletes were engaging in mixed sports (42.2%) followed by power (24.9%), endurance (19%) and skill (13.9%). Across sport disciplines, endurance athletes showed the greatest LV enlargement and smallest AoD/LVEDD ratio, while power athletes exhibited higher AoD values; however, the diagnostic accuracy of the ratio remained consistent in all subgroups. Conclusions The AoD/LVEDD ratio is a robust, physiologically grounded index that reliably distinguishes adaptive from pathological aortic enlargement in competitive athletes. Its high diagnostic accuracy and independence from body size variability support its use as a practical tool to improve evaluation and clinical decision-making in athletes with borderline aortic dimensions.