Aortic regurgitation in competitive athletes: The role of multimodality imaging for clinical decision-making

Systematic sports participation leads to morphological and functional adaptations in cardiac muscle that are collectively termed the Athlete’s heart. These include ventricular chamber enlargement, myocardial hypertrophy, left atrium dilation, enhanced diastolic filling, and alterations in autonomic function and resting electrocardiogram.1,2 Such structural and functional cardiac changes commonly overlap with cardiac disease conditions, challenging the diagnosis of “normal variants”. In the case of valvular heart disease (VHD) in athletes, the diagnostic assessment may be further perplexed, as, for example, in the case of aortic regurgitation (AR). AR and concomitant left ventricular (LV) dilation in athletes may pose challenging diagnostic and therapeutic dilemmas, since LV dilation could represent either a physiological adaptation to sports participation or the consequence of overt VHD. Current guidelines3 recommend aortic valve replacement surgery in asymptomatic patients with severe AR if the LVESD (left ventricular end-systolic diameter) index is above 25 mm/m2, but this evidence is derived from studies conducted more than 20 years ago.4 More recent evidence5 suggests that the mortality in patients with asymptomatic moderate/severe AR is significantly increased for LVESD index >20 mm/m2. An earlier timepoint for intervention in asymptomatic AR may have strong implications for current clinical guidelines, but the validity of these findings in special populations, such as elite athletes, should be explored. It should also be noted that different reference values for LV chamber size apply to athletes, which poses another diagnostic dilemma when assessing VHD-induced LV remodeling.6,7