Abstract
This case series study evaluates aortic outcomes in athletes performing endurance exercise or competition after ascending thoracic aortic aneurysm resection with bicuspid aortic valve aortopathy.
Individuals with heritable thoracic aortic aneurysm diseases (HTAD) are advised to avoid physical activity and endurance exercise generating high metabolic equivalents because of aortic disease concerns.1,2 Individuals with HTAD are at risk for proximal and distal aortic complications, and activity restrictions remain after proximal thoracic aortic aneurysm (TAA) resection.1
Bicuspid aortic valve (BAV) aortopathy differs from HTAD because the aortic disease involves the ascending aorta or aortic root.3 The localized ascending aortic disease in BAV aortopathy may be a factor in low risk for endurance exercise after TAA resection.
Methods
This case series study evaluated aortic outcomes in athletes performing endurance exercise or competition after ascending TAA resection in BAV aortopathy. The athletes participating in the study had TAA surgery beginning in 2005, and data collection occurred from 2019 to 2022. Individuals were recruited from the Ironheart Foundation and the Washington University School of Medicine, which approved the study. Informed written consent was obtained from each participant.
Clinical data, exercise regimens, endurance competitions, and imaging data were obtained from medical records, questionnaires, and telephone calls. Reports of echocardiograms, computed tomography, and magnetic resonance imaging from before surgery to the most recent follow-up were reviewed.
Results
Twenty-one athletes with BAV aortopathy (mean [SD] age at enrollment, 53 [12] years; 17 [80.9%] were male) participated in endurance exercise after TAA resection (Table). The mean (SD) aortic diameter before surgery (available in 16 individuals) was 50.1 (5.4) mm. One participant had prior coarctation of the aorta repair. Among those with aortic valve replacement (AVR), 66.7% underwent bioprosthetic AVR at a mean (SD) age of 50 (11) years (Table).
Table. Clinical Data, Aortic Imaging, Endurance Exercise Information, and Late Aortic Events in Study Participants.
| Participant | Age at TAA resection by decade | Surgical procedure | Aortic diameter at surgery, mm | Aortic size at last imaging, mm (location) | Follow-up after surgery, y | Endurance competition | Late aortic and aortic valve events |
|---|---|---|---|---|---|---|---|
| 1 | 40 | Asc graft and bio-AVR | 46 | 25 (SoV) | 7.5 | Half-marathons | None |
| 2 | 40 | Asc graft and bio-AVR | 49 | 29 (SoV) | 4.5 | 120-km cycling race | None |
| 3 | 60 | Asc graft and bio-AVR | NA | 35 (SoV) | 12.7 | Olympic triathlons, Ironman | TAVR (12.5 y postop) |
| 4 | 40 | Asc graft and mechanical AVR | NA | 35 (SoV) | 14.2 | Marathons, triathlons | None |
| 5 | 60 | Asc graft and bio-AVR | 50 | 36 (SoV) | 3.6 | Sprint triathlon, half-marathon | None |
| 6 | 50 | Asc graft and bio-AVR | 46 | 36 (SoV) | 3.2 | Sprint triathlon, Olympic triathlon | None |
| 7 | 50 | Asc graft | 50 | 39 (SoV) | 7.5 | 700-mile Cycling races | None |
| 8 | Teens | Asc graft | NA | 40 (SoV) | 14.8 | Sprint triathlon, Olympic weightlifting | None |
| 9 | 20 | Asc graft | 51 | 40 (SoV) | 3.5 | Marathon, ultramarathons | None |
| 10 | 40 | Asc graft and bio-AVR | 54 | 41 (SoV) | 9.7 | Marathons, ultramarathon, Olympic triathlons | Redo bio-AVR (8.5 y postop) |
| 11 | 50 | Asc graft | 56 | 42 (SoV) | 7.5 | Half-marathons, marathon, Olympic triathlon | None |
| 12 | 40 | Mod-Bentall with mechanical AVR | 49 | 27 (Asc Ao) | 2.6 | Triathlons | None |
| 13 | 30 | Mod-Bentall with bio-AVR | 52 | 30 (Asc Ao) | 14.1 | Ironman, triathlons | None |
| 14 | 50 | Mod-Bentall with mechanical AVR | 45 | 31 (Asc Ao) | 4.9 | Ironman, half-Ironman, half-marathon, 100-mile cycling race | None |
| 15 | 20 | Mod-Bentall with mechanical AVR | 64 | 34 (Asc Ao) | 8.7 | Marathons | None |
| 16 | 60 | Mod-Bentall with bio-AVR | 49 | 37 (Asc Ao) | 7.4 | Half-Ironman, Olympic triathlon | None |
| 17 | 40 | Primary aortoplasty and mechanical AVR | 45 | 44 (Asc Ao) | 2.6 | None | None |
| 18 | 40 | Asc graft and bio-AVR | NA | NA | 16.5 | Half-marathons, sprint triathlons | Redo mechanical AVR (5 y postop) |
| 19 | 40 | Mod-Bentall with bio-AVR | 54 | NA | 18.8 | Half-marathons, marathons, triathlons | Redo mechanical AVR (8.3 y postop) |
| 20 | 60 | Asc graft | 41 | NA | 2.5 | Half-Ironman, sprint triathlons | None |
| 21 | 50 | Asc graft | NA | NA | 1.7 | 100-mile Cycling races | None |
Abbreviations: Asc, ascending; Asc Ao, ascending aorta; bio-AVR, bioprosthetic aortic valve replacement; Mod-Bentall, modified Bentall procedure; NA, not available; postop, postoperatively; SoV, sinuses of Valsalva; TAA, thoracic aortic aneurysm; TAVR, transcatheter aortic valve replacement.
Athletes resumed endurance exercise or competition at a mean (SD) of 5.7 (3.8) months after TAA repair. Athletes cumulatively completed nearly 300 endurance events including marathons, triathlons, and Ironman competitions (Table). Sixteen participants (76.2%) exercised 4 to 6 days per week and 5 exercised daily. Athletes exercised for a mean (SD) of 1.4 (0.6) hours per day. All but one individual reported that they did not perform any intense weight training.
The largest native aortic diameter after TAA resection (available in 17 participants at a mean [SD] follow-up of 6.0 [4.4] years after surgery) measured a mean (SD) of 35.4 (5.5) mm. At last clinical follow-up, mean (SD) 8.0 (5.2) years after TAA resection, 21 individuals were actively exercising and competing. No adverse aortic outcomes were reported. Three athletes required repeated AVR for bioprosthetic AVR degeneration at a mean (SD) of 8.7 (3.7) years after AVR.
Discussion
Guidelines regarding participation in competitive athletics after TAA resection recommend low-level exercise and endurance over power sports.1,2 Isolated BAV aortopathy does not carry the risk of distal aortic disease as in other HTADs.4 Thus, these athletes might not require similar restrictions after surgery. Notably, professional athletes have returned to elite competition after TAA resection for BAV aortopathy.5 After ascending TAA resection in BAV aortopathy, the aortic root does not typically dilate substantially.6 Late aortic complications after BAV-TAA are uncommon; in the absence of residual aortic dilation, imaging the thoracic aorta once every 3 to 5 years after repair may be reasonable.3 In this study, no reports of aortic dilation or aortic complications occurred during follow-up. Continued imaging surveillance during follow-up is appropriate.
Study limitations include the small sample size and that enrollees were self-selected. The aortic diameter was unknown in 5 individuals before TAA resection and in 4 individuals during follow-up. Imaging modality and frequency post-TAA resection was at the discretion of the treating cardiologist. Aortic diameters reported were based on imaging reports.
Conclusions
Participation in endurance competitive athletics after TAA resection for BAV aortopathy involves shared decision making. Among select individuals with isolated BAV aortopathy and without residual aortic disease, endurance exercise after TAA resection was not associated with adverse aortic events.
References
- 1.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: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2398-2405. doi: 10.1016/j.jacc.2015.09.039 [DOI] [PubMed] [Google Scholar]
- 2.Pelliccia A, Sharma S, Gati S, et al. ; ESC Scientific Document Group . 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J. 2021;42(1):17-96. doi: 10.1093/eurheartj/ehaa605 [DOI] [PubMed] [Google Scholar]
- 3.Borger MA, Fedak PWM, Stephens EH, et al. The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: full online-only version. J Thorac Cardiovasc Surg. 2018;156(2):e41-e74. doi: 10.1016/j.jtcvs.2018.02.115 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.den Hartog AW, Franken R, Zwinderman AH, et al. The risk for type B aortic dissection in Marfan syndrome. J Am Coll Cardiol. 2015;65(3):246-254. doi: 10.1016/j.jacc.2014.10.050 [DOI] [PubMed] [Google Scholar]
- 5.Bembry J. Six years after open-heart surgery saved his life, Jeff Green saves the Cavaliers’ season. Accessed February 10, 2022. https://theundefeated.com/features/six-years-after-open-heart-surgery-saved-his-life-jeff-green-saves-the-cavaliers-season/
- 6.Hui SK, Fan CS, Christie S, Feindel CM, David TE, Ouzounian M. The aortic root does not dilate over time after replacement of the aortic valve and ascending aorta in patients with bicuspid or tricuspid aortic valves. J Thorac Cardiovasc Surg. 2018;156(1):5-13.e1. doi: 10.1016/j.jtcvs.2018.02.094 [DOI] [PubMed] [Google Scholar]