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............................................................................................................................................................................. also be performed up to submaximal intensities, in case of uncomplicated disease (see section 4.1.1).

A major limitation of endurance exercise is the reduced chronotropic response to exercise because of allograft denervation. Apart from chronotropic incompetence, other pathophysiological changes present after HTx should also be considered when prescribing and conducting an exercise programme (Table 13). Exercise-induced ischaemia from cardiac allograft vasculopathy should be considered, particularly when performing higher-intensity exercise, which has been advocated to have some superior effects on improving exercise capacity in these patients.311,312 Feasibility and safety of sports participation in stable asymptomatic HTx patients, after therapy optimization, has been reported. Therefore, participation in competitive sports, avoiding high-intensity power and endurance disciplines, may be considered in selected individuals.

5.3 Exercise recommendations

in individuals with valvular heart disease 5.3.1 Introduction Valvular heart disease affects approximately 12% of young exercising individuals in the general population. Reports on the natural history of valvular heart disease in athletes are sparse; however, there is a theoretical possibility that a large stroke volume, coupled with vigorous mechanical contractions of the heart, and an increased chronotropic state induced by exercise may accelerate valve dysfunction. The ensuing effects on chronic stenotic or regurgitant lesions may cause compensatory cardiac hypertrophy, impaired ventricular function, myocardial ischaemia, cardiac arrhythmias, and possibly SCD. 5.3.1.1 General principles in assessment and risk stratification of individuals with valvular heart disease prior to leisure exercise or competitive sports There are no prospective studies examining the impact of exercise on the progression of valvular disease; therefore, general guidance presented in this section is based on consensus opinions and longterm follow-up studies from non-athletic populations. Most individuals with valvular heart disease are asymptomatic or mildly symptomatic and some may aspire to engage in regular exercise programmes including leisure and competitive sports. The management of these individuals requires assessment of the symptomatic status, functional capacity, the nature of the valvular lesion, and impact of the resulting loading conditions on cardiac structure and function. All individuals should be assessed with a clinical history, physical examination, ECG, echocardiography, and exercise stress test. The clinical history should enquire about cardiac symptoms and functional capacity. Echocardiography should focus on the valve morphology and function with particular attention to the severity and the impact of cardiac chamber size and function. Exercise testing should resemble the intensity of the sport being engaged in and should focus on inducibility of symptoms, arrhythmias, myocardial ischaemia, and the haemodynamic (BP) response to exercise. Some individuals may require exercise echocardiography to assess the severity of the valve defect.

Asymptomatic individuals with mild to moderate valvular dysfunction who have preserved ventricular function and show good functional capacity without exercise-inducible myocardial ischaemia, abnormal haemodynamic response, or arrhythmias are considered to be at low risk and may participate in all sports. Indeed, mild valvular regurgitation (mostly tricuspid and pulmonary) are common among trained athletes and likely represent a feature of the athlete’s heart. Conversely, individuals with exertional symptoms, moderate or severe valvular dysfunction, left or right ventricular dysfunction, pulmonary hypertension, and exercise-induced cardiac arrhythmias or abnormal haemodynamic response are considered to be at high risk and should be considered for invasive intervention.

5.3.1.2 Surveillance All individuals with valvular heart disease should be assessed on a regular basis. The frequency of the assessment may vary from 6 monthly to 2 yearly depending on symptomatic status and the severity of valve dysfunction.

5.3.2 Aortic valve stenosis Aortic valve stenosis (AS) is most frequently the result of an agedependent degenerative process causing progressive thickening, calcification, and reduced mobility of the cusps.313 AS causes an increase in transvalvular pressure gradient and LV workload, with consequent LV hypertrophy, fibrosis, and increased myocardial oxygen demand. Left ventricular ejection fraction (LVEF) is usually preserved. Affected individuals may have a normal cardiac output at rest and even during exercise, therefore, some individuals with AS are capable of good exercise performance. Nonetheless, severe AS is associated with increased risk of heart failure and SCD from mechanical outflow obstruction, malignant VAs, or coronary hypoperfusion.18,314 The diagnosis and grading of AS during echocardiography is based on well-established criteria.315 Specifically, severe AS is defined by: (i)

Recommendations for exercise and participation in sport in heart transplant recipients

Recommendations Classa Levelb

Regular exercise through cardiac rehabilitation, combining moderate-intensity aerobic and resistance exercise, is recommended to revert pathophysiology to pre-transplantation time, reduce cardiovascular risk induced by post-transplantation medical treatment, and improve clinical outcome.305312 I B Recreational (low-intensity recreational) sports participation should be considered and encouraged in stable, asymptomatic individuals after therapy optimization. IIa C Eligibility for competitive sports involving lowand moderate-intensity exercise may be considered in selected, asymptomatic individuals with an uncomplicated follow-up.304,309,310 IIb C

aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026