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...................................................... sports involving low and moderate intensity and may be considered for more intensive exercise on an individual basis. Such individuals require more frequent surveillance on a 6-monthly basis to assess LV function. In asymptomatic individuals with severe AR and reduced LVEF, surgical valve replacement/repair is indicated, and they should not participate in competitive sports but may participate in leisure sports involving only low-intensity exercise. Surgery is recommended in symptomatic individuals with severe AR. These individuals should not participate in competitive or leisure sports; however, lowintensity aerobic exercise activity is encouraged to improve functional capacity and general well-being.

5.3.4 Bicuspid aortic valve Bicuspid aortic valve (BAV) is a common congenital abnormality with a prevalence of 12% in the general population.320 BAV may be associated with AS or AR and increased risk for ascending aortic aneurysm or dissection, and SCD.28,321 Compared with Marfan syndrome, the risk of aortopathy is lower; nonetheless BAV is much more frequent, and the relative risk of aortic dissection has been reported to be eight times greater than with a tricuspid aortic valve.321 BAV may not be identified during physical examination in the absence of valve dysfunction;58,322 however, the outcome of young individuals without valvular dysfunction is good.323,324

It is unclear whether intensive exercise accelerates aortic dilatation in the long term. A previous study comparing athletes with BAV, non-athletes with BAV, and athletes with a normal aortic valve reported that athletes with BAV showed a 0.11 ± 0.59 mm/year increase in aortic size at the sinuses of Valsalva and 0.21 ± 0.44 mm/ year for the proximal ascending aorta, which was not dissimilar to non-athletes with a BAV.325 Currently, expert consensus panels advise a cautious approach to sports activities when the ascending aorta is above the normal limits (see section 5.4). In the absence of aortopathy, exercise recommendations for individuals with BAV are identical to those in individuals with tricuspid aortic valve dysfunction.

Recommendations for participation in recreational/leisure-time sports in asymptomatic individuals with aortic regurgitation

Aortic regurgitationc

Recommendation Classa Levelb

Mild Participation in all recreational sports, if desired, is recommended. I C Moderate Participation in all recreational sports, if desired, should be considered in asymptomatic individuals with a non-dilated LV with LVEF>50% and normal exercise stress test. IIa C Severe Participation in all recreational sports involving low and moderate intensity, if desired, may

be considered with a mild or moderately dilated LV with LVEF>50% and normal exercise stress test. IIb C Participation in any moderate- or high-intensity recreational exercise is not recommended with LVEF<_50% and/or exercise-induced arrhythmias. III C

LV = left ventricle; LVEF = left ventricular ejection fraction. aClass of recommendation. bLevel of evidence. cFor mixed valvular disease, the recommendation for the predominant lesion should be followed.

Recommendations for participation in competitive sports in asymptomatic individuals with aortic regurgitation

Aortic regurgitationc

Recommendation Classa Levelb

Mild Participation in all competitive sports, if desired, is recommended. I C Moderate Participation in all competitive sports, if desired, should be considered in individuals with

LVEF>50% and normal exercise test. IIa C

Severe Participation in most competitive sports involving low to moderate intensity may be considered in individuals with a mild or moderately dilated LV with LVEF>50% and normal exercise

stress test. IIb C Participation in any moderate- or high-intensity competitive sports is not recommended in individuals with severe AR and/or LVEF<_50% and/or exercise-induced arrhythmias III C

AR = aortic regurgitation; LV = left ventricle; LVEF = left ventricular ejection fraction. aClass of recommendation. bLevel of evidence. cFor mixed valvular disease, the recommendation for the predominant lesion should be followed. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026