Athletes with mild AS can participate in all competitive

Sports, but should undergo serial evaluations of

AS severity on at least an annual basis.

Athletes with moderate AS can engage in low-intensity

Competitive sports (class IA). Selected athletes may

Participate in low and moderate static or low and

Moderate dynamic competitive sports (classes IA, IB,

And IIA) if exercise tolerance testing to at least the level

Of activity achieved in competition demonstrates satisfactory

Exercise capacity without symptoms, STsegment

Depression or ventricular tachyarrhythmias,

And with a normal blood pressure response. Those

1336 Bonow et al. JACC Vol. 45, No. 8, 2005

Task Force 3: Valvular Heart Disease April 19, 2005:1334–40

Athletes with supraventricular tachycardia or multiple or

Complex ventricular tachyarrhythmias at rest or with

Exercise can participate only in low-intensity competitive

Sports (class IA).

Patients with severe AS or symptomatic patients with

Moderate AS should not engage in any competitive

Sports.

AORTIC REGURGITATION

Aortic regurgitation has multiple etiologies, as any disease

affecting the aortic valve, annulus, or proximal ascending

aorta can result in AR. The common etiologies are: 1)

congenital bicuspid aortic valve; 2) rheumatic heart disease;

3) infective endocarditis; and 4) aortic root diseases, including

Marfan syndrome, ascending aortic aneurysm, aortic

dissection, systemic hypertension, and rheumatoid spondylitis.

Aortic regurgitation increases LV diastolic volume and

stroke volume, which may ultimately lead to LV systolic

dysfunction (10). In addition, myocardial oxygen supply/

demand imbalance may develop because of the increased

wall stress, LV hypertrophy, and reduced diastolic blood

pressure (reduced coronary perfusion pressure).

Patients with severe AR may remain asymptomatic and

athletic for many years, but angina pectoris, syncope, and

ventricular arrhythmias ultimately may appear. Sudden

death is rare among asymptomatic patients (less than 0.2%

per year [5]) but can occur.

Evaluation.The hemodynamic severity of AR can be

assessed noninvasively by physical examination (the severity

being reflected by the degree of LV dilation and the

peripheral signs of AR), chest radiography, and echocardiography.

As noted previously, the upper limit of normal LV

end-diastolic size is increased in the healthy, highly trained

athlete (12), and this may well affect assessment of LV

enlargement in the setting of AR.

Because of the importance of assessing LV function and

the size of the aortic root and proximal ascending aorta in

determining the etiology of AR, with resulting implications

for athletic participation, evaluation by echocardiography is

essential. Doppler echocardiography is very sensitive in

detecting any degree of AR. Similar to MR, the greatest

difficulty arises in differentiating moderate and severe AR.

Qualitatively, the width of the regurgitant jet and the

proportion of the LV outflow tract occupied by the jet are

related to the severity of the AR, as is the slope velocity

profile of the diastolic jet. The regurgitant volume can also

be measured quantitatively by Doppler methods (1).

The LV function should be assessed serially by twodimensional

echocardiography (5). Radionuclide angiography

or cardiac magnetic resonance may be helpful if

echocardiograms are of suboptimal quality. Exercise testing

can be useful in assessing exercise capacity, especially in

those patients having nonspecific or mild symptoms, and it

is recommended that testing be performed to at least the

level of exertion required by the proposed competitive sport.

Holter monitoring with intense exercise resembling competition

is recommended to detect ventricular arrhythmias in

patients who wish to participate in competitive athletics.

Effects of exercise.With exercise, regurgitant volume decreases

because of the decrease in peripheral vascular resistance

that reduces diastolic blood pressure and the decrease

in diastolic filling period that accompanies the increase in

heart rate (16). Because of these changes in preload and

afterload, the failure of the ejection fraction to increase with

exercise is of uncertain significance, and there are insuffi-

cient data with which to use this finding in formulating

recommendations regarding participation in competitive

athletics. There are also no data to define whether severe

increases in physical activity permanently affect the function

of the left ventricle.

For purposes of the following recommendations, hemodynamic

severity of AR is graded as follows: mild _ absent

to slight peripheral signs of AR, normal LV size; moderate _

peripheral signs of AR with mild-to-moderate increases in

LV size with normal systolic function; and severe _ peripheral

signs of AR with severe LV enlargement and/or LV

systolic dysfunction.

Recommendations:

Date: 2016-03-03; view: 648