This patient had a BAV with moderate AS (generally defined as peak Doppler gradient 40-64 mm Hg or mean Doppler gradient 25-40 mm Hg) and mild-to-moderate thoracic aorta dilation. In the setting of moderate AS, there is a continuum of risk that requires comprehensive evaluation and shared decision-making (SDM) with the family. Prior to counseling the family, the clinician should perform a careful assessment of symptoms and recommend exercise stress testing. Exercise testing can measure exercise capacity and evaluate for worrisome findings such as ST-segment changes, rhythm abnormalities, or abnormal BP response with exercise, and has proven value in patients with left-sided heart disease.¹ This is why exercise testing features in the 2020 American Heart Association/American College of Cardiology (AHA/ACC) Guideline for the Management of Patients With Valvular Heart Disease and is recommended for risk stratification for patients with moderate AS in the new 2025 AHA/ACC scientific statement on Clinical Considerations for Competitive Sports Participation for Athletes With CV Abnormalities.^2,3 Identification of worrisome findings on exercise testing would allow for a more tailored discussion of the risk/benefit calculus for this athlete who desires to participate in a higher-intensity competitive sport such as swimming. Therefore, the best next step in this scenario would be to order an exercise stress test.

Per the 2025 AHA/ACC scientific statement, both restriction from participation in swimming and clearance to participate in swimming are premature without obtaining additional exercise data.³ Genetic testing should be pursued in patients who also have physical or clinical signs suggestive of a known genetic syndrome (e.g., Turner syndrome, Loeys-Dietz syndrome, or other CTDs) or who have unexplained aortic dilation. The 2025 AHA/ACC scientific statement defines unexplained aortic dilation as an aortic z score of ≥3.³ The evaluation of patients with unexplained aortic dilation should include a comprehensive multigenerational family history along with imaging screening of parents and genetic evaluation. In this case, BAV was the probable nidus for aortic dilation and additional genetic testing would likely have been low yield.

The 2025 AHA/ACC scientific statement provides a comprehensive update of the 2015 AHA/ACC scientific statement on Eligibility and Disqualification Recommendations for Competitive Athletes With CV Abnormalities.^3,4 The 2025 document covers a wide range of topics, including preparticipation screening and sports clearance recommendations for various CV pathologies. Throughout the document, there is increased emphasis on SDM as an essential component of counseling. A framework of SDM should include an explanation of the diagnosis, discussion of risks and benefits of sports based on the diagnosis, and determination of patient and family wishes and values, followed by issuance of a recommendation to the athlete, who can then make an informed decision.

Per the 2025 AHA/ACC scientific statement, competitive athletes exhibiting mild AS or AI, or mild mitral valve (MV) stenosis or MV insufficiency, can participate in competitive sports.³ For athletes with moderate AS, the 2015 AHA/ACC scientific statement suggested clearance only for low and moderate static exercises or low and moderate dynamic exercises if exercise testing to the level of activity expected in competition has reassuring findings.⁴ Therefore, this document would suggest restricting this patient from swimming (high dynamic component) even if exercise testing had unremarkable findings. However, the 2025 AHA/ACC scientific statement states that, if stress testing has unremarkable results, sports participation is reasonable for asymptomatic patients with moderate AS using a framework of SDM.³ Notably, exercise testing should attempt to replicate conditions of the sport when able rather than aim for achievement of arbitrary heart rate thresholds.⁵ For athletes with severe AS or nonsevere symptomatic AS, the risk of sports participation likely outweighs the benefits, and these athletes may be considered for valvular intervention.

In addition to careful assessment of valve function, competitive athletes with a BAV must also be evaluated for HTAD. When performing the history and reviewing data, they should be assessed for features that could increase risk of dissection, including a family history of aortic dissection, rapid aortic growth (≥3 mm/year), significant coarctation, or findings suggesting HTAD. Historically, cardiologists may have suggested that avoidance of competitive sports could reduce the risk of progressive aortic dilation, but more recent literature has cast doubt on this paradigm.⁶ The 2025 AHA/ACC scientific statement suggests that athletes with BAV and normal aortic dimensions can participate in competitive sports.³ Those with BAV and mild-to-moderate thoracic aorta dilation (40-44 mm) and no additional risk factors for aortic dissection can be considered for sports participation with SDM. Although moderate to severe aortic dilation (≥45 mm) is thought to confer increased risk relative to benefit, sports can still be considered with SDM and expert consultation. Notably, although absolute aortic dimensions are used as a basis for recommendations in the 2025 AHA/ACC scientific statement, this document also acknowledges variations in aortic size according to body size and sex that should be considered when counseling patients and families.

In summary, the 2025 AHA/ACC scientific statement offers a wealth of recommendations for athletes and clinicians to use as a basis for evaluating candidacy for sports. The importance of SDM in counseling athletes is emphasized. Clinicians are encouraged to review these guidelines to become familiar with contemporary recommendations for sports participation in athletes.

References

1. Hollon H, Fernie JC, Rausch C. Serial exercise testing in children with known or suspected congenital and acquired heart disease: a narrative review and survey of current practice. J Am Heart Assoc. 2025;14(8):e038585. doi:10.1161/JAHA.124.038585
2. Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol. 2021 Feb 2;77(4):509. doi: 10.1016/j.jacc.2020.12.040.] [published correction appears in J Am Coll Cardiol. 2021 Mar 9;77(9):1275. doi: 10.1016/j.jacc.2021.02.007.] [published correction appears in J Am Coll Cardiol. 2023 Aug 29;82(9):969. doi: 10.1016/j.jacc.2023.07.010.] [published correction appears in J Am Coll Cardiol. 2024 Oct 29;84(18):1772. doi: 10.1016/j.jacc.2024.09.025.]. J Am Coll Cardiol. 2021;77(4):e25-e197. doi:10.1016/j.jacc.2020.11.018
3. Kim JH, Baggish AL, Levine BD, et al. Clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2025;85(10):1059-1108. doi:10.1016/j.jacc.2024.12.025
4. Maron BJ, Zipes DP, Kovacs RJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles, and general considerations: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2343-2349. doi:10.1016/j.jacc.2015.09.032
5. Churchill TW, Disanto M, Singh TK, et al. Diagnostic yield of customized exercise provocation following routine testing. Am J Cardiol. 2019;123(12):2044-2050. doi:10.1016/j.amjcard.2019.03.027
6. D'Ascenzi F, Cavigli L, Cameli M, et al. Sport practice and its effects on aortic size and valve function in bicuspid aortic valve disease: a cross-sectional report from the SPREAD study. Br J Sports Med. 2024;58(23):1419-1425. Published 2024 Dec 2. doi:10.1136/bjsports-2023-107772