Differentiating Cardiac (Mal)adaptation in 2 Athletes With Bicuspid Aortic Valves

Distinguishing left ventricular (LV) remodeling due to early decompensation from chronic aortic regurgitation (AR) from physiologic adaptation to intensive endurance training is challenging.

Two elite endurance athletes (and best friends) presented with bicuspid aortic valves complicated by moderate AR and marked LV remodeling. Despite near-identical valvular findings, LV volumes, and exceptional cardiorespiratory fitness at baseline, their clinical courses diverged. One developed exertional symptoms and underwent a Ross procedure, followed by rapid and profound reverse remodeling. The other remained asymptomatic with stable LV dimensions and supranormal exercise capacity on serial follow-up. Exercise imaging in the conservatively managed athlete demonstrated preserved contractile reserve and reduced AR during stress, consistent with compensated physiology.

These contrasting trajectories highlight the value of serial, multimodality assessment-integrating symptoms, imaging, stress testing and cardiopulmonary exercise testing-to distinguish physiologic from maladaptive volume overload and to guide timing of intervention in athletes with AR.