Aortopathy: limitations of diameter-based decision-making: a case report

Thoracic aortic aneurysms are often incidental findings that require close follow-up monitoring and eventual surgical or endovascular treatment to prevent life-threatening dissection. Their complex relationship with physical activity requires further research to balance cardiovascular risk reduction against the dangers of acute blood pressure peaks.

A 75-year-old male endurance athlete was evaluated in a sports cardiology clinic to assess the safety of intensive exercise with a known ascending thoracic aortic aneurysm (ATAA). He had adopted an active lifestyle at 65 and completed over thirty 70.3 Ironman races. In 2019, at the age of 75, echocardiography revealed an ATAA measuring 52 mm, along with a bicuspid aortic valve and moderate regurgitation. The patient declined surgery and wished to continue endurance training. After shared decision-making, continued training and racing were allowed under predefined limits for blood pressure and heart rate, with regular imaging surveillance. Over 6 years of follow-up using magnetic resonance imaging, computed tomography, and echocardiography, aneurysm size remained stable, with an aortic wall thickness of 2.5 mm. Based on Laplace's law, the calculated circumferential wall stress stayed below rupture thresholds during exercise. Exercise counselling should consider not only aneurysm diameter but also blood pressure, wall thickness, and wall stress.

In accordance with current guidelines, watchful waiting and a temporary restriction of physical activity are recommended in this case of aortic dilatation. However, because factors such as increased aortic wall thickness may allow for a more favourable distribution of wall stress, an individualized risk assessment can refine these recommendations. In the present case, a shared decision-making approach revealed that controlled physical exertion did not critically increase wall stress and potentially conferred a long-term protective effect against aneurysm progression, underscoring the value of individualized therapeutic strategies.