Bicuspid Aortic Valve and Triathlon Training

author : AMSSM

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Triathlon would be something to discuss further with your cardiologist, as cycling is an activity potentially associated with a high static load on the heart.

Member Question

I found out a couple of years ago that I have a bicuspid aortic valve. This was discovered during routine testing when I turned 50 (I’m now 52). I feel great and have been doing (for me) a lot of training and racing in the last couple of years. In fact I have a streak of four age group wins in my last four races (5km run, Spartan Sprint, Xterra Sprint Tri, Duathlon)!

I have mild leakage of my aortic valve (which I understand is not uncommon, even for people with normal valves). The diameter of the aorta is 4.1cm (4.0 and below is considered normal). I will have testing done yearly to monitor for changes. My cardiologist says I should definitely avoid strenuous weight lifting. However, he is a little vague regarding other types of vigorous exercise. Do you recommend backing off on intensity or duration of training?

Answer from Samuel Schimelpfenig, MD, FAAP
Member AMSSM

First, let’s do a review of the relevant anatomy and physiology of the heart in this particular instance. The aortic valve is what separates the aorta from the left ventricle; blood is forced through this valve into the aorta on its way to the rest of the body every time the heart beats. Normally, the valve is composed of three leaflets that open and then close completely with each cardiac cycle to prevent blood from flowing backwards into the left ventricle (a condition referred to as regurgitation or insufficiency). In the case of a bicuspid aortic valve there are only two leaflets. The two leaflets still function to prevent backflow into the left ventricle, but there are several conditions that can develop over time from this abnormal structure.

One problem is aortic valve insufficiency, as mentioned earlier - this can be thought of as a ‘leaky valve’. Another problem is called aortic valve stenosis - a condition where the valve leaflets become stiff and don’t open as wide as they should. Both of these conditions causes the heart to become less efficient as a pump, making it work harder to pump blood to the body. Eventually that leads to other problems such as heart failure. Dilation of the aorta can also occur with a bicuspid valve, and dilation can lead to dissection – a very serious condition where the layers of the aorta begin to separate from each other. Approximately two percent of the population is born with a bicuspid aortic valve, and the condition is more common in men. It can be completely asymptomatic for many years and is often found on routine testing, as it was in your case, or when signs of cardiac dysfunction begin to develop.

When we make recommendations regarding exercise for someone with a cardiac condition, we often need to consider the problem itself, and the type of stress that a particular activity will place on the cardiovascular system. Some activities cause a large dynamic or endurance type of load on the system (as measured by VO2max), others represent a large static or strength type of load (as measured by the effect on blood pressure), but all sports have components of both. Weightlifting, for example, would be classified as a sport with a high static load, but a low dynamic load. Distance running would be an example of a sport that places a high dynamic load on the heart, but has a low static load. Sports like golf are low in both categories; sports like competitive cycling are high in both categories.

In general, for your condition (a bicuspid aortic valve with mild insufficiency and mild dilation of the aorta) activities such as weight-lifting, that raise your blood pressure by creating a static load on the cardiovascular system, should be avoided. Lower intensity aerobic sports, however, should be well-tolerated. From the activities you describe, the triathlon would be something to discuss further with your cardiologist, as cycling is an activity potentially associated with a high static load on the heart depending on the type of training and intensity you do for that portion of the race. The overall intensity of your training regimen and race participation would be the other thing that you may need to back off of.

I would strongly recommend you discuss the specifics of your training regimen and fitness goals further with your cardiologist so he has an idea of what you do in your race preparation and can make more specific recommendations for you. Other than the information you have described above, there may be other factors he will consider as well. The other thing to mention is that a bicuspid aortic valve is felt to have a genetic etiology so 1^st degree relatives (parents, siblings, and children) should all be screened for this condition as well.

Samuel Schimelpfenig, MD, FAAP
Avera McGreevy Clinic, Sioux Falls SD

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date: November 17, 2014