Bicuspid aortic valve (BAV) is the most common congenital heart disease in adults and is associated with progressive dilation of the ascending aorta. Traditionally, diameters ≥4.0 cm have led to restrictive recommendations regarding physical exercise, particularly for activities with a high dynamic or static component.

These recommendations are based on plausible pathophysiological considerations, such as transient increases in blood pressure and wall stress, but are supported by limited robust empirical evidence. At the same time, regular exercise is a well-established intervention with cardiovascular, metabolic, and psychological benefits.

In this context, the study by Saleh and colleagues provides relevant longitudinal data on the safety of exercise in patients with BAV and aortic dilation, an area that until now has been shaped more by caution than by evidence.

A prospective cohort of 124 patients with bicuspid aortic valve and aortic dilation ≥4.0 cm without previous intervention was analyzed (mean age 46.9 ± 11.8 years; 78% male), with a median follow-up of 8.8 years. Participants were classified according to exercise intensity and duration into 2 groups: higher intensity/duration (≥4 h/week of activities with a high dynamic or static component; 56.5% of the cohort) and lower intensity/duration. Sensitivity analyses were performed using a threshold of 2 h/week, together with a subanalysis in patients with an indexed diameter ≥2.5 cm/m.

No significant differences were observed in the annual rate of aortic growth at the sinus of Valsalva, sinotubular junction, midascending aorta, or proximal arch between the 2 groups (approximately 0.15-0.27 mm/year depending on the segment). In multivariable models, the main determinant of final diameter was baseline size (p < .001), whereas exercise intensity showed no independent association with progression of dilation. No episodes of acute aortic syndrome occurred during follow-up.

The authors conclude that higher-intensity and longer-duration exercise is not associated with accelerated progression of aortic dilation in patients with bicuspid aortic valve and established dilation, suggesting that current restrictions should be reconsidered.

COMMENTARY:

The central finding is compelling: in a cohort followed for nearly 9 years, more intense exercise was not associated with greater aortic growth or with acute events. Annual growth rates were low in both groups and were clinically overlapping, remaining within tenths of a millimeter per year according to the segment analyzed.

In addition, no patient developed dissection or acute aortic syndrome. Even the need for elective surgery was comparable between groups. From the cardiovascular surgeon’s perspective, this is particularly relevant: if exercise were a clinically meaningful trigger, cumulative differences would be expected over the course of almost a decade.

Another important point is that baseline diameter was the main predictor of final diameter. This reinforces a well-known concept: the initial anatomic substrate carries more weight than behavioral factors in the structural evolution of the aorta in BAV.

The study addresses a common question in daily practice: “Can I keep running or lifting weights?” Until now, the answer has usually been conservative.

From a pathophysiological standpoint, concern has focused on hypertensive peaks and Valsalva maneuvers. However, this study suggests that repeated exposure to structured exercise does not translate into meaningful acceleration of aortic remodeling.

It is noteworthy that some models showed a statistical interaction between time and exercise at the sinus of Valsalva, although the magnitude was small and this was not confirmed after indexation to height. This indicates that even when differences are detected, their clinical relevance appears limited.

The study is consistent with previous literature showing a low absolute risk of dissection in BAV and with work in other aortopathies suggesting possible beneficial effects of moderate exercise on aortic wall biology.

From a practical standpoint, the message is not that “anything goes,” but rather that systematic prohibition may not be justified in well-controlled and well-monitored patients.

The study has limitations that should temper interpretation of its results: this was a nonrandomized design, in which exercise intensity depended on patient behavior and residual confounding may exist; physical activity was self-reported, introducing potential recall and classification bias; the sample size was moderate and derived from a single center, which limits generalizability; no objective measurements of hemodynamic load during exercise were available; and the expected number of events was low, given the infrequency of dissection in BAV, preventing exclusion of small increases in risk. In addition, the impact of predominantly dynamic vs static exercise was not analyzed separately, an issue of particular relevance in sports practice.

This work compels us to rethink a historically restrictive approach based more on physiological hypotheses than on longitudinal evidence.

In clinical practice, many young patients with BAV experience a substantial reduction in quality of life because of the limitations imposed on them. Exercise improves not only traditional cardiovascular parameters, but also blood pressure control, bone mass, body composition, and mental health.

From clinical experience, one of the most frequent questions in the outpatient setting is whether the patient can perform weight training. The answer can hardly be categorical. In my view, the key is to move away from a blanket prohibition toward truly individualized exercise prescription. Sedentary behavior is not neutral; it carries a real cardiovascular risk and, in some profiles, may even be greater than the theoretical risk we are trying to avoid with excessive restrictions. I am not in favor of saying “no weights ever,” but neither do I think high-load training should be trivialized. Recommendations should be based on aortic diameter, its rate of growth, and the specific way the patient trains—avoiding uncontrolled maximal efforts and prioritizing submaximal loads with appropriate supervision. In this setting, rather than prohibiting, we should accompany and monitor.

What probably does not change is the surgical indication based on diameter and growth rate. What may change, however, is the tone of the conversation with the patient: moving from preventive prohibition to responsible guidance.

Ultimately, this study does not eliminate the need for caution, but it does challenge excessive conservatism. And in preventive medicine, that is a meaningful paradigm shift