Don’t Play If….Part 2: Heart Valve Problems

This is the 2nd part in a series of blog posts that I’m devoting to the issue of “continued participation” for athletes who discover they have a heart condition of some sort. In the 1st part, I outlined a scheme to classify the various sports based upon their degrees of static or dynamic intensity. Today, I’m going to cover some of the common heart valve problems that athletes might encounter….and offer some thoughts about how these conditions impact “continued participation.” Just as in part 1, I’m drawing on the opinions from a consensus report, the 36th Bethesda Conference, that was formulated by a variety of medical experts who met in 2004 to review all of the accululated evidence in this area.

Let’s recall that there are 4 valves in the heart–2 each on the left and right sides of the heart. These valves are there to keep blood moving in 1 direction only. No backing up of blood, ordinarily. On the right side of the heart, the tricuspid valve is between the upper chamber (atrium) and lower chamber (ventricle) and the pulmonary valve is at the exit from the right ventricle. On the left side of the heart, the mitral valve is between the atrium and ventricle and the aortic valve is at the exit from the left ventricle (into the aorta, the blood vessel that carries blood to the rest of the body).

A variety of valve problems is possible, but they come in just 2 sorts: narrowing (that we call stenosis) or leaking (that we call regurgitation). Either of those sorts of problem makes the heart (as a pump) less efficient as it does its job. And, as you can imagine, these problems come in degrees that we could call mild, moderate, or severe.

By far, athletes are affected by problems of the valves on the left side of the heart–the mitral and aortic valves. Those are the problems that we’ll discuss here today.

Mitral Stenosis

Mitral stenosis is usually due to rheumatic disease and produces problems with breathing or arrhythmias. The severity of mitral stenosis is determined by echocardiogram, where the orifice area of the valve can be measured: mild (>1.5 cm2), moderate (1.0 – 1.5 cm2), or severe (less than 1.0 cm2).

1. Mild mitral stenosis. Athletes can participate in all sports.

2. Moderate mitral stenosis. Athletes can participate in low-moderate dynamic or low-moderate static sports.

3. Severe mitral stenosis. Athletes should not participate in any competitive sports.

4. For athletes with mitral stenosis AND arrhythmias, different recommendations may apply.

5. Athletes with mitral stenosis who are taking anticoagulants (blood thinners) because of arrhythmias should avoid sports where bodily contact injuries are possible.

Mitral Regurgitation

Mitral regurgitation can be due to many different causes. Over time, the left ventricle (pumping chamber) may enlarge to compensate for this problem. The severity of mitral regurgitation is determined by echocardiogram subjectively as mild, moderate, or severe.

1. Athletes with mild to moderate mitral regurgitation and no other heart problems may participate in all sports.

2. Athletes with mild to moderate mitral regurgitation and mild left ventricular enlargement may participate in low-moderate static or low-moderate-high dynamic sports.

3. Athletes with severe mitral regurgitation and left ventricular enlargement should not participate in any sports.

4. Athletes with mitral regurgitation who are taking anticoagulants (blood thinners) because of arrhythmias should avoid sports with a high risk of bodily contact injury.

Mitral Valve Prolapse

The frequency of mitral valve prolapse in the general population is 2% to 3%. Athletes with MVP can participate in all sports if they don’t also have:

1. History of syncope (blacking out)

2. History of arrhythmias

3. Mitral regurgitation

4. Weakened pumping of the left ventricle

5. History of stroke

6. Family history of MVP-related sudden death.

Athletes who have any of these features should participate only in low intensity sports or have a detailed discussion with their physician about continued participation.


Aortic Stenosis

Aortic stenosis, or narrowing of the aortic valve, produces symptoms of shortness of breath, syncope (blacking out), or chest pain, but these symptoms occur late in the course of this disease. Aortic stenosis may be suspected based on the presence of a characteristic heart murmur on physical examination. Echocardiography is used to classify aortic stenosis according to the valve orifice area: mild (>1.5 cm2), moderate (1.0 – 1.5 cm2), or severe (less than 1.0 cm2).

1. Athletes with mild aortic stenosis may participate in all sports.

2. Athletes with moderate aortic stenosis who have NO symptoms may participate in low intensity sports. Special exercise testing may be used to identify some such athletes who may safely participate in moderate intensity sports.

3. Athletes with severe aortic stenosis and those with moderate aortic stenosis who have symptoms should not participate in any competitive sports.

Aortic Regurgitation

Aortic regurgitation may be due to a variety of causes. Over time, the left ventricle enlarges and pumps less effectively. Echocardiography is used to classify the degree of regurgitation subjectively as mild, moderate, or severe.

1. Athletes with mild to moderate aortic regurgitation, no symptoms, and no other heart problems may participate in all sports.

2. Athletes with severe aortic regurgitation and left ventricular enlargement OR those with moderate aortic regurgitation who have symptoms should not participate in any sports.

3. Athletes with aortic regurgitation and enlargement of the ascending aorta (the blood vessel that carries bloodflow away from the heart) should participate in only low intensity sports.

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  1. says

    Thank you indeed for posting these details. (A pity about all the spam.)

    Have just been diagnosed with AR, I cannot bear the thought of life without sport. You give me some confidence to switch to a lower intensity but continue.

  2. Clarence dale Wilcock says

    Hi Dr.,
    What a great fantastic service you offer here. I have aortic insufficiency I am told it is now severe (it moved from mild to medium then severe over a ten-year period0 but still no symptoms. I participate in tennis and lap swimming, mild calisthenics and push ups and pull-ups etc. Stretching, mild weightlifting, walking biking jogging, racewalking etc, but I seldom to never push myself more than medium hard. I will be seeing my doctor in just a few days how do I pull from him all the information I need to know exactly my situation? In other words what specific questions and medical lingo do I need to ask him for? Or can I get a copy maybe from him of my exact present diagnosis?

    • Larry Creswell, MD says

      Many patients who have severe aortic regurgitation need valve replacement, which is usually recommended if there is any indication the heart is not tolerating the valve leakage well (eg, enlargement of ventricle, reduced heart function).

      Athletes with severe aortic regurgitation who do not get valve replacement should have a detailed conversation with their cardiologist about what forms of exercise are safe.

  3. Linda says

    Thanks for this information. I was diagnosed with mild-moderate AR two days ago. I am a masters athlete training for dragon boat world champs in April. I have had a few episodes of shortness of breath after intense training sets. I have yet to see a cardiologist and hope I won’t have to argue my case in order to continue with my training regime. Left ventricle is normal.

    • Larry Creswell, MD says

      Good luck with your upcoming cardiology visit.

      It will be important to ask about the safety of any planned exercise. Be prepared to describe the physical demands of dragon boat competition so that your doctor understands.

  4. Jason says

    Hello. I’m 38, male, run about 3 times a week and do p90x on the other days. I weigh 194 and am 5’11. I recently had a transthoracic echo report out of concern for a hx if splinter hemmorages. The impression yielded: rhythm-sinus bradycardia, mild biatrial enlargement, normal lv wall thickness, normal lv 60-65% and rv sys function. Trace mr, tr, and pr. Should I be concerned? I’ve been pretty active my whole life and have good endurance. I also have had strep several years ago abs did not start treating w antibiotics until about 4 days of high fever. I don’t know if this is a result of being active or a serious medical condition. Thank you in advance sir!

    • Larry Creswell, MD says

      Not sure about the splinter hemorrhages. Your doctor would be in a better position to comment on a possible cause.

      Regarding trace valve regurgitation….we don’t ordinarily restrict activities for athletes with only minor valve regurgitation.

  5. Ardi says

    i had an echo stress today. and my doc say i have 18% mitral regurgitation and respiratory arrhythmias.. i ask him for exercises and he say i can do all the sport i want. its safe for me to exercise? thank you Dr. Larry

    • Larry Creswell, MD says

      I would suggest that you follow your doctors’ advice. They will be in the best position to offer advice.

      That said, mild mitral regurgitation or minor changes with respiration, in the absence of other problems, wouldn’t be a reason to restrict activities.

  6. Bryan Ford says

    I had an echocardiogram done a few days ago. The results are as follows; Nonrheumatic mitral (valve) insufficiency; Rheumatic tricuspid insufficiency; Nonrheumatic aortic (valve) insufficiency; Atherosclerosis of aorta. I’m a triathlete and am supposed to be racing 140.6 miles in less than 6 weeks. I can’t get in to see a cardiologist before race day. Is it safe for me to continue training and race in 6 weeks?

  7. Brenda says

    Dr. Creswell,
    I have mild regurgitation in my aortic, mitral, and tricuspid valves with left ventricle enlargement. I have been training for a half-Ironman when symptoms started triggering my recent visit to cardiologist. The cardiologist is not concerned whatsoever and told me I can still train and race. I’m not feeling confident with that but he’s the cardiologist not me. I imagine a second-opinion would be valuable. I’m in Michigan, do you know any cardiologists who specialize in working with athletes?

  8. lanan says

    Hi, thanks for the great work. Am 36yrs was diagonised with mild mitral regurgitation but since then no sypmtoms .My question is am experiencing some mild pain in my left arm which radiates from shoulder down to the ankles ,now i want to knw whether its related to the heart condition coz wen i went to see the cardic he told me leakage is soo small cause the discomfort. If not the cause wat is the underlying problem

    • Larry Creswell, MD says

      There are obviously many potential causes of arm pain. Your doctor(s) would need to look I to the possibilities.

  9. says


    I am just writing and want to know something. I am 30 years old guy and discovered that I am born with bicuspid valve disease. I am more concern about my health and I love fitness program. These are part of my life. Before, I was doing gym, since doctor told me not to lift heavy weights I left gym but I wanna be active in my daily life, that’s why I am currently doing p90x program. Since -p90x states that it is a extreme fitness program , my question is should I be doing it or should I stop it?

  10. Elizabeth says

    Hi Dr. Creswell

    I ran across your blog on heart conditions in athletes and their participation in sports.

    My son is 15 year old and was just diagnosed with an isolated cleft mitral valve and moderate MR. The left chamber of the heart is showing just slight enlargement. He is a competitive athlete, playing both high school football and baseball. In fact, this situation was only discovered when his HS football coach arranged for a non-profit foundation and Baylor Hospital to provide free baseline cardiac screening for players. While the testing is looking for athletes who are at risk for SCA, I am told my son’s condition does not fall into that category. Learning that he has this malformation of the mitral valve was simply a benefit of participating in the screening.

    We immediately secured an appt. with a pediatric cardiologist at Childrens Medical/UT Southwestern in Dallas (we reside in a suburb about 30 miles north of the city). After a 2 hour echo and additional input from surgeon, their recommended course of action is to stop all sports and proceed with valve repair through open heart surgery. They predict he can likely make a full recovery and return to both football and baseball.

    After this news we had the images sent to Cook Children’s Hospital in Ft. Worth for input. After reviewing his echo, they conclude that monitoring for increase in MR and enlargement, while continuing to play sports, as the course of action. That recommendation hinges on him passing a stress test. We are scheduled for the test next week.

    Do you have any research/studies/data on ICMV with moderate MR and even more specifically the progression of the MR in athletes with ICMV? We realize we will have to do the surgery at some point, but we are trying to understand if we should do it now or wait until he becomes symptomatic. Should we wait, we want to make sure we know all of the risks. Any input you can provide is greatly appreciated.

    • Larry Creswell, MD says

      I can’t put my fingers on any research that is specific to the question you raise.

      That said, there can sometimes be legitimate differences of opinion about how to handle a particular situation. And in the end, parents have to take the advice that’s been provided and settle on a course of action that seems best.

    • Jeanne says

      My son at 14 was recently diagnosed with the same thing. Our cardiologist said to stay the course as my son plays travel soccer and rugby. Only limitation was in certain types of lifting.

      Would love to find a way to tie off with you as we have a yearly check up coming and he is hoping to play football in high school this fall.

  11. Eli says

    I am a 46 year old woman and an echo just confirmed MR (dr had heard murmur during annual that she had never noticed before so she ordered the ultrasound). I run 40 or so miles a week and have had no symptoms, bp is great, low pulse rate, no fatigue, etc. I kicked it up this summer in hot and humid TN to prepare for a fall ultra doing 3-4 hour trail runs. Is it possible the intense running this summer could have brought the MR on? How does this just show up and can it go away? Am waiting for follow up from cardiologist, but assuming I remain completely asymptomatic, is it silly to keep running or is it reasonable? I can’t imagine stopping but don’t want to be dumb about it. Can running make a mild case go to a more severe case and/or is that just something that is bound to happen over time anyway? Could not running help MR clear up? I will obviously follow my doctor’s advice but know I’ll still have questions.
    Thanks! Enjoyed listening to you on science of ultra podcast!

    • Larry Creswell, MD says

      Great questions, Eli.

      Running probably doesn’t cause MR. For most people, MR creeps up gradually over time. For some people, a portion of the mitral valve can “break” suddenly and cause MR.

      We generally don’t restrict the activities for athletes with mild degrees of MR. For most such athletes, exercise is unlikely to make it worse.

      Glad you enjoyed the podcast!

  12. Simon Fox says

    Hi, thanks for this – it’s tough to find good resources regarding exercise and these conditions.

    I’m a 30 yr old man who has previously been very active, though recently in a fallow period. Was diagnosed with a bicuspid aortic valve and mild/moderate regurgitation. I’ve had conflicting advice from cardiologists ranging from ‘don’t lift weights/rock climb/train for a marathon’ to ‘most people never notice this condition live your life as normal’.

    The complicating issue here is anxiety. I experience chronic anxiety with sometimes extreme physical symptoms. Recently I experience dizziness, shortness of breath, chest pain and palpitations (ectopic beats). I’ve been seen by a doctor since the appearance of these symptoms, echo done recently and so on. I’m having a lot of trouble gaining confidence in my ability to exercise and it feels as though my physical ability is greatly compromised.

    Any advice on how to proceed? What kind of support I should seek to gain confidence?


    • Larry Creswell, MD says

      Terrific question, Simon. I wonder if your cardiologists could get you enrolled in a cardiac rehab program. These programs allow monitored exercise (eg, treadmill, exercise bike) while somebody keeps an eye on your heart rhythm. This could build up your endurance AND your confidence that exercise can be safe.

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