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 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 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, 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 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.