Differentiating Cardiac (Mal)adaptation in 2 Athletes With Bicuspid Aortic Valves.

backgroundDistinguishing left ventricular (LV) remodeling due to early decompensation from chronic aortic regurgitation (AR) from physiologic adaptation to intensive endurance training is challenging. CASE SUMMARY: Two elite endurance athletes (and best friends) presented with bicuspid aortic valves complicated by moderate AR and marked LV remodeling. Despite near-identical valvular findings, LV volumes, and exceptional cardiorespiratory fitness at baseline, their clinical courses diverged. One developed exertional symptoms and underwent a Ross procedure, followed by rapid and profound reverse remodeling. The other remained asymptomatic with stable LV dimensions and supranormal exercise capacity on serial follow-up. Exercise imaging in the conservatively managed athlete demonstrated preserved contractile reserve and reduced AR during stress, consistent with compensated physiology. TAKE-HOME MESSAGE: These contrasting trajectories highlight the value of serial, multimodality assessment-integrating symptoms, imaging, stress testing and cardiopulmonary exercise testing-to distinguish physiologic from maladaptive volume overload and to guide timing of intervention in athletes with AR.