Editorial
Aortic Root Size in Elite Athletes
When No Change Matters
Lucy M. Safi, DO; Malissa J. Wood, MD
I t is known that sport-specific remodeling of the heart may
occur with exercise. Although some overlap exists, exer-
cise activity can be segregated into 2 forms: isotonic exer-
cise (endurance training) and isometric exercise (strength
training), with defining hemodynamic differences. Increased
cardiac output leads to a volume challenge that occurs with
isotonic exercise that affects all 4 heart chambers and may
cause an increase in left ventricular (LV) mass, biventricular
chamber dilation, biatrial enlargement, and enhanced diastolic
function.1 Conversely, isometric exercise (strength training)
will increase the peripheral vascular resistance and cause
a pressure load on the heart. This results in concentric LV
hypertrophy and reduction in LV diastolic function. Although
an athlete may have expertise in one particular sport, usually
elite athletes train with combined isotonic and isometric com-
ponents (weight training, plyometrics, speed drills, running,
etc.) and may not fit into one specific category of training.
See Article by Boraita et al
There is limited data on the effect of exercise training
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on the aorta and whether aortic dilation occurs because of
the hemodynamic effects of chronic exercise training. One
could hypothesize that with isometric exercise, there is a
transient increase in peripheral vascular resistance and sys-
tolic hypertension that leads to increased aortic wall tension
and chronically may result in aortic dilation. A meta-anal-
ysis performed by Iskandar and Thompson2 showed minor
enlargement associated with training in elite athletes at the
level of the aortic valve annulus and the sinus of Valsalva
compared with controls. The degree of enlargement at the
aortic valve annulus was less than at the level of the sinuses
suggesting that the fibrous skeleton of the heart may have
a protective effect.2 Another study of 100 elite, strength-
trained athletes showed that all levels of the ascending aorta
were greater in size when compared with healthy, age- and
height-matched controls.3 They also found that the duration
of the high-intensity training to be the strongest predictor of
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the Division of Cardiology, Massachusetts General Hospital,
Boston.
Correspondence to Malissa J. Wood, MD, Division of Cardiology,
Massachusetts General Hospital, Yawkey 5, 55 Fruit St, Boston, MA
02114. E-mail MWood@MGH.HARVARD.edu
(Circ Cardiovasc Imaging. 2016;9:e005575.
DOI: 10.1161/CIRCIMAGING.116.005575.)
© 2016 American Heart Association, Inc.
Circ Cardiovasc Imaging is available at
http://circimaging.ahajournals.org
DOI: 10.1161/CIRCIMAGING.116.005575
1
aortic root enlargement. Similarly, in a study of 615 patients,
D’Andrea et al4 found the body surface area (BSA), exercise
type and duration, and LV circumferential end-systolic stress
were independent predictors of the aortic root diameter at all
levels. Although the aorta may be enlarged compared with
controls, it is unclear how and if this minor aortic enlarge-
ment will affect the athlete clinically.
In this issue of Circulation: Cardiovascular Imaging,
Boraita et al5 evaluated 3281 elite athletes and found that only
1.8% of the athletes had dilated aortas (>40 mm in men or 34
mm in women) and also found that age, LV mass, and BSA
were the main predictors of aortic dimensions. These results
are similar to the percent of athletes (elite and nonelite) who
were found to have aortic dilatation in the study by Pellicca
et al6 using similar cut-off values for aortic dilatation. These
findings suggest that ascending aortic dilation in elite athletes
is rare and if found on echocardiogram, work up of underlying
aortopathy should be considered.
The inclusion of male and female athletes is important and
allowed the authors to examine the effect of sex on cardiac
dimensions in their populations. Similar cardiovascular adap-
tations to training occur in men and women; however, unique
adaptations to exercise in women have been described. Both
men and women demonstrate an increase in heart chamber
sizes and muscle mass, and when adjusted for BSA, the find-
ings are not as substantial in women when compared with
men. In this study, 1242 female athletes were included, and
after BSA adjustment, LV end-diastolic diameter and atrial
size remained larger in women compared with men. Similar
findings were seen, albeit on a smaller scale of female patients,
in a longitudinal study published by Baggish et al.7 Sex differ-
ences were also seen in the aortic diameters that were adjusted
for BSA. Larger aortic diameters were found at all levels of
the aorta in men except at the sinotubular junction and the
ascending aorta. These sex differences are intriguing and
potentially implicate a hormonal effect on vascular remodel-
ing in females. Further studies evaluating the hormonal effects
on the aorta in elite female athletes would be an interesting
future investigational study.
A few limitations should be considered in the study by
Boraita et al5 including that it is a cross-sectional study that
comes with its inherent limitations, including the inability
to exclude the possibility that the findings are from innate
changes that may have occurred without training. A longitudi-
nal study design that assesses athletes before and after training
would be more informative, however challenging with such a
large cohort of patients. Given that echocardiographic imag-
ing is mandatory in many European countries, a study exam-
ining serial changes in cardiac dimensions during the course
of years in athletes would be truly original and helpful. In
 2   Safi and Wood   Aortic Root in Athletes: When No Change Matters
this study, the use of the term remodeling is in fact incorrect
because of the absence of data supporting a change in dimen-
sions over time.
There is an ongoing controversy about the technique used
to measure aortic dimensions. The most recent echocardio-
gram guidelines recommend measuring the aortic annulus in
midsystole, where all other ascending aorta measurements
should be performed in end diastole.8 Also, measurements
should be performed from leading edge-to-leading edge pref-
erably using 2-dimensional echocardiography over M-mode
imaging. Boraita et al5 study evaluated patients over a long
time period and inconsistency in the method of measurement
may lead to variability in absolute measurements. The inves-
tigators in this study indexed their measurements to BSA. A
recent investigation by Giraldeau et al9 compared indexing
dimensions and LV mass to BSA and lean body mass mea-
sured by allometry in a group of collegiate athletes. Although
sex differences in mass and volumes were present when
indexed by BSA, with correction by lean body mass there
were no significant sex differences noted.9
It is known that race has an effect on the amount of cardiac
remodeling that occurs with exercise and that black athletes
have more LV hypertrophy than their white counterparts.10,11 In
the study by Boraita et al5, blacks were excluded. Care should
be taken to generalize the findings of this study, specifically the
normal reference ranges of the aorta provided, to all athletes.
Using the reference values for populations who were not stud-
ied may cause misdiagnosis of aortic disease that could limit
exercise and affect the overall quality of life of the athlete.
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The value of this article is that it adds to the abundant body
of literature devoted to imaging the athlete’s heart. It supports
the work of groups where large, heterogeneous groups of male
and female athletes were assessed.12 Cardiac adaptations to
training seem to primarily involve the atria and ventricles.13
Unlike the atria and ventricles, the occurrence of ascending
aortic dilation in elite athletes is rare and if found, work up of
underlying aortopathy should be considered.
The data once again highlight the importance of using a
consistent and structured approach to the assessment of the
athlete’s heart. It is imperative that uniform approach be taken
when interpreting echocardiographic data in athletes and clear
normative, sex-specific indexed data should be readily avail-
able for reference. Such an approach will hopefully improve
sensitivity and specificity of echocardiographic imaging.
Disclosures
None.
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Key Words: Editorials ◼ aorta ◼ athletes ◼ dilatation ◼ vascular remodeling