**10. Sport participation**

**8.10. Transcatheter aortic valve implantation**

320 Calcific Aortic Valve Disease

**9. Surveillance**

Transcatheter aortic valve implantation (TAVI) is a novel minimally invasive technique indicated for patients who are contraindicated for cardiac surgery due to associated comor‐ bilities or who have a high risk of perioperative mortality. TAVI is an alternative treatment for patients with valve disease in which a valve replacement is introduced through the femoral artery via a small incision or in some cases, an incision into the chest after which the catheter is inserted into the left ventricular apex, also known as the transapical approach. Other methods include subclavian in which the catheter is inserted beneath the collar bone and direct aortic incision in which the catheter is inserted directly into the aorta via a minimally invasive incision in the chest [120]. Due to the asymmetric anatomy which is observed with BAV disease, the TAVI device could potentially be affected to a noncircular expansion, thus creating an elevated risk of paravalvular leak [121]. Due to this major concern, BAV is considered a contraindication with respect to TAVI. BAV have been overall excluded in all the major TAVI trials in which little clinical experience is now known with regard to TAVI in BAV cases. However, several centres showed acceptable results in selected BAV patients with AS [121-123]. A high risk of suboptimal device seating has been observed in BAV patients with asymmetric valvular anatomy, AR, and bulky leaflets. Whether novel valve designs could

All patients with BAV disease whether AS, AR, operated or not, should receive lifelong serial follow-up depending on symptoms and degree of the functional disorder. Moreover, serial follow-up with imaging assessment with respect to the cardiac and aortic anatomy including valve function, LV function, diameter of both ascending aorta, sinotublular junction, sinuses of Valsvalva and the annulus should be performed in BAV patients regardless the severity of the pathology. TTE is a reliable diagnostic tool to monitor the aortic valve and ascending aorta. However, it should be noted that it is difficult to obtain adequate imaging with the TTE regarding the mid and distal ascending aorta and arch, especially in BAV patients with large

The occurrence of imaging should depend on the size of the aortic root at the initial assessment. If the aortic root is < 40 mm with no clinical symptom alternations, the ascending aorta should be reimaged every 2 years. Whereas, if the aortic root is ≥ 40 mm, it is should be reimaged annually or even more often if progression of the aortic root dilatation is present or whenever a change in clinical symptoms and/or findings occur with echocardiography or MRI [39]. Also of importance, first degree family members of patients with BAV disease should receive echocardiographic screening due to the increased risk of cardiovascular abnormalities [39].

improve TAVI performance in the BAV group, still remains uncertain.

body index, in which MRI or CT scan should be used.

The vast majority of young adults with BAV disease are asymptomatic. Little is known regarding the risks of aortic dissection and sudden cardiac death in young adults with BAV who participate in athletic activity. Also, the severity of the valve pathology and aortic root dilatation in this subgroup of BAV patients influence the clinical decision making with respect to strategy and recommendations for sport activity.

No restrictions are necessary with respect to BAV patients with an athletic lifestyle who present with a mild AS. However, asymptomatic BAV patients with moderate AS can only conduct low-intensity athletic competitive activities. Exercise stress testing is mandatory for BAV patients with moderate AS to detect any additional risk factors including unusual blood pressure during exercise, onset of symptoms during exercise or pathological arrhythmias, which could eventually alter the clinical strategy and recommendations. In addition, BAV patients with symptomatic moderate or severe AS should receive immediate surgical inter‐ vention and should therefore not participate in any form of competitive sport activities upon surgery [124].

BAV patients with mild enlargement of the left ventricular end-diastolic dimension and mild to moderate AR have no restriction in participating in all forms of athletic activity. Also in this case, an exercise stress testing should be performed to estimate the risk. Patients with BAV disease who have a definite LV enlargement of ≥ 60 mm, pulmonary hypertension, or any degree of LV systolic dysfunction at rest should avoid any form of competitive sport activities [124]. BAV patients who underwent an AVR should avoid any form of contact sport.

Also, BAV patients with severe AR and left ventricular end-diastolic diameter > 65 mm should avoid any form of competitive sport activities. This also includes BAV patients with mild-to moderate AR associated with positive symptoms for valve disease [124]. Young adults with uncalcified AS with a peak-to-peak gradient > 50 mm Hg should who play competitive sports are candidates for aortic balloon valvuloplasty [39]. The recommendation for sport activity for BAV patients with respect to dilatation of the proximal aortic root depends on the level of severity the aortic dilatation. BAV patients with an aortic root diameter of 40 to 45 mm should only perform low to moderate intensity sport activity and preferably avoid any form of contact sport. Moreover, BAV patients with an aortic root diameter of > 45 mm are allowed to conduct low-intensity sport activity due to due to the potential risk of aortic root dissection [125].
