Bicuspid aortic valve:
follow-up, exercise and daily life

Article written and reviewed by Dr Luca Moretti

Having a bicuspid aortic valve does not mean that surgery is necessary or that exercise must automatically be avoided. Many people lead a normal life, but follow-up is needed because over time the valve may become stenotic or regurgitant and because a bicuspid valve can be associated with dilation of the aortic root or ascending aorta.
Practical management therefore depends on two separate aspects: how the valve functions and the size of the aorta.

For the anatomy, morphological variants and complications of this congenital abnormality, see the monograph on the bicuspid aortic valve. Here the aim is to understand what changes in daily life after the diagnosis.

Which follow-up tests are needed after diagnosis

An echocardiogram is the basic test. It shows whether the valve opens properly, whether stenosis or regurgitation is present, how the left ventricle is functioning and, when technically possible, the dimensions of the aortic root and ascending aorta.
If the aorta cannot be visualized completely or appears dilated, computed tomography or magnetic resonance imaging may be needed. It is important that subsequent measurements are comparable and that aortic growth is assessed over time rather than on the basis of a single isolated number.

The frequency of follow-up is not the same for everyone. A young person with a well-functioning valve and a normal-sized aorta may be reassessed less often than someone with stenosis, regurgitation or aortic dilation. When the aorta reaches dimensions that require surveillance, the interval is determined according to its diameter, rate of growth and other risk factors.

Why the aorta also needs to be monitored

A bicuspid valve does not involve only the valve leaflets. Some patients have an associated aortopathy, with dilation of the aortic root or, more commonly, the ascending aorta. Individual risk depends on the dimensions, rate of growth, family history, presence of aortic coarctation and pattern of dilation.
For this reason, two people with the same bicuspid valve may receive very different recommendations even if their valves function similarly.

Thresholds for aortic surgery should not be interpreted without context. Guidelines consider absolute dimensions, body surface area or height, risk factors and whether the patient already needs valve surgery. In a person who requires valve surgery, less advanced aortic dilation may be treated at the same time if the expected benefit outweighs the additional risk.

Exercise: what you can do and when restrictions are needed

In a person with a bicuspid valve without significant stenosis or regurgitation and without aortic dilation, recommendations for physical activity may be substantially similar to those for someone with a tricuspid aortic valve. There is therefore no general prohibition against running, cycling, swimming or training.
Before intense activity or competitive sports, however, a cardiology assessment that considers the echocardiogram, blood pressure, symptoms and, when indicated, an exercise test is useful.

Restrictions become more important if a dilated aorta or significant valvular heart disease is present. Very high-intensity strength efforts and activities that cause marked blood pressure surges may be discouraged in patients with aortopathy. The appropriate level of activity should be individualized according to aortic diameter, family history of dissection or sudden death and the type of sport practiced.

Relatives, blood pressure and other daily considerations

Bicuspid aortic valve has a familial component. Guidelines recommend assessing first-degree relatives, such as parents, brothers, sisters and children, with echocardiography to look for a bicuspid valve and aortic dilation. This does not mean that every relative will be affected, but screening can identify conditions that may be completely asymptomatic.
If echocardiography does not adequately visualize the aorta, the physician may recommend other imaging tests.

Good control of blood pressure is also important, especially when the aorta is dilated. Smoking, physical inactivity and other cardiovascular risk factors are not consequences of a bicuspid valve, but they should still be managed because they affect overall cardiovascular health.
Antibiotic prophylaxis for endocarditis is not routinely recommended for everyone with a bicuspid valve. The 2023 ESC guidelines classify bicuspid aortic valve among intermediate-risk conditions: oral hygiene and prevention are essential, while possible antibiotic prophylaxis for dental procedures is assessed individually in appropriate cases.

When to seek medical review before the scheduled follow-up

Do not wait until the next appointment if new shortness of breath, a clear reduction in exercise capacity, chest pain, dizziness or syncope develops. These symptoms may indicate progression of valve stenosis or regurgitation and require reassessment.
Sudden, very severe and unusual chest or back pain requires urgent evaluation because, although rare, an acute aortic complication must be ruled out promptly.

A bicuspid valve is therefore a condition that requires long-term follow-up, not a diagnosis that automatically imposes restrictions. The key is to know the status of the valve and the aorta and to adapt follow-up and physical activity to these findings.

Frequently asked questions about bicuspid aortic valve

Is a bicuspid aortic valve dangerous?
Many people remain free of major problems for a long time. It does, however, require follow-up because it can be associated with stenosis, regurgitation and aortic dilation.

Can you exercise?
Often, yes. In the absence of significant valve disease and aortopathy, restrictions may be minimal. If the aorta is dilated or the valve is diseased, the intensity and type of sport should be individualized.

How often should an echocardiogram be performed?
It depends on valve function and aortic dimensions. There is no single interval that is appropriate for everyone.

Should family members be screened?
Yes. Echocardiographic screening of first-degree relatives for a bicuspid valve and aortic dilation is appropriate.

Does a bicuspid valve always require surgery?
No. Intervention is performed when indications arise because of valve function or the aorta, not simply because a bicuspid valve is present.