Working Diagnosis:
Normal variant with incidental finding of aortic root dilation

Treatment:
Patient followed a graduated return to play protocol and strenuous weightlifting was restricted.

Outcome:
The athlete developed chest pain and participation was stopped until after workup. He was started on a proton pump inhibitor and returned to play in a monitored home game environment. The athlete will repeat echocardiogram and follow-up with cardiology every 6-12 months.

Author's Comments:
Genetic testing for hereditary aortopathy was recommended. The absolute risk of dissection in asymptomatic athletes with moderate aortic dilation, no history of connective tissue disorder or genetic aortopathy is unknown. Based on a z-score of 2.59-2.98, the AHA/ACC 2015 Guidelines recommend close monitoring with regular imaging to assess for progression; participation in athletic activity may be considered. This asymptomatic patient was identified because of return to sport testing following COVID-19 infection highlighting some of the downstream effects of increased cardiac testing during the global pandemic and contributing to the discussion of universal cardiac testing in select groups.

Editor's Comments:
Return to play (RTP) in athletes following COVID-19 infection is a rapidly developing discussion among experts. Initial consensus statements by ACC had previously recommended triad testing (ECG, echo, troponin) be part of RTP screening for all competitive athletes with symptoms. However, the most recent 2022 ACC Expert Consensus Decision Pathway indicated that only patients who have increased suspicion of cardiac involvement, defined as chest pain/pressure, dyspnea, palpitations, and syncope, to undergo testing. This recommendation stems from recent data from registries pointing to a low prevalence of clinical myocarditis among competitive athletes with COVID-19.

In regards to this athlete with an aortic root dilation of 40mm, it is unlikely to represent normal physiological consequence of exercise training and more likely due to a pathological condition needing close clinical surveillance. An 8 year follow up study on athletes with aortic root dilation showed significant increases during midlife with 20% of this group progressing a need for prophylactic surgical treatment.

References:
1. Gluckman, T. J., Bhave, N. M., Allen, L. A., Chung, E. H., Spatz, E. S., Ammirati, E., Baggish, A. L., Bozkurt, B., Cornwell, W. K., Harmon, K. G., Kim, J. H., Lala, A., Levine, B. D., Martinez, M. W., Onuma, O., Phelan, D., Puntmann, V. O., Rajpal, S., Taub, P. R., & Verma, A. K. (2022). 2022 ACC expert consensus decision pathway on cardiovascular sequelae of covid-19 in adults: Myocarditis and other myocardial involvement, post-acute sequelae of SARS-COV-2 infection, and return to play. Journal of the American College of Cardiology, 79(17), 1717-1756. https://doi.org/10.1016/j.jacc.2022.02.003
2. Pelliccia, A., Di Paolo, F. M., De Blasiis, E., Quattrini, F. M., Pisicchio, C., Guerra, E., Culasso, F., & Maron, B. J. (2010). Prevalence and clinical significance of aortic root dilation in highly trained competitive athletes. Circulation, 122(7), 698-706. https://doi.org/10.1161/circulationaha.109.901074

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