Elite athletes have larger absolute aortic sinus of Valsalva diameters than non-athlete healthy controls

AIMS: To assess the presence and the extent of an 'aortic remodelling' in elite athletes. METHODS AND RESULTS: A systematic review and meta-analysis of literature were conducted for studies (1981-2024) reporting echocardiographic aortic diameters of elite athletes compared with non-athlete healthy controls. Among the 5494 studies retrieved, 21 (9464 elite athletes vs. 2637 non-athlete controls) fulfilled all eligibility criteria. Data were aggregated using a random-effects model for estimating the pooled risk ratio and mean difference (MD). Absolute aortic diameters at the sinus of Valsalva (AoSV) were higher in overall elite athletes compared with non-athlete healthy controls {MD 1.69 [95% confidence interval (CI) 1.01-2.37] mm; P < 0.001} and if stratified to sex. This difference was maintained if AoSV was indexed to height (AoSV/h) [MD 0.04 (95% CI -0.00-0.08) mm/m; effect size 2.18 (95% CI 1.10-3.26); P < 0.001]. The analysis of AoSV/h according to sex was not performed for the paucity of studies. However, when indexed to body surface area (AoSV/BSA), no differences were found between the two groups [MD 0.04 (95% CI -0.25-0.34) mm/m2; P = 0.880], also according to sex. Above findings were not influenced by age. CONCLUSION: Absolute AoSV was mildly larger in athletes compared with non-athlete healthy controls, even when indexed to height. However, no differences were evident when indexed by BSA, irrespective of sex, type of sport, and age. Therefore, assessment of the aortic size in elite athletes should consider the proper normalization in order to avoid misdiagnosis of aortopathies. REGISTRATION: PROSPERO: CRD42024561255. LAY SUMMARY: Aortic diameters evaluation in athletes represents an important topic in cardiology and the knowledge about the aortic remodelling driven by intense exercise would allow for the correct management of athletes by differentiating those with pathologic enlargement from those with physiologic adaptation.This comprehensive meta-analysis highlights mildly larger absolute aortic diameters at the sinus of Valsalva diameters in elite athletes compared with non-athlete healthy controls, even when indexed to height. However, no differences were evident when indexed by body surface area, irrespective of sex, type of sport, and age.Assessment of the aortic size in elite athletes should consider the proper normalization in order to avoid misdiagnosis of aortopathies.