ABC | Volume 112, Nº3, March 2019

Updated The Brazilian Society of Cardiology and Brazilian Society of Exercise and Sports Medicine Updated Guidelines for Sports and Exercise Cardiology - 2019 Arq Bras Cardiol. 2019; 112(3):326-368 cannot be estimated/determined non-invasively, right cardiac catheterization is used for such evaluation. “Physiological” tricuspid regurgitation can be detected by echocardiography in approximately 80% of healthy athletes and does not imply any structural valve abnormality. 231 6.3.5.1. Recommendations Athletes with primary tricuspid regurgitation, regardless of severity, and normal RV function, in the absence of right atrial pressure > 20 mmHg or elevated RV systolic pressure, may participate in any competitive sport. 6.3.6. Multivalvular Heart Disease Multivalvular heart disease, a combination of stenotic and/ or regurgitant lesions of two or more heart valves, is a highly prevalent clinical condition among patients with valvular heart disease. It occurrence is mainly due to rheumatic heart disease, although the incidence of this etiological factor has decreased dramatically in the last five decades. 250 Myxomatous valvulopathy and infective endocarditis are also associated with multivalvular disease. Diagnosis is through physical examination, echocardiogram (the main imaging mode for diagnosis and follow-up), and sometimes cardiac/ coronary angiography. 6.3.6.1. Recommendations The cumulative effects of multiple significant valve lesions on an individual’s physiological response to exercise may be difficult to predict, and multiple moderate lesions may also have physiological effects on the somatosensory system. Generally speaking, athletes with moderate-to- severe multivalvular disease should not participate in competitive sports. 6.4. Sports after Valve Surgery Although much progress has been made in cardiac surgery, mortality after valve replacement is still higher than that of the general population of the same age group. Mechanical heart valve prosthesis requires anticoagulant therapy and transvalvular gradients of varying degrees, which could be exacerbated by exercise. Thus, for athletes who have had a valve replacement, such factors determine their adequacy for competitive sports. 251 An exercise stress testing or CPET involving at least at the activity level achieved during training and competition is of great value for analyzing the functional capacity of the athletes who have undergone valve replacement/repair. 6.4.1. Recommendations and Evidence Level Athletes with an aortic or mitral bioprosthesis who are not on anticoagulant therapy and have normal LV ejection fraction and valvular function may participate in competitive sports (class IA, IB, IC and IIA). Athletes with an aortic or mitral mechanical heart valve prosthesis who are undergoing anticoagulant therapy and have normal LV ejection fraction and valvar function may participate in competitive sports (class IA, IB and IIA) if there is no risk of collision/trauma. Athletes who have undergone successful mitral balloon valvuloplasty or surgical commissurotomy may participate in competitive sports based on the severity of their residual mitral regurgitation or aortic stenosis and their pulmonary arterial pressure during rest and exercise. Athletes who have undergone mitral valve surgery to correct mitral regurgitation or aortic valve repair, having no residual or moderate mitral regurgitation and having normal LV ejection fraction, may participate in sports (class IA, IB and IIA), but only at the discretion of the attending physician and if there is no risk of collision/trauma. Recommendation grade: IIa. Evidence level: C. 6.4.2. Transcatheter Aortic Valve Implantation Transcatheter aortic valve implantation is a minimally invasive percutaneous procedure that was performed for the first time in 2002. It is considered the gold standard for patients with aortic stenosis who are at high surgical risk, especially older adults. 252 Since these patients often have low functional capacity, therapeutic exercise intervention can improve their physical integrity and performance in activities of daily living. Several recent studies have confirmed the benefits of exercise in patients who have undergone transcatheter aortic valve implantation. They are unanimous in reporting improved functional capacity (as measured by CPET or the 6-minute walk test). 253-256 Altisent et al., 257 in a 4-year follow-up, found that an increase < 20% in the 6-minute walk test 6 months after the procedure correlates with an all-cause mortality of 65%. Therefore, exercise increases the functional capacity of these individuals, improving prognosis and quality of life. It should be pointed out that we are not aware of any studies on athletes who have undergone transcatheter aortic valve implantation. 7. Athlete’s Heart Syndrome in Women 7.1. Introduction Since the passage of Title IX in 1972, women’s participation in sports has increased dramatically. During the 2014-2015 school year, approximately 8 million United State. high school students participated in sports, over 40% of whomwere girls. 258 Female athletes have been historically underrepresented in research that has guided exercise and sports cardiology. However, in the last three decades there has been an exponential increase in the number of women participating in competitive sports. Thus, female gender should be considered an important biological variable in this context. As in men, the body of female athletes also undergoes physiological adaptations to physical training and may present structural and electrical changes compatible with athlete’s heart syndrome. Such adaptations can occur in all athletes, but their magnitude depends on several factors, including gender. There are anthropometric, physiological 353