Risk Stratification, Exercise Prescription, and Sport Participation in Individuals with Aortic Valve Disease

Aortic valve disease (AVD), including bicuspid aortic valve (BAV) and aortic regurgitation (AR), presents a complex challenge in sports cardiology. Balancing the cardiovascular benefits of physical activity with the hemodynamic risks associated with valvular dysfunction and aortopathy requires precise risk stratification. The present review comprehensively analyses the contemporary criteria for exercise prescription and competitive sports participation in individuals with AVD, highlighting also the distinctions between the European guidelines (European Society of Cardiology—ESC), the Italian Sports Cardiology Guidelines for competitive sport practice (COCIS 2023) and the recommendations for exercise prescription in cardiovascular diseases promoted by the Italian Sports Cardiology Society (SIC Sport) and the Italian Federation for Sports Medicine (FMSI). Relevant differences with the 2025 AHA/ACC recommendations are also highlighted where they may influence sports eligibility. Eligibility hinges primarily on the degree of valvular defect, left ventricular ejection fraction (LVEF), and aortic dimensions. Furthermore, post-operative sports participation is highly contingent on the intervention type, post-operative results and follow-up. Ultimately, safe exercise prescription relies on meticulous clinical surveillance, advanced imaging, maximal stress testing, and a shared decision-making process to maximize cardiovascular health while mitigating the risk of acute adverse events.