T
he spectrum of congenital malformations of the heart is diverse and ranges from mild
cardiac changes without substantial hemodynamic relevance to severe congenital heart
disease, from cardiac conditions that do not require surgery to severe, inoperable conditions.
Consequently, the physical exercise capability in children with congenital heart conditions
varies widely. In mild, uncomplicated cardiac malformations, exercise capability remains
normal. Where the congenital heart conditions are serious, however, exercise capability is
clearly reduced (1, e1, 2, e2, 3, e3, 4, 5, 6). However, it is not only these children who show
limitations. In some children with mild or completely corrected malformations, reduced
exercise capability is probably predominantly related to overprotection and the resulting
lack of exercise; this can be balanced by suitable exercise training (7). Even doctors often
advise restrictions quite unnecessarily in this setting.
Sports for children covers a wide range of activities that place very different demands on
the body: from swimming for infants, gymnastics for mothers and children, leisure time
play/exercise, sports in schools, sports in clubs, to competitive sports. Thus far, only few,
mostly small, studies have dealt with the effects of sport on children with congenital heart
problems. Without exception, these show the positive effects of sports on psychomotor
development and physical exercise capacity in such children. None of the studies reported
any deterioration of the hemodynamic function and/or increased health risks to the children.
Larger, randomized controlled trials are urgently needed in this area.
This article aims to provide doctors practising in their own practices with information
that might help them assess the exercise capacity of children with cardiovascular conditions
and provide targeted recommendations about their fitness to exercise.
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SUMMARY
Introduction: Children with congenital heart disease (CHD) can participate in sport on an individualized
basis, if their exercise capability is formally tested. Methods:
Selective review of the literature on

into groups by severity. The recommendations given here are based on recommendations
from German and international expert societies (e1, 8, e4, e5, 13) and on longstanding
experience in the treatment, sports advice, and care provided in sports activities for children
with congenital heart disease.
Types of exertion in exercise
Predominantly static exercise can result in very high stress on the systemic and pulmonary
circulations, which can have extreme effects on the hemodynamic function in congenital
heart disease. Acute, malignant arrhythmias can result in sudden cardiac death (e6).
Predominantly dynamic sports activities, however, reduce the afterload in children with
congenital heart disease and can therefore be expected to have a protective effect (14).
Box 1 gives an overview of types of exercise and games in childhood that are associated
predominantly with high dynamic or static exercise.
Little is currently known about the concrete hemodynamic stress that emerges in different
types of activity, e.g., during sports classes. A study conducted in Cologne showed that
during games that entail much running and catching, children's heartbeat rates show high
frequencies (on average 167.8 ± 17.9 beats per minute), which occasionally exceeded the
maximum measurements reached during the exercise tests. The heartbeat frequency was
also high when children started a new type of exercise, but fell the better they mastered the
exercise (15).
Importance of sports for the development of children with congenital
malformations
Children have an elementary need to move. A child's experiences of perception and
movement determine not only its physical and motor development but also crucially influence
its emotional, psychosocial, and cognitive development (16, e7). Heart disease often means
limitations to a child's perceptive and movement-related experiences. Fears and worries for
the ill child often result in the parents adopting an over-protective educational style. Fear
and insecurity prevail in parents as well as in teachers and educators, especially with regard to
a possible risk associated with physical exercise. Doctors often recommend restrictions,
owing to ignorance. By informing and educating parents, doctors, and (sports) teachers,
serious attempts will have to be made to reverse this trend. Children with congenital heart

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BOX 2
Findings after cardiac surgery and/or
interventions
Minor remaining findings (1.2)
– Scar after ventriculotomy
– Incomplete right bundle branch block
– Ventriculotomy-related complete right bundle branch block
– Small residual ventricular septal defect
– Trivial pulmonary (residual) stenosis/insufficiency
– Trivial aortic (residual) stenosis/insufficiency
– Mild mitral insufficiency
– Mild tricuspidal insufficiency
– Supraventricular and ventricular singular extrasystoles
– After surgery for aortic isthmus stenosis without arterial hypertonus
Important remaining findings (1.3)
– Functional impairment of right ventricle
– Right ventricle = system ventricle
– Functional impairment of left ventricle
– Pulmonary (residual) stenosis (❧ p>30 mm Hg)
– Aortic (residual) stenosis (❧ p>30 mm Hg)
– Hemodynamically important AV valvar insufficiencies/stenoses
– Replacement valve (biologic and mechanic)
– Supraventricular tachycardias
– Ventricular tachycardias
– After surgery for aortic isthmus stenosis with arterial hypertonus
TABLE 1

pulmonary insufficiency. It is therefore not sensible to assign a particular degree of physical
exercise capability to certain cardiac defects (8).
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TABLE 2
Group categories of pediatric cardiologic pathologies
Group 0 Patients with hemodynamically important cardiac defects before cardiac
surgery/interventions (including ablations)
Group 1 Patients after cardiac surgery/interventions
(including ablations)
1.1 Without remaining findings (complete correction)
1.2 With minimal findings
1.3 With clinically significant findings
1.4 After palliative interventions:
1.4a With seperation of the circulations (e.g., Fontan procedure)
1.4b Without seperation of the circulations (e.g., aorto-pulmonary shunt operations)
Group 2 Patients with cardiac defects not requiring surgery
2.1 Shunt defects with clinically insignificant left-right shunt
2.2 Clinically insignificant valvar defects/anomalies
2.3 Clinically insignificant cardiac arrthythmias/changes to ECG
2.4 Clinically insignificant myocardial changes
Group 3 Patients with inoperable cardiac defects
Group 4 Patients with chronic myocardial disorders
4.1 Clinically significant
4.2 Clinically insignificant
Group 5 Patients with problematic long term/permanent threapy
5.1 Pacemaker
5.2 Anticoagulants

Patients with long term therapies that are problematic for sports activity – especially
pacemaker implants or anticoagulation treatment – need additional recommendations. In
anticoagulation treatment, patients should not indulge in any sports activities that are prone
to contracting injuries. Pacemaker patients are at risk from having the pacemaker
generator or the pacemaker pocket damaged in contact sports. Extreme stretching of the
arms, as for example in hanging from and swinging on the still rings, may, in an unfavorable
scenario – such as when the reserve loop of the pacemaker lead has been used up owing to
somatic growth – cause the lead to detach.
Patients in category group D – those with severe (remaining) findings (table 3) – show
severe impairments in everyday life owing to cyanosis or cardiac insufficiency. The kind of
exertion and intensity of sportive activity have to be adapted to their impaired exercise
capability.
Patients after heart transplantations are a special group who can be categorized in any of
the groups listed here, depending on their functional status.
A patient will have to be totally banned from sports (table 4) when physical exercise
results in a threat to his/her life. This is mainly the case for patients with pulmonary
hypertension (8). The pressure on the pulmonary circulation can rise during exertion and
result in death. Hypertrophic obstructive cardiomyopathy is an insidious disease. Patients
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TABLE 3
Severity categories of pediatric cardiologic disorders
Severity Category
A No (residual) heart defect 1. 1
B Mild (residual) findings 1.2.; 2.1; 2.2; 2.3; 2.4; 4. 2
C Clinically significant 1.3; 5.1; 5.2; 5.3
(residual) findings
D Severe (residual) findings 1.4a; 1.4b; 3; 4.1; 5.4; (6)

judgment more.
School sports
At primary school, children with congenital heart disease as a rule encounter great
understanding or tolerance for their situation. In secondary schools, problems may arise if
teachers do not find themselves able to concede a special role to such children/adolescents.
They are then not "able to bear the responsibility for the student" and suggest his or her
"release" from sports lessons. Others grade exercises in which a student cannot participate
owing to his or her condition, as "unsatisfactory" (the bottom grade). This increases the
temptation to avoid a poor grade with the help of a doctor's certificate. Teachers in this
scenario should be encouraged to use their own judgment in allocating grades, to make
participation in sports lessons attractive to such chronically ill children (25).
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TABLE 4
Assessing fitness to exercise
Group Severity Category Recommendation for exercise
0 Cardiac defects requiring surgery 0 No sports
A No (remaining) cardiac defects 1.1 Unlimited
B Mild (remaining) findings
1.2; 2.1; 2.2; 2.3; 2.4; 4.2 Unlimited
C Clinically significant (remaining findings) 1.3; 5.1; 5.2; 5.3 No competitive sports
D Severe (remaining) findings 1.4a; 1.4b; 3; 4.1; 5.4; (6) Limited sports
E Vitally threatening findings No sports
Club sports and competitive sports
In considering the pros and cons of club sports it should be remembered that children do not
meet in this setting merely for the purposes of competition. Often, the sharing of experiences
in the club are priority. In such a setting, the recommendation vis-a-vis club sports should
be positive. Competitive or professional sports, however, require a healthy cardiovascular

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Corresponding author
Dr. med. Sabine Schickendantz
Klinik und Poliklinik für Kinderkardiologie
Klinikum der Universität zu Köln
Kerpener Str. 62
50937 Köln, Germany
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