Tài liệu Sport and Physical Activity in Children with Congenital Heart Disease ppt

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

sport in children with CHD, and analysis of the authors' own findings. Results:
Few studies have
addressed the effects of regular sporting activities on children with CHD. The available literature
confirms that regular sport has a positive effect on exercise capacity and psychomotor development
in this group of children, without any negative hemodynamic effects or additional risks.
Discussion:
The current internationally accepted recommendations on physical activity and sport
for children with CHD are almost entirely based on diagnosis. It may however be more appropriate
to classify children in terms of their current hemodynamic status. Children have a basic need for
physical activity which is an integral aspect of normal somatic, motor, emotional, psychosocial and
cognitive development. The majority of children with CHD following corrective surgery or definitive
palliation may participate in normal sporting activities in an unrestricted fashion. Recommendations
concerning sport should also be based on a hemodynamic classification, taking into account the
nature of the condition, disease severity, and potential risks. Dtsch Arztebl 2007; 104(9): A 563–9.
Key words: congenital heart disease, psycho-motor development, physical activity, physical
performance
Klinik und Poliklinik für Kinderkardiologie, Klinikum der Universität zu Köln (Dr. med. Schickendantz); Psychologisches Institut,
Universität zu Köln (PD Dr. phil. Sticker ); Institut für Schulsport und Schulentwicklung,Deutsche Sporthochschule Köln (Dr. rer. nat.
Dordel); Institut für Kreislaufforschung und Sportmedizin, Deutsche Sporthochschule Köln (PD Dr. sportwiss. Bjarnason-Wehrens)
REVIEW ARTICLE
Sport and Physical Activity
in Children with Congenital
Heart Disease
Sabine Schickendantz, Elisabeth J. Sticker,
Sigrid Dordel, Birna Bjarnason-Wehrens
In all international recommendations published thus far, the original cardiac malformation
is given priority in assessing a child's fitness to exercise. It is, however, better to primarily use
(postoperative) hemodynamic function and not the type of malformation for this assessment.
The basis for this is a classification of postoperative (residual) findings or of the clinical
conditions of children with cardiovascular disorders, as well as a categorization of these

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

disease at risk after physical exercise will, however, have to be identified and prevented
from partaking in sports.
In view of the high priority given to exercise, games, and sports in current society,
participating in activities of healthy peers means improved quality of life and has a strong social
and socializing aspect for children and adolescents. Being forbidden to participate in sports
and/or limitations to the extent to which they can exercise is particularly disagreeable to them.
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BOX 1
Selected forms of exercise and games in childhood
Types of exercise with a high dynamic/low static component
Running, skipping, jumping, cycling, swimming, inline skating, skateboarding, running games,
ball games such as football – so-called small games
Types of exercise with a high static/low dynamic component
Climbing, swinging, leaning on both arms, pulling, pushing, martial arts such as judo, gymnastics,
e. g. on the high bar or the parallel bars (leaning on both arms, hanging)
Recommendations
Many specialist societies have published recommendations on types of sport suitable for all
persons with congenital heart disease (e1, 8, e5, 9, 11, 12, 13, e8, e9, 17). Physical activity
in children with congenital heart disease should start as often as possible at nursery school,
school, or the children's heart group. The specific conditions and individual exercise
capability/capacity have to be taken into consideration. Deficits in terms of perceptive and
movement-related experiences, which might otherwise have negative consequences for the
development of a child's personality, will thus remain small or can be eradicated (7).
Demands on the muscular system should be made from infancy and during children's
preschool years. Children need to have the opportunity to live out their natural instinct and
drive to move. As far as possible, they should participate without limitations in exercise,
games, and sports of their peers (7, 11, 12, 13, 18, 19, 20, 21).

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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

(Pediatric) cardiologic examination to assess exercise capability in sports
and fitness for sports
Method Aim
Clinical examination Age-appropriate development of the cardiopulmonary
status and blood pressure
ECG at rest Age-appropriate regularity of ECG curve
24-hour Holter ECG Regularity of cardiac rhythm over 24 hours
Exercise ECG with Cardiac rhythm and blood pressure development
spiroergometry under physical exertion, and cardiopulmonary fitness
Echocardiography Cardiac function and hemodynamic findings
Exercise echocardiography Cardiac function and hemodynamic findings under
exertion
Regular, independent or guided sports activity can improve the physical and motor
capacity in children with congenital heart disease. The results of empiric studies show
significant improvements in coordination and skillfulness (7), stamina (21, 22, e10, e11),
strength, and flexibility (22, e10, e11). In none of the studies was there any evidence of
a deterioration of hemodynamic function in and/or risk to the children by the intervention
program.
Fundamentals for assessing the exercise capability of children with
congenital heart disease
To assess physical exercise capability in sports activity, the usual (pediatric) cardiologic
investigations should be conducted (table 1).
In most cases, congenital cardiac malformations are corrected in infants or toddlers,
using surgery or catheter interventions. Once the question of sports activity arises, a child's
physical exercise capability is then not dependent of its original cardiac malformation but
on the extent of postoperative (residual) findings and functional assessment. Cardiac
findings in a child with Fallot's tetralogy, for example, after corrective surgery to close the
ventricular defect and valvulotomy of the pulmonary valve, may be close to normal.
Another child with Fallot's tetralogy may, however, have significant right ventricular
impairment and thus be significantly impaired in terms of its exercise capability due to

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

5.3 Antiarrthythmics
5.4 Anticongestives
Group 6 Patients after heart transplantation
Tables 2 and 3 and box 2 show classifications of postoperative findings or clinical
findings and their categorization into degrees of severity.
Category group "0" includes patients with hemodynamically important cardiac defects
before necessary corrective procedures and has been included for completeness's sake only
(table 2). For patients who have to be treated with surgical or catheter interventions, the
question about sports and exercise should not be asked. This is true also for children in
whom a time delay has been decided for their surgical correction, e.g., in aortic stenosis or
combined aortic defects. These children are at risk from overexertion. Directly after their
surgical intervention, those children are usually released from sports lessons for three to six
months, until they have totally recovered. Subsequently, an individually tailored exercise
program is recommended.
Patients in category groups A and B, in whom no cardiac defects or only mild residual
findings exist (table 3), are not expected to show negative effects from their cardiac
condition and can exercise without limitations.
Patients in group C (clinically significant remaining findings) (table 3) are able to tolerate
normal physical exertion levels in everyday life. These children play with their siblings and
friends without showing any signs of impairment. They are, however, impaired in terms of
their maximum exercise capacity by a reduced capacity to increase their heartbeat rate either
owing to hemodynamic problems, such as valvar stenoses or insufficiencies, or to myocardial
dysfunction or inadequate increase in heartbeat rate, such as sinus node dysfunction or
pacemaker therapy. Such children have to be protected from overexertion. It is recommended
that such children do not pursue competitive sports and avoid types of sports with a high static
load. High pressure and volume strain on pre-damaged ventricles may cause malignant
arrhythmias. In the long term, an increase in myocardial dysfunction has to be
expected in this setting. Recommended types of exercise include interval training at moderate
intensity, e.g., ball games and running games, or moderate stamina training. Their afterload
reducing effect should even result in a protective cardiac effect.

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)

often feel fit and well. Sudden death during sports activity is not rare and is often caused by
undetected myocardial disease (23), as a result of hypoxia in the hypertrophic cardiac
musculature. Because of the findings on auscultation – characteristic-uncharacteristic
systoles – hypertrophic obstructive cardiomyopathy should not remain undetected in children
who are monitored well with preventive examinations. It can present immense difficulties
to tell such patients – who feel completely well – that they should not do any sports
whatsoever.
The jury is out whether a sports ban is needed in patients with a long QT syndrome. Diverse
molecular genetic forms of this syndrome have been recognized, and the extent of risk from
physical exercise can be ascertained (24). Such expensive investigations are usually
conducted in genetic centers at the request of pediatric cardiologic centers.
Certifying fitness for sports
The wide range of congenital heart disease makes issuing a so-called sports certificate
difficult. A form that covers all forms of disease does not exist. In many children with
successfully treated heart disease, an unlimited certificate for participation in sports can be
issued. In a few children, however, sports has to be forbidden. The term "release from
sports" should be avoided. Often, the wording "is not allowed to participate in competitive
sports or primarily static exercises" is sufficient. In some, individual mention has to be
made of additional limitations, such as those with pacemakers or anticoagulation treatment.
It is particularly important in which setting the proposed activity will take place. The
categorization in table 4 may help in assessing fitness for participation in sports exercise.
Playful exercise
The predominantly playful character of baby swimming or mother-child gymnastics should
not result in substantial exertion for the children, but no scientific studies exist that cover
this topic. Children learn the pleasure of sports exercise in a group of other children their
own age. Owing to the absence of competitive pressure, leisure exercise, playing with
friends and siblings, does not entail the same risks from overexertion as, e.g., sports lessons
at school – especially because, in all experience, children are well able to limit their own
levels of exertion through self-chosen breaks. Overworried mothers should be encouraged
to leave their children enough independence for exercise and trust their child's own

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

system.
Rehabilitation sports / children's heart group
The children's heart group is a medically prescribed and supervised outpatient therapeutic
service for children with congenital heart disease, which is run by a qualified sports therapist.
It provides the opportunity for children to be physically active in a medically supervised
"rest room." If needed, existing psychomotor deficiencies can be examined or even
eliminated, and simultaneously, the conditions can be created for a complete integration
into physical activities of healthy children of the same age, as far as this is possible.
A scientific study of the Cologne children's heart group found a significant improvement
in movement coordination, measured with the physical coordination test for children (e12),
as a result of the training. The motor quotient rose from 83.0 ± 16.4 to 92.9 ± 18.2
(p<0.001). The number of children with striking or impaired motor development was
lowered from 63.2% to 39.9%.
For most children, participation with a time limit (90–120 exercise units) is sufficient.
For children who have to be medically supervised during sports because of the severity of
their disease, longer participation is desirable and sensible, to enable such children to also
be physically active. The statutory health insurances fund participation in the children's
heart group with 6 Euros per exercise unit (11). Recently, a current position paper about the
group has been published.
Conclusions
The eminent importance of exercise, games, and sports for the physical and motor, emotional,
psychosocial, and cognitive development of children (7) makes it necessary to pay increased
attention to sports activities among children with congenital heart disease. In the
recommendations, as much sports as possible should be permitted and limitations should be
imposed only in cases where a health risk is to be expected.
Conflict of Interest Statement
The author’s declare’s that no conflict of interest exists according to the Guidelines of the International Committee of Medical
Journal Editors.
Manuscript received on 12 January 2006, final version accepted on 1 September 2006.
Translated from the original German by Dr Birte Twisselmann.

REFERENCES
For e-references please refer to the additional references listed below.
1. Fredriksen PM, Ingjer F, Nystad W, Thaulow E:A comparison of VO2(peak) between patients with congenital heart
disease and healthy subjects, all aged 8–17 years. Eur J Appl Physiol Occup Physiol 1999; 80: 409–16.
2. Iserin L, Chua TP, Chambers J, Coats AJ, Somerville J: Dyspnoea and exercise intolerance during cardiopulmonary
exercise testing in patients with univentricular heart. The effects of chronic hypoxaemia and Fontan procedure.
Eur Heart J 1997; 18: 1350–6.
3. Sarubbi B, Pacileo G, Pisacane C et al.: Exercise capacity in young patients after total repair of Tetralogy of Fallot.
Pediatr Cardiol 2000; 21: 211–5.
4. Durongpisitkul K, Driscoll DJ, Mahoney DW et al.: Cardiorespiratory response to exercise after modified Fontan
operation: determinants of performance. J Am Coll Cardiol 1997; 29: 785–90.
5. Nir A, Driscoll DJ, Mottram CD et al.: Cardiorespiratory response to exercise after the Fontan operation: a serial
study. J Am Coll Cardiol 1993; 22 : 216–20.
6. Wessel HU, Paul MH: Exercise studies in tetralogy of Fallot: a review. Pediatr Cardiol 1999; 20: 39–47; discussion 48.
7. Dordel S, Bjarnason-Wehrens B, Lawrenz W, Leurs S, Rost R, Schickendantz S, Sticker E: Zur Wirksamkeit
motorischer Förderung von Kindern mit (teil-)korrigierten angeborenen Herzfehlern. Deutsche Zeitschrift für
Sportmedizin 1999; 50: 41–6.
8. Mitchell JH, Maron BJ, Epstein SE: 16th Bethesda Conference: Cardiovascular abnormalities in the athlete:
recommendations regarding eligibility for competition. October 3–5, 1984. J Am Coll Cardiol 1985; 6: 1186–232.
9. Graham TP Jr, Driscoll DJ, Gersony WM, Newburger JW, Rocchini A, Towbin JA: Task Force 2: congenital heart
disease. J Am Coll Cardiol 2005; 45: 1326–33.
10. Reybrouck T, Mertens L: Physical performance and physical activity in grown-up congenital heart disease.
Eur J Cardiovasc Prev Rehabil 2005; 12: 498–502.
Dtsch Arztebl 2007; 104(9): A 563–9
⏐⏐
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MEDICINE
11. Bjarnason-Wehrens B, Sticker E, Lawrenz W, Held K: Die Kinderherzgruppe (KHG) – Positionspapier der DGPR.
Z Kardiol 2005; 94: 860–6.
12. Hirth A, Reybrouck T, Bjarnason-Wehrens B, Lawrenz W, Hoffmann A: Recommendations for participation in

ompetitive and leisure sports in patients with congenital heart disease. A consensus document. Eur J Cardiovasc
Prev Rehabi 2006; 13: 293–9.
13. Picchio FM, Giardini A, Bonvicini M, Gargiulo G: Can a child who has been operated on for congenital heart
disease participate in sport and in which kind of sport? J Cardiovasc Med (Hagerstown) 2006; 7: 234–8.
14. Eriksson BO: Cardiac output during exercise in pubertal boys. Acta Paediatr Scand Suppl. 1971; 217: 53–5.
15. Leurs S: Die kardiale Leistungsfähigkeit, der motorische Entwicklungstand und die psychosoziale Situation
herzkranker Kinder und Jugendlicher sowie deren Beeinflussbarkeit durch eine Kinderherzgruppe. Dissertation.
Köln: Deutsche Sporthochschule 2004.
16. Dordel S: Bewegungsförderung in der Schule. Handbuch des Sportförderunterrichts. Dortmund: Verlag modernes
Lernen 2003.
17. Lou JE, Ganley TJ, Flynn JM: Exercise and children's health. Curr Sports Med Rep 2002; 1: 349–53.
18. Massin MM, Hovels-Gurich HH, Gerard P, Seghaye MC: Physical activity patterns of children after neonatal arterial
switch operation. Ann Thorac Surg 2006; 81: 665–70.
19. Lunt D, Briffa T, Briffa NK, Ramsay J: Physical activity levels of adolescents with congenital heart disease. Aust J
Physiother 2003; 49: 43–50.
20. Dunbar-Masterson C, Wypij D, Bellinger DC et al.: General health status of children with D-transposition of the
great arteries after the arterial switch operation. Circulation 2001; 104: 138–42.
21. Rhodes J, Curran TJ, Camil L et al.: Impact of cardiac rehabilitation on the exercise function of children with
serious congenital heart disease. Pediatrics 2005; 116: 1339–45.
22. Fredriksen PM, Kahrs N, Blaasvaer S et al.: Effect of physical training in children and adolescents with congenital
heart disease. Cardiol Young 2000; 10: 107–14.
23. Coplan NL, Gleim GW, Nicholas JA: Exercise and sudden cardiac death. Am Heart J 1988; 115: 207–12.
24. Schwartz PJ, Priori SG, Spazzolini C et al.: Genotype-phenotype correlation in the long-QT syndrome:
gene-specific triggers for life-threatening arrhythmias. Circulation 2001; 103: 89–95.
25. Sticker EJ, Leurs S, Bjarnason-Wehrens B, Dordel S, Schickendantz S: „Sport macht stark“ – Herzkranke Kinder
und Jugendliche im Sportunterricht. Aachen: Bundesverband Herzkranke Kinder e.V. (Hrsg.) 2003.
ADDITIONAL REFERENCES
e1. Driscoll DJ: Exercise rehabilitation programs for children with congenital heart disease:A note of caution.
Pediatric Exercise Science 1990; 2: 191–6.
e2. Reybrouck T, Bisschop A, Dumoulin M, van der Hauwaert LG: Cardiorespiratory exercise capacity after surgical

closure of atrial septal defect is influenced by the age at surgery. Am Heart J 1991; 122: 1073–8.
e3. Balderston SM, Daberkow E, Clarke DR, Wolfe RR: Maximal voluntary exercise variables in children with
postoperative coarctation of the aorta. J Am Coll Cardiol 1992; 19: 154–8.
e4. Sklansky MS, Bricker JT: Guidelines for exercise and sports participation in children and adolescents with
congenital heart disease. Prog Pediatr Cardiol 1993; 2: 55–66.
e5. Kaminer SJ, Hixon RL, Strong WB: Evaluation and recommendations for participation in athletics for children with
heart disease. Curr Opin Pediatr 1995; 7: 595–600.
e6. Graf C, Rost R: Herz und Sport. Balingen: Spitta Verlag 2001.
e7. Zimmer R: Handbuch der Psychomotorik. Freiburg-Basel-Wien: Verlag Herder 1999.
e8. Washington RL: Cardiac rehabilitation programmes in children. Sports Med 1992; 14: 164–70.
e9. Goldberg B: Sports and exercise for children with chronic health conditions. Guidelines for participation from
leading pediatric authorities. Champaign: Human Kinetics 1995.
e10. Longmuir PE, Tremblay MS, Goode RC: Postoperative exercise training develops normal levels of physical activity
in a group of children following cardiac surgery. Pediatr Cardiol 1990; 11: 126–30.
e11. Longmuir PE, Turner JA, Rowe RD, Olley PM: Postoperative exercise rehabilitation benefits children with congenital
heart disease. Clin Invest Med 1985; 8: 232–8.
e12. Schilling F: Körperkoordinationstest für Kinder. KTK Manual. Weinheim: 1974.
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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