The following are key points to remember from the European recommendations for participation in competitive sport in adolescent and adult athletes with congenital heart disease (CHD):

1. Improved clinical care has led to a rise in the number of adults with CHD engaging in leisure time and competitive sports activities.
2. Although the benefits of exercise in patients with CHD are well established, there is a low but appreciable risk of exercise-related complications.
3. This document introduces an approach which is based on the assessment of hemodynamic, electrophysiological, and functional parameters, rather than anatomic lesions only. The recommendations provide a comprehensive assessment algorithm that allows for patient-specific assessment and risk stratification of athletes with CHD who wish to participate in competitive sports. These recommendations apply to patients with CHD aged ≥16 years.
4. Assessment should incorporate the general European Society of Cardiology guidelines for adult CHD.
5. A comprehensive medical and surgical history is necessary with particular emphasis on the underlying primary CHD diagnosis, surgical and catheter interventions, and their timings and noncardiac comorbidities and prescribed and nonprescribed medication and nutritional supplements. The physician should perform a thorough physical examination with particular reference to resting heart rate and rhythm, blood pressure, features of ventricular dysfunction, and the presence or absence of central cyanosis.
6. Assessment of five parameters at rest (i.e., ventricular structure and function, pulmonary artery pressure, aorta, arrhythmia, and arterial oxygen saturation) is indicated.
7. Cardiopulmonary exercise testing provides invaluable information relating to physiological sequelae of anatomical lesions, risk of morbidity and mortality, and timing of intervention. It is an important tool for assessing the baseline fitness of individual athletes and helps to inform decision making on different types of sport.
8. The physician should assess each of the five parameters at rest and exercise and assign the individual athlete with CHD to a specific route which will dictate the recommended sporting disciplines. The recommendations provide a comprehensive assessment algorithm which allows for individualized advice in athletes with CHD who wish to participate in competitive sports.
   • When all parameters fall within normal limits or there is evidence of mild hypertrophy or mild pressure or volume load (green route), athletes can participate in all competitive sports.
   • When one of the parameters is outside these limits, restriction applies to endurance disciplines that are likely to pose the highest hemodynamic demands and require high volumes of training (orange route) or athletes should be restricted to skill sports only (brown route).
   • Athletes with severe structural, hemodynamic, or electrophysiological sequelae (red route) or symptomatic limitation should be restricted to recreational sport only and not allowed to participate in competitive sports.
9. Patients with cyanotic, unrepaired, or palliated complex CHD or CHD with associated pulmonary hypertension should be advised against competitive sport at moderate or high altitude (above 1500 m).
10. Finally, these recommendations are based on expert opinion and should not discourage physicians to practice outside the remit of this document, based on their scientific and professional experience. Furthermore, in line with good clinical practice, the decision-making process should always include the athlete and respect her/his autonomy.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Sports and Exercise Cardiology, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, Acute Heart Failure, Pulmonary Hypertension, Exercise, Hypertension, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging

Keywords: ESC Congress, ESC20, Adolescent, Arrhythmias, Cardiac, Athletes, Blood Pressure, Cyanosis, Diagnostic Imaging, Exercise, Exercise Test, Heart Defects, Congenital, Heart Failure, Hemodynamics, Hypertension, Pulmonary, Primary Prevention, Sports, Ventricular Dysfunction

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