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syndromes such as 22q11 microdeletion and Turner syndrome. However, aortic dissection is very rare in CHD.609 Athletes have mildly increased aortic dimensions in comparison to sedentary controls, but it is not known if this has a cumulative effect in CHD athletes with aortic dilatation.345 The presence of ascending aorta dilatation should lead to assessment for coarctation of the aorta as this can be associated with severe coarctation, which may be missed on clinical assessment but may cause severe exercise-related hypertension.610 Exercise risks in aortopathy are described in detail in section 5.4. Contact sports should be avoided in patients with dilated aortas >5 cm. (4) Arrhythmia assessment Arrhythmias are responsible for 25% of CHD hospital admissions. Over 80% are atrial but life-threatening VAs can occur.611 Independent risk factors include increasing age, male gender, double outlet right ventricle, atrioventricular septal defect, HF, obstructive sleep apnoea, transposition of the great arteries, congenitally corrected transposition, and tetralogy of Fallot.599 Assessment of the CHD athlete should include a symptom history with evaluation of palpitations, presyncope and syncope, particularly during exercise.

©ESC 2020

Figure 9 Pre-participation assessment of individuals with congenital heart disease.598 CPET = cardiopulmonary exercise test; HR = heart rate; MHR = maximum heart rate; RPE = rate of perceived exertion. AE represent pathways linking static and intensity components for each column. After assessment of CPET and the five variables (Table 16), an individual recommendation can be given (solid arrow). If a higher static level sport is chosen, then a lower intensity level is advised (dotted arrow).

Table 16 Baseline parameters for assessment in congenital heart disease

©ESC 2020

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