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Exercise Recommendations, Congenital Heart Disease

History and Physical
All patients with cardiac disease who wish to participate in sports should be screened for possible residual cardiac compromise or complications. This includes those individuals who have had surgical or other interventional repair. The Medical Home provider should inquire about: shortness of breath,syncope or pre-syncope, chest pain, and palpitations during exercise. The pre-participation assessment should include a careful physical examination with close attention paid to findings related to their specific lesion, corrective surgery, and possible associated sequelae or complications. If suspicious historical or physical findings are identified, basic cardiac evaluation studies such as a chest x-ray and electrocardiogram should be obtained; consider referral to a cardiologist if concern warrants.
Exercise and Sport Classifications
Specific sports have been categorized into levels of static and dynamic intensity. Sports that involve both static and dynamic exercise impose the greatest amount of stress on the cardiovascular system. Each sport can also be classified as either competitive or recreational. A competitive setting generally reflects a higher degree of physical exertion.
Static exercise: increases systolic and diastolic blood pressure (afterload) while minimally increasing cardiac output and heart rate.
Dynamic exercise: increases cardiac output and heart rate while minimally increasing systolic and diastolic blood pressure.
Recommendations for specific congenital cardiac lesions, adapted from the American College of Cardiology 2005 Bethesda Conference Task Force on eligibility recommendations for competitive athletes with cardiovascular abnormalities [Graham: 2005]:

Atrial Septal Defects (ASD), untreated
  • Athletes with small defects, normal right heart volume, and no pulmonary hypertension can participate in all sports.
  • Athletes with a large ASD and normal pulmonary artery pressure can participate in all competitive sports
  • Athletes with an ASD and mild pulmonary hypertension can participate in low-intensity competitive sports (class 1A). Patients with associated pulmonary vascular obstructive disease who have cyanosis and a large right-to-left shunt cannot participate in competitive sports.
  • Athletes with ASD and symptomatic atrial or ventricular tachyarrhythmia or moderate-to-severe mitral regurgitation should follow the American College of Cardiology 2005 Task Force recommendations for sports participation for athletes with arrhythmias [Zipes: 2005], and valvular heart disease [Bonow: 2005], respectively.

Atrial Septal Defect, closed at operation or by interventional catheterization
  • Three to six months after the surgery or device placement via catheter, patients may participate in all sports unless any of the following are present:
    • Presence of pulmonary hypertension
    • Symptomatic atrial or ventricular tachyarrhythmias or second- or third-degree heart block
    • Evidence of myocardial dysfunction
    • Patients with any of these symptoms should have an exercise evaluation and an individualized exercise prescription with respect to competitive sports

Ventricular Septal Defect (VSD), untreated
  • Athletes with a VSD and normal pulmonary artery pressure can participate in all sports.
  • Athletes with a large VSD who do not have marked elevation of pulmonary vascular resistance are candidates for repair, and full participation in all sports would normally occur after a successful VSD closure.

Ventricular Septal Defect, closed at operation or by interventional catheterization
  • Three to six months after repair, asymptomatic athletes with no defect or only a small residual defect can participate in all competitive sports if they have no evidence of pulmonary artery hypertension, ventricular or atrial tachyarrhythmia, or myocardial dysfunction.
  • Athletes with symptomatic atrial or ventricular tachyarrhythmias or second- or third-degree atrioventricular (AV) block should follow the recommendations in the American College of Cardiology 2005 Task Force recommendations for sports participation in athletes with arrhythmias [Zipes: 2005].
  • Athletes with mild-to-moderate pulmonary hypertension or ventricular dysfunction should follow the recommendations in the Elevated Pulmonary Resistance section below.
  • Athletes with persistent, severe pulmonary hypertension cannot participate in competitive sports.

Patent ductus arteriosus (PDA), untreated.
  • Athletes with a small PDA and normal left heart chamber dimension can participate in all competitive sports.
  • Athletes with a moderate or large PDA causing left ventricular enlargement should undergo surgical or interventional catheterization closure before unrestricted competition.
  • For athletes with a moderate or large PDA, severe pulmonary hypertension, and cyanosis, see the elevated PVR section

Patent Ductus Arteriosus, closed at operation or by interventional catheterization.
  • Three months after PDA closure, patients with no symptoms, with normal cardiac examination and with no evidence of pulmonary hypertension or LV enlargement can participate in all competitive sports.
  • For athletes with residual pulmonary artery hypertension, see the elevated PVR section.

Pulmonary valve stenosis (PS), untreated.
  • Athletes with a peak systolic gradient less than 40 mm Hg and normal right ventricular function can participate in all competitive sports if no symptoms are present.
  • Athletes with a peak systolic gradient greater than 40 mm Hg can participate in low-intensity competitive sports (classes 1A and 1B). Patients in this category are usually referred for balloon valvuloplasty or operative valvulotomy before sports participation.

Pulmonary valve stenosis , treated surgically or via balloon valvuloplasty.
  • Athletes with no or only residual mild PS and normal ventricular function without symptoms can participate in all competitive sports. Participation in sports can begin two to four weeks after balloon valvuloplasty. After operation, an interval of approximately 3 months is recommended before resuming sports participation.
  • Athletes with a persistent peak systolic gradient greater than 40 mm Hg should follow the same recommendations as those for patients prior to operative treatment.
  • Athletes with severe pulmonary insufficiency characterized by a marked right ventricular enlargement can participate in class 1a and 1B competitive sports.

Aortic valve stenosis (AS), untreated. This section refers to congenital valvular AS in young patients. Differentiation between mild and either moderate or severe AS is accomplished by physical examination, ECG, and Doppler echocardiography. The distinction between moderate or severe stenosis is more difficult and may require cardiac catheterization in rare situations when clinical examination, ECG, echocardiography, and/or other data are discrepant. Patients with a history of fatigue, light-headedness, dizziness, syncope, chest pain, or pallor on exercise deserve a full evaluation, which may include cardiac catheterization and exercise testing. Because AS may progress, periodic re-evaluation is needed. Sudden death is more likely to occur in patients with severe LV hypertrophy, exertional syncope, chest pain or dyspnea and a LV strain pattern on the ECG. The following link directs the reader to the Amercan College of Cardiology classification of Aortic Stenosis: Definitions of Mild, Moderate, and Severe.
  • Athletes with mild AS can participate in all competitive sports if they have a normal ECG, normal exercise tolerance, and no history of exercise-related chest pain, syncope, or atrial or ventricular tachyarrhythmia associated with symptoms.
  • Athletes with moderate AS can participate in low static/low-to-moderate dynamic, and moderate static/low-to-moderate dynamic (classes IA, IB, and IIA) sports if the following conditions are met:
    1. Mild or no LV hypertrophy by echocardiography and the absence of LV strain pattern on the ECG.
    2. Normal exercise test without evidence of myocardial ischemia or atrial or ventricular tachyarrhythmia and with normal exercise duration and blood pressure response. Those athletes with supraventricular tachycardia or multiple or complex ventricular tachyarrhythmias at rest or with exercise can participate only in low-intensity competitive sports, classes IA and IB.
    3. Absence of symptoms, as defined above.
    4. Athletes with severe AS should not participate in competitive sports.
The criteria in this section also apply to athletes with discrete (membranous) subaortic stenosis and supravalvular aortic stenosis.
Aortic stenosis, treated by operation or balloon valvuloplasty. After operation, a variable degree of residual stenosis or regurgitation, or both, can be present. Re-evaluation by physical examination, ECG, and echocardiography is necessary for reassessment. In addition, exercise stress testing or catheterization, or both, can be required for patients whose physiologic and anatomic severity cannot otherwise be determined.
  • Athletes with residual mild, moderate, or severe stenosis should follow the same guidelines as above for untreated patients.
  • Athletes with moderate to severe aortic regurgitation should follow the specific recommendations for athletes with valvular heart disease developed by the American College of Cardiology which can be found at the following link Exercise Recommendations for Patients with Valvular Disorders [Bonow: 2005]
  • Because of the propensity for recurrence of LV outflow obstruction in discrete subaortic stenosis postoperatively, these patients require continued follow-up and re-evaluation annually for exercise recommendations. This also applies to all other forms of fixed AS.

Coarctation of the aorta, untreated. Virtually all patients, except those with mild coarctation, will undergo either surgical repair or balloon dilation/stenting.
  • Athletes with mild coarctation and the absience of large collateral vessels or significant aortic root dilation with a normal exercise test and a small pressure gradient at rest and a peak systolic blood pressure 230 mm Hg or less with exercise can engage in all competitive sports.
  • Athletes with a systolic arm/leg gradient more than 20 mm Hg or exercise-induced hypertension with a systolic blood pressure more than 230 mm Hg during exercise can engagin in only low-intensity sports (class IA) until treated.

Coarctation of the aorta, treated by surgery or balloon angioplasty.
  • Participation in sports, three or more months after surgical or balloon angioplasty for coarctation of the aortia, is permitted for athletes with a 20 mm Hg or less arm/leg gradient at rest and a normal peak systolic blood pressure during rest and exercise.
  • During the first postoperative year, ahtletes s hould refrain from high-intensity static exercise (classes IIIA, IIIB, IIIC) and sports that pose the danger of bodily collision.
  • After 3 months, if patients continue to be asymptomatic, with normal blood pressure at rest and exercise, all sports are permissible except those with a large static component (particularly, classes IIIA, IIIB, IIIC).
  • For athletes with evidence of significant aortic dilation, wall thinning, or aneurysm formation, participation should be restricted to low-intensity competitive sports (class IA and IB).

Elevated pulmonary resistance with congenital heart disease. Patients who have pulmonary vascular disease and congenital heart disease are at risk for sudden death during sports activity. As pulmonary vascular obstruction progresses, these patients develop cyanosis at rest and intense cyanosis with exercise. Although most of these patients self-limit their activity, they should not participate in competitive sports. Patients who have suspected elevated pulmonary artery pressure after operation or interventional catheterization for shunt lesions should be evaluated by echocardiography and/or cardiac catheterization before engaging in competitive athletics.
  • If pulmonary artery peak systolic pressure is 30 mm Hg or less, athletes can participate in all sports.
  • If pulmonary artery pressure is more than 30 mm Hg, a full evaluation and individual exercise prescription are required for athletic participation.

Ventricular dysfunction after cardiac surgery. Left and/or right ventricular dysfunction can occur after surgical treatment of both simple and complex congenital heart diseases and affect exercise performance. Periodic assessment of ventricular function is required for participation in sports because ventricular function may deteriorate over time.
  • For full participation, normal or near-normal ventricular function is required (ejection fraction 50% or more).
  • Athletes with mildly depressed ventricular function (ejection fraction 40-50%) should participate in low-intensity static competitive sports only (classes IA, IB, and IC).
  • Athletes withmoderately to severely depressed ventricular function (ejection fraction less than 40%) should not participate in competitive sports.

Cyanotic congenital cardiac disease, unoperated. Cyanotic congenital heart disease is associated with exercise intolerance and progressive hypoxemia with increasing effort. Patients are unlikely to engage in competitive sports because of their own self-limiting activity. There are rare patients with cyanotic congenital heart disease (such as pulmonary stenosis or mildly elevated pulmonary vascular resistance plus atrial or ventricular defects) who reach adolescence or even adult life with mild cyanosis at rest and shortness of breath only with exercise. These patients may experience a profound increase in cyanosis during sports participation.
  • Patients with untreated cyanotic heart disease can ususally participate in low-intensity competitive sports of only class IA.


Congenital coronary artery anomalies
. Congenital coronary anomalies of wrong sinus origin are the second most common cardiovascular cause of sudden death in young athletes.Identification of these anomalies during life can be difficult because patients often do not experience warning symptoms, and rest and exercise ECGs are usually normal. Coronary anomalies should be considered in athletes with exertional syncope or symptomatic ventricular arrhythmia and should be investigated using appropriate studies such as echocardiography, CMR, or ultrafast computed tomography imaging. Surgery is usually performed when the diagnosis is made.
  • Detection of coronary anomalies of wrong sinus origin in which a coronary artery passes between great arteries should result in exclusion from all participation in competitive sports.
  • Participation un all sports three months after successful operation would be permitted for an athlete without ischemia, ventricular or tachyarrhythmia, or dysfunction furing maximal exercise testing.
  • Athletes with previous myocardial infarction (MI) should follow the appropriate American College of Cardiology 2005 Task Force recommendations for sports participation in athletes with coronary artery disease [Thompson: 2005].

Kawasaki disease. Kawasaki disease, an acute, self-limited vasculitis of unknown etiology, is now the most common cause of acquired heart disease in children in the U.S. Coronary artery aneurysms develop in approximately 20% of untreated children and in 4% of those treated with high-dose intravenous gammaglobulin in the acute phase. Coronary aneurysms, together with progressive coronary artery stenosis, can lead to ischemic heart disease, MI, or sudden death. Because coronary artery morphology evolves over time, the risk of exercise for the individual patient may change. Patients without coronary artery changes on echocardiography at any stage of the illness appear to have risk for ventricular tachyarrhythmias and sudden death similar to that of the normal population in the first 20 years after illness onset. When aneurysms regress to normal lumen diameter, structural and functional coronary abnormalities persist. Arteries with persistent aneurysmal morphology may develop stenoses or occlusion, increasing the risk of myocardial ischemia. The risk associated with competitive sports in individuals who have had Kawasaki disease depends upon the degree of coronary artery involvement. Of note, because of the general cardiovascular benefits of exercise, all patients with Kawasaki disease should avoid a sedentary lifestyle.
  • Patients with no coronary artery abnormalities or transient coronary artery ectasia resolving during the convalescent phase of the disease are encouraged to participate in all sports after 6 to 8 weeks.
  • Patients with regressed aneurysms can participate in all competitive sports if they have no evidence of exercise induced ischemia by stress testing with myocardial perfusion imaging.
  • Patients with isolated small- to medium-sized sneurysms in one or more coronary arteries and judged to be at low risk for ischemic complications (normal LV function, absence of exercise-induced ischemia or arrhythmia) may participate in low to moderate static and dynamic competitive sports (classes IA, IB, IIA, and IIB). Stress testing with evaluation of myocardial perfusion should be repeated at one- to two-year intervals to monitor ischemia and guide further recommendations about sports competition.
  • Patients with one or more large coronary aneurysms or multiple (segmented) or complex aneurysms with or without obstruction to coronary flow may participate in class IA and IIA sports if they have not evidence of reversible ischemia on stress testing, normal LV function, and absence of exercise-induced arrhythmia. Stress testing with evaluation of myocardial perfusion should be repeated at one-year intervals to monitor ischemia and guide further recommendations about sports competition.
  • Athletes with recent MI or revascularization should avoid competitive sports until their recovery is complete--usually 6 to 8 weeks. Those with normal LV ejection fraction, exercise tolerance, absence of reversible ischemia or myocardial perfusion testing, and absence of exercise-induced arrhythmias can participate in class IA and IB sports. Those with LV ejection fraction less than 40%, exercise intolerance, or exercise-induced ventricular tachyarrhythmias should not participate in competitive sports.
  • Patients with coronary lesions who are taking anticoagulants and/or antiplatelet drugs (aspirin, clopidogrel) should not participate in sports that pose a danger of high speed collision.

H ypertrophic Cardiomyopathy (HCM) [Maron: 2005]
  • Athletes with a probable or unequivocal clinical diagnosis of HCM should be excluded from most competitive sports, with the possible exception of those of low intensity (class IA). This recommendation is independedt of age, gender, and phenotypic appearance, and does not differ for those athletes with or without symptoms, LV outflow obstruction, or prior treatment with drugs or major interventios withsuftery, alcohol septal ablation, pacemaker, or implantable defibrillator.
  • Although the clinical significance and natural history of genotype positive-phenotype negative individuals remains unresolved, no compelling data are available at present with which to preclude these patients from competitive sports, particularly in the absence of cardiac symptoms or a family history of sudden death.
  • The placement of an implantable cardioverter-defibrillator (ICD) does not change exercise and sports recommendations for this disease. Restriction from all contact and most other sports is advisable. Such individuals may participate in low intensity (class IA) competitive sports only.

Marfan Syndrome [Maron: 2005]
  • Athletes with Marfan syndrome can participate in low and moderate static/low dynamic competitive sports (classes IA and IIA) if they do not have one or more of the following:
    1. Aortic root dilatation (i.e., transverse dimension 40 mm or greater in adults, or more than 2 standard deviations from the mean for body surface area in children and adolescents; z-score of 2 or more)
    2. Moderate-to-severe mitral regurgitation
    3. Family history of dissection or sudden death in a Marfan relative.
    4. It is recommended, however, that these athletes have an echocardiographic measurement of aortic root dimension repeated every six months, for close surveillance of aortic enlargement.
  • Athletes with unequivocal aortic root dilatation, prior surgical aortic root reconstruction, chronic dissectionof aorta or other artery, moderate-to-severe mitral regurgitation, or family history of dissection or sudden death can participate only in low-intensity competitive sports (class IA).
  • Athletes with Marfan syndrome, familial aortic aneurysm or dissection, or congenital bicuspid aortic valve with any degree of ascending aortic enlargement (as defined above) also should not participate in sports that involve the potential for bodily collision.

Ehlers-Danlos Syndrome [Maron: 2005]
The vascular form of Ehlers-Danlos syndrome carries a substantial risk of rupture of the aorta and its major branches. This is a rare autosomal dominant disorder, caused by a defect in type III collagen, encoded by the COL3A1 gene. Patients have variable joint hypermobility, susceptibility to bruising, difficult wound healing, and often prematurely aged appearance.
  • Individuals with the vascular form of Ehlers-Danlos syndrome should not engage in any competitive athletic activity.

Postoperative palliated cyanotic congenital heart disease. Palliative surgical intervention can be performed to increase pulmonary blood flow in patients with decreased flow or to limit blood flow in those with excessive flow. Often these patients have significant relief of symptoms at rest, but arterial desaturation during exercise frequently persists.
  • Patients can participate in low-intensity competitive sports (class IA), provided that the following criteria are met:
    1. Arterial saturation remains above approximately 80%.
    2. Tachyarrhythmias associated with symptoms of impaired consciousness are not present
    3. There is no moderate or severe ventricular dysfunction.

Postoperative tetralogy of Fallot (T/F). The current treatment for T/F is early repair, and patients have varying degrees of pulmonary stenosis and mild/moderate pulmonary insufficiency. Patients with important residual abnormalities, such as a significant left-to-right shunt, right ventricular hypertension, moderate-to-severe pulmonary regurgitation, or right ventricular dysfunction, who also have a history of syncope and/or arrhythmia, may be at risk for sudden death.
  • Athletes with an excellent repair should be allowed to participate in allsports, providing that the following criteria are met:
    1. Normal or near-normal right heart pressure
    2. No or only mild right ventricular volume overload
    3. No evidence of a significant residual shunt.
    4. No atrial or ventricular arrhythmia abnormality on ambulatory ECG monitoring or exercise testing.
  • Patients with marked pulmonary regurgitation and right ventricular volume overload, residual right ventricular hypertension (peak systolic right ventricular pressure greater than or equal to 50% systemic pressure), or atrial or ventricular tachyarrhythmias, should participate in low-intensity competitive sports only (class IA).

Transposition of the great arteries (TGA)—postoperative Mustard or Senning operation. Patients who have had atrial repair of TGA can have significant hemodynamic abnormalities including impaired systemic venous return, abnormal right ventricular (systemic ventricular) function, pulmonary stenosis or pulmonary hypertension, abnormalities of pulmonary venous return, tricuspid insufficiency, and significant atrial or ventricular arrhythmias .
  • Selected patients can engage in low and moderate static/low dynamic competitive sports (classes IA and IIA) provided there is:
    • Mild or no cardiac chamber enlargement on chest radiograph, echocardiography, or CMR
    • No history of atrial flutter, supraventricular tachycardia, or ventricular tachyarrhythmia
    • No history of syncope or other cardiac symptoms
    • A normal exercise test defined as normal duration, workload, heart rate, ECG, and blood pressure response for age and gender.
  • Patients not in this category require and individualized exercise prescription.

Postoperative arterial switch for TGA. A significant cohort of patients have had arterial switch repair of TGA and are now old enough to engage in competitive sports. These patients have a low prevalence of ventricular dysfunction, arrhythmia with symptoms, and hemodynamic sequelae. Limited exercise data are available.
  • Athletes withnormal ventricular funciton, normal exercise test, and no atrial or ventricular tachyarrhythmias can participate in all sports.
  • Athletes with more than mild hemodynamic abnormalities or ventricular dysfunction can participate in low and moderate static/low dynamic competitive sports (classes IA, IB, IC, and IIA), provided that their exercise test is normal.

Congenitally corrected transposition of the great arteries (CCTGA). Usually, CCTGA is associated with other congenital malformations of the heart, such as ventricular septal defect, pulmonary stenosis, and systemic AV valve abnormalities, which may dictate the level of participation in competitive sports. These patients are at risk for development of supraventricular tachycardia and spontaneous AV block.
  • Asymptomatic patients with CCTGA without other cardiac abnormalities may be eligible for participation in class IA and IIA sports if there is no systemic ventricle enlargement, no evidence of atrial or ventricular tachyarrhythmia on ambulatory ECG monitoring or exercise testing or normal exercise tests (including normal maximum oxygen consumption for age and gender).
  • Periodic re-evaluation is important to detect development of arrhythmias and deterioration of systemic (right) ventricular function and systemic (tricuspid) AV valve regurgitation. In particular, sports with a large static component (classes IIIA, IIIB, IIIC) such as power weightlifting are not recommended.

Postoperative Fontan operation. The Fontan operation is characterized by systemic venous return bypassing the right ventricle. The operation is used for the long-term palliation of patients with tricuspid atresia or other complex types of single ventricle. Although many patients improve clinically after the Fontan operation, they usually have limited exercise capacity and reduced cardiac output at rest and during exercise. Postoperative arrhythmias have been associated with significant morbidity and mortality. Diagnostic evaluation before sports participation should include a chest radiograph, ECG, echocardiography or CMR, and exercise testing with oxygen saturations.
  • Athletes can participate in low-intensity competitive sports (class IA).
  • Athletes can engage in class IB sports if they have normal ventricular funciton and oxygen saturation.

Ebstein’s anomaly. A great deal of variability exists in the severity of this malformation, which is characterized by variable degrees of tricuspid regurgitation and right-heart enlargement caused by a malformed and displaced tricuspid valve. Cyanosis may be present due to atrial right-to-left shunting. Even mild cases may be associated with important arrhythmias. Severe cases can be associated with physical disability and increased risk for sudden death with exercise.
  • Athletes with a mild expression of Ebstein's anomaly without cyanosis, with normal right ventricular size, and with no evidence of atrial or ventricular tachyarrhythmias can participate in all sports.
  • Athletes with tricuspic regurgitation of moderate severity can participate in low intensity competitive sports (class IA) if there is no eveidence of arrhythmia on ambulatory ECG monitoring other than isolated premature contractions
  • Athletes with severe Ebstein's anomaly are precluded from all sports participation. After surgical repair, however, low-intensity competitive sports (class IA) can be permitted if tricuspid regurgitation is absent or mild, cardiac chamber size on chest radiograph or by echocardiography is not substantially increased, and symptomatic atrial or ventricular tachyarrhythmias are not present on ambulatory ECG monitoring and exercise test. Selected athletes with an excellent hemodynamic result after repair may be permitted additional participation on an individual basis.

Resources

Practice Guidelines

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(8):1326-33. PubMed abstract

Kaplan NM, Gidding SS, Pickering TG, Wright JT Jr.
Task Force 5: systemic hypertension.
J Am Coll Cardiol. 2005;45(8):1346-8. PubMed abstract

Maron BJ, Ackerman MJ, Nishimura RA, Pyeritz RE, Towbin JA, Udelson JE.
Task Force 4: HCM and other cardiomyopathies, mitral valve prolapse, myocarditis, and Marfan syndrome.
J Am Coll Cardiol. 2005;45(8):1340-5. PubMed abstract

Maron BJ, Chaitman BR, Ackerman MJ, Bayés de Luna A, Corrado D, Crosson JE, Deal BJ, Driscoll DJ, Estes NA 3rd, Araújo CG, Liang DH, Mitten MJ, Myerburg RJ, Pelliccia A, Thompson PD, Towbin JA, Van Camp SP.
Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular diseases.
Circulation. 2004;109(22):2807-16. PubMed abstract
Free article available at http://circ.ahajournals.org/cgi/content/full/109/22/2807 .

Services

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Authors

Compiled and edited by: Catherine Jolma, MD - 12/2009
Content Last Updated: 4/2010

Page Bibliography

Bonow RO, Cheitlin MD, Crawford MH, Douglas PS.
Task Force 3: valvular heart disease.
J Am Coll Cardiol. 2005;45(8):1334-40. PubMed abstract

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(8):1326-33. PubMed abstract

Maron BJ, Ackerman MJ, Nishimura RA, Pyeritz RE, Towbin JA, Udelson JE.
Task Force 4: HCM and other cardiomyopathies, mitral valve prolapse, myocarditis, and Marfan syndrome.
J Am Coll Cardiol. 2005;45(8):1340-5. PubMed abstract

Mitchell JH, Haskell W, Snell P, Van Camp SP.
Task Force 8: classification of sports.
J Am Coll Cardiol. 2005;45(8):1364-7. PubMed abstract

Thompson PD, Balady GJ, Chaitman BR, Clark LT, Levine BD, Myerburg RJ.
Task Force 6: coronary artery disease.
J Am Coll Cardiol. 2005;45(8):1348-53. PubMed abstract

Zipes DP, Ackerman MJ, Estes NA 3rd, Grant AO, Myerburg RJ, Van Hare G.
Task Force 7: arrhythmias.
J Am Coll Cardiol. 2005;45(8):1354-63. PubMed abstract