Background: Sudden cardiac death (SCD) in children and adolescents is rare. Several studies have reported a higher risk of SCD during athletic competition. High risk congenital coronary artery abnormalities are the second leading cause of SCD in young athletes in the USA. Echocardiographic assessment of coronary arteries has not been routinely used in screening programmes for junior athletes so far. Design: Prospective cohort study in 1045 consecutive adolescent elite football players. Methods: All athletes underwent a standardized cardiovascular screening protocol with a medical history, a physical examination, 12-lead resting electrocardiogram and a complete transthoracic 2D-echocardiography. Results: Two athletes (0.19%) showed a high-risk coronary artery abnormality (CAA) with a right coronary artery originating abnormal from the aorta and coursing inter-arterial. Low-risk CAAs were found in 16 athletes (1.53%). There was an ectasia of the left coronary artery (+3.9z and +4.3z) and a fistula from the left coronary artery in two cases (0.19%), respectively. In 1.05% ( n = 11) we found a high take-off (2.3–6.8 mm) and in one case (0.096%) there was a tangential take-off of the right main coronary artery. Variants of coronary arterial anatomy were identified in 335 of 1045 athletes (32.06%). Conclusion: Basic pre-participation screening tests including 12-lead or exercise electrocardiogram do not safely identify high-risk CAAs. In adolescent athletes an expert cardiologist is able to describe the origin and the proximal course of the coronary arteries and identify major abnormalities in most of the cases by transthoracic 2D-echocardiography.

Kawasaki disease (KD) is an acute vasculitis predominantly affecting the small arteries of young children. Up to 25% of untreated patients suffer from coronary artery (CA) complications. Early diagnosis and treatment is mandatory in incomplete KD to reduce the risk of coronary involvement. Between 2002 and 2018, 124 patients have been diagnosed suffering from KD at the University Children’s Hospital Regensburg (KUNO). We assessed luminal diameters of both CAs normalized as Z-scores by 2D-echocardiography. A total of 94 patients were analyzed. Of them, 31 (33%) were affected by an incomplete form of KD. In 24 children (26%), serial echocardiography was necessary in order to confirm diagnosis. Mean Z-scores for the left main coronary artery (LMCA), right main coronary artery (RMCA), and left anterior descending artery increased significantly between the initial (LMCA 0.79z, RMCA 0.15z, LAD 0.49z) and second (LMCA 1.69z, RMCA 0.99z, LAD 1.69z) examination (p < 0.05).Conclusion:To confirm diagnosis of KD, it might not be necessary to detect dilation or aneurysms. Our observation suggests that patients suspected having KD should be monitored with serial echocardiography in order to detect a possible enlargement of the CA diameters, even if Z-scores are within the normal range. What is Known:• Kawasaki disease (KD) is an acute vasculitis predominantly affecting the small arteries of young children. Up to 25% of untreated patients suffer from coronary artery (CA) complications.• Due to less classic clinical criteria in patients with incomplete KD, the risk for CA pathology is even higher. What is New:• A significant progression of patients’ CA Z-scores in serial echocardiographic measurements may be helpful to ensure diagnosis of KD early even if Z-scores are within the normal range.• Twenty-seven patients (90%) with incomplete KD could be diagnosed within 10 days of fever, early enough to prevent significantly higher rates of CA aneurysm.

Paediatric athletes are not simply ‘mini adults’. Most existing recommendations for cardiac screening in paediatric athletes are primarily based on evidence in adults and are designed for adult athletes. Paediatric-specific recommendations are needed due to the specifics of cardiac physiology, maturation and growth, age-related disease expression, modified diagnostic pathways, training adaptations, and to address relevant ethical considerations. This clinical consensus document from the European Association of Preventive Cardiology (EAPC) of the ESC and the Association for European Paediatric and Congenital Cardiology (AEPC) introduces specific advice for paediatric athletes for the first time, based on expert consensus, and where available, data from paediatric athlete populations. Members of the writing group voted anonymously on key advice statements, with ≥80% agreement required for consensus. All advice in this document applies to paediatric athletes aged <16 years, including those under 12 years of age. This document advises that cardiac screening of paediatric athletes with personal and family medical history, physical examination and 12-lead resting electrocardiogram (ECG) should be performed and should start no later than the age of 12 years. Implementing a screening programme requires ensuring the availability of necessary healthcare resources. One transthoracic echocardiogram may be appropriate to identify high-risk structural cardiac diseases not identifiable on ECG, provided appropriate infrastructure for baseline diagnostic assessments is in place. This document also includes suggested definitions of normal, borderline and abnormal ECG findings in paediatric athletes. Detailed advice is provided for further evaluation if suspicious findings are identified on initial tests. This document highlights that further research is required to optimise screening strategies, accurately assess and quantify the risk of sudden cardiac death and provide evidence-based eligibility recommendations for paediatric athletes with cardiac disease. It is also noted that increased opportunities for paediatric sports cardiology training are required to provide adequate medical care for the paediatric athlete population.

Recent studies showed contrasting findings in morphological changes due to competitive soccer in adolescent players (SP). We present a prospective study in 315 consecutive adolescent (10–14 years) male elite SP and 53 healthy matched active controls (CON). All participants underwent a complete transthoracic two-dimensional echocardiography (TTE). The mean age in SP was 12.8 ± 0.65 years compared to 12.6 ± 0.8 years in CON. For all left ventricular (LV) dimensions, mean Z-score values were higher in SP. There was a significant Z-score increase in interventricular septum diastolic diameter (2.47z vs. 1.62z, p < 0.05), left ventricular posterior wall diastolic and systolic diameter (1.15z vs. 0.47z, p < 0.05 and 1.05z vs. − 0.4z, p < 0.05). Athletes had significant greater LV mass indexed for BSA (94 ± 12 g/m² vs. 81 ± 13 g/m², p < 0.05). There was no significant difference in LV function or diameters. Conclusion: Our findings suggest that elite soccer training in adolescent male is a type of sport predominantly related to cardiac resistance remodeling. Adolescent SP may develop supernormal left ventricular wall dimensions (+ 2.0 to + 2.5z). If in SP Z-scores, any LV dimension above + 2.5 is measured, primary or secondary cardiomyopathies should be excluded. What is Known:• Morphological cardiac adaptation in response to exercise depends on the type, duration, and intensity of training.• Morphological and functional changes due to competitive sports (athlete’s heart) occur even in pre-adolescent athletes. What is New:• Our findings point out that German elite soccer training in adolescent male (10–14 years of age) is a type of sport predominantly related to cardiac resistance remodeling.• If in an adolescent competitive soccer player any LV dimension Z-score value above + 2.5 is measured, a primary or secondary cardiomyopathy should be excluded.