CMR may be indicated for assessment of right ventricular function and CHD anatomy not clarified with TTE. Baseline study is recommended with periodic follow-up CMR, with frequency of repeat imaging determined by anatomic and physiological findings. 6-minute walk test or CPET, depending on clinical indication. Cardiac catheterization should be performed at baseline and as needed. ACHD indicates adult congenital heart disease; CMR, cardiovascular magnetic resonance; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; and TTE, transthoracic echocardiogram. CLINICAL STATEMENTS AND GUIDELINES d. Older age at repair. e. Female sex. f. Otherwise unexplained symptoms potentially attributable to PAH (decreased exercise ca- pacity, syncope, chest pain, hemoptysis). g. Findings on clinical examination: systemic ar- terial desaturation, elevated systemic venous pressures, other evidence of fluid retention, loud P2, new TR or PR, new arrhythmia, decreased exercise capacity, electrocardi- ographic findings consistent with subpul- monary ventricular hypertrophy or dilation. Echocardiography may demonstrate subpul- monic ventricular dysfunction and/or enlarge- ment and estimate central venous and PA pressures. However, echocardiography alone is insufficient to accurately determine PA pressure or pulmonary vascular resistance, so echocardiography is best used in conjunction with data obtained at cardiac catheterization when making decisions about instituting or changing therapy for PAH.S4.4.6.1-19 S4.4.6.1-21 3. Cardiac catheterization remains the standard for accurate diagnosis of pulmonary hypertension syndromes and for selection of optimal thera- pies for patients with ACHD with pulmonary hypertension. 4. Mechanical interventions targeting relief of ana- tomic contributors to PAH (eg, closure of septal or great arterial defects to eliminate shunting) may be considered as part of short-term plans of care for patients with ACHD with PAH. However, even modest residual levels of PAH substantially determine intermediate and longer-term out- comes. Patients should be followed for pulmo- nary hypertension. 5. 