ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; CMR, cardiovascular magnetic resonance imaging; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; PS, pulmonary stenosis; and TTE, transthoracic echocardiogram. CLINICAL STATEMENTS AND GUIDELINES 2. VSD is often present and may communicate with the higher or lower pressure chamber in the right ventricle, with resulting differences in shunt di- rection and flow characteristics. In patients with a severe gradient through the right ventricle, the VSD may be associated with right-to-left shunting if proximal to the obstruction, or associated with left-to-right shunting if distal. Exercise testing performed in a subjectively asymptomatic patient will often be abnormal. Patients may benefit from repair of both the VSD and outflow obstruction, especially if exercise capacity is decreased. 4.3.4. Ebstein Anomaly Recommendations for Ebstein Anomaly Referenced studies that support recommendations are summarized in Online Data Supplement 42. 