CCT may be used if CMR is not feasible and to evaluate cross-sectional imaging status post-stent therapy for coarctation of the aorta; the frequency should be weighed against radiation exposure. 6-minute walk test or CPET, depending on the clinical indication. ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; CMR, cardiovascular magnetic resonance imaging; CoA, coarctation of the aorta; CPET, cardiopulmonary exercise; ECG, electrocardiogram; and TTE, transthoracic echocardiogram. CLINICAL STATEMENTS AND GUIDELINES extremity/lower extremity blood pressure gra- dient and echocardiography Doppler gradient as defined above, and anatomic evidence of CoA. Multiple factors help determine whether surgery or stenting is optimal, including anatomic features such as proximity of native coarctation to head and neck vessels or concomitant aneurysm, and, if stenting, whether a covered stent is needed. 7. The long-term complications of CoA are gener- ally related to chronic upper body systemic hyper- tension, therefore, systemic hypertension should be identified by resting, ambulatory, or exercise blood pressure assessment and medical treatment should follow GDMTS4.2.6-13,S4.2.6-25 8. Balloon angioplasty alone is associated with a higher rate of intimal tears and aneurysm forma- tion compared with stent placement. 4.3. Right-Sided Lesions 4.3.1. Valvular Pulmonary Stenosis Recommendations for Valvular Pulmonary Stenosis Referenced studies that support recommendations are summarized in Online Data Supplement 39. COR LOE Recommendations I B-NR In adults with moderate or severe valvular pulmonary stenosis and otherwise unexplained symptoms of HF, cyanosis from interatrial right-to-left communication, and/ or exercise intolerance, balloon valvuloplasty I B-NR In adults with moderate or severe valvular pulmonary stenosis and otherwise unexplained symptoms of HF, cyanosis, and/ or exercise intolerance who are ineligible for or who failed balloon valvuloplasty, surgical repair is recommendedS4.3.1-1,S4.3.1-5 S4.3.1-8 IIa C-EO In asymptomatic adults with severe valvular pulmonary stenosis, intervention is reasonable. 