ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; CMR, cardiovascular magnetic resonance imaging; CPET, cardiopulmonary exercise test; CXR, chest x-ray; ECG, electrocardiogram; and TTE, transthoracic echocardiogram. CLINICAL STATEMENTS AND GUIDELINES pathways is beyond the scope of these guide- lines but can be found elsewhere, such as the PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in 7. Systemic desaturation and arrhythmias are fre- quently signs of worsening hemodynamics, pro- gressive TR, or worsening RV function. Surgery for the tricuspid valve as well as closure of the ASD or stretched patent foramen ovale and ar- rhythmia surgery can be beneficial. When ar- rhythmia surgery is required, it typically involves a modified right atrial maze procedure. In the pres- ence of AF, the addition of a left atrial Cox Maze III procedure can be beneficial to reduce the risk of recurrent AF. 8. The use of the bidirectional cavopulmonary shunt is much more common in children than in adults. When it is applied in the adult, it is usu- ally reserved for patients with severe RV dysfunc- tion with concern that the right ventricle will not tolerate supporting the entirety of stroke Preoperative catheterization to determine hemodynamics and feasibility of applying the bidirectional cavopulmonary shunt becomes progressively more important in older patients, particularly those with longstanding hy- pertension with LV hypertrophy, which can lead to diastolic dysfunction and elevated pulmonary pressures. 4.3.5. Tetralogy of Fallot Recommendations for TOF Referenced studies that support recommendations are summarized in Online Data Supplement 43. (See Section 4.3.6. for recommendations regarding evaluation and management of right ventricle to-PA conduits.) 