Indications and clinical applications for stress echocardiography in adults with congenital heart disease

Background Stress echocardiography is an established tool to guide clinical decision-making in adults with acquired heart disease. However, its utility in adult congenital heart disease (ACHD), a population requiring lifelong follow-up, particularly after childhood intervention, is not well documented and is not included in most major ACHD guidelines. Purpose To assess the indications and clinical impact of stress echocardiography in a contemporary ACHD population. Methods In this retrospective study we analysed consecutive patients, aged >16 years referred for stress echocardiography at our tertiary centre between January 2015 and December 2025 (n=369). Indications, stress and echocardiographic parameters, reasons for test termination, and impact on clinical management were recorded. Results Subjects were aged 43±16 years and 53.9% were female. Underlying diagnoses included left heart obstructive lesions (29.3%), complex CHD (28.7%), shunt lesions (21.7%), congenital coronary anomalies (8.4%), and right heart obstructive lesions (4.9%). Prior surgical repair was present in 70.2%, including repeat surgery in 29.3%, and 18.2% had prior percutaneous intervention. Sinus rhythm was present in 92.1%. Common indications were assessment of inducible ischaemia (40.7%), aortic stenosis severity (13.8%), right ventricular contractile reserve (11.9%), left ventricular contractile reserve (9.5%), and pulmonary stenosis severity (6.5%). Treadmill testing was performed in 60.2% (10.3±3.9 METS), semi-supine bicycle in 36.6% (99±34 Watts), and dobutamine stress in 3.3% (peak dose 30 µg/kg/min), achieving 85±15% of predicted target heart rate. ST depression occurred in 8.2%, occasional and frequent ventricular ectopy in 14.4% and 7.6%, respectively, and sustained ventricular arrhythmia requiring defibrillation in one patient. Tests were most commonly terminated due to fatigue (31.7%), dyspnoea (27.7%), or target heart rate achievement (20.3%). In those referred for inducible ischemia 2.7% showed a positive result, aortic stenosis gradient became significant in 23.5% and pulmonary stenosis gradient significant in 50% for each respective indication. Clinical management changed in 41.7% of cases (Figure 1), including initiation of new medication (10.6%), referral for congenital surgery (10%), congenital percutaneous intervention (7.6%), advanced imaging (6.8%), electrophysiology review (2.7%), coronary angiography (1.1%) and cardiac transplantation referral (1.1%). Conclusions Stress echocardiography is feasible in contemporary ACHD populations and provides clinically meaningful information that influences management decisions.