Two young athletes with Tetralogy of Fallot-stress echocardiography in therapeutic decision-making: a case report.

Background: The surveillance of athletes with congenital heart disease remains challenging despite recent recommendations. Stress echocardiography as a diagnostic tool is not yet part of the routine follow-up but has emerged as an innovative approach to assess cardiac reserve and exercise capacity. It can unmask cardiac exercise pathophysiology and hence inform decision making for repeat interventions in athletes with complex congenital heart disease. Case summary: This case report describes two athletes with Tetralogy of Fallot who, despite similar conditions, exhibit different cardiovascular risks. Their above average exercise capacity masks early cardiac deterioration, underscoring the limitations of cardiopulmonary exercise testing in assessing myocardial function. Stress echocardiography revealed severe biventricular dyssynchrony in one athlete, playing a major role in decision-making to perform a pulmonary valve replacement (PVR). Post transcatheter PVR, improved left ventricular-right ventricular synchrony was seen at rest and during exercise stress echocardiography. Conclusion: In athletes with congenital heart disease (CHD), disease worsening might be masked by above-normal exercise capacity, and detailed assessment, including cardiopulmonary exercise testing and exercise echocardiography, might be needed to detect underlying pathophysiology and hence guide the therapeutic approach. Two-strain during exercise echocardiography can be used to quantify cardiac function but also decipher interventricular dyssynchrony in CHD.