Advances in medical and surgical care have produced remarkable improvements in the survival of children with congenital heart disease (CHD); around 90% of children with CHD now reach adulthood . The number of adults with CHD now exceeds the number of children with CHD, and is estimated to be > 1–2 million in the USA and 2–3 million in Europe . Many of these adult patients develop late cardiac and extracardiac complications . Lapses in care affect patient management, and may occur during the time of transition from a specialized paediatric CHD centre to an adult CHD (ACHD) centre, which is, nevertheless, highly recommended ( Fig. 1 ). In Quebec, Mylotte et al. reported a significant reduction in mortality when patients were referred to specialized ACHD centres ( Fig. 2 ) . In response to the increasing population, ACHD has been recognized as a specialty, and training has been integrated into the cardiovascular fellowship ( Fig. 3 ). However, the number of ACHD specialists is inadequate . The European Society of Cardiology (ESC) Working Group on Grown-up Congenital Heart Disease (GUCH) has detailed the staff requirements for a specialized ACHD centre ( Table 1 ) . Only specialized centres can provide cardiac and extracardiac medical and surgical skills, and gather cohorts of patients, to ensure the triple mission of adequate care, research and training.
| Adult/paediatric cardiologist with GUCH certification | At least 2 |
| GUCH imaging specialist with GUCH certification | At least 2 |
| Congenital invasive cardiologist | At least 2 |
| CHD surgeon | At least 2 |
| Anaesthesiologist with CHD experience and expertise | At least 2 |
| Invasive electrophysiologist with GUCH experience | At least 1 |
| Psychologist | At least 1 |
| Social worker | At least 1 |
| Cardiovascular pathologist | At least 1 |
Training in ACHD varies according to countries and continents. The International Society for Adult Congenital Heart Disease (ISACHD) reported results from a survey of ACHD fellows from 24 different countries . The mean rating for satisfaction with their training in CHD was 3.11/5, and was clearly insufficient (2/5) for training related to advanced imaging modalities (computed tomography and magnetic resonance imaging); 40% of responders defined their training as “stressful”. Indeed, training in ACHD involves a wide range of diagnostic and therapeutic methods used in the care of adults with CHD, including direct experience in echocardiography, magnetic resonance imaging, computed tomography, diagnostic catheterization, electrophysiology and exercise testing. The American Board of Medical Specialities has recognized ACHD as a separate subspecialty of cardiology, and has issued guidelines for ACHD training . This ACHD fellowship training is a 24-month commitment, including full-time clinical training and 6 months of elective clinical or research experience. The trainee should spend 9–12 months on inpatient service and/or ACHD consultative service, 3 months on ACHD imaging (including echocardiography and cardiac magnetic resonance imaging), 2 months on cardiac catheterization and 1 month in the intensive care unit caring for postoperative patients. The ESC Working Group on GUCH also recommends a training period of 24 months, and has quantified the experience required for qualification in ACHD ( Table 2 ) . However, the gaps in knowledge and experience differ between adult and paediatric cardiologists. The American Academy of Pediatrics and the American Heart Association has published recommendations for including CHD training in both paediatric and adult cardiology fellowships : trainees with a paediatric cardiology background should spend 2 months taking care of ACHD inpatients, and those with an adult cardiology background should spend 2 months with paediatric CHD patients. Specific knowledge in ACHD must be acquired during training in women’s contraception and pregnancy, participation in sports and exercise, psychosocial aspects and legislative aspects of employment and advocacy . It is important for fellows to know when to refer ACHD patients to non-ACHD medical expertise, including the fields of general internal medicine, obstetrics, gynaecology, nephrology, hepatology, haematology and psychiatry. Specific exposure to multidisciplinary teams caring for ACHD should be emphasized.
