Owing to improvements in the management of congenital heart disease (CHD), the number of adults living with a diagnosed, repaired or palliated CHD is increasing constantly. The specificity and the complexity of this population have justified the adaptation of centres performing surgery for CHD and the specification of many “paediatric and congenital cardiologists” also as “adult congenitalists”. On the other hand, it is not uncommon that these patients require surgical and/or interventional procedure(s) during their adult life. Despite the increasing number of centres offering 24-hour access to catheterization staff, imaging staff and surgical staff competent in the management of adult CHD, the debate continues as to who should/can optimally care for such patients when a procedure is justified, and what is the optimal environment?

In 2000, presentations given at the 32nd Bethesda Conference resulted in significant contributions to the management of adult CHD. One recommendation that arose from the meeting was that – with the exception of simple septal defects and isolated valve disease – interventionists and surgeons specialized in CHD should perform procedures for adults with CHD .

It is well known that – in the management of CHD more than anywhere – optimal surgical outcomes are obtained not only through surgical performance, but also with the equivalent contribution of perioperative care, including anaesthesia, cardiopulmonary bypass and postoperative care. Thus, a department that aims to perform procedures for adults with CHD requires not only a surgeon competent in CHD, who is able to deal with often complex and challenging adult patients, but also a perioperative medical environment that meets the specificity and complexity of each particular patient. This is more likely to be a team that is routinely involved in the care of CHD than one focusing on adults with acquired diseases such as ischaemic or degenerative cardiovascular pathologies. Unfortunately, the rarity of adults with CHD requiring surgery and also the regionalization of care do not allow the constitution of a fully dedicated team-centre for this purpose. Two clinical environmental options remain:

• 1.
  

  the same physicians, same “surgery–anaesthesia–postoperative care” team, in a single institution organized for the surgical management of CHD, from birth to old age (the ideal scenario);

  
  
• 2.
  

  if not, a surgeon specialist in CHD practising in a children’s hospital, performing procedures for adults with CHD in a different institution (the most common scenario).

Surgery for adults with CHD is demanding. It requires knowledge of the different historical steps in the surgical management of CHD, the anatomo-pathology of CHD, and also skills necessary to manage conditions such as aortic arch pathology in adults, to repair both arterial and atrio-ventricular valves, to understand the anti-arrhythmic procedures, and to deal with the specific conditions as anatomical variations complicating cardiopulmonary bypass management or long-term consequences of chronic cyanosis. Nowadays, the relative rarity of adults with CHD does not yet justify the attribution of a “label” for that purpose. However, to optimize outcomes and improve experiences, it seems that complex patients and heart transplantation for adults with CHD should better be concentrated towards dedicated surgeons…