Advances in ACHD

August 11, 2015
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Aug 11, 2015 | Jeremy Nicolarsen
Education

With vast improvements in fetal and neonatal diagnosis, surgical techniques and outcomes, and post-operative and long-term care, patients with complex congenital heart defects have been surviving to adulthood at increasing rates.1,2 Currently, there are not enough cardiologists with expertise in adult congenital heart disease (ACHD) to take care of this growing population of patients. To adequately prepare trainees for this task, the field of ACHD has recently undergone three important advances:

New ACHD Fellowship Training Program

Until now, there have been widely variable routes to practicing ACHD medicine. Some providers have no formal training in ACHD, while others have undergone one- or two-year fellowships. In the wake of the American Board of Medical Subspecialties recognizing ACHD as a subspecialty of cardiology in 2012, leaders in the field have created a standardized 24-month fellowship that is expected to be approved by the Accreditation Council for Graduate Medical Education (ACGME) by July 1, 2016.3 Trainees will get exposure to ACHD patients in multiple disciplines, including imaging, electrophysiology, diagnostic/interventional cardiology, and post-operative care, as well as gain experience in pediatric or acquired cardiovascular disease depending on prior training (18 months).4 The fellowship will additionally allow for research and elective time in ACHD (six months).4

Inaugural Certification Examination in ACHD The second advance focuses on recognizing cardiologists who provide exceptional care and certifying them as ACHD subspecialists. In October 2015, the inaugural ACHD subspecialty examination will be offered by the American Board of Internal Medicine (ABIM). The certification examination will be offered every other year. For the first three examinations (2015, 2017 and 2019), admission will be offered under two pathways, a Practice Pathway and a Training Pathway.

The Practice Pathway will apply to ABIM Diplomates in Cardiovascular Disease or American Board of Pediatrics (ABP) Diplomates in Pediatric Cardiology who have not completed ACHD training but have completed training in their specific disciplines and can demonstrate that for three out of the last five years they have spent 40 percent of their post-training clinical time (or 25 percent, if an ACHD researcher or program director) in the clinical practice of ACHD medicine and display competence in the field as judged by their hospital’s ACHD program director or department chair. The last non-ACHD-trained cardiologists who will be eligible for the Practice Pathway need to complete training in their respective disciplines by July 1, 2016 to be eligible for the 2019 examination (those who wish to take the certifying examination in 2015 need to have completed their training by July 1, 2012).

The Training Pathway to admission for the 2015, 2017 or 2019 examinations requires completion of training required for certification in Cardiovascular Disease or Pediatric Cardiology, plus 24 months of dedicated ACHD fellowship training (separate from categorical training requirements) OR 12 months of ACHD training after categorical fellowship followed by two years of ACHD clinical experience. The Training Pathway is intended for current and upcoming trainees in ACHD in the timeframe before there are only ACGME-approved 24-month ACHD fellowships.

The Training Pathway, which applies to most active fellows in training interested in ACHD, is explained in more depth on the ABIM website. Two particularly important points are the following:

  • The Training Pathway requires a 12 month ACHD training program to be completed by July 1, 2016 to allow for two years of clinical experience before the 2019 examination. Any 24 month ACHD training program can be followed immediately by the examination as long as it is completed by July 1 before the subsequent examination.
  • The 2021 examination will admit only those who have completed an ACGME-approved 24-month ACHD fellowship, i.e., those starting a 24-month fellowship on July 1, 2018 need to ensure their program is ACGME-approved as their training will not be complete in time for the 2019 examination.

Program Accreditation

The third key advance aims to improve quality and transparency of care via ACHD program accreditation. Formal program accreditation in ACHD should be available by 2016 and will require that ACHD clinics document expertise in ACHD care by providing services that meet all the needs of patients, such as having around-the-clock ACHD expert coverage, access to subspecialists in electrophysiology, interventional cardiology, and advanced imaging, experienced congenital cardiothoracic surgeons, and the infrastructure and support staff necessary to provide exceptional, team-based care.

Future of ACHD Care

Through a standardized fellowship in ACHD, subspecialty board certification, and program accreditation, ACHD is emerging as an important field and will continue to be led by thoughtful, inquisitive, and collaborative cardiologists. For those interested in further details about the ACHD fellowship, ACHD certifying examination, and program accreditation, explore the links below.

Important Links

References

  1. Marelli A, Mackie A, Ionescu-Ittu R, et al. Congenital heart disease in the general population: changing prevalence and age distribution. Circ 2007;115:163-72.
  2. Marelli A, Ionescu-Ittu R, Mackie A, et al. Lifetime prevalence of congenital heart disease in the general population from 2000 to 2010. Circ 2014;130(9):749-56.
  3. Madan P and Kim Y. Training in adult congenital heart disease. J Am Coll Cardiol. 2015;65(20):2254-2256. See also, response from M. Landzberg.
  4. Warnes C, Bhatt, A, Daniels, C, et al. COCATS 4 Task Force 14: Training in the care of adult patients with congenital heart disease. J Am Coll Cardiol. 2015;65(17):1887-1898.

The author would like to express his gratitude to Curt Daniels, MD, FACC for his contributions and guidance to this article.

For more information on this topic visit the ACC In Touch Blog for Dr. Daniel’s thoughts on the future of graduating ACHD fellows.

This post was authored by Jeremy Nicolarsen, a fellow in training at Children’s Hospital Colorado and University of Colorado Health.