Invited Commentary The specialty of adult congenital heart disease

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ver the last three decades, adults with congenital heart disease (ACHD) have become one of the fastest growing populations of adults with chronic heart disease. Despite significant progress in laying the foundations to meet the rising care needs for ACHD patients, limited access to care and suboptimal data are impediments to continued progress. The successes of pediatric cardiologists and surgeons have permitted individuals with conditions that previously would have been lethal in childhood to live and thrive well into adulthood. This fact, in combination with improvements in imaging technology permitting identification of clinically silent lesions, has led to rapid growth in the numbers of patients with ACHD in the general population (1, 2). This success, however, has created a unique challenge to the field of cardiology. Adult cardiologists are not required by the Accreditation Council for Graduate Medical Education (ACGME) to have specific training in caring for patients with congenital heart disease. As a result, most adult cardiologists lack adequate familiarity with congenital cardiac problems to provide optimal care. ACGME requirements for pediatric cardiology training, in contrast, focus on congenital heart disease and require fellows to have experience specifically in ACHD. Nevertheless, pediatric cardiologists have limited exposure to cardiologic issues common in adult patients, such as coronary vascular disease or the cardiovascular effects of cocaine abuse, for example. In recognition of the need for a uniquely trained cadre of individuals to care for this population, the ACGME has recently created a training pathway for ACHD, open to both pediatric and adult cardiologists, and ACHD is now recognized as a subspecialty of both pediatric and adult cardiology. In addition, the most recent guideline statement from the American College of Cardiology and American Heart Association on the management of patients with ACHD recommends that patients with all but the most simple of lesions be evaluated by ACHD specialists (3). The benefits of these recommendations were demonstrated in a recent population-based study from Quebec, Canada, in which referrals for ACHD specialty care resulted in decreased mortality rates (4). As rates of hospitalization and inpatient care costs among ACHD patients continue to grow and the ACHD population ages, the importance of access to ACHD-trained practitioners will increase (5–8). To meet the growing needs to serve the ACHD population, more ACHD-trained specialists are needed. In 2009, there were just over 2000 board-certified or -eligible pediatric cardiologists in the United States (9). In contrast, only approximately 200 examinees sat for the first ACHD board exam in October 2015. In the US and Canada, however, it is estimated there are now more adults than children living with congenital heart disease (2, 3).

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In addition to meeting the growing demand for clinical care, more ACHD specialists are needed to broaden the therapeutic options available to improve outcomes in this unique population. The few well-conducted, randomized, placebocontrolled trials in ACHD have failed to demonstrate the efficacy of modern neurohumoral modulation in improving outcomes in ACHD patients (10–16). Although these failures may indicate inefficacy of the tested medications, trends present in these studies suggest that patient heterogeneity and inadequate study power may have contributed to their failure. Continued progress demands cooperation between providers to optimize patient recruitment and to identify novel ACHDspecific outcomes with greater sensitivity to clinical changes in this population. It is essential that adult cardiologists make good on the promises implied by the successes of our pediatric colleagues, to improve quality and quantity of life for ACHD patients. To achieve this goal, the cardiology community must encourage fellowship training in ACHD, increase cooperation between providers, and increase awareness of the importance of diseasespecific care. In this way we can continue to make a major difference in the lives of some of the greatest medical success stories of the last century. —Ari M. Cedars, MD Baylor University Medical Center at Dallas E-mail: [email protected] 1.

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Marelli AJ, Mackie AS, Ionescu-Ittu R, Rahme E, Pilote L. Congenital heart disease in the general population: changing prevalence and age distribution. Circulation 2007;115(2):163–172. Marelli AJ, Ionescu-Ittu R, Mackie AS, Guo L, Dendukuri N, Kaouache M. Lifetime prevalence of congenital heart disease in the general population from 2000 to 2010. Circulation 2014;130(9):749–756. Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, del Nido P, Fasules JW, Graham TPJr, Hijazi ZM, Hunt SA, King ME, Landzberg MJ, Miner PD, Radford MJ, Walsh EP, Webb GD, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American Society of Echocardiography; Heart Rhythm Society; International Society for Adult Congenital Heart Disease; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease. J Am Coll Cardiol 2008;52(23):e143–e263. Mylotte D, Pilote L, Ionescu-Ittu R, Abrahamowicz M, Khairy P, Therrien J, Mackie AS, Marelli A. Specialized adult congenital heart disease care: the impact of policy on mortality. Circulation 2014;129(18):1804–1812. Opotowsky AR, Siddiqi OK, Webb GD. Trends in hospitalizations for adults with congenital heart disease in the U.S. J Am Coll Cardiol 2009;54(5):460–467.

Proc (Bayl Univ Med Cent) 2016;29(2):174–175

6.

O’Leary JM, Siddiqi OK, de Ferranti S, Landzberg MJ, Opotowsky AR. The changing demographics of congenital heart disease hospitalizations in the United States, 1998 through 2010. JAMA 2013;309(10):984– 986. 7. Tutarel O, Kempny A, Alonso-Gonzalez R, Jabbour R, Li W, Uebing A, Dimopoulos K, Swan L, Gatzoulis MA, Diller GP. Congenital heart disease beyond the age of 60: emergence of a new population with high resource utilization, high morbidity, and high mortality. Eur Heart J 2014;35(11):725–732. 8. Afilalo J, Therrien J, Pilote L, Ionescu-Ittu R, Martucci G, Marelli AJ. Geriatric congenital heart disease: burden of disease and predictors of mortality. J Am Coll Cardiol 2011;58(14):1509–1515. 9. Rodgers GP, Conti JB, Feinstein JA, Griffin BP, Kennett JD, Shah S, Walsh MN, Williams ES, Williams JL. ACC 2009 survey results and recommendations: addressing the cardiology workforce crisis. A report of the ACC Board of Trustees Workforce Task Force. J Am Coll Cardiol 2009;54(13):1195–1208. 10. Babu-Narayan SV, Uebing A, Davlouros PA, Kemp M, Davidson S, Dimopoulos K, Bayne S, Pennell DJ, Gibson DG, Flather M, Kilner PJ, Li W, Gatzoulis MA. Randomised trial of ramipril in repaired tetralogy of Fallot and pulmonary regurgitation: the APPROPRIATE study (Ace inhibitors for Potential PRevention Of the deleterious effects of Pulmonary Regurgitation In Adults with repaired TEtralogy of Fallot). Int J Cardiol 2012;154(3):299–305. 11. Norozi K, Bahlmann J, Raab B, Alpers V, Arnhold JO, Kuehne T, Klimes K, Zoege M, Geyer S, Wessel A, Buchhorn R. A prospective, randomized, double-blind, placebo controlled trial of beta-blockade in patients who

April 2016

12.

13.

14.

15.

16.

have undergone surgical correction of tetralogy of Fallot. Cardiol Young 2007;17(4):372–379. van der Bom T, Winter MM, Bouma BJ, Groenink M, Vliegen HW, Pieper PG, van Dijk AP, Sieswerda GT, Roos-Hesselink JW, Zwinderman AH, Mulder BJ. Effect of valsartan on systemic right ventricular function: a double-blind, randomized, placebo-controlled pilot trial. Circulation 2013;127(3):322–330. Dos L, Pujadas S, Estruch M, Mas A, Ferreira-González I, Pijuan A, Serra R, Ordóñez-Llanos J, Subirana M, Pons-Lladó G, Marsal JR, García-Dorado D, Casaldàliga J. Eplerenone in systemic right ventricle: double blind randomized clinical trial. The EVADES study. Int J Cardiol 2013;168(6):5167–5173. Schuuring MJ, Vis JC, van Dijk AP, van Melle JP, Vliegen HW, Pieper PG, Sieswerda GT, de Bruin-Bon RH, Mulder BJ, Bouma BJ. Impact of bosentan on exercise capacity in adults after the Fontan procedure: a randomized controlled trial. Eur J Heart Fail 2013;15(6):690–698. Galiè N, Beghetti M, Gatzoulis MA, Granton J, Berger RM, Lauer A, Chiossi E, Landzberg M; Bosentan Randomized Trial of Endothelin Antagonist Therapy-5 (BREATHE-5) Investigators. Bosentan therapy in patients with Eisenmenger syndrome: a multicenter, double-blind, randomized, placebo-controlled study. Circulation 2006;114(1):48–54. Hebert A, Mikkelsen UR, Thilen U, Idorn L, Jensen AS, Nagy E, Hanseus K, Sørensen KE, Søndergaard L. Bosentan improves exercise capacity in adolescents and adults after Fontan operation: the TEMPO (Treatment With Endothelin Receptor Antagonist in Fontan Patients, a Randomized, Placebo-Controlled, Double-Blind Study Measuring Peak Oxygen Consumption) study. Circulation 2014;130(23):2021–2030.

The specialty of adult congenital heart disease

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Invited Commentary: The specialty of adult congenital heart disease.

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