Paving the Way for Integrated Advanced Heart Failure and Adult Congenital Heart Disease Training

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H eart failure (HF) is the leading cause of morbidity and mortality in adults with congenital heart disease (CHD). 1 However, compared to patients with acquired HF, the adult CHD (ACHD) population of patients with HF is unique and includes those with complex forms of CHD, systemic right ventricles, and single ventricle anatomy with Fontan palliation.Additionally, patients with ACHD and HF are less likely to be treated with advanced HF therapies, including durable mechanical circulatory support or heart transplant. 2 This may be in part due to the under-recognition of the unique indications for transplant in the ACHD population, and lack of dedicated training in ACHD HF during adult advanced HF transplant cardiology (AHFTC) fellowship.3 While general Accreditation Council for Graduate Medical Education (ACGME) milestones in HF training for all ACHD fellows-in-training (FITs) have been outlined, given the growing number of ACHD HF patients with medical, anatomic, and surgical complexity, there is a need to train an ACHD HF physician workforce to provide tailored care for this emerging population.Though there have been prior calls for cross disciplinary training 3 and "sub-subspecialization" in an area of ACHD during training, 4 to date no clear roadmap exists for training in ACHD HF.It is possible to pursue a third fellowship in HF (Figure 1A, top), and a specific ACHD "circulatory failure" fellowship has been proposed; 5 however, these all require an additional year of training in an already lengthy pathway.Other cardiology subspecialties have formalized competency-based training pathways which can reduce training time, 6 though a similar pathway for HF and ACHD does not exist.Authors W.H.M.V. and R.D.B. have had the opportunity to integrate HF training within their ACHD training time (Figure 1A, bottom) and would like to share those pathways and disseminate developed curricula to help others aspiring to train in this important and developing field.Although competency-based milestones exist for ACHD and AHFTC training, due to time-based requirements, it is not possible to become certificated in ACHD and AHFTC without completing both fellowships (Figure 1A, top).While some may chose this pathway, another solution is to train a physician workforce with complementary skillsets, where an ACHD physician can serve as a "bridge" between the ACHD and HF/transplant teams to optimize medical therapy and streamline the assessment of ACHD patients for advanced HF therapies.To accomplish this, author W.H.M.V. and colleagues developed and implemented a competency-based curriculum for

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