A National Survey of Cardiologists on Scope of Practice, Knowledge Gaps, and Educational Priorities in Adult Congenital Heart Disease Care in Canada

Abstract

Background

The increasing number of people with adult congenital heart disease (ACHD) leads to greater involvement of non-ACHD cardiologists in their care. Defining and supporting the educational priorities of non-ACHD cardiologists is key to ensure care of this population.

Methods

Between November 2023 and March 2024, Canadian cardiologists were invited to participate via email and the Canadian Cardiology Society bulletin. They self-identified as ACHD or non-ACHD cardiologists. The survey explored (1) self-identified knowledge gaps of non-ACHD cardiologists, (2) current scope of practice of non-ACHD cardiologists, and (3) ACHD perspectives on the recommended scope of practice of non-ACHD cardiologists. Educational priorities were defined as diagnoses or topics frequently identified as self-identified knowledge gaps or in the current or recommended scope of practice.

Results

A total of 133 of 1263 Canadian Cardiology Society members participated, of whom 32 were ACHD specialists. Thirty-three percent of non-ACHD cardiologists did not have an ACHD specialist on-site, and 24% indicated that there was no ACHD specialist within 100 km. Non-ACHD cardiologists encountered patients with ACHD in the inpatient (42%) and outpatient settings (42%), whereas ACHD cardiologists predominantly encountered outpatients (81%). Frequent self-identified knowledge gaps included great complexity diagnoses and management of pregnancy, arrhythmias, and heart failure. Recommended and current scope of practice involved simple and moderate diagnoses.

Conclusions

Targeted educational resources for non-ACHD cardiologists should initially focus on the identified educational priorities, including simple and some moderate diagnoses, a primer on great complexity diagnoses, acute management of heart failure and arrhythmias, and a primer on pregnancy in patients with ACHD.

Graphical abstract

Over 95% of individuals born with congenital heart disease now survive into adulthood, with approximately 45% having simple diagnoses, 35%-40% moderate complexity diagnoses, and 15%-17% great complexity diagnoses.¹ This growing population of adults with congenital heart disease places strain on specialized adult congenital heart disease (ACHD) services worldwide.² In Canada, the increasing number of patients with ACHD exceeds the capacity of trained ACHD cardiologists despite national and international guideline recommendations for involvement of ACHD specialists.3, 4, 5 Consequently, there is greater involvement of non-ACHD cardiologists in the care of people with ACHD.

In response to this challenge, professional societies such as the Canadian Adult Congenital Heart Network (CACH Net) have proposed several strategies, which include enhancing the education and training of non-ACHD cardiologists. These initiatives aim to better prepare cardiologists to manage this growing patient population across various clinical settings by improving knowledge of congenital cardiac anatomy and pathophysiology, postoperative sequelae, and complications. Importantly, given the distribution of the population and ACHD centers in Canada, non-ACHD cardiologists may have distinct roles in the acute care of patients with ACHD. Consequently, existing educational resources for ACHD cardiologists may not meet the needs of non-ACHD cardiologists. From a practical perspective, tailored resources for non-ACHD cardiologists need to be prioritized based on diagnoses and topics frequently encountered, as it is not feasible for them to acquire the same breadth of expertise as an ACHD specialist. In designing educational resources tailored to non-ACHD cardiologists, the first step is to identify specific educational priorities, which will then inform the development of a tailored ACHD curriculum for non-ACHD cardiologists.

The aim of the survey was to identify the perspectives of both ACHD and non-ACHD cardiologists on educational needs of non-ACHD cardiologists. The findings could be used to inform educational resources, including topics of continuing medical education, conferences, and virtual modules, as well as objectives of training for cardiology residents.

Methods

We conducted online, cross-sectional surveys (Qualtrics, Provo, UT). Canadian ACHD and non-ACHD cardiologists were invited to participate in an electronic survey between November 2023 and March 2024. All Canadian Cardiology Society (CCS) members (n = 1263) had access to the invitation on the CCS bulletin board. All CACH Net members (n = 84) were emailed the invitation. In recognizing the variable engagement in the CCS bulletin board, CACH Net members also emailed the invitation to their non-ACHD colleagues. Surveys were anonymous, and unique participation was ensured through the registration of Internet Protocol addresses. Participants were compensated with a CAD$25 gift card. This survey received approval from the Western University Research Ethics Board (REB 123469).

Survey design

In approaching survey design, we used 3 metrics to define educational priorities: (1) self-identified knowledge gaps of non-ACHD cardiologists, (2) current scope of practice of non-ACHD cardiologists, and (3) recommended scope of practice of non-ACHD cardiologists by ACHD cardiologists.

We designed 2 surveys: one for non-ACHD cardiologists and one for ACHD cardiologists. Both surveys (Supplemental Appendix S1) were created by ACHD experts. We included all ACHD lesions listed in the 2018 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines.⁴ We included additional topics related to ACHD based on the 2018 AHA/ACC guidelines, including endocarditis prophylaxis, assessing atherosclerotic risk, providing exercise recommendations, diagnosis and management of arrhythmias, diagnosis and management of heart failure, care of patients with cyanosis, transition to adult care, referral to ACHD specialists, indications for percutaneous interventions, indications for surgical interventions, counseling on risks of pregnancy, and management of pregnant patients with congenital heart disease. Participants self-identified at the beginning of the survey as non-ACHD or ACHD cardiologists.

Survey for non-ACHD cardiologists

This survey contained 5 sections. The first section was on demographics, including gender. Participants were asked to self-report their gender, with the following options: male, female, nonbinary/third gender, prefer not to say, or an open text box for customization. Additional demographic information requested included the province of practice, years in practice, clinical focus of practice (ie, electrophysiology, imaging expertise, and heart failure), percentage of clinical time in outpatient setting, percentage of clinical time in university-affiliated setting, presence of ACHD specialists at their center, and distance from ACHD specialists if no ACHD specialists on site. The second section collected the current scope of practice relating to patients with ACHD including the average number of patients with ACHD annually. Isolated bicuspid aortic valve (BAV) was excluded only from this number given its high prevalence. Participants indicated the percentage of their practice dedicated to ACHD care, whether they refer patients with ACHD for percutaneous or surgical procedures, whether they provide perioperative recommendations for non-cardiac surgery, and the setting in which they typically assess patients with ACHD. The third section also focused on current scope of practice by collecting data on diagnoses and topics they encountered at least annually. We followed the classification in the 2018 AHA/ACC guidelines.⁴ In doing so, we included all ACHD diagnoses, including isolated BAV. The fourth section collected data on self-identified knowledge gaps by asking the diagnoses and topics they needed to learn more about during cardiology training to prepare them for practice. The fifth section asked participants to provide a free text response indicating the top 3 diagnoses or topics that should be included in educational resources.

Survey for ACHD cardiologists

This survey contained 4 sections. The first section focused on demographics encompassing gender (using the same question as in the non-ACHD cardiologist survey), province of practice, years in practice, percentage of time in outpatient setting, and percentage of time in university-affiliated setting. The second section collected the extent of exposure to patients with ACHD including the average number of patients with ACHD annually (excluding patients with isolated BAV), how much of their practice involves assessing patients with ACHD, whether they refer patients with ACHD for percutaneous procedures or surgical procedures, whether they provide perioperative recommendations for non-cardiac surgery, and the setting in which they typically assess patients with ACHD. The third section collected data on the recommended scope of practice of non-ACHD cardiologists by asking which diagnoses and topics ACHD cardiologists deemed should be independently managed by a non-ACHD cardiologist. The listed diagnoses and topics were the same as listed in the survey for non-ACHD cardiologists. Similar to the non-ACHD cardiologist survey, the final section asked participants to provide a free text response outlining the top 3 diagnoses or topics that should be included in educational resources.

Analysis

Descriptive statistics were calculated for demographic characteristics, clinical exposure, practice patterns, and self-identified educational needs. Nominal and categorical variables were expressed as absolute numbers or percentages. Continuous variables are presented as median (interquartile range [IQR]).

We defined an educational priority as a diagnosis or topic frequently identified as a self-reported knowledge gap, or frequently encountered in current or recommended practice. In doing so, we first calculated the average frequency of participants reporting a diagnosis or topic for each metric (non-ACHD self-identified knowledge gaps, non-ACHD current scope of practice, and recommended scope of practice by ACHD cardiologists). This average frequency served as the threshold for each metric. Because the metrics were analyzed separately, the numerical thresholds for defining educational priorities were different for each metric. Diagnoses and topics meeting or exceeding the average frequency threshold within a given metric were considered frequent enough to be considered an educational priority for a targeted curriculum.

Analyses were conducted using IBM SPSS Statistics (version 26; IBM SPSS, Chicago, IL).

Results

The online survey was completed by 133 Canadian cardiologists from 9 provinces between November 2023 and March 2024 (Supplemental Table S1). The survey invitation was viewed by up to 1347 Canadian cardiologists (non-ACHD 1263 and ACHD 84). Of these, 101 identified as non-ACHD cardiologists (response rate 8%), and 32 as ACHD cardiologists (response rate 38%). This section presents the data relating to non-ACHD cardiologists, followed by data relating to ACHD cardiologists and a summary of educational priorities.

Non-ACHD cardiologists

Characteristics of non-ACHD cardiologists

Non-ACHD cardiologists identified most frequently as general cardiologists (39%) or cardiologists with imaging expertise (25%). In terms of career stage, 36% of the respondents had been in practice for >10 years, and 27% were in their first years of practice, with most respondents (77%) practicing in university-affiliated settings (Table 1). Notably, 33% of non-ACHD cardiologists lacked on-site ACHD subspecialty services, and 24% reported no ACHD support within 100 km. Non-ACHD cardiologists reported that they spent 46% of their clinical time assessing patients in the outpatient setting (Table 1).

Table 1.

Demographics

	Non-ACHD cardiologists (%) (n = 101)	ACHD cardiologists (%) (n = 32)
Gender
Female	27	31
Subspecialty
ACHD		100
General cardiology	39
Cardiac imaging	25
Electrophysiology	10
Interventional	10
Advanced heart failure	4
Prevention/rehabilitation	2
Other	10
Percent of time in university-affiliated setting	77	86
Percent of time in outpatient setting	46	45
Duration of practice (y)
<2	27	13
3-5	22	6
6-10	15	21
>10	36	60
Do not have ACHD support on site	33	–
>100 km from an ACHD specialist	24	–
Location where patients with ACHD are assessed
General cardiology clinic	42	16
Specialty outpatient clinic	16	81
Inpatient service	42	3
Inpatient ward∗	69	100
Inpatient critical care unit∗	31	0

ACHD, adult congenital heart disease.

^∗Percentage of the 42% of inpatient service.

Self-identified knowledge gaps

The average response of any diagnosis or topic recognized as a knowledge gap by non-ACHD cardiologists was 37%. Consequently, diagnoses and topics reported by ≥37% of respondents were classified as frequently cited knowledge gaps and represented an educational priority.

Frequent self-identified knowledge gaps included adults living with Fontan circulation (55%), followed by unrepaired partial anomalous pulmonary venous connection (51%) and aortopathies (50%), as well as repaired transposition of the great arteries (atrial switch = 48% and arterial switch = 47%) (Fig. 1) (Supplemental Table S2). Notably, these lesions are all moderate or great complexity lesions. The 5 most frequently identified topics for further education by non-ACHD cardiologists were the management of congenital heart disease patients during pregnancy (54%), arrhythmia management (51%), exercise recommendations (50%), heart failure management (50%), and counseling around risks of pregnancy (49%) (Supplemental Table S2 and Fig. S1).

Figure 1.

ACHD diagnoses and topics identified as educational priority (red). The priority diagnoses and topics are based on the frequently reported self-identified knowledge gaps and the current or recommended scope of practice of non-ACHD cardiologists. ACHD, adult congenital heart disease; ASD, atrial septal defect; AVSD, atrioventricular valve defect; BAV, bicuspid aortic valve; ccTGA, congenitally corrected transposition of great arteries; PAPVC, partial anomalous pulmonary vein connection; PDA, patent ductus arteriosus; PS/PR, pulmonary stenosis/pulmonary regurgitation; TGA, transposition of great arteries; VSD, ventricular septal defect.

Current scope of practice

The exposure to patients with ACHD (excluding isolated BAV) among non-ACHD cardiologists represented a median of 5% (IQR: 3%-10%) of their current practice. Non-ACHD cardiologists encounter patients with ACHD with similar percentages in inpatient settings (42%) and general cardiology clinic (42%) (Table 1). Inpatients with ACHD were generally encountered by non-ACHD cardiologists when admitted to a ward environment (69%) or acute care unit (31%). Twenty-nine percent of non-ACHD cardiologists report providing perioperative recommendations for non-cardiac surgery. With respect to referrals, 44% of non-ACHD cardiologists refer patients for surgical procedures and 71% refer patients for percutaneous procedures.

Nearly half (48%) of non-ACHD cardiologists assess simple ACHD lesions annually, whereas 33% report encountering moderate lesions, and 12% encounter great complexity lesions annually. The average frequency of any diagnosis or topic encountered by non-ACHD cardiologists was 32%. Therefore, a threshold of ≥32% was used to define diagnoses and topics as frequently encountered in this category, which represent educational priorities. Frequently encountered diagnoses include simple and moderate lesions. Simple lesions encompass repaired (83%) and unrepaired (70%) secundum atrial septal defects, as well as unrepaired (55%) and repaired (52%) ventricular septal defects (Supplemental Fig. S2). Among the moderate lesions, the frequently reported were isolated BAV (97%), aortopathies (65%), coronary anomalies (54%), aortic coarctation (44%), tetralogy of Fallot (39%), and Ebstein anomaly (34%) (Supplemental Table S2 and Fig. S3). Most topics were addressed annually, with frequent topics being recommendation for endocarditis prophylaxis (74%), referrals to ACHD specialists (63%), and management of arrhythmias (38%) and heart failure (37%).

ACHD cardiologists

Characteristics of ACHD cardiologists

Sixty percent had been in practice for >10 years. ACHD cardiologists reported spending an average of 86% of their clinical time in university-affiliated centers, with 45% of their clinical time assessing patients in the outpatient setting (Table 1).

ACHD cardiologists reported evaluating a median of 309 (IQR: 201-412) patients with ACHD annually. ACHD cardiologists predominantly encounter patients with ACHD in outpatient clinics (81% of patients encountered) and less frequently in inpatient settings (3% of patients encountered).

ACHD perspectives on recommended scope of practice of non-ACHD cardiologists

The average rate at which ACHD cardiologists identified a diagnosis or topic that could be managed by non-ACHD cardiologists was 24%. Thus, any diagnosis or topic identified by ≥24% of respondents was considered to be frequently identified in the recommended scope of practice and represents an educational priority.

ACHD cardiologists frequently identified that most simple congenital heart conditions and some moderate diagnoses could be independently managed by non-ACHD cardiologists (Supplemental Table S2). Among the simple lesions, the most frequently cited were repaired and unrepaired secundum atrial septal defects (94% and 41%, respectively), repaired and unrepaired ventricular septal defects (78% and 47%, respectively), isolated pulmonary stenosis or regurgitation (50%), and patent ductus arteriosus (25%) (Supplemental Fig. S2). For moderate lesions, isolated BAV was most commonly regarded as manageable by non-ACHD cardiologists (91%), followed by repaired partial anomalous pulmonary venous connection (38%), coronary anomalies (34%), coronary fistulas (34%), and aortopathies (34%) (Fig. 2) (Supplemental Fig. S3). Conversely, other moderate diagnoses, including tetralogy of Fallot, Ebstein anomaly, and aortic coarctation, along with all great complexity congenital heart conditions, were rarely considered appropriate for non-ACHD specialists to manage. Frequent topics that could be part of the scope of practice of non-ACHD cardiologists included endocarditis prophylaxis (69%), referrals to ACHD specialists (69%), and atherosclerosis risk stratification (65%) (Fig. 3).

Figure 2.

Contrast between adult congenital heart disease (ACHD) diagnoses encountered by non-ACHD cardiologists and the perspectives of ACHD cardiologists, categorized by complexity classification. The blue line represents the 32% threshold, distinguishing high-frequency diagnoses encountered by non-ACHD cardiologists, and the red line the 24% threshold of ACHD cardiologists’ perspectives. ASD, atrial septal defect; AVSD, atrioventricular valve defect; BAV, bicuspid aortic valve; PAPVC, partial anomalous pulmonary vein connection; PDA, patent ductus arteriosus; PS/PR, pulmonary stenosis/pulmonary regurgitation; TGA, transposition of great arteries; VSD, ventricular septal defect.

Figure 3.

Topics encountered by non-ACHD cardiologists and perspectives of ACHD cardiologists on topics. The blue line represents high-frequency diagnoses and topics in current scope of practice (≥32%), whereas the red line represents high-frequency diagnoses and topics in recommended scope of practice (≥24%). ACHD, adult congenital heart disease.

In terms of suggestions for educational resources, ACHD cardiologists emphasized the management of frequently encountered and simple lesions, including atrial septal defect, ventricular septal defect, and isolated BAV. They also highlighted the need for education on frequently encountered moderate lesions, such as tetralogy of Fallot, and education on current ACHD guidelines.

Educational priorities for a targeted curriculum for non-ACHD cardiologists

Educational priorities were identified in all 3 metrics. Educational priorities based on diagnoses represented in the current and recommended scope of practice include repaired and unrepaired secundum atrial septal defects, repaired and unrepaired ventricular septal defects, patent ductus arteriosus, isolated BAV, aortopathies, and anomalous coronaries (Fig. 1). Although the ACHD group did not recommend Ebstein anomaly and tetralogy of Fallot to be part of the scope of practice of non-ACHD cardiologists, these conditions were identified as an educational priority by non-ACHD cardiologists. Great complexity diagnoses were categorized as an educational priority on self-identified knowledge gaps by non-ACHD cardiologists; however, they were not an educational priority based on the current or recommended scope of practice (Supplemental Fig. S4).

With respect to topics, both the current scope of practice of non-ACHD cardiologists and the recommendations by ACHD specialists frequently highlighted endocarditis prophylaxis, atherosclerosis risk stratification, and referrals to ACHD specialists as educational priorities. In addition, non-ACHD cardiologists identified arrhythmia management, heart failure management, and referrals for percutaneous interventions frequently as educational priorities based on current practice and as self-identified knowledge gaps. They also self-identified pregnancy counseling and management as self-identified knowledge gaps, despite ACHD cardiologists not identifying these topics as educational priorities.

Discussion

The results of this national survey of non-ACHD and ACHD cardiologists will help inform priorities for the continuing professional development of nonspecialist clinicians. Key findings include (1) insights on the broad scope and diverse clinical scenarios encountered by non-ACHD cardiologists managing patients with ACHD, with nearly one-quarter practicing more than 100 km from the closest ACHD specialist; (2) identification of educational priorities based on self-identified knowledge gaps of non-ACHD cardiologists, the current scope of practice of non-ACHD cardiologists, and the recommendations of ACHD cardiologists, to inform the development of targeted curricula for non-ACHD cardiologists; and (3) further identification of challenges in the specialized care of patients with ACHD.

Our findings highlight the current role of Canadian non-ACHD cardiologists in the care of patients with ACHD. We acknowledge that the number of patients with ACHD encountered is approximate given that cardiologists self-reported the number of patients being evaluated; however, the trends provide important insights. Nonspecialists manage patients with ACHD in both inpatient and outpatient settings, primarily encountering simple and some moderate diagnoses. In contrast, ACHD cardiologists mostly encounter patients in outpatient settings across a broader spectrum of complexity. The greater inpatient involvement suggests that acute cardiac issues, such as heart failure, arrhythmias, or infective endocarditis, are often managed by non-ACHD cardiologists. With only 15 ACHD centers in Canada, many regions lack specialized care, aligning with reports that up to 24% of non-ACHD cardiologists are geographically distant from a referral center and serve as first-line providers for these patients.³ The differences in how non-ACHD and ACHD cardiologists encounter patients with ACHD reinforce the need for a tailored curriculum for non-ACHD cardiologists.

The identified educational priorities inform tailored educational resources for non-ACHD cardiologists, including continuous professional development for any non-ACHD cardiologist (eg, general cardiologist, electrophysiologist, echocardiographer, and heart failure specialist). The findings can also be translated to general cardiology residents. Based on our data, tailored resources could focus on (1) frequently encountered diagnoses and topics with inclusion of inpatient and outpatient management principles, (2) a primer on great complexity congenital lesions specifically oriented to non-ACHD cardiologists, (3) approaches to heart failure and arrhythmias across the spectrum of complexity, and (4) a primer on pregnancy in patients with congenital heart disease specifically oriented to non-ACHD cardiologists.

The frequently encountered diagnoses that represent educational priorities include most simple and some moderate diagnoses (eg, isolated BAV, aortopathies, anomalous coronaries, tetralogy of Fallot, and Ebstein anomaly). The moderate diagnoses included align with the relatively high prevalence of these diagnoses.⁶ Content on each diagnosis should include the approach to diagnosis, principles of management, and high-priority topics such as endocarditis prophylaxis, exercise counseling, atherosclerosis risk stratification, and referral to ACHD centers. The goal of these resources is to ensure that providers are equipped with the knowledge and skills to manage these conditions effectively, while recognizing when collaborative management or referral to ACHD specialists is necessary, as recognized by international guidelines.^1,7 We deprioritized comprehensive content on great complexity diagnoses because they are infrequently encountered by non-ACHD cardiologists, and studies have demonstrated the considerable benefits of specialized care provided by ACHD cardiologists for patients with such diagnoses.8, 9, 10

However, in recognizing that non-ACHD cardiologists self-identified knowledge gaps relating to some great complexity lesions (eg, Fontan circulation and transposition of the great arteries), we prioritized the development of a primer dedicated to these conditions. This primer will focus on common sequelae encountered in patients with these lesions and provide high-level management recommendations. Special emphasis will be placed on treatment approaches that differ significantly from those for patients without congenital heart disease, ensuring clarity and practical guidance for clinicians.¹¹

The third priority for these resources is arrhythmias and heart failure, the leading causes of hospitalization in patients with ACHD.¹² Although these complications occur across all ACHD lesions, those with complex conditions—such as adults living with Fontan circulation and post–atrial switch transposition of the great arteries—face particularly high rates of heart failure hospitalizations.¹³ Importantly, arrhythmia and heart failure pathophysiology and management in patients with ACHD differ significantly from those in the general cardiology population.¹⁴ Consequently, it is essential that non-ACHD cardiologists have the knowledge and skills to manage heart failure and arrhythmias in patients with ACHD.

Non-ACHD cardiologists self-identified knowledge gaps regarding counseling and management of pregnant patients with congenital heart disease. Although we deprioritized comprehensive resources due to current recommendations emphasizing the involvement of specialized cardio-obstetrics teams to manage these patients,¹⁵ we acknowledge the value of equipping all cardiologists with foundational knowledge. Previous studies have identified educational needs related to pregnant patients with congenital heart disease and could inform the content of this primer.¹⁶

While not the primary focus, this survey highlights potential challenges in specialized ACHD care in Canada. Although it did not assess ACHD service organization or specialist roles, responding ACHD cardiologists reported spending less than half their time in clinical practice, primarily in outpatient care. Further research is needed to define their clinical and nonclinical responsibilities. Limited clinical time and resources may contribute to the number of patients with ACHD seen annually, aligning with a national report indicating that only 24% of estimated ACHD patients receive specialized care.³ These findings underscore the need for further investigation and strategies to optimize ACHD specialized care in Canada.

Limitations

There are limitations that warrant acknowledgment. First, the response rate among non-ACHD cardiologists was 8%; however, respondents are likely representative given the distribution of genders, stage of career, and location of practice.¹⁷ This may be in part due to our distribution strategy, as we could not directly email every cardiologist the survey. Instead, we relied on invitations posted on the CCS bulletin board, emailed to CACH Net members, and distributed by CACH Net members to reach the largest number of potential participants.

In addition, our reliance on self-reported data introduces the possibility of response bias. This is particularly relevant when considering participants’ comfort levels in managing various ACHD lesions, as individuals may overestimate their confidence or experience. Future study analyzing administrative health databases could overcome this limitation.

Furthermore, the survey did not explore whether non-ACHD cardiologists would be interested in accessing additional education or resources regarding non-cardiac surgery in patients with ACHD, nor did it examine the factors influencing their willingness or ability to manage specific lesions. Understanding these factors could provide additional insights into barriers to care and inform targeted educational strategies. Moreover, the survey did not assess patient outcomes associated with care provided by non-ACHD cardiologists, which could provide additional understanding of the effectiveness of care by non-ACHD cardiologists.

We acknowledge that incorporating patient perspectives could have provided valuable insights into their preferences regarding care, and this could be explored in future studies.

Finally, we did not inquire about job descriptions of ACHD cardiologists, including how much time is allocated to patient care. We recognize that exploring this aspect in future projects could provide valuable insights for organizing and optimizing ACHD services.

Conclusions

The survey identified educational priorities for non-ACHD cardiologists relating to ACHD. The findings emphasize the need for targeted educational resources focused on simple and moderate ACHD diagnoses, a primer on great complexity diagnoses, acute management of heart failure and arrhythmias across varying levels of ACHD lesion complexity, and a primer on pregnancy in patients with ACHD. Addressing these priorities within cardiology training programs and continuing education initiatives will be essential in equipping non-ACHD cardiologists with the skills and knowledge to provide optimal care for this growing patient population.