Adult congenital heart disease (ACHD) has evolved from a pediatric-focused field to a growing adult cardiovascular subspecialty, driven by advances in surgery and medical therapy that now allow nearly 2 million adults in the United States to live with congenital heart disease. Despite these advances, an estimated workforce of board-certified ACHD cardiologists remains insufficient for the growing patient population, underscoring a continued mismatch between workforce needs and the trainee pipeline. This manuscript reviews contemporary pathways to ACHD sub-specialization, including a combined internal medicine and pediatrics (‘Med-Peds’) residency followed by adult or pediatric cardiology, internal medicine followed by adult cardiology, and pediatrics followed by pediatric cardiology, each culminating in dedicated ACHD fellowship. For each route, the article outlines key strengths, limitations, and typical curricular emphases, and describes how Accreditation Council for Graduate Medical Education-recommended clinical blocks can be tailored to remediate background-specific gaps while preserving a common competency-based endpoint. By clarifying training structures, expectations, and career implications, this work seeks to demystify the pathway to ACHD cardiology and encourage workforce interest in caring for this rapidly growing, high-need population.
Multimodal cardiac imaging has fundamentally reshaped the evaluation of anomalous aortic origin of the coronary artery, yet risk stratification remains challenging because anatomy, symptoms, and physiological demands vary widely across patients. This review summarizes contemporary anomalous aortic origin of the coronary artery classification and emphasizes anatomic features associated with higher risk, including interarterial and intramural courses, adverse ostial morphology, and compression related to the intercoronary pillar or myocardial bridges, which contribute to both fixed and dynamic ischemia. The complementary roles of echocardiography, coronary CT angiography with CT-derived fractional flow reserve, nuclear myocardial perfusion imaging, cardiac magnetic resonance, and hybrid anatomic–functional imaging are discussed, with attention to the specific clinical contexts in which each modality is most informative. Finally, we discuss the Vanderbilt management approach that integrates age, symptoms, detailed anatomic assessment, and functional testing to guide observation, exercise recommendations, invasive evaluation, and surgical intervention, with particular focus on individualized counseling and safe return-to-play decisions in young and athletic patients.
MI with non-obstructive coronary arteries (MINOCA) represents a complex, heterogeneous syndrome with variable underlying mechanisms and substantial morbidity. The role of multimodality cardiovascular imaging in clarifying etiology and guiding therapy continues to evolve. Multimodality imaging offers insights into the pathophysiology of MINOCA. Coronary angiography remains the first-line diagnostic tool to exclude obstructive coronary disease, while adjunctive functional testing can identify epicardial or microvascular vasospasm. Echocardiography evaluates ventricular function, wall motion abnormalities, and embolic sources, whereas cardiac MRI differentiates ischemic from non-ischemic injury, detects myocardial edema, and assesses scar burden. Intravascular imaging can detect plaque rupture, erosion, or thrombus. Nuclear imaging modalities provide a quantitative assessment of microvascular perfusion and coronary flow reserve. Coronary CT angiography may further characterize non-obstructive plaque or coronary anomalies. This review summarizes the comprehensive evaluation of MINOCA. Integrating modalities can improve diagnostic accuracy, identify the underlying etiology, guide targeted therapy, and inform prognosis, underscoring the importance of a multimodal imaging approach.
The term ‘cardiac electrogram’ (EGM) was initially used to describe the surface ECG, but now EGMs represent the electrical potential within the immediate vicinity of a catheter (including pacemaker and implantable cardioverter defibrillator lead) within the heart. These EGMs are generated from electrodes on catheters that are placed in different regions of the heart: the right atrium, the right ventricle, in the coronary sinus, and near the His bundle. These EGMs, in conjunction with a surface ECG, can then be used to study the timing of electrical activity within the heart, as well as arrhythmias in the cardiac electrophysiology (EP) lab. The goals of this article are to give readers the basics of EGMs, the basics of cardiac EP catheters, and the placement of EP catheters in the heart, and to introduce readers to EGMs and intervals measured.
