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.

Cardiology residents need to identify appropriately complex transthoracic echocardiograms (TTE) to maximize learning and to meet current training standards. Residents currently use TTE indication to identify complexity, however this is time consuming and may not accurately identify TTE complexity. Alternative strategies, such as sonographer ratings of complexity or using TTE characteristics could aid trainees in identifying the complexity. In this multicentre study, we found resident and sonographer ratings had fair agreement with experts. Sonographers with teaching experience had greater agreement with experts than junior residents. The number of images correlated with expert ratings of complexity.

BackgroundAdult congenital heart disease (ACHD) patients have significant morbidity and rise in cardiac admissions. Their outcome with high-dose influenza vaccination is unknown in comparison to those without ACHD.ObjectivesThe purpose of this study was to compare all-cause mortality or cardiopulmonary hospitalizations in self-identified ACHD versus non-ACHD patients receiving high- or low-dose influenza vaccination within the INfluenza Vaccine to Effectively Stop cardioThoracic Events and Decompensated heart failure trial.MethodsWe prospectively included ACHD patients in the INVESTED (INfluenza Vaccine to Effectively Stop cardioThoracic Events and Decompensated heart failure) trial. The primary end point was all-cause death or hospitalization for cardiovascular or pulmonary causes.ResultsOf the 272 ACHD patients, 132 were randomly assigned to receive high-dose trivalent and 140 to standard-dose quadrivalent influenza vaccine. Compared to the non-ACHD cohort (n = 4,988), ACHD patients were more likely to be younger, women, smokers, have atrial fibrillation, and have a qualifying event of heart failure. The primary outcome was 49.8 events versus 42.8 events per 100 person-years (adjusted HR: 1.17; 95% CI: 0.95-1.45; P = 0.144) in the ACHD group and non-ACHD group, respectively. The interaction between ACHD status and randomized treatment effect was not significant for the primary outcome (P = 0.858). Vaccine-related adverse events were similar in both groups.ConclusionsPatients who self-identify as being ACHD had similar primary outcome of all-cause death or hospitalization for cardiovascular or pulmonary causes compared to non-ACHD cohort. High-dose influenza vaccination was similar to standard-dose influenza vaccination on the primary outcome in patients who self-identify as ACHD.

Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.

Background Patients with adult congenital heart disease (ACHD) are at increased risk of comorbidity and death compared with the age-matched population. Specialized care is shown to improve survival. The purpose of this study was to analyze current measures of quality of care in Canada compared with those published by our group in 2012. Methods A survey focusing on structure and process measures of care quality in 2020 was sent to 15 ACHD centres registered with the Canadian Adult Congenital Heart Network. For each domain of quality, comparisons were made with those published in 2012. Results In Canada, 36,708 patients with ACHD received specialized care between 2019 and 2020. Ninety-five cardiologists were affiliated with ACHD centres. The median number of patients per ACHD clinic was 2000 (interquartile range [IQR]: 1050, 2875). Compared with the 2012 results, this represents a 68% increase in patients with ACHD but only a 19% increase in ACHD cardiologists. Compared with 2012, all procedural volumes increased with cardiac surgeries, increasing by 12% and percutaneous intervention by 22%. Wait time for nonurgent consults and interventions all exceeded national recommendations by an average of 7 months and had increased compared with 2012 by an additional 2 months. Variability in resources were noted across provincial regions. Conclusions Over the past 10 years, ACHD care gaps have persisted, and personnel and infrastructure have not kept pace with estimates of ACHD population growth. Strategies are needed to improve and reduce disparity in ACHD care relative to training, staffing, and access to improved care for Canadians with ACHD.

Patients with Ebstein anomaly are known to have a higher incidence of interatrial communications and shunting of blood and its components through, mainly due to either streaming of tricuspid regurgitation or due to elevated right atrial pressure. Here we describe a case where permanent pacemaker lead kept a patent foramen ovale open leading to right-to-left shunting of blood and exertional hypoxemia. This is the first such case report in the published literature.

Background:The COVID-19 pandemic significantly impacted health care access across Canada with the reduction in in-person evaluations. The aim of the study was to examine the effects of the COVID-19 pandemic on access to health care services among the Canadian population with adult congenital heart disease (ACHD).Methods:All Canadian adult congenital heart affiliated centres were contacted and asked to collect data on outpatient clinic and procedural volumes for the 2019 and 2020 calendar years. A survey was sent detailing questions on clinic and procedural volumes and wait times before and after pandemic restrictions. Descriptive statistics were used with the Student t-test to compare groups.Results:In 2019, there were 19,326 ACHD clinic visits across Canada and only 296 (1.5%) virtual clinic visits. However, during the first year of the pandemic, there were 20,532 clinic visits and 11,412 (56%) virtual visits (P < 0.0001). There were no differences in procedural volumes (electrophysiology, cardiac surgery, and percutaneous intervention) between 2019 and 2020. The mean estimated wait times (months) before the pandemic vs the pandemic were as follows: nonurgent consult 5.4 ± 2.6 vs 6.6 ± 4.2 (P = 0.65), ACHD surgery 6.0 ± 3.5 vs 7.0 ± 4.6 (P = 0.47), electrophysiology procedures 6.3 ± 3.3 vs 5.7 ± 3.3 (P = 0.72), and percutaneous intervention 4.6 ± 3.9 vs 4.4 ± 2.3 (P = 0.74).Conclusions:During the pandemic and restrictions of social distancing, the use of virtual clinic visits helped to maintain continuity in ACHD clinical care, with 56% of ACHD visits being virtual. The procedural volumes and wait times for consultation and percutaneous and surgical interventions were not delayed.

Echocardiography and medical education have changed significantly since the 2010 publication of the Canadian Cardiovascular Society (CCS) and Canadian Society of Echocardiography (CSE) guidelines for training in adult echocardiography. New training standards are needed to ensure that physicians who provide echocardiography services are appropriately prepared. This summary pro-vides an overview of the substantive changes that address: (1) new echocardiography applications now considered standard practice; (2) the shift to competency-based edu-cation; and (3) the need for objective documentation of competency achievement. The overarching goal of this update is to support excellence in the provision of echo-cardiography services to patients across all practice settings.

Preeclampsia is a hypertensive disorder of pregnancy characterized by new onset of hypertension after 20 weeks gestational age, in the setting of proteinuria and/or other end organ damage. It is a multisystem disorder and is caused by abnormal placentation and release of angiogenic factors with resultant maternal vascular dysfunction. Preeclampsia complicates 5% of pregnancies and the incidence has increased 25% in the last 20 years. Severe forms of preeclampsia can result in dysfunction of maternal neurologic, renal, cardiac, hepatic, pulmonary function, as well as haematologic disturbances and death. Fetal complications include severe growth restriction, preterm birth and stillbirth/neonatal death. Screening, timely diagnosis and management of preeclampsia are integral to optimizing outcomes, with definitive therapy being delivery of the fetus. However, preeclampsia may also be diagnosed in the postpartum period, highlighting the need for post-partum assessment. Though much work has been done in the antepartum diagnosis and management of preeclampsia, a growing body of evidence has shown an increased risk of long-term cardiovascular disease in patients who develop preeclampsia. Not only must healthcare providers be able to diagnose and manage preeclampsia, providers must also understand the role that preeclampsia plays in the lifelong cardiovascular risk of their patients.

The PRECISE-DAPT score predicts the bleeding risk in patients treated with dual antiplatelet treatment after PCI. We asess the prediction power of the score in patients suffering from non–ST elevation acute coronary syndromes. Our cohort included 862 patients from Buenos Aires 1 registry. The PRECISE-DAPT score was calculated upon admission and the follow up period was 15 months. The score as a continuous variable had low to moderate ability to predict bleeding events BARC 2, 3 or 5 (c-statistics 0.58 [95% CI, 0.52-0.61]); moderate at BARC 3 or 5 (c-statistics 0.72 [95% CI, 0.64-0.78]), and poor for MACE (c-statistics 0.49 [95% CI, 0,45-0.51]). PRECISE-DAPT score as a dichotomous variable (≥25, n= 210 [24%]) was associated with very high risk of bleeding (HR 2.1) and ischemic events (HR 1.9, 95% CI 1.8-2.1). As conclusion, PRECISE-DAPT score ≥25 was able to identify a subgroup of patients with high bleeding, and thrombotic events.

Echocardiography is an essential imaging modality for clinical care. Currently, by virtue of graduating from car-diology residency and performing/interpreting an arbi-trary number of echocardiograms, cardiology trainees are deemed competent to independently practice echocardi-ography. There is no formal assessment to ensure their competence. Recognizing this unmet need, we developed a novel echocardiography assessment tool and piloted it in a sample of 38 participants (including 7 expert echocardi-ographers). The tool was shown to be valid and reliable in assessing independent echocardiography interpretation skills; thus it can be used during training to ensure car-diology residents achieve competence in echocardiography before completing their training.

Late gestational supine positioning reduces maternal cardiac output due to inferior vena caval (IVC) compression, despite increased collateral venous return. However, little is known about the impact of maternal position on oxygen (O2) delivery and consumption of the gravid uterus, fetus, placenta and lower limbs. We studied the effects of maternal positioning on these parameters in 20 healthy pregnant subjects at 36 +/- 2 weeks using magnetic resonance imaging (MRI); a follow-up MRI was performed 6-months postpartum (n = 16/20). MRI techniques included phase-contrast and T1/T2 relaxometry for blood flow and oximetry imaging, respectively. O-2 transport was measured in the following vessels (bilateral where appropriate): maternal abdominal descending aorta (DAoabdo), IVC, ovarian, paraspinal veins (PSV), uterine artery (UtA) and external iliacs, and umbilical. Maternal cardiac output was measured by summing DAothoracic and superior vena cava flows. Supine mothers (n = 6) had lower cardiac output and O2 delivery in the DAoabdo, UtA and external iliac arteries, and higher PSV flow than those in either the left (n = 8) or right (n = 6) lateral positions during MRI. However, O-2 consumption in the gravid uterus, fetus, placenta and lower limbs was unaffected by maternal positioning. The ratio of IVC/PSV flow decreased in supine mothers while ovarian venous flow and O-2 saturation were unaltered, suggesting a major route of pelvic venous return unaffected by maternal position. Placental-fetal O-2 transport and consumption were similar between left and right lateral maternal positions. In comparison to non-pregnant findings, DAoabdo and UtA O-2 delivery and pelvic O-2 consumption increased, while lower-limb consumption remained constant , despite reduced external iliac artery O-2 delivery in late gestation.

The population of adult patients with both Down syndrome and congenital heart disease is increasing due to better medical and surgical care. This cohort presents with multiple unique comorbidities, secondary to both progressions of health conditions associated with the aging of patients with Down syndrome, as well as due to pathophysiologic effects of uncorrected, corrected, or palliated congenital heart disease. These patients need frequent medical care and interventions requiring multiple anesthetics. This review focuses on the various factors relevant to the perioperative medical care of adult patients with both Down syndrome and congenital heart disease, founded on existing literature. Various anesthetic considerations for the different patterns of noncardiac and cardiac comorbidities are reviewed, and a systematic approach for the perioperative anesthetic management of these patients is presented.

Background:Transitioning from paediatric to adult congenital heart disease (CHD) care is a high-risk time for being lost to follow-up. Existing CHD transition programmes have not included patients, caregivers, and health care providers as partners in their development. This study aimed to develop recommendations for a CHD transition programme driven by lived and clinical experiences. Methods:We used a multilevel participatory process that engaged adult and paediatric people living with CHD, their caregivers, and CHD health care providers as members of the research team. We also consulted members of these stakeholder groups through a series of 3 virtual workshops that culminated in the generation of recommendations for the essential components of a CHD transition programme. Results:The Transition Essentials recommendations inform what information, education, or support is required, who should provide it, and when and how it should be provided. Information, education, and support for self-management and knowledge are required for people living with CHD. Caregivers require information, education, and support to build capacity in people living with CHD and navigate their new role in their loved ones' life. The health care team should provide this information, education, and support with peer support options when people living with CHD are 15-22 years of age. This information, education, and support should be individualized, navigate limitations, build over time, have multimodal options, and be available virtually or in person. Conclusions:Engaging those with lived and clinical expertise to develop recommendations for the essential components of a CHD transition programme provides important insights missing from previous studies.

Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care path-ways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.

Patients with adult congenital heart disease (ACHD) are at increased risk for poor outcomes when compared to the age matched non-ACHD population and require specialist care to optimize outcomes including well-being and survival. The COVID-19 pandemic significantly impacted healthcare provision across Canada with reduction on in person evaluations. The effect of the COVID-19 restrictions on ACHD care including clinic evaluation, diagnostic and procedures in Canada has not been well characterized. All Canadian Adult Congenital Heart Network affiliated ACHD centers were contacted and asked to collect data on outpatient clinic and procedural volumes for the 2019 and 2020 calendar years. A survey was sent to each site detailing questions on clinic and procedural volumes and wait times pre and post pandemic restrictions. Descriptive statistics were used with student t test to compare groups. Pre-pandemic (2019) there were 19326 ACHD clinic visits across Canada with 296 (1.5%) being virtual. During the first year of the pandemic (2020) there were a similar number of total clinic visits 20532, however 11412 (56%) visits were virtual p< 0.0001. Total procedural volumes for ACHD care are presented in figure 1. Pre-pandemic mean estimated clinic waiting times (in months) for non-urgent consults were: 5.4 + 2.57 vs. pandemic wait time 6.5 + 4.22, p=0.65, for elective ACHD cardiac surgery 6.0 + 3.46 vs.7.3 + 4.59, p=0.47, for ACHD electrophysiology procedures 6.3 + 3.33 vs 6.7 + 3.27 p=0.72, for ACHD percutaneous intervention 4.6 + 3.89 vs 4.4 + 2.33 p=0.74. During the pandemic, despite social distancing restrictions, the use of virtual clinics visits have helped to maintain continuity in ACHD clinical care. The procedural volumes and wait times for consultation, percutaneous and surgical interventions were not delayed.