Georges Ephrem

A Year to Learn It All: A Call-to-Action for a Comprehensive, Yet Not Longer, Training of the Next Generation of Interventional Cardiologists

Two recent fellows in training (just graduated) express their views on the structure and duration of training. We welcome other opinions.—Spencer King III, MDA year to learn it all. In the United States, the duration of interventional cardiology fellowship is 12 months as mandated by the

Contemporary ACHD training and the reality of the field in the United States

BACKGROUND Care delivery for the growing population of adults living with congenital heart disease (CHD) has been met with challenges due to a shortage of physicians trained to care for this population. To meet this urgent need, restructuring and standardization of the training programs were implemented in 2015. The consequences of such a system on the graduating fellows have not been examined. METHODS A 25-question electronic survey was distributed to early career physicians who graduated following training in adult CHD (ACHD) care between 2015 and 2017 and are currently practicing in the United States. The survey results were anonymous. RESULTS Of the 30 physicians who trained in ACHD between 2015 and 2017 in the U.S., 21 (70%) responded to the survey. The majority completed a 2-year ACHD program, practice at an adult hospital, are happy with their current job, spend most of their time in ACHD-related activities, make on average around 250,000 USD for entry level positions, and prioritize supportive leadership and colleagues. Their training was adequate for their job requirements. However, the acquisition of an additional skill, in addition to clinical ACHD care, allowed them to secure a more ideal job. A sizeable number of jobs required program building or expansion with only 9.5% of trainees comfortable doing so immediately after graduation. CONCLUSIONS The new ACHD training curriculum successfully meets most of the needs for ACHD jobs. Integration of specialty tracks, ensuring uniformity in the quality of training between programs, and promoting leadership skills may improve career prospects.

Relationship of Red Cell Distribution Width to Adverse Outcomes in Adults With Congenital Heart Disease (from the Boston Adult Congenital Heart Biobank)

Red cell distribution width (RDW), a measure of variability in red cell size, predicts adverse outcomes in acquired causes of heart failure. We examined the relation of RDW and outcomes in adults with congenital heart disease. We performed a prospective cohort study on 696 ambulatory patients ≥18years old enrolled in the Boston Adult Congenital Heart Disease Biobank between 2012 and 2016 (mean age 38.7 ± 13.5 years; 49.9% women). The combined outcome was all-cause mortality or nonelective cardiovascular hospitalization. Most patients had moderately or severely complex congenital heart disease (42.5% and 38.5%, respectively). Mean RDW was 14.0 ± 1.3%. RDW >15% was present in 81 patients (11.6%). After median 767days of follow-up, 115 patients sustained the primary combined outcome, including 31 who died. Higher RDW predicted both the combined outcome (hazard ratio [HR] for RDW >15% = 4.5, 95% confidence interval [CI] 3.0 to 6.6; HR per + 1SD RDW = 1.8, 95% CI 1.6 to 2.0, both p <0.0001) and death alone (HR for RDW >15% = 7.1, 95% CI 3.5 to 14.4; HR per + 1SD RDW = 1.8, 95% CI 1.6 to 2.0, both p <0.0001). RDW remained an independent predictor of the combined outcome after adjusting for age, cyanosis, congenital heart disease complexity, ventricular systolic function, New York Heart Association functional class, hemoglobin concentration, mean corpuscular volume, high-sensitivity C-reactive protein and estimated glomerular filtration rate (HR per + 1SD RDW = 1.5, 95% CI 1.2 to 1.9, p <0.0001). RDW also remained an independent predictor of mortality alone after adjustment for age plus each variable individually. In conclusion, elevated RDW is an independent predictor of all-cause mortality or nonelective cardiovascular hospitalization in adults with congenital heart disease. This simple clinical biomarker identifies increased risk for adverse events even among patients with preserved functional status.

RED BLOOD CELL DISTRIBUTION WIDTH AND OUTCOMES IN FONTAN PATIENTS

Background: Fontan palliation results in late multi-organ co-morbidity. However, predictors of worse prognosis are lacking. We evaluated the association of red blood cell distribution width (RDW) with functional capacity and inflammatory biomarkers shown to be elevated in adult Fontan patients

BIOMARKER PROFILE IN ADULTS WITH FONTAN CIRCULATION

Background: Fontan palliation causes systemic changes in hemodynamics resulting in multi-organ co-morbid conditions. We evaluated biomarker levels representative of various systemic pathways in stable Fontan patients in comparison with healthy controls. Methods: We compared 23 stable Fontan

Coincidental Significant Tricuspid Regurgitation at the Time of Right Ventricle–to–Pulmonary Artery Conduit Intervention

![Figure][1] Since its inception nearly 2 decades ago, transcatheter pulmonary valve replacement (TPVR) has brought on a paradigm shift in the approach to patients with significant right ventricle–to–pulmonary artery (RV-PA) conduit dysfunction [(1)][2]. Excellent immediate-, short-,