Khairy P, Etheridge SP, Araujo JJ, Aronis KN, Kalis VM, Kamp AN, Lloyd MS, Madhavan M, Sherwin ED, Triedman JK, Moore JP, et al. HRS/ISACHD/PACES Scientific Statement on Provider and Institutional Best Practices for Comprehensive Adult Congenital Heart Disease Electrophysiology Programs. Heart Rhythm. 2026;23:e1275-e1288. doi:10.1016/j.hrthm.2026.02.002.
PubMed: https://pubmed.ncbi.nlm.nih.gov/41679448/
Take-Home Points
- Adults with congenital heart disease (ACHD) now outnumber children with congenital heart disease, and arrhythmias have become a leading cause of morbidity, hospitalization, and late mortality.
- The statement formally recognizes ACHD electrophysiology (EP) as a distinct subspecialty requiring dedicated expertise beyond traditional adult or pediatric EP training.
- Five core competency domains are proposed: congenital anatomy and physiology, arrhythmia mechanisms and risk stratification, imaging and diagnostic interpretation, procedural EP/device expertise, and longitudinal multidisciplinary care.
- Most current ACHD electrophysiologists acquired expertise through clinical exposure rather than structured fellowships, highlighting the need for standardized training pathways.
- Comprehensive ACHD EP programs require advanced imaging, 3D electroanatomic mapping, congenital surgery support, ACHD anesthesia expertise, multidisciplinary conferences, and dedicated longitudinal device follow-up programs.
- The document proposes the first ACHD-specific procedural volume targets and quality metrics to guide future accreditation and benchmarking efforts.
Commentary from Dr. Varun Aggarwal (Wilmington, DE, USA), editor-in-chief of Congenital Heart Disease Journal Watch:
This scientific statement arrives at a pivotal moment in the evolution of congenital heart disease care. The congenital heart community has spent decades celebrating a remarkable achievement: survival. Conditions that once carried near-universal childhood mortality now routinely allow survival into middle age and beyond. As a result, adults with congenital heart disease now outnumber children with congenital heart disease, representing one of the most dramatic demographic shifts in modern cardiovascular medicine.
Success, however, has revealed a new challenge.
As ACHD patients age, arrhythmias have emerged as one of the most common and consequential complications they face. Atrial flutter, intra-atrial reentrant tachycardia, atrial fibrillation, ventricular tachycardia, sinus node dysfunction, atrioventricular conduction disease, and sudden cardiac death now account for substantial morbidity, recurrent hospitalization, procedural interventions, and mortality. Importantly, these arrhythmias are not simply versions of those encountered in standard adult electrophysiology practice. They arise from congenital abnormalities of the conduction system, decades-old surgical scars, altered chamber geometry, baffles, conduits, ventriculotomies, Fontan pathways, residual hemodynamic lesions, ventricular dysfunction, and increasingly, acquired cardiovascular disease. The result is a uniquely complex arrhythmia substrate that often defies traditional training paradigms.
The central achievement of this document is its formal recognition that ACHD electrophysiology has matured into a distinct subspecialty. While this reality has long been appreciated by congenital heart specialists, previous guidelines largely focused on arrhythmia management rather than defining the infrastructure and expertise required to provide that care. This statement fills that gap by outlining what an ACHD electrophysiologist should know, how ACHD EP programs should function, and what resources institutions should provide to ensure high-quality care.
One of the most striking observations is the absence of a standardized workforce pathway. Survey data cited by the authors demonstrated that 87% of contemporary ACHD electrophysiologists obtained their expertise during fellowship training, usually through pediatric EP programs, whereas 13% developed competency entirely after formal training. Dedicated ACHD EP fellowships remain uncommon. Consequently, the current workforce consists of physicians entering through highly variable pathways, including pediatric cardiology, adult cardiology, pediatric electrophysiology, adult electrophysiology, and ACHD fellowships.
The statement wisely avoids prescribing a single educational model. Instead, it adopts a competency-based framework focused on five essential domains. First is mastery of congenital cardiac anatomy and physiology, including surgical modifications and lesion-specific arrhythmia patterns. Second is expertise in arrhythmia substrates and risk stratification. Third is advanced imaging integration and interpretation. Fourth is procedural proficiency in ablation and device therapy. Finally, practitioners must participate in lifelong multidisciplinary ACHD care. This approach reflects the reality that expertise arises from diverse backgrounds while establishing consistent expectations for practice.
The procedural section highlights why ACHD EP has become so specialized. Few fields require such extensive preparation before a procedure even begins. Electrophysiologists must routinely review operative reports from surgeries performed decades earlier, reconstruct complex anatomy from CT and MRI imaging, understand prior conduits and patch placements, anticipate challenging venous access routes, and account for unusual conduction system relationships. Cases may require transbaffle puncture, transconduit access, transhepatic access, robotic magnetic navigation, hybrid surgical approaches, or specialized imaging support. In many situations, familiarity with congenital anatomy is just as important as technical electrophysiology expertise.
The statement also emphasizes the critical importance of multidisciplinary care. ACHD arrhythmia management rarely occurs in isolation. Decisions regarding catheter ablation, cardiac implantable electronic devices, anticoagulation, ventricular dysfunction, Fontan failure, and surgical intervention frequently require coordinated input from congenital cardiologists, congenital surgeons, advanced imaging specialists, anesthesiologists, heart failure experts, and electrophysiologists. High-quality ACHD EP programs therefore function as integrated systems rather than collections of individual practitioners.
Particularly noteworthy are the proposed institutional standards. For perhaps the first time, the field is provided with concrete guidance regarding the infrastructure necessary for a comprehensive ACHD EP program. Recommended resources include advanced three-dimensional electroanatomic mapping systems, multimodality imaging capabilities, congenital surgical backup, expertise in alternative vascular access techniques, device extraction programs, and dedicated outpatient clinics with remote monitoring capabilities. These recommendations help define what constitutes a true ACHD electrophysiology center of excellence.
The procedural volume recommendations are likely to generate discussion. Although largely consensus-based and not yet validated, the authors suggest annual institutional volumes of at least 25 ACHD atrial arrhythmia ablations, 10 ventricular arrhythmia ablations, 25 ACHD device implantations, 10 CRT or conduction-system pacing procedures, and 5 lead extractions. Rather than functioning as rigid requirements, these recommendations are intended to encourage sufficient case exposure to maintain expertise and support training programs.
The quality section may ultimately prove one of the document’s most important contributions. Unlike coronary intervention or heart failure management, ACHD electrophysiology lacks mature performance metrics. The statement therefore proposes candidate benchmarks encompassing acute procedural success, complication rates, fluoroscopy exposure, long-term arrhythmia recurrence, device performance, hospital readmissions, and patient-reported outcomes. Importantly, the authors note that quality-of-life measures may be particularly valuable in ACHD populations, where symptom burden often exceeds what traditional clinical endpoints capture.
The document also highlights a broader challenge facing congenital cardiology. The ACHD population continues to expand rapidly, but specialized expertise remains concentrated within relatively few centers. Without deliberate workforce development and institutional investment, disparities in access to ACHD arrhythmia care are likely to widen. The proposed framework therefore serves not only as a blueprint for individual programs but also as a roadmap for future healthcare planning.
Ultimately, this statement recognizes what clinicians caring for ACHD patients have long understood. Arrhythmias are now among the most important determinants of long-term outcomes in congenital heart disease. Optimal management requires far more than conventional electrophysiology training. It requires specialized knowledge, dedicated infrastructure, multidisciplinary collaboration, and lifelong engagement across the continuum of congenital heart disease care.
The greatest contribution of this publication may not be any single recommendation. It is the formal acknowledgment that ACHD electrophysiology has evolved into its own discipline and that patients deserve systems of care designed specifically for their unique needs.
Clinical Perspective
As the adult congenital heart disease population continues to grow, arrhythmias have become a dominant source of morbidity and mortality. This HRS/ISACHD/PACES Scientific Statement establishes ACHD electrophysiology as a distinct subspecialty and provides the first comprehensive framework for training, program development, procedural infrastructure, quality assessment, and multidisciplinary care. For ACHD centers, successful arrhythmia management increasingly depends on dedicated expertise integrated within specialized congenital heart disease programs.
