ABIM ACHD common mistakes
ABIM ACHD · Understand the traps and how to avoid them.
Referring an adult with an atrial septal defect for closure on the basis of a Qp/Qs ratio above 1.5 alone, without calculating pulmonary vascular resistance or testing pulmonary vasoreactivity.
Adult-acquired cardiology criteria and simplified shunt equations are overlearned, and pulmonary hypertension is underappreciated in long-standing CHD.
What to do instead
Calculate PVR and the PVR/SVR ratio, test reversibility with oxygen or nitric oxide, and avoid closure when PVR is severely elevated and nonreactive.
Treating a normal resting oxygen saturation as proof that a cyanotic or mixing lesion is absent.
Bidirectional mixing with high pulmonary blood flow can preserve arterial saturation, and exam vignettes often omit an obvious cyanosis clue.
What to do instead
Obtain simultaneous arterial and venous saturations, review prior catheterization data, and use a hyperoxia challenge when mixing is suspected.
Applying standard adult ECG voltage criteria to diagnose left ventricular hypertrophy in a patient with a single ventricle or after Fontan palliation.
Altered ventricular geometry, position, and mass make adult voltage thresholds unreliable in CHD.
What to do instead
Compare with prior tracings, use CHD-appropriate criteria, and correlate with echocardiographic or MRI ventricular mass and function.
Clearing a patient with severe pulmonary arterial hypertension or a systemic right ventricle for pregnancy without formal prepregnancy risk stratification.
Patients may request pregnancy and clinicians may extrapolate from general obstetric cardiology rather than ACHD-specific risk models.
What to do instead
Use modified WHO pregnancy risk classification, assess ventricular function and pulmonary pressures, and document contraception and preconception counseling.
Prescribing antibiotic prophylaxis for every dental visit in all adults with repaired congenital heart disease.
Overgeneralization from older guidelines and patient anxiety leads to unnecessary antibiotics.
What to do instead
Restrict prophylaxis to prosthetic valve or material, unrepaired cyanotic lesions, repaired lesions with residual defect at the site, and prior endocarditis.
Attributing new exertional dyspnea in a Fontan patient to deconditioning without evaluating for Fontan circuit obstruction, arrhythmia, or protein-losing enteropathy.
Familiarity with the palliated anatomy creates anchoring, and nonspecific symptoms are easily downplayed.
What to do instead
Perform systematic evaluation with echocardiography, advanced imaging or catheterization, arrhythmia monitoring, and hepatic and enteric protein assessment.
Missing superior QRS axis and an incomplete right bundle branch block on ECG in an adult with a large atrioventricular septal defect.
CHD-specific ECG patterns are not taught in general adult ECG interpretation, so the tracing is read as nonspecific.
What to do instead
Recognize superior axis as a clue to atrioventricular septal defect and confirm with echocardiographic imaging of the atrial and ventricular septum.
Performing right heart catheterization in a patient with Ebstein anomaly and classifying pulmonary hypertension from right ventricular pressures alone.
Right ventricular pressures are unreliable with severe tricuspid regurgitation, and operators may omit wedge or left atrial pressure measurement.
What to do instead
Measure pulmonary artery wedge or direct left atrial pressure and left ventricular end-diastolic pressure, and interpret right-sided pressures in that context.
Counseling recurrence risk for a patient with 22q11.2 deletion syndrome using general population CHD recurrence figures.
Epidemiologic population risks are memorized, but syndrome-specific inheritance is overlooked.
What to do instead
Recognize autosomal dominant transmission with up to 50% risk and refer for genetic counseling and prenatal testing.
Considering coarctation repair curative and discontinuing surveillance for hypertension, recoarctation, bicuspid aortic valve, or aortic aneurysm.
A successful childhood repair is mistaken for normalization of anatomy and vascular risk.
What to do instead
Maintain lifelong blood pressure monitoring, aortic imaging, and endocarditis counseling when prosthetic material is present.