Navigating the Road to Specialization in Adult Congenital Heart Disease

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.