Adult congenital heart disease transition — branching viva

Branch 1 — Define the task

Examiner: She is about to leave paediatric care. What is your overall goal, and what is the difference between transition and transfer? [3]

Candidate: My goal is to get her safely into lifelong adult ACHD care without a gap. Transition is the planned, staged process of preparing her and her family for that move — building her knowledge of her own anatomy, her self-management, and her self-advocacy over years. Transfer is only the single event of her first adult appointment. The danger is treating the transfer as the whole task and discharging her with a letter; that is how young people fall out of care. I want a deliberate process ending in a confirmed appointment at a named adult centre, ideally near her new university city. [3] [1]

Branch 2 — Measure readiness

Examiner: How do you decide she is ready, and what do you actually do in the visits you have left? [14]

Candidate: Readiness is measurable, not a matter of impression. I would use a validated tool such as the Transition Readiness Assessment Questionnaire to assess her skills in managing medications, appointments, tracking her health, and talking with providers, and repeat it to track progress. In the visits remaining I would see her alone for part of each consultation, teach her to name her diagnosis and operation, hand over responsibility for her medications and bookings, cover contraception, pregnancy, exercise, alcohol and careers, and prepare a written health summary she carries and understands. Readiness, not age alone, drives the timing of transfer. [14] [3]

Branch 3 — The lesion and its surveillance

Examiner: Her systemic right ventricle is mildly impaired. Why does that matter, and what surveillance does she need? [1]

Candidate: After an atrial switch the morphological right ventricle pumps to the body, and that systemic right ventricle tends to fail over time, often silently, along with atrial arrhythmia and baffle problems. This is a complex lesion, so she needs review at a specialist ACHD centre every six to twelve months with ECG and oxygen saturation, echocardiography, cardiac MRI of the systemic ventricle and baffles, Holter monitoring for arrhythmia, and exercise testing to track function objectively. Because the decline is silent, feeling well is not reassurance — the surveillance is what catches deterioration in a window where treatment still helps. [1] [2]

Branch 4 — Contraception and pregnancy

Examiner: She has a new partner and has not considered contraception. Advise her, and counsel her about a future pregnancy. [7]

Candidate: I would avoid combined oestrogen-containing contraception because of thrombotic risk in a systemic right ventricle with atrial arrhythmia risk, and prefer progestogen-only methods or long-acting reversible contraception such as an implant or intrauterine device — effective and safe. For pregnancy I would counsel before conception, using the modified WHO classification: a systemic right ventricle sits at class III, high risk, needing expert shared maternal-cardiac care, with real risks of ventricular failure, arrhythmia, and adverse fetal outcomes. I would give individualised figures from registry data rather than vague reassurance and ensure effective contraception until a planned, optimised pregnancy is agreed. [7] [8]

Branch 5 — Prevent the gap

Examiner: She is moving cities and is casual about follow-up. What is your single biggest worry, and how do you act on it? [4]

Candidate: My biggest worry is loss to follow-up: a young adult moving cities, feeling well, and disengaged is the exact profile that drops out of care and re-presents years later with advanced systemic ventricular failure or arrhythmia. Gaps peak in young adulthood. I would act by identifying and booking a specific adult ACHD clinic in her new city, ideally a warm handover to a named clinician, giving her a portable health summary, explaining the warning symptoms that should prompt urgent review, using telehealth to bridge if needed, and flagging her for active recall so that if she does not attend, someone chases her rather than waits. [4] [6]

Branch 6 — Endocarditis prophylaxis

Examiner: She asks whether she needs antibiotics before dental work. What do you tell her, and who does need prophylaxis? [11]

Candidate: With an atrial-switch repair and no prosthetic material or prior endocarditis, she does not routinely need antibiotic prophylaxis. Current guidance reserves it for the highest-risk lesions only: a prosthetic valve or prosthetic repair material, previous infective endocarditis, unrepaired cyanotic disease, and the first six months after a prosthetic repair. For those who qualify it is given before dental procedures involving the gingiva, using amoxicillin 2 g orally, or an alternative for penicillin allergy. For everyone with congenital heart disease, meticulous oral and skin hygiene matters more for lifetime endocarditis risk than procedural antibiotics. [11] [2]