Why I Chose to Care for the Most Complex Hearts in Adult Cardiology

By Pradyumna Agasthi, MD

Interventional Cardiologist with Advanced Training in Adult Congenital Heart Disease
Saint Francis Heart and Vascular Institute 

There is a population of cardiac patients in this country who, until relatively recently, were not expected to survive into adulthood. Thanks to the extraordinary advances of pediatric cardiac surgery over the past few decades, they do survive—and they are living longer than ever.  

But surviving is not the same as being cared for. And that gap is why I do what I do.

I am an interventional cardiologist with specialized additional training in adult congenital heart disease (ACHD). It is one of the most demanding subspecialties in all of cardiology, and one of the least populated. This is the story of why I chose it, what the field looks like today, and where I believe it is headed. 
 

A Field Born From Success

Adult congenital heart disease as a formal subspecialty is relatively young; dedicated training programs have only existed for a little over a decade. The reason is straightforward: for most of medical history, patients born with complex congenital heart defects simply did not live long enough to need adult cardiologists.

Thankfully, that has changed dramatically.  

Pediatric cardiac surgeons have become extraordinarily skilled at repairing even the most severe structural defects in infants and children. The result is a generation of adults—and now middle-aged patients—who carry the legacy of those early interventions in their hearts, their blood vessels, and their long-term health trajectories.

The challenge is that the physicians who treated congenital heart disease patients as children were trained to care for children, only. Pediatric cardiologists are experts in what they do, but their training centers on the developing heart and the specific physiology of younger patients.

Once these individuals become adults, they accumulate adult health problems—hypertension, arrhythmias, coronary disease, pregnancy considerations—on top of their underlying congenital anatomy. Neither the pediatric cardiologist nor the general adult cardiologist is ideally equipped to manage that combination. That is the gap that adult congenital cardiologists are trained to fill.

“The whole field of adult congenital heart disease exists because of the success of pediatric cardiac surgery. These patients earned their survival. My job is to make sure they receive the longitudinal care that survival requires.”
 

The Access Problem in Oklahoma

When I look at the patient population I see here in Oklahoma, one thing stands out immediately: many of these patients have not seen a qualified adult congenital cardiologist in years; some have never seen one.  

That is not a criticism of local practitioners—general cardiologists are not trained to manage complex congenital anatomy, and it is unfair to expect otherwise. It is simply a reflection of where the specialty has and has not taken root.

Patients with resources and flexibility can travel. Dallas, Kansas City, Saint Louis, and other larger centers have established ACHD programs. But a substantial number of patients in this region do not have that option. Travel costs money. It requires time away from work. It requires support systems that not everyone has. Those patients—the ones who cannot leave—have been going without specialized care.

That is what ultimately drew me to Saint Francis. I recognized a need that was not being met, and I knew I had the training to begin addressing it. 
 

Why There Are So Few of Us

I am often asked why the field remains so sparsely populated. The honest answer is that the barriers to entering it are significant, and they stack on top of one another.

The first barrier is complexity. Adult congenital heart disease patients are, without question, the most complex subgroup in adult cardiology. Not every cardiologist wants to spend their career managing the most difficult cases they will ever encounter, every single day. That is a reasonable preference, and I do not say it critically. But it does mean the pool of interested candidates is smaller from the outset.

The second barrier is the training pathway itself. To become a board-certified adult congenital cardiologist, you must complete either adult cardiology fellowship or pediatric cardiology fellowship, and then complete an additional two-year subspecialty fellowship in ACHD. By the time most physicians reach that decision point, they have already spent four years in college, four in medical school, three in internal medicine residency, and three in cardiology fellowship. Adding two more years, often with loan obligations and family commitments already in place, is genuinely difficult.

The third barrier is financial. This is uncomfortable to acknowledge, but it is real.  

An adult congenital cardiologist managing a complex patient may spend two to three times the clinical effort required for a straightforward adult cardiology case. Reimbursement structures have not kept pace with that reality. It is entirely possible for a physician who completes two additional years of subspecialty training to earn less than a general interventional cardiologist. That is a structural problem the field needs to solve.

Finally, there is the question of pathway mismatch. Adult congenital cardiologists can come from either pediatric or adult cardiology backgrounds. In practice, pediatric cardiologists often choose their field precisely because they prefer working with children—and the prospect of transitioning to adult patients does not appeal to them. Adult cardiologists, meanwhile, may not have had meaningful exposure to congenital anatomy during their training; until recently, it was not even a mandatory component of adult cardiology fellowship. That has begun to change, but slowly.
 

How We Think About Intervention: Making Every Surgery Count

The patients I care for are often extraordinary in one specific way: by the time they reach me as adults, many have already undergone five, six, seven, or even eight open-heart surgeries. That is not unusual in this population. I have cared for patients who had nine open surgeries before their twentieth birthday.

Every open-heart surgery carries risk. And each successive sternotomy—each time a chest is opened—the risk increases. Scar tissue accumulates. The surgical field becomes more hostile. The margin for error narrows.

This shapes how I think about intervention fundamentally. I am an interventional cardiologist by training, which means I work in the cardiac catheterization laboratory, approaching problems percutaneously—through the skin and blood vessels, without opening the chest.  

My goal in managing a congenital patient is not simply to fix a problem today. It is to fix what I can fix through the catheter, so that when the patient eventually does need another open-heart surgery, we have preserved that option for a problem we cannot address any other way.  

Open-heart surgery is a finite and precious resource for these patients. We do not want to spend it prematurely.

I sometimes describe it in simple terms: cardiology problems are either electrical problems or plumbing problems. I am more of a plumber. And part of being a good plumber for this population is knowing what not to touch, and when to wait.

“Open-heart surgery is like a savings account for these patients—you do not want to spend it until you have to. Everything I can fix through the catheter is money I am keeping in that account.” 

Working at the Frontier: Off-Label Devices and First-in-Human Cases

One of the defining realities of adult congenital interventions is that we frequently work without a roadmap.  

Many of the conditions I treat affect so few patients that randomized clinical trials are not feasible. There is simply not a large enough population to power a trial, and the economic incentives for device manufacturers to pursue FDA approval for these indications are limited. The parallel in pharmacology would be orphan drug development—except that pharmaceutical companies have legislative incentives to invest in orphan drug research. No equivalent framework exists for devices used in congenital interventions.

In practice, this means we often adapt equipment designed for other purposes. A stent intended for vascular use in adults might be precisely what a congenital patient needs to maintain flow through a reconstructed pulmonary artery. A closure device developed for a different defect might be repurposed with careful planning. We call this off-label use, and it is common, thoughtful, and done within a rigorous team framework.

At Saint Francis, we have performed a number of first-in-human cases—procedures that, to our knowledge, had not been attempted before in the way we approached them. That kind of work is only possible because of the team around me. Our cardiac surgeons, ICU physicians, imaging specialists, anesthesiologists, and nursing staff review these cases together. We talk through every plausible complication before we begin. We do not proceed unless we have a credible plan for what to do if something goes wrong. In this work, the ability to “bail out” safely is not a fallback—it is a prerequisite.

I also lean heavily on the relationships I built during my training at Mayo Clinic. When I encounter a particularly complex case, I reach out to my mentors there. We review imaging together, debate approaches, and arrive at a plan collaboratively. That consultation network is part of what allows us to take on cases that might otherwise be declined elsewhere. 

The Patients Themselves

I want to close with something that does not appear in clinical literature but is central to why I do this work.

The patients I treat are among the most resilient people I have ever encountered. They have lived their entire lives with a condition that required repeated hospitalizations, multiple surgeries, and ongoing vigilance. They have done all of this—often from infancy—and they have built lives, raised families, pursued careers. By the time they reach my clinic, they carry years of medical complexity with a matter-of-factness that I find genuinely humbling.

But, they do not need my admiration. They need someone who understands their anatomy, takes their history seriously, and has the technical skills and institutional support to intervene when intervention is warranted. My job is to be that person—and to make sure that, whatever comes next in their care, they have a qualified specialist in their corner.

That is why I trained as long as I did. That is why I came to Saint Francis. And that is why, as the population of adults living with congenital heart disease continues to grow, I remain committed to growing alongside the field. 

Pradyumna Agasthi, MD, is an interventional cardiologist with advanced fellowship training in adult congenital heart disease, including training at Mayo Clinic. He practices at the Saint Francis Heart and Vascular Institute in Tulsa, Oklahoma, where he specializes in complex structural and congenital interventions.