• heart failure
• heart defects
• congenital
• health services

Major advances in the management of children with congenital heart disease (CHD) have evolved over the past five decades. As a result, most of the children reach adulthood, and the population of adults with CHD is exponentially growing. This evolution is particularly marked for patients with complex CHD. Consequently, the spectrum of congenital lesions is changing over time, with more patients having complex CHD reaching older age with additional acquired comorbidities. Heart failure (HF) is the most common complication in adults with CHD (ACHD) with a life prevalence of at least 30% in most patients with complex underlying diagnoses. This comorbidity is become the leading cause of premature death in this population.1 As more patients with complex heart disease survive to older age and there is a general increase in the ACHD population, HF is becoming an epidemic. This evolution has important implications on healthcare organisation and resources for ACHD. The originality and strength of the paper by Burstein et al2 is to compare the contemporary use of hospital resources and outcomes in patients with ACHD with HF (ACHD-HF) and those without ACHD with HF (HF-non-ACHD) using two administrative databases in the USA, the Nationwide Emergency Department Sample and Nationwide Inpatient Sample. They confirmed the dramatic augmentation of HF prevalence in ACHD with an increase in rate of HF-related hospitalisations of 46% between 2006 and 2016 compared with 6% in patients with no ACHD. This progression was particularly high in one of the most complex CHDs which was CHD with single ventricle usually palliated by Fontan circulation. However, HF-related hospitalisation may only be the tip of the iceberg. Indeed, …