100+ Free ABIM ACHD Practice Questions

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Question 1

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In the staged palliation of hypoplastic left heart syndrome (HLHS), which procedure constitutes Stage 1 (neonatal)?

Bidirectional Glenn anastomosis

Norwood procedure with Sano or BT shunt

Total cavopulmonary Fontan completion

Arterial switch operation

to track

2026 Statistics

Key Facts: ABIM ACHD Exam

~$2,500

Exam Fee

ABIM 2026

24 months

ACGME Fellowship

Required since 2019

~10 hours

Test Duration

4 sessions, up to 60 Q each

Odd years

Exam Cadence

2025, 2027, 2029

~1.4M

US Adults with CHD

Now exceeds pediatric CHD

10 years or LKA

Cert Maintenance

ABIM MOC options

The ABIM ACHD exam is one of cardiology's newest and most specialized subspecialty boards (first administered 2015). Only ~40-80 physicians certify per cycle, and the exam is given only in odd-numbered years. Eligibility requires a 24-month ACGME-accredited ACHD fellowship on top of cardiology or pediatric cardiology training, reflecting the complexity of lifelong CHD care. ACHD cardiologists work in ~150 accredited ACHD centers in the US, with the adult CHD population now exceeding pediatric CHD (~1.4 million US adults). The exam tests Fontan physiology, repaired TOF, d/l-TGA, Eisenmenger, Marfan aortopathy, and mWHO pregnancy risk at subspecialty depth.

Sample ABIM ACHD Practice Questions

Try these sample questions to test your ABIM ACHD exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1In the staged palliation of hypoplastic left heart syndrome (HLHS), which procedure constitutes Stage 1 (neonatal)?

A.Bidirectional Glenn anastomosis

B.Norwood procedure with Sano or BT shunt

C.Total cavopulmonary Fontan completion

D.Arterial switch operation

Explanation: Stage 1 (neonatal) for HLHS is the Norwood procedure, which reconstructs the hypoplastic aorta from the pulmonary trunk and provides pulmonary blood flow through a modified BT shunt (classic Norwood) or a right ventricle-to-pulmonary artery conduit (Sano modification). The Glenn is stage 2 (~4-6 months) and Fontan is stage 3 (~2-4 years).

2Which of the following best describes Fontan circulation hemodynamics?

A.Pulmonary blood flow is driven by a subpulmonic ventricle

B.Pulmonary blood flow depends on passive flow from systemic veins with obligate elevation of central venous pressure

C.Systemic venous return bypasses the lungs entirely

D.Pulmonary artery pressure is typically subnormal (<5 mmHg)

Explanation: After Fontan completion, systemic venous return flows passively from the SVC and IVC directly to the pulmonary arteries without a subpulmonic pump. This obligates an elevated CVP (typically 12-15 mmHg) and makes cardiac output profoundly preload-dependent. Any rise in PVR, atrial arrhythmia with loss of AV synchrony, or dehydration can precipitate low cardiac output.

3A 28-year-old man with a fenestrated lateral tunnel Fontan presents with peripheral edema, chronic diarrhea, and serum albumin 2.0 g/dL. Which diagnostic test is most specific for protein-losing enteropathy (PLE)?

A.Serum total protein

B.24-hour urine protein

C.Fecal alpha-1 antitrypsin clearance

D.Stool osmotic gap

Explanation: Fecal alpha-1 antitrypsin clearance (not just concentration) is the most specific test for PLE. Alpha-1 antitrypsin is a large plasma protein resistant to digestion; its appearance in stool indicates enteric protein loss. PLE affects 5-15% of Fontan patients and carries a 5-year mortality of ~50%. Treatment includes budesonide, heparin/spironolactone, and Fontan conversion or transplant.

4Which of the following is a recognized late complication of the Fontan circulation?

A.Pulmonary stenosis

B.Fontan-associated liver disease (FALD) with cirrhosis and hepatocellular carcinoma risk

C.Bronchiectasis

D.Severe aortic regurgitation

Explanation: Chronic elevation of systemic venous (hepatic) pressure in Fontan patients leads to sinusoidal congestion, fibrosis, and eventually cirrhosis (Fontan-associated liver disease). By 10-20 years post-Fontan, nearly all patients have histologic fibrosis, and HCC risk is elevated. Annual screening with MRI/ultrasound and AFP is recommended. Plastic bronchitis and PLE are other late complications.

5A 35-year-old with a Fontan palliation presents with expectoration of rubbery bronchial casts. What is this complication called?

A.Allergic bronchopulmonary aspergillosis

B.Plastic bronchitis

C.Diffuse alveolar hemorrhage

D.Cryptogenic organizing pneumonia

Explanation: Plastic bronchitis is a rare but potentially fatal Fontan complication in which lymph-rich fibrinous casts form in the airways and are expectorated (sometimes in branching airway shapes). It shares pathophysiology with PLE — elevated lymphatic pressure from Fontan hemodynamics. Treatment includes inhaled tPA, corticosteroids, lymphatic embolization, and ultimately Fontan conversion or transplant.

6Which of the following is NOT a classic component of tetralogy of Fallot?

A.Pulmonary stenosis (RVOT obstruction)

B.Overriding aorta

C.Ventricular septal defect

D.Atrial septal defect

Explanation: Tetralogy of Fallot consists of pulmonary stenosis (RVOT obstruction), overriding aorta, VSD (typically malalignment), and right ventricular hypertrophy. An ASD is NOT part of the tetrad, though an associated ASD (pentalogy of Fallot) may coexist. The underlying embryologic defect is anterocephalad deviation of the infundibular septum.

7In an adult with repaired tetralogy of Fallot (transannular patch repair in infancy), what is the most common hemodynamic lesion contributing to late RV dilation?

A.Residual VSD

B.Pulmonary stenosis

C.Severe pulmonary regurgitation

D.Tricuspid stenosis

Explanation: Transannular patch repair of TOF relieves RVOT obstruction but leaves the pulmonary valve incompetent, producing chronic severe pulmonary regurgitation. Over decades this causes progressive RV dilation and dysfunction, exercise intolerance, atrial/ventricular arrhythmias, and sudden death risk. Pulmonary valve replacement (PVR) — surgical or transcatheter — is the corrective intervention.

8According to current ACHD guidelines, which of the following supports pulmonary valve replacement (PVR) in an asymptomatic adult with repaired TOF and severe PR?

A.RVEDVi >=160 mL/m2 or RVESVi >=80 mL/m2

B.LVEF 55%

C.RV/LV volume ratio 1.2

D.Mild RV dilation without other findings

Explanation: The 2018 AHA/ACC ACHD guidelines support PVR in asymptomatic adults with repaired TOF and severe PR when RV enlargement or dysfunction is objective: RVEDVi >=160 mL/m2, RVESVi >=80 mL/m2, RV/LV end-diastolic volume ratio >=2.0, RVEF <47%, LVEF <55%, sustained tachyarrhythmia, or objective exercise intolerance. The goal is to intervene before irreversible RV dysfunction.

9A 32-year-old with d-transposition of the great arteries repaired with a Mustard procedure as a child now has progressive dyspnea and an LVEF of 30% measured on MRI. Which ventricle is this 'LVEF'?

A.The morphologic left ventricle, which is the systemic pumping chamber

B.The morphologic right ventricle, which is the systemic pumping chamber

C.The common ventricle in a single-ventricle heart

D.The subpulmonic left ventricle

Explanation: In d-TGA after an atrial switch (Mustard or Senning), the morphologic RIGHT ventricle remains the systemic pumping chamber because the aorta arises from it. Systemic RV failure is the hallmark late complication of atrial switch. The reported 'systemic ventricular EF' refers to the morphologic RV. Other complications include baffle leaks/obstruction, sinus node dysfunction, and atrial arrhythmias.

10Which of the following distinguishes the arterial switch (Jatene) procedure from the atrial switch (Mustard/Senning) for d-TGA?

A.The arterial switch restores the morphologic LV as the systemic ventricle

B.The arterial switch creates atrial baffles

C.The arterial switch is only used in adults

D.The arterial switch requires a Fontan completion

Explanation: The arterial switch (Jatene) transects the great arteries above the valves, translocates them, and reimplants the coronaries, restoring the morphologic LEFT ventricle as the systemic pump. It became the standard neonatal repair in the mid-1980s, replacing atrial switches. Late complications are different: neo-aortic root dilation, coronary ostial stenosis, and supravalvular pulmonary stenosis.

About the ABIM ACHD Exam

The ABIM Adult Congenital Heart Disease (ACHD) subspecialty certification — first offered in 2015 and jointly sponsored by ABIM and ABP — validates expertise in caring for adults with congenital heart disease. Content spans single ventricle/Fontan physiology, repaired tetralogy of Fallot, d-TGA and l-TGA, coarctation, bicuspid aortopathy, ASD/VSD/AVSD, Ebstein anomaly, Eisenmenger syndrome, pulmonary hypertension, genetic aortopathies (Marfan, Loeys-Dietz), ACHD pregnancy risk (mWHO), and transcatheter/surgical interventions. Eligibility requires completion of a 2-year ACGME-accredited ACHD fellowship after primary certification in Cardiovascular Disease or Pediatric Cardiology.

Questions

100 scored questions

Time Limit

~10 hours total (four sessions, up to 60 items each)

Passing Score

Criterion-referenced (pass/fail; specific cut not published by ABIM)

Exam Fee

~$2,500 ABIM registration fee (American Board of Internal Medicine (ABIM), jointly with American Board of Pediatrics (ABP))

ABIM ACHD Exam Content Outline

18%

Single Ventricle & Fontan Physiology

Staged palliation (Norwood stage 1, bidirectional Glenn stage 2, Fontan stage 3), Fontan circulation (preload-dependent, no subpulmonic pump, obligate CVP elevation), PLE, plastic bronchitis, Fontan-associated liver disease, Fontan failure.

20%

Conotruncal & Septal Defects

Repaired tetralogy of Fallot (residual PR, RV dilation, PVR thresholds), d-TGA atrial switch (Mustard/Senning, systemic RV failure) vs arterial switch, l-TGA (congenitally corrected), ASD types, VSD types, AVSD (Down syndrome).

15%

Left-Sided Obstruction & Aortopathy

Coarctation with recoarctation/aortopathy surveillance, bicuspid aortic valve and ascending aortic dilation, Marfan (FBN1, root thresholds 5.0-5.5 cm, beta-blockers/losartan), Loeys-Dietz (TGFBR1/2), vascular Ehlers-Danlos.

12%

Pulmonary Hypertension & Eisenmenger

WHO PH groups 1-5, Eisenmenger (shunt reversal, cyanosis, erythrocytosis/hyperviscosity), PAH therapy (bosentan, macitentan, sildenafil, tadalafil, selexipag), avoidance of rapid fluids or afterload drop, pregnancy contraindicated.

13%

Arrhythmias, HCM & Cardiomyopathy in CHD

Atrial arrhythmias in Fontan/TOF, WPW in Ebstein (~25%), HCM (MYH7/MYBPC3, SCD in athletes, septal reduction at LVOT gradient >=50 mmHg), LV noncompaction, SCD risk and ICD indications.

12%

Pregnancy, Contraception & Multisystem Care

Modified WHO classification (mWHO I-IV), cyanotic pregnancy, anticoagulation in mechanical valves, avoidance of estrogen in Eisenmenger/Fontan, stroke prevention, endocarditis prophylaxis, cyanotic erythrocytosis management.

10%

Imaging, Hemodynamics & Interventions

TTE/TEE/cardiac MRI/CT, cath hemodynamics (Qp:Qs, PVR), transcatheter pulmonic valve replacement (Melody/Harmony), ASD/PFO closure (RESPECT trial), PVR surgery, Fontan conversion.

How to Pass the ABIM ACHD Exam

What You Need to Know

Passing score: Criterion-referenced (pass/fail; specific cut not published by ABIM)
Exam length: 100 questions
Time limit: ~10 hours total (four sessions, up to 60 items each)
Exam fee: ~$2,500 ABIM registration fee

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

ABIM ACHD Study Tips from Top Performers

1Master Fontan circulation cold: preload-dependent, no subpulmonic pump, obligate CVP elevation 12-15 mmHg, and the complication triad of PLE (check alpha-1 antitrypsin clearance), plastic bronchitis, and Fontan-associated liver disease (screen with MRI and AFP).

2For repaired tetralogy of Fallot, memorize PVR (pulmonary valve replacement) indications in symptomatic patients and asymptomatic patients with severe PR plus RVEDVi >=160 mL/m2, RVESVi >=80 mL/m2, RV/LV volume ratio, or objective exercise intolerance.

3Differentiate d-TGA (Mustard/Senning with systemic RV failure, baffle leaks, sinus node dysfunction) from l-TGA (congenitally corrected, systemic RV also fails over time, associated VSD/pulmonary stenosis/Ebsteinoid TV) — the systemic RV is the unifying pathology.

4Know Marfan aortic root thresholds for surgery (5.0 cm with risk factors, 5.5 cm otherwise; Loeys-Dietz 4.0-4.4 cm) and mWHO pregnancy classes (IV = avoid: Eisenmenger, severe PAH, Fontan with complications, Marfan root >4.5 cm, severe left heart obstruction).

5Practice ECG and imaging pattern recognition: RBBB after TOF repair, sinus node dysfunction in Mustard, WPW in Ebstein (~25%), atrialized RV on echo, Fontan protein-losing enteropathy clues (low albumin, edema, elevated alpha-1 antitrypsin fecal clearance).

Frequently Asked Questions

Who is eligible for the ABIM ACHD exam?

Candidates must hold ABIM certification in Cardiovascular Disease or ABP certification in Pediatric Cardiology, plus complete a 2-year (24-month) ACGME-accredited Adult Congenital Heart Disease fellowship. Since July 2019, the 24-month ACGME fellowship has been mandatory — older grandfathered practice pathways are closed.

How often is the ABIM ACHD exam administered?

The ACHD certification exam is offered only in odd-numbered years (for example 2025, 2027, 2029). If you do not pass or miss a cycle, you must wait until the next administration two years later. Registration windows open earlier in the exam year via the ABIM Physician Portal.

What is the format and length of the exam?

The exam is approximately 10 hours total, divided into four sessions of up to 60 multiple-choice (single-best-answer) questions each. Items include brief stems, case histories, graphs, ECGs, and imaging. It is delivered at Pearson VUE testing centers. There is no oral or OSCE component.

How much does the ABIM ACHD exam cost?

The 2026 ABIM ACHD registration fee is approximately $2,500 (subject to ABIM updates). Fees are covered by many ACHD fellowship programs or hospital CME stipends. Late registration surcharges may apply; check your Physician Portal for current deadlines.

Is the certification jointly offered by ABIM and ABP?

Yes. ACHD is one of the few certifications jointly sponsored by ABIM (internal medicine) and ABP (pediatrics). Candidates can enter through either an adult cardiology or pediatric cardiology pathway. ABP candidates must request an ABIM candidate number before registering through the ABIM portal.

How do I maintain ABIM ACHD certification after passing?

ABIM ACHD certification is valid for 10 years with two MOC options: the traditional 10-year recertification exam, or the ABIM Longitudinal Knowledge Assessment (LKA) — a continuous assessment with 30 quarterly questions and open-resource format. Most ACHD diplomates now choose LKA.

What topics carry the most weight on the exam?

Conotruncal and septal defects (repaired TOF, d/l-TGA, ASD/VSD/AVSD) are the largest single block, followed by single ventricle/Fontan physiology. Pulmonary hypertension/Eisenmenger, aortopathy (Marfan, bicuspid), pregnancy risk, arrhythmias, and imaging each carry 10-15% of content.

How hard is the ABIM ACHD exam?

The exam is considered very challenging even for ACHD fellowship graduates, because it tests both adult and pediatric cardiac physiology at subspecialty depth over a 10-hour testing day. Candidates with 300-500 hours of focused review (ACC ACHD SAP, textbooks, and practice questions) typically pass on first attempt.