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DOI: 10.1161/CIRCULATIONAHA.105.170308 2005

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DOI: 10.1161/CIRCULATIONAHA.105.170308 2005

  1. 1. ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology. A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence (ACC/AHA/AAP Writing Committee to Develop Training Recommendations for Pediatric Cardiology) Circulation 2005;112;2555-2580 DOI: 10.1161/CIRCULATIONAHA.105.170308 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 Copyright © 2005 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/cgi/content/full/112/16/2555 Subscriptions: Information about subscribing to Circulation is online at http://circ.ahajournals.org/subscriptions/ Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Fax: 410-528-8550. E-mail: journalpermissions@lww.com Reprints: Information about reprints can be found online at http://www.lww.com/reprints Downloaded from circ.ahajournals.org by on April 30, 2008
  2. 2. ACCF/AHA/AAP Recommendations ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence (ACC/AHA/AAP Writing Committee to Develop Training Recommendations for Pediatric Cardiology) AUTHORS Introduction: Training Guidelines for Pediatric Cardiology Fellowship Programs Chair: Thomas P. Graham, Jr, MD, FACC, FAHA, FAAP, Nashville, Tenn; Co-Chair: Robert H. Beekman III, MD, FACC, FAHA, FAAP, Cincinnati, Ohio Task Force 1: General Experiences and Training Chair: Hugh D. Allen, MD, FACC, FAHA, FAAP, Columbus, Ohio; J. Timothy Bricker, MD, FACC, FAAP, Houston, Tex; Michael D. Freed, MD, FACC, FAHA, FAAP, Boston, Mass; Roger A. Hurwitz, MD, FACC, FAAP, Indianapolis, Ind; Tim C. McQuinn, MD, FAAP, Charleston, SC; Richard M. Schieken, MD, FACC, FAHA, FAAP, Richmond, Va; William B. Strong, MD, FACC, FAAP, Augusta, Ga; Kenneth G. Zahka, MD, FACC, FAAP, Cleveland, Ohio Task Force 2: Pediatric Training Guidelines for Noninvasive Cardiac Imaging Chair: Stephen P. Sanders, MD, FACC, Durham, NC; Steven D. Colan, MD, FACC, Boston, Mass; Timothy M. Cordes, MD, FACC, FAAP, Indianapolis, Ind; Mary T. Donofrio, MD, FACC, FAAP, Washington, DC; Gregory J. Ensing, MD, FACC, Ann Arbor, Mich; Tal Geva, MD, FACC, Boston, Mass; Thomas R. Kimball, MD, FACC, FAAP, Cincinnati, Ohio; David J. Sahn, MD, MACC, FAAP, Portland, Ore; Norman H. Silverman, MD, FACC, FAHA, Stanford, Calif; Mark S. Sklansky, MD, FACC, Los Angeles, Calif; Paul M. Weinberg, MD, FACC, FAAP, Philadelphia, Pa *AHA CVDY representative; †AAP representative. ‡Former Task Force member during writing effort. This document was approved by the American College of Cardiology Foundation Board of Trustees in June 2005, by the American Heart Association Science Advisory and Coordinating Committee in July 2005, and by the American Academy of Pediatrics Board in July 2005. When citing this document, the American Heart Association would appreciate the following citation format: Beekman RH III, Graham TP, et al. ACCF/AHA/AAP recommendations for training in pediatric cardiology: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence (ACC/AHA/AAP Writing Committee to Develop Training Recommendations for Pediatric Cardiology). Circulation. 2005;112:2555–2580. This document has been copublished in the October 4, 2005, issue of the Journal of the American College of Cardiology. Copies: This document is available on the Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (www.americanheart.org), and the American Academy of Pediatrics (www.aap.org). Single copies of this document may be purchased for $10.00 each by calling 1-800-253-4636 or by writing to the American College of Cardiology, Resource Center, 9111 Old Georgetown Road, Bethesda, Maryland 20814-1699. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please direct requests to copyright_permissions@acc.org. (Circulation. 2005;112:2555-2580.) © 2005 by the American College of Cardiology Foundation, the American Heart Association, Inc., and the American Academy of Pediatrics. Circulation is available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.170308 2555 Downloaded from circ.ahajournals.org by on April 30, 2008
  3. 3. 2556 Circulation October 18, 2005 Task Force 3: Training Guidelines for Pediatric Cardiac Catheterization and Interventional Cardiology Chair: Robert H. Beekman III, MD, FACC, FAAP, Cincinnati, Ohio; William E. Hellenbrand, MD, FACC, New York, NY; Thomas R. Lloyd, MD, FACC, Ann Arbor, Mich; James E. Lock, MD, FACC, FAAP, Boston, Mass; Charles E. Mullins, MD, FACC, FAHA, FAAP, Houston, Tex; Jonathan J. Rome, MD, FACC, Philadelphia, Pa; David F. Teitel, MD, San Francisco, Calif Task Force 4: Recommendations for Training Guidelines in Pediatric Cardiac Electrophysiology Chair: Victoria L. Vetter, MD, FACC, FAHA, Philadelphia, Pa; Michael J. Silka, MD, FACC, Los Angeles, Calif; George F. Van Hare, MD, FACC, FAAP, Palo Alto, Calif; Edward P. Walsh, MD, FACC, Boston, Mass Task Force 5: Requirements for Pediatric Cardiac Critical Care Chair: Thomas Kulik, MD, Ann Arbor, Mich; Therese M. Giglia, MD, FACC, New Hyde Park, NY; Keith C. Kocis, MD, FACC, FAAP, Chapel Hill, NC; Larry T. Mahoney, MD, FACC, FAHA, Iowa City, Iowa; Steven M. Schwartz, MD, Cincinnati, Ohio; Gil Wernovsky, MD, FACC, FAAP, Philadelphia, Pa; David L. Wessel, MD, FAHA, Boston, Mass Task Force 6: Training in Transition of Adolescent Care and Care of the Adult With Congenital Heart Disease Chair: Daniel J. Murphy, Jr, MD, FACC, FAAP, Palo Alto, Calif; Elyse Foster, MD, FACC, FAHA, San Francisco, Calif Task Force 7: Training Guidelines for Research in Pediatric Cardiology Chair: D. Woodrow Benson, Jr, MD, PhD, Cincinnati, Ohio; H. Scott Baldwin, MD, FACC, FAHA, Nashville, Tenn; Larry T. Mahoney, MD, FACC, FAHA, Iowa City, Iowa; Tim C. McQuinn, MD, FAAP, Charleston, SC STEERING COMMITTEE Thomas P. Graham, Jr, MD, FACC, FAHA, FAAP, Chair; Robert H. Beekman III, MD, FACC, FAHA, FAAP, Co-Chair; Michael D. Freed, MD, FACC, FAHA, FAAP; John W. Hirshfeld, Jr, MD, FACC, FAHA; Thomas Kulik, MD; John D. Kugler, MD, FACC, FAAP*†; Tim C. McQuinn, MD, FAAP; David J. Sahn, MD, MACC, FAAP; Victoria L. Vetter, MD, FACC, FAHA; William B. Moskowitz, MD, FACC, FAAP† TASK FORCE MEMBERS Mark A. Creager, MD, FACC, FAHA, Chair; John W. Hirshfeld, Jr, MD, FACC, FAHA; Beverly H. Lorell, MD, FACC, FAHA‡; Geno Merli, MD, FACP; George P. Rodgers, MD, FACC; John D. Rutherford, MB, ChB, FACC, FAHA; Cynthia M. Tracy, MD, FACC, FAHA; Howard H. Weitz, MD, FACC, FACP Downloaded from circ.ahajournals.org by on April 30, 2008
  4. 4. ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology 2557 INTRODUCTION Training Guidelines for Pediatric Cardiology Fellowship Programs Thomas P. Graham, JR, MD, FACC, FAHA, FAAP, Chair Robert H. Beekman III, MD, FACC, FAHA, FAAP, Co-Chair Pediatric cardiology is a complex, multifaceted specialty com- important subspecialties within the field of pediatric cardi- posed of diverse clinical and academic subspecialty areas. It is ology. Although we understand that the pediatric RRC sets characterized by rapid growth of subspecialty areas and swift minimum standards for accreditation of fellowship pro- incorporation of new information from the clinical and labo- grams, this document endeavors to define a more compre- ratory sciences. It is important, therefore, to define the fellow- hensive set of guidelines for pediatric cardiology fellowship ship training required to launch a successful career in pediatric training. Fellowship training guidelines are presented for: cardiology. The following document represents the first broad- general pediatric cardiology (including inpatient care and based effort to do so. consultations); echocardiography and noninvasive imaging; In 2000, the Society of Pediatric Cardiology Training electrophysiology; cardiac catheterization and intervention; Program Directors (SPCTPD) embarked on the process of cardiac intensive care; adult congenital heart disease; and defining fellowship training guidelines. The process itself was research participation. Each section other than general pedi- broad-based and inclusive. All pediatric cardiology training atric cardiology specifies “core” and “advanced” training expe- program directors were invited to nominate members to riences. Core recommendations are intended to be common participate in the training guidelines task forces; in turn, each training experiences for all pediatric cardiology trainees task force was comprised of all nominated members who regardless of long-term career goals. Advanced recommen- agreed to participate. Therefore, all training programs were dations are additional training experiences for trainees provided an opportunity to actively participate. intending to develop a clinical or academic area of special In 2002, the American College of Cardiology (ACC) approved competence. All guidelines are recommended experiences, and published the Revised Recommendations in Adult Cardio- and not absolute mandates, as it is recognized that each vascular Medicine Core Cardiology Training (1). As the training program has unique strengths and that clinical and SPCTPD was concluding its training guideline development, academic variation across training programs provides im- plans were formalized to use a similar process through the ACC portant diversity for the specialty. Pediatric Cardiology/Congenital Heart Disease Committee and Table 1 summarizes the approximate time commitment the ACC Training Program Directors Committee. Accordingly, (in months) recommended for core training in the task force a steering committee was developed with original authors of the reports that follow. Variations in these time commitments Pediatric Cardiology Training Guidelines to form a liaison with should be allowed, as pediatric cardiology programs vary the ACC, the American Heart Association (AHA), and the widely in size, organization, and emphasis. For example, in Section on Pediatric Cardiology and Cardiac Surgery of the some programs, fellows may get considerable cardiac inten- American Academy of Pediatrics (AAP) to agree on the final sive care unit training during their general inpatient expe- guidelines and to publish them widely. riences and not require a two- to four-month stand-alone These guidelines are written with the planned goal of rotation. Thus, the training guidelines must provide pro- serving as a practical resource for directors of pediatric grams with flexibility to address individual trainee clinical cardiology training programs. We also hope that this and/or research training needs during a core fellowship of document will prove useful to the Residency Review Com- 36 months’ duration. mittee (RRC) for pediatric training programs in the revision The training program must possess the faculty expertise, of requirements for the accreditation of pediatric cardiology patient volume, and inpatient/outpatient facilities to provide programs. The general requirements, clinical competencies, meaningful trainee experiences as outlined in this docu- and oversight for fellows in pediatric cardiology would ment. All faculty should be board certified or possess remain the same as outlined by the Accreditation Council suitable equivalent qualifications. Recommendations for for Graduate Medical Education (ACGME). trainee and faculty evaluation are those outlined in the “general and special requirements” as published by the ACGME, and training should take place within a program GENERAL CONSIDERATIONS that is accredited by the ACGME. The guidelines proposed in this document address overall A comment about trainee research participation is appro- recommendations for training in pediatric cardiology and priate. The field of pediatric cardiology is absolutely depen- Downloaded from circ.ahajournals.org by on April 30, 2008
  5. 5. 2558 Circulation October 18, 2005 Table 1. Core Training Recommendations training will continue to be a major issue for training Time Commitment programs. It is highly probable that trainees who want to Experience (in months) pursue a physician-scientist career will require at least four General experience (inpatient) 3–6 years of fellowship to begin the academic process and to Echocardiography/imaging 4–6 finish training in the clinical areas. The authors are in Cardiac catheterization 3–4 (estimate*) complete agreement with the newly published American Electrophysiology 2–3 Board of Pediatrics (ABP) Training Requirements for Cardiac intensive care 2–4 subspecialty certification concerning scholarly activity, Adult congenital heart disease 0–2 (estimate*) Research 12–18 meaningful accomplishments in research, scholarship over- Total 36 sight, and differing pathways to train physician-scientists. *Task Force identified experience-based recommendations. See individual section for numbers. REFERENCE 1. Beller GA, Bonow RO, Fuster V. ACC revised recommendations for dent upon research (basic and clinical) for meaningful training in adult cardiovascular medicine. Core Cardiology Training II progress. There is a critical need for the development of (COCATS 2) (revision of the 1995 COCATS training statement). physician-scientists in our specialty to assure such future J Am Coll Cardiol 2002;39:1242– 6. progress. Therefore, it is key that training programs begin to prepare trainees for a successful investigative career. Such APPENDIX preliminary research training will in most instances require The authors of this section declare they have no relation- 18 months or more. The balancing of clinical and research ships with industry pertinent to this topic. Downloaded from circ.ahajournals.org by on April 30, 2008
  6. 6. ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology 2559 TASK FORCES Task Force 1: General Experiences and Training Hugh D. Allen, MD, FACC, FAHA, FAAP, Chair, J. Timothy Bricker, MD, FACC, FAAP, Michael D. Freed, MD, FACC, FAHA, FAAP, Roger A. Hurwitz, MD, FACC, FAAP, Tim C. McQuinn, MD, FAAP, Richard M. Schieken, MD, FACC, FAHA, FAAP, William B. Strong, MD, FACC, FAAP, Kenneth G. Zahka, MD, FACC, FAAP INTRODUCTION three months. The continuity outpatient clinic should begin early in fellowship and continue throughout training, pref- The goals of pediatric cardiology training include acquiring erably on a biweekly basis. Both inpatient and outpatient the cognitive and procedural expertise required to provide experiences should include exposure to the management of high-quality care to children with cardiovascular disease, the adult patient with congenital heart disease. acquiring the academic skills to make meaningful scholarly There are many ways for general inpatient and outpatient contributions to the specialty, and, importantly, to develop practices to be organized. In the delivery of high-level the capacity for ongoing self-education beyond the years of inpatient and outpatient care the pediatric cardiologist must formal training. demonstrate effective team leadership, accurate and efficient The general training of pediatric cardiology fellows builds medical record keeping, sensitivity to medical ethical issues, on the general clinical and academic skills acquired during an ability to communicate with and support patients and residency training. The pediatric cardiology fellow should be their families through stressful decisions and experiences, given broad exposure to clinical activities in pediatric cardiol- and show strict compliance with federal regulatory statutes. ogy inpatient and outpatient care, pediatric cardiology inpa- The general inpatient and outpatient training environment tient and outpatient consultations, and in preventive cardiol- for pediatric cardiology fellows must provide full opportu- ogy. The academic skills of formal presentation, small-group nity for observation, acquisition, and application of these teaching, literature review, data analysis, and study design are skills by the trainee. also components of the general training guidelines. During the course of inpatient and outpatient activities the pediatric cardiology fellow will become familiar with a CLINICAL TRAINING core knowledge base, as outlined in Table 1, at a minimum. A fundamental goal of clinical training is to acquire bedside diagnostic skill and the ability to provide high-qualilty consultative inpatient and outpatient pediatric cardiology DIDACTIC CONTENT care. The core skills of history-taking and physical exami- The Core Curriculum nation are the only means for correctly initiating diagnostic and management options appropriate to the individual The program should offer courses, seminars, workshops, patient, and these must be heavily stressed at all points of and/or laboratory experiences to provide appropriate back- patient contact. Pediatric cardiology fellows should be ground in basic and fundamental disciplines related to the observed by faculty while performing key portions of the heart and cardiovascular system. A lecture series encompass- history and physical examination, and to also have the ing a core curriculum in clinical and basic science topics opportunity to observe faculty perform history-taking and must be provided for pediatric cardiology fellows. It should physical examination, so that meaningful discussion of be designed so that the spectrum of topics presented will be useful strategies and techniques may develop. Consulta- completed at least once in the three years of accredited tion services, general inpatient wards, and outpatient fellowship training. Pediatric cardiology fellows should clinics all provide excellent opportunities for such inter- contribute formal presentations of selected topics in the action. core curriculum, both to strengthen their knowledge base The pediatric cardiology fellow must have the opportu- and to develop formal presentation skills. General areas nity to provide not only inpatient and outpatient consulta- to be covered in the core curriculum include those listed tion services but also direct patient care in both inpatient in Table 1. and outpatient settings. There must be a continuity of care Additional Conferences in the outpatient clinic so that fellows can begin to appre- ciate the course of pediatric cardiac disease over time and its Preoperative conferences with the cardiovascular surgical cumulative impact on individual patients and their families. service are essential. Journal clubs are a recommended The combined time commitment of the general inpatient element of an academic environment and provide an excel- and inpatient consultation services should be no less than lent venue for participatory evaluation of study design and Downloaded from circ.ahajournals.org by on April 30, 2008
  7. 7. 2560 Circulation October 18, 2005 Table 1. Core Knowledge Base Anatomy and physiology of congenital heart defects (e.g., tetralogy of Fallot, hypoplastic left heart syndrome, ventricular septal defect) Cardiac, autonomic and noncardiac causes of syncope and near-syncope Cardiac MRI/CT Cardiac sequelae of chronic hepatic disease Cardiac sequelae of chronic renal disease Cardiac sequelae of HIV/AIDS Cardiac sequelae of obstructive sleep apnea Cardiac sequelae of oncologic therapy Cardiomyopathy, heart failure, and transplantation in the pediatric patient Cardiopulmonary bypass Cardiovascular pharmacology Cardiovascular physiology and anatomy Cardiovascular sequelae and follow-up in Marfan, William, DiGeorge, Turner, and Noonan syndromes Cardiovascular sequelae of pregnancy and the impact of congenital heart disease Cardiovascular sequelae of rheumatologic disease Cardiovascular sports medicine Care of the single ventricle patient Cellular electrophysiology (e.g., action potentials and ion channels) Chest pain Clinical electrophysiology (e.g., mechanisms of arrhythmias, pacemakers, ablative therapy) Coagulation and anticoagulation Diagnosis and management of arrhythmias Diagnosis and management of elevated pulmonary vascular resistance Diagnosis and management of intravascular/intracardiac thrombosis Diagnosis and management of left-to-right shunt lesions Diagnosis and management of patent ductus arteriosus in premature infants Diagnosis and management of right to left shunt lesions Diagnosis and management of valvular heart disease, including artificial heart valves Diagnostic evaluation of heart murmurs Differential diagnosis and management of cardiac tumors Differential diagnosis and management of pericardial effusion and pericardial tamponade Embryonic, fetal, and postnatal cardiovascular development Endocarditis Exercise testing Fetal/neonatal/perinatal cardiovascular physiology Genetics of cardiovascular diseases of childhood Hyperlipidemia Hypertension Kawasaki disease Medical ethics Normal cardiovascular anatomy and physiology, including exercise physiology Obesity Pericarditis and pericardial effusions Physics of echocardiography and Doppler analysis Physiology and natural history of congenital heart disease Population health Preventive cardiology, including prevention of adult acquired heart disease Quality assurance and process improvement methodology Rationale, expectations, and methods of screening for congenital heart disease in neonates with trisomy of chromosome 21, 18, or 13 Rationale, expectations, and methods of screening for congenital heart disease infants of diabetic pregnancies Rationale, expectations, and methods of screening for congenital heart disease in the presence of neonatal emergencies such as gastroschisis, omphalocele, congenital diaphragmatic hernia, or cardiorespiratory failure leading to extracorporeal membrane oxygenation Rheumatic fever Risk factors in childhood and adolescence Segmental cardiac analysis Statistics and study design data analysis. Quality assurance evaluation and morbidity/ contributors might include neonatology, cardiothoracic sur- mortality conferences should be held periodically. Multidis- gery, adult cardiology, cardiac pathology, physiology, phar- ciplinary clinical and research conferences are highly desir- macology, pulmonology, intensive care, cardiac anesthesiol- able; according to the strengths of the institution, ogy, cardiovascular radiology, clinical genetics, molecular Downloaded from circ.ahajournals.org by on April 30, 2008
  8. 8. ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology 2561 genetics, tissue engineering, stem cell biology, or develop- critique of these skills by the attending physician as well as mental biology. In all of these conferences, pediatric cardi- demonstration of these skills to the fellow by the attending. ology fellows should be provided with active roles appropri- Pediatric cardiology fellows should develop formal ate to their level of knowledge and training. evaluation of trainees and training skills during their fellowship. To do so, they should participate in feedback TEACHING AND EVALUATION SKILLS to residents, students, and cardiology attendings It is a fundamental responsibility in academic medicine that throughout their rotations regarding their own educa- those with the most experience must teach. The pediatric tional and technical progress and the progress of other cardiology fellow will often be the most clinically experi- team members. Accurate self-evaluation is the most enced house officer on a team of residents, interns, and/or valuable skill of all and should be nurtured in all phases medical students. The fellow in that setting should be of pediatric cardiology training. expected to provide lectures/seminars to the team of house officers. The pediatric cardiology fellow should also be allowed the opportunity to practice clinical leadership, organizational skills, and impromptu educational activities APPENDIX as appropriate to his/her demonstrated level of knowledge The authors of this section declare they have no relation- and training. There should be occasion for observation and ships with industry pertinent to this topic. Task Force 2: Pediatric Training Guidelines for Noninvasive Cardiac Imaging Endorsed by the American Society of Echocardiography and the Society of Pediatric Echocardiography Stephen P. Sanders, MD, FACC, Chair, Steven D. Colan, MD, FACC, Timothy M. Cordes, MD, FACC, FAAP, Mary T. Donofrio, MD, FACC, FAAP, Gregory J. Ensing, MD, FACC, Tal Geva, MD, FACC, Thomas R. Kimball, MD, FACC, FAAP, David J. Sahn, MD, MACC, FAAP, Norman H. Silverman, MD, FACC, FAHA, Mark S. Sklansky, MD, FACC, Paul M. Weinberg, MD, FACC, FAAP INTRODUCTION PEDIATRIC ECHOCARDIOGRAPHY Noninvasive imaging, including echocardiography and Echocardiography, as used in this document, includes two- magnetic resonance imaging (MRI), is a primary means for dimensional imaging of the heart and related structures, elucidating the anatomy and physiology of childhood heart M-mode echocardiography for assessment of chamber size disease. Competence in performance and interpretation of and function, color M-mode and Doppler tissue and flow echocardiography and MRI is now essential to the practice mapping, pulsed and continuous-wave spectral Doppler of pediatric cardiology. Depending upon one’s individual flow analysis, and other variations of these basic modalities career goals, varying levels of expertise may be expected to used to assess the structure and function of the heart and be achieved during fellowship training. This document related organs, including new technologies such as three- defines the levels of knowledge and expertise that pediatric dimensional echocardiography as they become available. cardiology trainees should acquire in echocardiography and MRI during training, and it offers guidelines for achieving Facilities and Environment these levels of competence. The pediatric echocardiography laboratory should serve a Training guidelines have been previously published for hospital with inpatient and outpatient facilities, neonatal and pediatric echocardiography (1), fetal echocardiography (2), pediatric intensive care units, a pediatric cardiac catheteriza- and pediatric transesophageal echocardiography (3). Those tion/interventional laboratory, and an active pediatric cardiac documents were reviewed and considered during prepara- surgical program. The pediatric echocardiography laboratory tion of these guidelines. The guidelines presented here differ should be under the supervision of a full-time pediatric in some instances from previous recommendations because cardiologist-echocardiographer qualified to direct a laboratory, this task force recognizes that training programs have and whose primary responsibility is supervision of the labora- changed significantly over the decade since the last guide- tory. The laboratory must perform a sufficient number of lines were promulgated. pediatric transthoracic, pediatric transesophageal, and fetal Downloaded from circ.ahajournals.org by on April 30, 2008
  9. 9. 2562 Circulation October 18, 2005 echocardiograms (1,4) each year to allow trainees sufficient • Recognition of cardiac structures displayed by echocar- exposure to both normal and abnormal examinations. diography and the correlation between echocardiographic images and cardiac anatomy. LEVELS OF EXPERTISE • Interpretation of Doppler flow information and deduc- Training goals defined here are to enable trainees to achieve tion of cardiovascular physiology. one of two levels of expertise in echocardiography as • Performance and interpretation of complete transtho- appropriate for career goals. racic two-dimensional and M-mode echocardiograms, Doppler color-flow mapping, and pulsed- and continuous- Core wave spectral Doppler flow analysis in normal pediatric • Understanding of the general physical properties of patients and in those with childhood heart disease, with ultrasound and clinical ultrasound technology. consultation as needed. • Ability to perform and interpret transthoracic echocardi- • Assessment of systolic, diastolic, and regional myocardial ography in normal infants, children and adolescents, and function in normal pediatric patients and those with in those with childhood heart disease, with consultation childhood heart disease, with consultation as needed. as needed. • Ability to review critically published clinical research in • Basic introduction to the principles of performing and echocardiography. interpreting transesophageal and fetal echocardiograms. Advanced Physicians with core expertise only are not expected to perform transesophageal and fetal echocardiograms In addition to core competencies, other goals include: independently. • Independent performance and interpretation of complete Advanced transthoracic two-dimensional and M-mode echocardio- grams, Doppler color-flow mapping, and pulsed- and • Special expertise in performance and interpretation of continuous-wave spectral Doppler flow analysis in nor- transthoracic echocardiography in all forms of congenital mal pediatric patients and in those with childhood heart and acquired pediatric heart disease, including the adult disease. with congenital heart disease, enabling the practitioner to • Independent assessment of systolic, diastolic and regional function independently. myocardial function in normal pediatric patients and in • Ability to perform and interpret transesophageal and those with congenital or acquired heart disease, to in- fetal echocardiography independently. clude stress echocardiographic studies. • Ability to supervise training and performance of sonog- • Special expertise in the performance and interpretation of raphers, fellows, and other physicians. pediatric transthoracic, pediatric transesophageal, and fetal echocardiography. TRAINING GUIDELINES • Training of sonographers and junior pediatric cardiology Core training should be achieved by all pediatric cardiology trainees. fellows during core clinical training, typically during four to • Participation in basic or clinical research in echocardiog- six months dedicated to echocardiography over the course of raphy, including presenting original data at one or more the standard three-year training program. This level of scientific meetings. expertise is anticipated to be sufficient for those fellows who do not plan to pursue echocardiography as an area of TRAINING METHODS subspecialization. Each level of training may be achieved by the methods Advanced training requires an additional 9 to 12 months outlined in the following text or by comparable alternative of training and may be achieved through a dedicated methods. A summary of the recommended minimum num- experience in pediatric echocardiography after completion ber of procedures is found in Table 1. of core pediatric echocardiography instruction. This level of training is appropriate for those physicians who intend to be Core dedicated pediatric echocardiographers. Each trainee should perform and interpret at least 150 pediatric echocardiograms, including at least 50 in patients TRAINING GOALS one year of age or younger, under the supervision of the Successful completion of each training level should result in laboratory director or other qualified staff pediatric competence in the following specific areas. cardiologist-echocardiographer(s). Each trainee should also review at least 150 additional pediatric echocardiograms. Core In addition, the laboratory director or other staff pediatric • Understanding of the physical properties of ultrasound. cardiologist-echocardiographer(s) should conduct regular • Proper, safe, and facile use of ultrasound instruments. laboratory conferences with the trainee(s) to present illus- • Knowledge of the limitations of echocardiography. trative cases and to teach proper interpretation and the Downloaded from circ.ahajournals.org by on April 30, 2008
  10. 10. ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology 2563 Table 1. Echocardiography Training—Recommended Minimum The trainee should observe and participate in the discussion of Procedure Numbers the findings with the parents by the staff echocardiographer Core training responsible for the examination. As the trainee’s experience TTE perform and interpret 150 (50) progresses, a significant proportion (30% to 50%) of ( 1 year of age) TTE review 150 studies should be performed independently, including Advanced training* cases with normal and abnormal cardiac anatomy and TTE perform and interpret 200 (50) rhythm, with supervision by a dedicated pediatric ( 1 year of age) cardiologist-echocardiographer. Each trainee should un- TTE review 200 TEE perform and interpret 50 derstand how to recognize and approach fetal heart Fetal echocardiogram 50 failure, and he or she should understand the association *Numbers are in addition to those obtained during core training. of fetal heart disease with extracardiac structural abnor- TEE transesophageal echocardiogram; TTE transthoracic echocardiogram. malities, syndromes, and chromosomal abnormalities. Research training for pediatric cardiology trainees should limitations of echocardiography. Pathological specimens, include, at a minimum, active participation in reviews of models, or photographs for echocardiographic-anatomic correlation are excellent teaching aids that should be incor- scientific journal articles that pertain to echocardiography. porated wherever possible. In addition, participation in basic or clinical research in Integration of echocardiography into the clinical practice echocardiography should be encouraged. of pediatric cardiology should be demonstrated on inpatient Each advanced-level trainee should be given responsibility and outpatient rotations and at medical-surgical manage- for participating in the training of sonographers and junior ment conferences. pediatric cardiology fellows, initially with supervision of the Research training for pediatric cardiology trainees should laboratory director and then independently and also pre- include active participation in reviews of scientific journal senting echocardiography-related teaching conferences and articles that pertain to echocardiography. formal didactic lectures. Advanced Each advanced-level trainee should perform and interpret EVALUATION at least 200 additional pediatric transthoracic echocardio- grams and review, or perform and interpret, another 200 The laboratory director, in consultation with the teaching pediatric echocardiograms. As with core training, at least staff, should evaluate each trainee in writing on a regular 50 of these should be done in infants one year of age or basis. Trainees should maintain a log of all echocardiograms younger. Each trainee should perform a significant num- performed and reviewed, including the age of the patient ber of echocardiograms independently (one-third to one- and the diagnosis. The log should be reviewed regularly by half of the exams), with subsequent review and critique of both the laboratory director and the training program the examination by the responsible staff pediatric director to ensure that each trainee is obtaining adequate cardiologist-echocardiographer. Teaching methods out- and balanced experience. lined in the previous text should be continued here. The evaluation should be reviewed with each trainee and Each advanced-level trainee should perform and interpret a written copy provided. If a trainee does not appear to be at least 50 pediatric transesophageal echocardiograms, in- progressing adequately during the rotation, a meeting cluding manipulation of the transducer and registration of should be scheduled as soon as possible to inform the trainee images, under direct supervision by a dedicated pediatric and to discuss potential remedial measures. The evaluation cardiologist-echocardiographer. The trainee should perform should be based on achievement of the expected levels of intubation of the esophagus in at least 20 patients under the competence in the areas outlined in the previous text. direct supervision of a pediatric cardiologist-echocardiographer Direct observation of the trainee during performance of or anesthesiologist experienced in the procedure. An ideal echocardiograms provides information about imaging skills environment for learning pediatric transesophageal echocar- diography is the operating suite during performance of and understanding of the ultrasound instruments. Conferences intraoperative examinations, but the training experience in which echocardiograms are presented provide an opportu- should not be limited to this venue and should include the nity to assess skills in interpretation of images and Doppler intensive care unit, cardiac catheterization suite, and outpa- recordings. The trainees’ understanding of research design and tient examinations. methods and ability to review research can be critically evalu- Each advanced trainee should perform and/or review at ated during journal club meetings or other venues for medical least 50 fetal echocardiograms. The trainee must master the literature review. Teaching skills and effectiveness can be fundamental skills of determining fetal position, situs, evaluated by direct observation and from evaluations by sonog- cardiac anatomy, and cardiac rhythm under the supervision raphers and more junior trainees and by performance at of a dedicated pediatric cardiologist-echocardiographer. teaching conferences prepared and delivered by trainees. Downloaded from circ.ahajournals.org by on April 30, 2008
  11. 11. 2564 Circulation October 18, 2005 PEDIATRIC CARDIOVASCULAR This level of expertise may be sufficient for those fellows MAGNETIC RESONANCE IMAGING who plan to practice clinical pediatric cardiology with access to a pediatric cardiologist or radiologist with special exper- Magnetic resonance imaging (MRI) as used in this docu- tise in pediatric cardiovascular MRI. ment includes anatomic and functional cardiovascular MRI Advanced training requires a minimum of six months of in congenital and acquired pediatric heart disease as well as instruction in addition to core training. This level of training in the adult with congenital heart disease. At present, there is appropriate for those physicians who intend to have are no specific guidelines for training or credentialing in special expertise in pediatric cardiovascular MRI and is pediatric cardiovascular MRI. It is likely that the training recommended for directors of pediatric cardiovascular MRI guidelines for pediatric cardiovascular MRI proposed here laboratories. will require amendment as the field evolves. These guide- lines must be considered as goals and should not be TRAINING GOALS considered as requirements. Successful completion of each training level should result in LEVELS OF EXPERTISE competence in the following specific areas. Trainees may achieve one of two levels of expertise in Core pediatric cardiovascular MRI as appropriate for career goals. • Physical principles of MRI and physiologic analysis. Core • Limitations of, and contraindications to, MRI. • Recognition of cardiac structures displayed by MRI and the • Familiarity with the general physical principles upon correlation between MR images and cardiac anatomy. which MRI is based. • Basic familiarity with commonly used imaging protocols, • Ability to view and understand MR images in normal their clinical uses, and MRI terminology. infants, children, and adolescents and those with child- • Critical review of published clinical research in pediatric hood heart disease. cardiovascular MRI. • Introduction to commonly used imaging protocols and MRI terminology. Advanced Advanced • Thorough understanding of MRI physics, instrumenta- tion, nomenclature, and safety. • Thorough understanding of clinical MRI instruments • Special expertise in the performance and interpretation of and the imaging protocols used for cardiovascular imag- pediatric cardiovascular MRI, including all commonly ing and physiological analysis (e.g., quantitative analysis used imaging and flow analysis protocols. of ventricular function and blood flow). • Training of technologists and junior pediatric cardiology • Ability to independently perform and interpret all types trainees. of MRI in childhood heart disease and congenital heart • Management of and quality assurance for the MRI disease at all ages. laboratory. • Ability to supervise training of technologists, fellows, and • Basic or clinical research in pediatric cardiovascular MRI, other physicians. including presenting original data at one or more scien- tific meetings. TRAINING GUIDELINES TRAINING METHODS Training in pediatric cardiovascular MRI should occur within a pediatric cardiology fellowship program and/or a Each level of training may be achieved by the methods pediatric radiology training program accredited by the outlined in the following text or by comparable alternative Accreditation Council for Graduate Medical Education methods. (ACGME). The MR laboratory should serve a hospital Core with both inpatient and outpatient facilities, neonatal and pediatric intensive care units, a pediatric cardiac catheter- Pediatric cardiology trainees should gain exposure to car- ization/interventional laboratory, and an active pediatric diovascular MRI through active review of scientific journal cardiac surgical program. The MRI laboratory should be articles that pertain to pediatric cardiovascular MRI, discus- under the supervision of a full-time cardiologist and/or sion with cardiologists and radiologists who perform car- radiologist qualified in cardiovascular MRI, and it must diovascular MRI, and, if possible, review of cardiovascular perform a sufficient number of annual examinations to allow MRI examinations. each trainee sufficient exposure to both normal and abnor- Advanced mal examinations. Core training should be achieved by all pediatric cardiol- During a fellowship in pediatric cardiovascular MRI, each ogy fellows during the core clinical years of the program. trainee should perform and/or interpret at least 100 cardio- Downloaded from circ.ahajournals.org by on April 30, 2008
  12. 12. ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology 2565 vascular MRI examinations in patients with congenital or provided. The trainee should maintain a log of all examina- acquired childhood heart disease, including adult patients tions performed and reviewed, including the age of the patient, with congenital heart disease. As the trainee’s experience diagnosis, and role of the trainee in the examination. progresses, an increasing proportion of these examinations should be performed independently, with review and cri- tique by the laboratory director. Research training should include continued critical review REFERENCES of the pediatric cardiovascular MRI literature and an op- 1. Meyer RA, Hazier D, Huhta J, Smallhorn J, Snider R, Williams R. portunity to perform basic or clinical research leading to Guidelines for physician training in pediatric echocardiography, recom- publication or presentation of scientific data. mendations of the Society of Pediatric Echocardiography Committee on Physician Training. Am J Cardiol 1987;60:164 –5. Each trainee should be given responsibility for participat- 2. Meyer RA, Hagler D, Huhta J, et al. Guidelines for physician training ing in the training of technologists and junior pediatric in fetal echocardiography: recommendations of the Society of Pediatric cardiology fellows, initially with supervision of the labora- Echocardiography Committee on Physician Training. J Am Soc Echo- cardiogr 1990;3:1–3. tory director and subsequently independently. In addition, 3. Fyfe DA, Ritter SB, Snider AR, et al. Guidelines for transesophageal each trainee should have opportunities to observe and echocardiography in children. J Am Soc Echocardiogr 1992;5:640 – 4. participate in the management of the laboratory, especially 4. Peariman AS, Gardin JM, Martin RP, et al. Guidelines for optimal physician training in echocardiography: recommendations of the Amer- quality improvement initiatives. ican Society of Echocardiography Committee for Physician Training in Echocardiography. Am J Cardiol 1987;60:158 – 61. EVALUATION The laboratory director, in consultation with the teaching APPENDIX staff, should evaluate each trainee in writing. The evaluation The authors of this section declare they have no relation- should be reviewed with each trainee and a written copy ships with industry pertinent to this topic. Task Force 3: Training Guidelines for Pediatric Cardiac Catheterization and Interventional Cardiology Endorsed by the Society for Cardiovascular Angiography and Interventions Robert H. Beekman III, MD, FACC, FAAP, Chair, William E. Hellenbrand, MD, FACC, Thomas R. Lloyd, MD, FACC, James E. Lock, MD, FACC, FAAP, Charles E. Mullins, MD, FACC, FAHA, FAAP, Jonathan J. Rome, MD, FACC, David F. Teitel, MD INTRODUCTION natural history of the defect), and must skillfully perform the appropriate catheter intervention. It is appropriate, The purpose of this document is to recommend minimum therefore, to delineate minimal training requirements in training experiences in cardiac catheterization for clinical cardiac catheterization for pediatric cardiology trainees. fellows in pediatric cardiology training programs. Training There are no studies relating training experiences to guidelines in cardiac catheterization are well-established in subsequent clinical skill in pediatric cardiac catheterization. adult cardiovascular medicine (1,2), and they have been Therefore, the recommendations in Task Force 3 represent considered recently in pediatric cardiology as well (3,4). the opinions of the authors. To help guide this process, all Pediatric cardiac catheterization is a unique specialty Accreditation Council for Graduate Medical Education encompassing a wide range of diagnostic and therapeutic (ACGME)-accredited pediatric cardiology training pro- techniques applied to a diverse group of congenital and grams were surveyed in 2001 to inquire about current acquired cardiovascular disorders. A physician who per- practices and opinions regarding fellow training in pediatric forms a pediatric cardiac catheterization must possess the cardiac catheterization and intervention. Thirty-two programs technical skills and clinical judgment to safely and accurately responded. The responses represented the opinions of fel- perform a thorough diagnostic cardiac catheterization and lowship directors (n 21), catheterization laboratory direc- angiographic study. Furthermore, an interventional pediat- tors (n 15), and division directors (n 13) (in some ric cardiologist must also assess the indications for a catheter programs one individual holds more than one position). intervention, including the risks of performing or not This document draws on this Training Program Survey to performing the procedure (i.e., requires knowledge of the help define training guidelines in this specialty. Downloaded from circ.ahajournals.org by on April 30, 2008
  13. 13. 2566 Circulation October 18, 2005 FACILITIES AND ENVIRONMENT Table 2. Core Training—Recommended Minimum Case Numbers* Training in cardiac catheterization should occur within a Total cardiac catheterizations 100 pediatric cardiology fellowship program that is accredited by Interventional procedures 20 the ACGME. The cardiac catheterization laboratory should Type of intervention serve a hospital with inpatient and outpatient facilities, Balloon septostomy† 5 neonatal and pediatric intensive care units, and an active Other Not specified pediatric cardiac surgical program. The pediatric cardiac *Numbers represent the median response from the Training Program Survey. †Fluoroscopic or echocardiographic guidance. catheterization laboratory should be under the supervision of a full-time pediatric cardiologist, whose primary respon- Core Training: Goals and Methods sibility is supervision of the laboratory. The laboratory must perform a sufficient number of cardiac catheterizations and Core training in cardiac catheterization refers to the training interventional procedures to provide each trainee with an experiences recommended for all clinical cardiology fellows, acceptable experience. regardless of specific career goals. In the Training Program The cardiac catheterization program must have a regular Survey, there was unanimous support for core training in teaching conference in which diagnostic data (hemody- cardiac catheterization for all clinical fellows. The goal of namic and angiographic) and therapeutic outcomes are such core training is to introduce fellows to the field of formally discussed. In addition, each program that provides cardiac catheterization and the risks and benefits of advanced interventional training must have a regular mor- catheter-based procedures, to teach basic diagnostic cathe- bidity and mortality conference in which all adverse out- terization skills, and to provide a basic knowledge of hemody- comes of catheter interventions are systematically reviewed. namics, angiography, and radiation safety. A core curriculum Participants in this conference should include cardiology in pediatric cardiac catheterization should include the topics faculty, clinical fellows, and preferably pediatric cardiotho- and experiences outlined in Table 1. racic surgeons and cardiac anesthesiologists. Active partici- The core training should involve each clinical fellow in a pation in these conferences by all clinical cardiology fellows, minimum of 100 cardiac catheterizations, at least 20 of particularly those at advanced levels, is essential to clinical which include an interventional component (Table 2). training that emphasizes quality outcomes. These experiences should familiarize the fellow to the indications for cardiac catheterization and intervention, LEVELS OF EXPERTISE femoral vessel access techniques, basic catheter manipula- tions, hemodynamic measurements and calculations, and In this report we discuss core training for all fellows, and angiographic interpretations. Participation by the fellow as advanced training for fellows desiring special expertise in either the primary operator or the primary assistant is cardiac catheterization and interventional cardiology. The satisfactory involvement. A log book should be maintained core training is recommended for all clinical fellows during by the fellow to document the experience and outcomes of their core clinical experience. It is intended to be sufficient catheterization. for fellows who do not plan a career in interventional pediatric cardiology, but who may be required to perform Advanced Training: Goals and Methods simple diagnostic studies and to interpret catheterization Advanced training in cardiac catheterization refers to the and angiographic data in their clinical practices. (Cardiolo- training recommended for pediatric cardiology fellows who gists who provide “diagnostic only” catheterization services intend to pursue a career in pediatric cardiac catheterization must coordinate the care closely with interventional cardi- ologists and surgeons at referral centers to minimize the Table 3. Advanced Training—Recommended Minimum need for repeat catheterization procedures.) The advanced Case Numbers* training provides expertise in both diagnostic and interven- Total cardiac catheterizations 200 tional catheterization procedures, and it is intended to Interventional procedures 100 qualify a fellow to embark upon a career in cardiac cathe- Type of intervention terization and intervention. Balloon septostomy† 5 Transseptal puncture 10 Table 1. Recommended Body of Knowledge Covered During Pulmonary valve dilation 10 (5 newborns) Core Training Aortic valve dilation 10 (5 newborns) Pulmonary artery dilation 10 ● Indications for and risks of cardiac catheterization and angiography Pulmonary artery stent 10 ● Indications for and risks of therapeutic catheter procedures Coarctation dilation 10 ● Interpretation of pressure waveforms Coarctation stent 5 ● Interpretation of O2 saturation data Collateral occlusion 10 ● Fick principle and shunt calculations Ductus arteriosus occlusion 10 ● Vascular resistance calculations Atrial septal defect occlusion 10 ● Cardiac angiography: basic techniques/angles/interpretation ● Radiation safety *Numbers represent the median response from the Training Program Survey. †Fluoroscopic or echocardiographic guidance. Downloaded from circ.ahajournals.org by on April 30, 2008
  14. 14. ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology 2567 and interventional cardiology. Therefore, the advanced it is strongly recommended that the advanced fellow participate training goal is to prepare the trainee to independently in at least one clinical research project related to cardiac perform diagnostic and therapeutic catheter procedures with catheterization and/or interventional cardiology. excellent outcomes. Prerequisite to these advanced training Advanced training in pediatric cardiac catheterization experiences is the successful completion of core training. requires a dedicated 12-month experience, at a minimum. Advanced training should involve each fellow in a minimum Some fellowship programs may be able to offer the recom- of 200 catheterization procedures, at least 100 of which are mended advanced training experiences during a 3- or interventional. The minimum recommended numbers of 3.5-year training program. Nevertheless, even in those procedures are specified in Table 3 (and are in addition to programs additional training provides the fellow an oppor- those obtained during the core training). The procedure tunity to enhance technical skills and clinical judgment in types and numbers in Table 3 are recommended guidelines, this very complex specialty. The authors of this document not mandates, as it is understood that some qualified believe that the highest-quality training is obtained during a programs may not perform every procedure. Participation by fourth-year experience. Three or 3.5 years of training may the fellow as either the primary operator or the primary be satisfactory for some individuals if all advanced training assistant is satisfactory involvement. guidelines are achieved, and particularly if the fellow’s next A minimum number of procedures is necessary, but this postgraduate position can be anticipated to provide ongoing is not sufficient to prepare a trainee for a career in cardiac mentoring for complex interventions. catheterization and intervention. Also important to a suc- cessful career, and perhaps more crucial, are technical facility and good clinical judgment. During advanced train- ing the trainee must acquire sophisticated skills in complex REFERENCES catheter manipulations, wire and sheath exchanges, device 1. Pepine CJ, Babb JD, Brinker JA, et al. Guidelines for training in adult implantation techniques, and retrievals. Furthermore, good cardiovascular medicine. Core Cardiology Training Symposium clinical judgment regarding the indications for and against (COCATS). Task Force 3: Training in Cardiac Catheterization and intervention require a thorough knowledge of the natural Interventional Cardiology. J Am Coll Cardiol 1995;25:14 – 6. 2. Hirshfeld JW, Banas JS, Cowley M, et al. American College of history of congenital cardiac defects (5,6), and of the Cardiology training statement on recommendations for the structure of medical, catheter, and surgical options available for treat- an optimal adult interventional cardiology training program. J Am Coll ment. It is the responsibility of the training program Cardiol 1999;34:2141–7. 3. Ruiz CE, Mullins CE, Rocchini AP, et al. Core curriculum for the director to assure that each advanced trainee graduates with training of pediatric invasive/interventional cardiologists: report of the the technical skills, clinical judgment, and cognitive knowl- Society for Cardiac Angiography and Interventions Committee on edge to pursue an independent career in pediatric cardiac Pediatric Cardiology Training Standards. Cath Cardiovasc Diag 1996; 37:409 –24. catheterization. 4. Benson L, Coe Y, Houde C, Human D, Paquet M. Training standards A log book is to be maintained by the advanced fellow to for pediatric cardiac catheterization and interventional cardiology. Can document the nature and outcome of each diagnostic and J Cardiol 1998;14:907–10. 5. Nadas AS, Ellison RC, Weidman WH. Report from the Joint Study on interventional procedure he or she participated in throughout the Natural History of Congenital Heart Defects. Circulation 1977;56 training. The fellow should also participate actively in regular Suppl I:I1– 87. cardiac catheterization teaching and morbidity conferences 6. O’Fallon WM, Weidman WH. Long-term follow-up of congenital aortic stenosis, pulmonary stenosis, and ventricular septal defect. Report where outcomes and complications of interventional proce- from the Second Joint Study on the Natural History of Congenital dures are thoroughly discussed (see the previous text). Finally, Heart Defects (NHS-2). Circulation 1993; 87 Suppl I:I1–126. APPENDIX. Author Relationships With Industry and Others Scientific Research Advisory Speakers’ Steering Name Consultant Grant Board Bureau Committee Stock Holder Other Dr. Robert H. Beekman III None None None None None None Dr. William E. Hellenbrand ● AGA None ● AGA ● AGA None None Dr. Thomas R. Lloyd None None None None None None Dr. James E. Lock None None None None None ● NMT ● Royalties greater than 10%— Cook, NMT Dr. Charles E. Mullins ● NuMED Inc. None None ● AGA None ● Boston Scientific ● Proctor for ● NMT devices— AGA, NMT Dr. Jonathan J. Rome None ●Gore, Inc. None None None None Dr. David F. Teitel None None None None None None Downloaded from circ.ahajournals.org by on April 30, 2008
  15. 15. 2568 Circulation October 18, 2005 Task Force 4: Recommendations for Training Guidelines in Pediatric Cardiac Electrophysiology Endorsed by the Heart Rhythm Society Victoria L. Vetter, MD, FACC, FAHA, Chair, Michael J. Silka, MD, FACC, George F. Van Hare, MD, FACC, FAAP, Edward P. Walsh, MD, FACC INTRODUCTION for catheter ablation facilities have been published (2,9). Pediatric catheterization laboratory facilities should be The field of clinical cardiac electrophysiology has rapidly available with the appropriate EP equipment to perform EP expanded over the past 30 years. Advances in the diagnosis studies and catheter ablation. These facilities should ensure and treatment of pediatric cardiac rhythm disorders, and the a safe, sterile, and effective environment for invasive EP increasing trend in medicine in general to develop criteria or studies and implantation of pacemakers and arrhythmia guidelines for competence and training in specific fields, control devices. In many settings, the operating room can be have led to the need to develop guidelines for training in used for the pacing/arrhythmia control devices. Although pediatric clinical cardiac electrophysiology (CCEP). experience at outside institutions, including adult programs, The American College of Cardiology (ACC), American may be valuable, no more than two to four months of the Heart Association (AHA), and Heart Rhythm Society one-year advanced training should be spent at other insti- (formerly NASPE) have addressed training guidelines in tutions. In particular, added experience in pacemaker and adult CCEP (1–3). The extensive body of literature regard- implantable cardioverter-defibrillator (ICD) implantation, ing adult CCEP training and basic electrophysiology (EP) as well as in ventricular tachycardia studies, may be acquired knowledge provides an important background and should at a certified adult CCEP program, provided that it is be applied in an appropriately modified form to pediatric within the previously noted time frame. CCEP training (4 –21). Recognizing the considerable dif- At least one board-certified pediatric cardiologist with ferences in the pediatric and adult cardiology populations, advanced CCEP skills should be identified as the director of guidelines that are unique to the pediatric and congenital the core and advanced Electrophysiology Training Program. heart disease population must be developed. Canadian Because there is currently no pediatric EP examination, recommendations for training in pediatric EP have been consideration should be given for one pediatric EP faculty published (22). It should be recognized that pediatric member to take the NASPExAM, or its successor exami- patients are unique, as recognized by the separate training nation. For advanced training of fellows, at least one faculty programs and board certification for pediatricians and in- member should be skilled in the implantation of pacemakers ternists, and for adult and pediatric cardiologists. In addi- and ICDs. tion, the pediatric electrophysiologist will have experience and expertise in groups unique to pediatric cardiac electro- LEVELS OF EXPERTISE physiology, including the fetus with in utero arrhythmias, the child with a structurally normal heart and supraventric- In this report we discuss core training for all fellows and ular tachycardia, ventricular tachycardia, or other arrhyth- advanced training for fellows desiring special expertise in mias, the child with preoperative or postoperative arrhyth- pediatric CCEP. The core training is recommended for all mias after surgery for congenital heart disease, and the adult clinical fellows during their core clinical experience. It is with congenital heart disease, both in the pre- and postop- intended to be sufficient for fellows who do not plan a career erative states. This unique group of adults with congenital in EP. The advanced training provides expertise in both heart disease is best served by those with a combined diagnostic and therapeutic EP and it is intended to qualify knowledge of congenital heart disease and age-specific a fellow to embark upon a career in pediatric CCEP. disease processes, whether this be provided by a combina- Within the advanced level are two tracks related to expertise tion of pediatric and adult cardiologists or single individuals in pacemaker/ICD care: track 1 physicians prescribe and with broad training or dual training in pediatric and adult follow patients who require pacemaker/ICD care; track 2 cardiology. physicians will also be skilled in device implantation. Core Training: Goals and Methods Core EP training is required of all trainees to be a competent FACILITIES AND ENVIRONMENT pediatric cardiologist. The goal is to enable all trainees to be Training should be obtained in an Accreditation Council skilled in electrocardiographic (ECG) interpretation, in- for Graduate Medical Education (ACGME)-accredited cluding standard, ambulatory (Holter), exercise ECGs, and pediatric cardiology training program. Recommendations transtelephonic ECGs. Downloaded from circ.ahajournals.org by on April 30, 2008
  16. 16. ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology 2569 Table 1. Core Competence Skills end of service characteristics. Participation by the trainee ● Interpretation of ECGs, Holters, exercise testing, and event monitors in at least 20 pacemaker evaluations is recommended to with arrhythmia recognition develop these skills. The trainee should receive instruction ● Recognition of developmental changes in cardiac rates and rhythm in the insertion, management, and follow-up of temporary with age and of “normal” variants of rhythm pacemakers, including measurement of pacing and sensing ● Management of arrhythmias in the acute care setting, including uses of pharmacologic agents, cardioversion with esophageal or intracardiac thresholds. He or she should understand the general indi- pacing, and direct current cardioversion cations for consideration of the use of arrhythmia control ● Management of common chronic arrhythmias such as infant devices (ICDs and anti-tachycardia devices) and know when supraventricular tachycardia to refer these patients for more advanced EP evaluation. ● Evaluation of the patient with documented arrhythmia, symptoms of arrhythmia (palpitations, increased or decreased heart rate, irregular The trainee should understand the indications and tech- heart rhythm), and syncope or presyncope niques for elective and emergency cardioversion. Four elec- ● Treatment of patients with all forms of syncope tive direct current cardioversions are required. ● Evaluation of patients with long QT syndrome or family history of The core training to obtain the previously described skills sudden death and management of these patients ● Knowledge of indications for use of noninvasive EP testing and knowledge should occur in the first three years of ● Knowledge of indications for invasive EP studies and general pediatric cardiology training and be equivalent to two to three understanding of information obtained from EPS, including months of concentrated study, but may be acquired through- interpretation of basic EP information out the three years as needed to obtain designated compe- ● Knowledge of indications for catheter ablation, understanding of tence skills (Table 1). procedure and complications of procedure ● Knowledge of indications for pacing, anti-tachycardia device, and ICD placement Advanced Training (Year 4 Year 5): ● Knowledge of pacing modes, basic pacemaker interrogation, Goals and Methods reprogramming, and trouble-shooting for loss of capture, under or over sensing, battery end of life The goal of advanced training is to enable the pediatric ● Temporary transvenous and transcutaneous pacing electrophysiologist to perform, interpret, and train others to ● Evaluation of EP literature conduct and interpret specific procedures at a high skill level. Tables 2 and 3 describe the competence skills neces- Additionally, the trainee should understand the indica- sary for advanced-level training. The recommended mini- tions for and the use of noninvasive diagnostic techniques mum procedures are summarized in Table 4 for both core including exercise testing, 24-h ambulatory and event mon- and advanced training. itors, and tilt table testing and should have a general Advanced-level skills involve understanding the evalua- understanding of their interpretation. All trainees should be tion and management of common arrhythmias, from the able to properly interpret cardiac arrhythmias and manage fetus to young adult. In addition, advanced understanding arrhythmias in the acute care setting. There should be an of complex arrhythmia management, especially in the post- understanding of the use of non-pharmacologic methods and pharmacologic agents to treat arrhythmias, including Table 2. Advanced EP Clinical Competence Skills drug interactions and proarrhythmic potential. The trainee Advanced competence skills include core basic skills plus: should understand the indications for the selection of ● Management of all types of cardiac arrhythmias in all ages from the patients for specialized electrophysiologic studies, including fetus to young adult ablation. In addition, the trainee should obtain a basic ● Evaluation and management of patients with specific arrhythmia understanding of the indications for, and the information syndromes including long QT syndrome, Brugada syndrome, and right ventricular dysplasia obtained from, invasive EP studies. This should include an ● Evaluation of patients with family history of sudden cardiac death understanding of the use of information obtained from ● Management of complex arrhythmias, especially in postoperative these testing modalities for the management of the patient’s congenital heart disease patients clinical condition. The trainee should have skills in the ● Evaluation of patient with syncope including, when appropriate, interpretation of basic EP information obtained from elec- performance of tilt table testing with appropriate interpretation and management of patient trophysiology study (EPS). ● Performance of esophageal EPS Participation in at least 10 EPS cases including catheter ● Knowledge of the indications, risks, and benefits of EPS/catheter placement and analysis of electrophysiologic tracings are ablation needed to acquire these skills. The trainee should under- ● Interpretation and use of EPS data ● Technical and cognitive skills to perform EPS/catheter ablation, stand the evaluation of patients with syncope, palpitations, using current mapping technology and techniques chest pain, and irregular heart rhythms. All trainees should ● Advanced knowledge of selection of pacemaker type, programming, understand the indications for pacemaker placement, know follow-up, and trouble-shooting the differences in pacing modes, understand and be able to ● Advanced knowledge of pacemakers and implantable cardioverter- perform basic pacemaker interrogation, reprogram and defibrillators ● Intraoperative evaluation and programming of pacemakers and troubleshoot pacemakers, recognizing basic malfunctions ICDs such as capture failure, sensing malfunctions, and battery Downloaded from circ.ahajournals.org by on April 30, 2008
  17. 17. 2570 Circulation October 18, 2005 Table 3. Advanced EP Research Competence Skills requirement for participation in 75 diagnostic procedures. ● Evaluation of EP literature Participation should include scrubbing for the case, catheter ● Development of clinical research skills manipulation, analysis, review of tracings, and generation of ● Completions of EP project which results in an abstract and/or a report. manuscript ● Grant submission is encouraged Advanced understanding of pacemaker indications, opti- mal pacemaker choices, and follow-up of pacemaker pa- tients should be obtained. The Heart Rhythm Society has operative period after repair of congenital heart defects and recommended two tracks for those caring for pacemaker in special groups such as long QT syndrome, Brugada patients. Track 1 involves electrophysiologists who will be syndrome, and right ventricular dysplasia, should be at- involved in prescribing and following pacemaker and ICD tained. Evaluation and management of the patient with all patients. Track 2 individuals prescribe, implant, and forms of syncope should be accomplished, including the follow patients with pacemakers and ICDs. In both performance of tilt table testing when appropriate. In those tracks, advanced understanding of pacemaker and ICD programs that employ tilt testing, participation in at least 10 indications, optimal pacemaker choices, and evaluation or procedures in a pediatric or adult laboratory is advisable. A follow-up of 75 pacemaker/ICD patients should be thorough understanding of pathophysiology and therapy of syncope and tilt testing should be required of all trainees. obtained. In addition, attendance—including intraoperative Advanced-level trainees should develop the cognitive skills testing of 35 pacemaker or ICD implants (20 new, 10 to evaluate the patient with a family history of sudden revisions, 5 ICDs)—is required. To implant pacemakers cardiac arrest or death. Skill and experience should be and ICDs, direct participation in a total of at least 50 encouraged in pediatric EPS interpretation and use of the pacemaker and device implants is required, of which a EP data to make management and therapeutic decisions. reasonable number should be complex devices including Experience with esophageal EPS should be obtained with ICDs. As new technology develops, the number of device participation in 10 procedures. The indications, risks, and implants necessary to achieve competence may change. benefits of these procedures should be known. Participation should include scrubbing for the surgery, Advanced-level trainees will develop technical and cog- catheter manipulation, participation in intraoperative test- nitive skills and experience in the performance of invasive ing, and generation of a report. As the skills for implanting diagnostic and therapeutic CCEP. At least 75 diagnostic devices in smaller children are specific to pediatric EP, at intracardiac EPS should be performed, of which at least 10 least 15 of these implantation procedures should be in should be patients with ventricular tachycardia. At least 40 children less than 12 years of age. Also, experience with of these diagnostic procedures must be in patients who are implantation in patients with repaired congenital heart 12 years of age or younger, and at least 10 should be in disease is essential. patients with repaired or palliated congenital heart disease. Advanced-level pediatric electrophysiologists should have In addition, participation in at least 40 catheter abla- all the skills noted in the previous text, but they may or may tion procedures is required. The diagnostic portion of a not perform the implantation of pacemakers and ICDs. If catheter ablation procedure may be used to satisfy the the pediatric clinical cardiac electrophysiologist does not Table 4. Core and Advanced Training: Recommended Minimum Experiences Level of Training Core Pediatric Cardiology Training Advanced Pediatric EP Training Training time 2 to 3 months equivalent 12 months or more post general PC training* ECG interpretation 500† 1,500 Ambulatory ECG interpretation 50 200 Exercise ECG 10 40 Tilt table tests 2 10 Transesophageal EPS/temporary postoperative epicardial wire study 5 10 Intracardiac EPS 10 75‡ Intracardiac EPS 12 years of age or less 40 Intracardiac EPS in repaired congenital heart disease 10 Catheter ablation 5 40 Catheter ablation 12 years of age of age or less 20 Catheter ablation in repaired congential heart disease 10 DC cardioversion 4 10 Pacemaker ICD Evaluations/follow-up 20 50 Intraoperative evaluation pacemakers and devices 35 (20 new, 10 revisions, 5 ICDs) Track 2: implant pacemaker and complex devices 50 (15 in ages 12 yrs or less) *4 to 6 months of this training could be obtained during a regular 3-year pediatric cardiology training program if it did not interfere with other required training. †ECG reading may be performed throughout three-year fellowship. ‡The diagnostic portion of an ablation procedure may be used to satisfy this requirement. 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