Catheterization and Cardiovascular Interventions 84:779–784 (2014)
PEDIATRIC AND CONGENITAL HEART DISEASE Core Curriculum SCAI Expert Consensus Statement for Advanced Training Programs in Pediatric and Congenital Interventional Cardiac Catheterization Laurie Armsby,1 MD, Robert H. Beekman III,2 MD, Lee Benson,3 MD, Thomas Fagan,4 MD, Donald J. Hagler,5 MD, Ziyad M. Hijazi,6 MD, Ralf Holzer,7 MD, MSc, Frank Ing,8 MD, Jacqueline Kreutzer,9 MD, Peter Lang,10 MD, Daniel S. Levi,11 MD, Larry Latson,12 MD, Phillip Moore,13 MD, Charles Mullins,14 MD, Carlos Ruiz,15 MD, PhD, and Robert Vincent,16* MD Pediatric and Congenital Interventional Cardiology is the practice of catheter-based techniques that improve cardiac physiology and circulation through the treatment of heart disease in children and adults with congenital or acquired heart defects. Over the last decade, and since last published training guidelines for pediatric cardiac catheterization and interventional cardiology were published in 2005 [1] the field of Pediatric and Congenital Cardiac Catheterization has evolved into a predominantly interventional discipline. As there is no sub-specialty certification for interventional cardiac catheterization in pediatrics, the Congenital Heart Disease Committee of the Society of Cardiovascular Angiography and Interventions has put together this consensus statement for advanced training in pediatric and congenital interventional cardiac catheterization. The statement puts forth recommendations for program infrastructure in terms of teaching, personnel, equipment, facilities, conferences, patient volume and trainee assessment. This is meant to set a standard for training programs as well as
1
Doernbecher Children’s Hospital, Oregon Health and Sciences University, Portland, Oregon 2 Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 3 Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Canada 4 Aurora - Children’s Hospital Colorado, University of Colorado, Aurora, Colorado 5 Mayo Clinic College of Medicine, Rochester, Minnesota 6 Sidra Medical and Research Center, Weill Cornell Medical College in Qatar, Qatar 7 Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, Ohio 8 Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California 9 University of Pittsburg School of Medicine, Pittsburgh, Pennsylvania 10 Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 11 Mattel Children’s Hospital at UCLA, University of California, Los Angeles, California 12 Joe Di Maggio Children’s Hospital, Memorial Healthcare System Florida Atlantic University Medical School, Hollywood, Florida C 2014 Wiley Periodicals, Inc. V
13
University of California San Francisco, San Francisco, California 14 Professor Emeritus at Baylor College, Houston, Texas 15 North Shore Health System and Lenox Hill Heart and Vascular Institute of New York, Hofstra University, Hempstead, New York 16 CM Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia Conflict of interest: Nothing to report. *Correspondence to: Robert Vincent, The McGill Building, 2835 Brandywine Rd. Suite 300, Atlanta, GA 30341. E-mail: [email protected] Received 13 May 2014; Revision accepted 17 May 2014 DOI: 10.1002/ccd.25550 Published online 29 May 2014 (wileyonlinelibrary.com)
in Wiley Online Library
780
Armsby et al. C 2014 Wiley Perigiving applicants a basis on which to judge and compare programs. V odicals, Inc.
Key words: advanced training; interventional congenital catheterization
INTRODUCTION
Pediatric and Congenital Interventional Cardiology is the practice of catheter-based techniques that improve cardiac physiology and circulation through the treatment of heart disease in children and adults with congenital or acquired heart defects. Over the last decade, and since last published training guidelines for pediatric cardiac catheterization and interventional cardiology were published in 2005 [1] the field of Pediatric and Congenital Cardiac Catheterization has evolved into a predominantly interventional discipline. In most cases, it is no longer appropriate to perform a diagnostic cardiac catheterization without the ability to perform an intervention if indications for an interventional procedure are met. The knowledge base and scope of practice for Pediatric Cardiology has grown tremendously over the last few decades, and although virtually all subspecialty areas of Pediatric Cardiology have evolved into ever more complex fields, the time available for each subspecialty experience during the General Pediatric Cardiology fellowship training has not increased, and in many areas, has actually decreased. Given the greatly increased complexity and potential risks of Pediatric and Congenital Interventional Cardiac Catheterization procedures, it is no longer appropriate to expect graduating General Pediatric Cardiology fellows to be qualified in this subspecialty at the completion of their core 3-year fellowship. Advanced training programs in Pediatric and Congenital Interventional Cardiac Catheterization have been available at some institutions for a number of years; however, there is marked variation in cumulative experience, educational structure, and the scope of practice among these programs. The Society of Cardiac Angiography and Interventions recognizes the importance of advanced training in Pediatric and Congenital Interventional Cardiac Catheterization and recommends the development of guidelines and assessment tools for such programs. The Society feels that it is important for pediatric cardiologists who wish to perform cardiac catheterizations to become proficient in all aspects of cardiac catheterization through at least one additional year of advanced training. Individuals in these programs should perform procedures of gradually increasing complexity under the supervision of an attending interventional cardiologist until they become competent as the sole or primary operator.
Advanced training programs in Pediatric and Congenital Interventional Cardiac Catheterization should provide sufficient experience and advanced training for the fellow to become proficient in the applicable techniques and devices available during training, as well as competent to evaluate and learn new techniques as they emerge. By the end of the training program, the fellow should have sufficient expertise to act as an independent provider of diagnostic and interventional cardiac catheterization procedures for affected infants and children, and to act as a primary or consultant provider of these procedures in adults with congenital or acquired structural heart disease. Although newly graduated fellows should be competent, they may benefit greatly from ongoing mentorship by a senior colleague (when available) during the early years following training.
GENERAL REQUIREMENTS FOR PROGRAMS
An advanced trainee in Pediatric and Congenital Interventional Cardiac Catheterization should have successfully completed a core training program in Pediatric Cardiology as specified by the country in which they practice. A thorough understanding of the anatomy, physiology, and alternative treatment strategies for the great variety of congenital heart defects is essential to provide the best patient care; this includes an understanding of the natural history of congenital defects, which is required to determine if treatment of a defect is indicated at all. The duration of advanced training can vary, but should be sufficient to gain the experience needed and the skills required to fulfill the competencies listed below. Programs offering advanced training must have the appropriate infrastructure for training in place. In addition to the institutional requirements listed below, the program should provide trainees with exposure to, and experience with, a large number and wide variety of techniques and procedures. The case numbers of specific procedures listed below are only guidelines and may vary among training centers and individual trainees. These numbers (as with previous suggestions) [1] are based on expert consensus and have not been validated as either necessary or adequate. It is also expected that the interventional cardiology training director will utilize an effective performance evaluation tool for ongoing trainee assessment. The ability to
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Advanced Training in Interventional Congenital Heart Disease
measure the outcome of training efforts will be an increasingly important issue in the future. The Competence Assessment Tool below is meant as a guideline for trainers and trainees to consider. In the absence of formal accreditation of advanced training in Pediatric and Congenital Interventional Cardiac Catheterization, no uniform level of competence is as yet defined; however we feel the Competence Assessment Tool offers a valuable guideline to encourage and promote consistency of evaluations during the period of advanced training.
6.
7.
8. 9. 10.
INSTITUTIONAL REQUIREMENTS
In order to offer training for advanced fellows, an institution or program should have the following in place and a commitment to the training and mentorship of the trainee: 1. An experienced interventional catheterization program director: at least 5 years post-training with current certification in Pediatric Cardiology (by the American Board of Pediatrics or other country specific credentialing body), current medical licensure and appropriate medical staff appointment. An established record of teaching and research and demonstrated evidence of productivity in scholarship, including publications of original research in the field is desirable. They must have knowledge and experience with, and commitment to, pediatric and congenital interventional cardiology. 2. Sufficient annual case volume to allow for training. 3. A robust teaching environment: The institution and the program must jointly ensure the availability of adequate resources for fellows’ education. There must be space and equipment for the program, including meeting rooms, examination rooms, computers, visual and other educational aids, and work/ study space. There should be a demonstrated commitment of the institution to teaching programs (resident, fellow, nursing, other). In addition, fellows should be expected to participate in teaching within the program and institution. 4. Inpatient and outpatient facilities suitable for the treatment of children with congenital heart defects pre- and post-catheterization including intensive care units experienced in the care of all age groups treated in the catheterization laboratory. 5. A cardiac catheterization laboratory, preferably with biplane fluoroscopic and digital imaging equipment along with adequate hemodynamic monitoring and recording equipment and specialtytrained personnel. There must be a full complement
11.
781
of interventional devices (including retrieval and bail-out devices) and resuscitative equipment. A pediatric/congenital cardiac surgical program with adequate staff and facilities to appropriately respond to emergencies related to catheter interventions. Adequate non-invasive imaging facilities including echocardiography, cardiac CT, and MRI imaging with expertise in congenital heart disease. An established process for pre-catheterization review and planning of all procedures by the operators. A catheterization report system suitable for reporting congenital cardiac defects. An active local quality improvement program, including an M&M (morbidity and mortality conference). Participation in at least one national or international registry/quality improvement program related to pediatric and/or adult congenital cardiac catheterization is desirable. Research facilities, to include at a minimum: adequate personnel and resources for literature review, data collection and analysis for clinical research reviewed by an IRB.
CASE NUMBERS
Although the appropriate number of cases is arbitrary and difficult to define, during the period of advanced training the fellow should participate as primary operator or first assistant in at least 250 total cases, of which 150 should be interventional procedures and at least 25 interventional procedures should be in neonates (
PEDIATRIC AND CONGENITAL HEART DISEASE Core Curriculum SCAI Expert Consensus Statement for Advanced Training Programs in Pediatric and Congenital Interventional Cardiac Catheterization Laurie Armsby,1 MD, Robert H. Beekman III,2 MD, Lee Benson,3 MD, Thomas Fagan,4 MD, Donald J. Hagler,5 MD, Ziyad M. Hijazi,6 MD, Ralf Holzer,7 MD, MSc, Frank Ing,8 MD, Jacqueline Kreutzer,9 MD, Peter Lang,10 MD, Daniel S. Levi,11 MD, Larry Latson,12 MD, Phillip Moore,13 MD, Charles Mullins,14 MD, Carlos Ruiz,15 MD, PhD, and Robert Vincent,16* MD Pediatric and Congenital Interventional Cardiology is the practice of catheter-based techniques that improve cardiac physiology and circulation through the treatment of heart disease in children and adults with congenital or acquired heart defects. Over the last decade, and since last published training guidelines for pediatric cardiac catheterization and interventional cardiology were published in 2005 [1] the field of Pediatric and Congenital Cardiac Catheterization has evolved into a predominantly interventional discipline. As there is no sub-specialty certification for interventional cardiac catheterization in pediatrics, the Congenital Heart Disease Committee of the Society of Cardiovascular Angiography and Interventions has put together this consensus statement for advanced training in pediatric and congenital interventional cardiac catheterization. The statement puts forth recommendations for program infrastructure in terms of teaching, personnel, equipment, facilities, conferences, patient volume and trainee assessment. This is meant to set a standard for training programs as well as
1
Doernbecher Children’s Hospital, Oregon Health and Sciences University, Portland, Oregon 2 Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 3 Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Canada 4 Aurora - Children’s Hospital Colorado, University of Colorado, Aurora, Colorado 5 Mayo Clinic College of Medicine, Rochester, Minnesota 6 Sidra Medical and Research Center, Weill Cornell Medical College in Qatar, Qatar 7 Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, Ohio 8 Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California 9 University of Pittsburg School of Medicine, Pittsburgh, Pennsylvania 10 Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 11 Mattel Children’s Hospital at UCLA, University of California, Los Angeles, California 12 Joe Di Maggio Children’s Hospital, Memorial Healthcare System Florida Atlantic University Medical School, Hollywood, Florida C 2014 Wiley Periodicals, Inc. V
13
University of California San Francisco, San Francisco, California 14 Professor Emeritus at Baylor College, Houston, Texas 15 North Shore Health System and Lenox Hill Heart and Vascular Institute of New York, Hofstra University, Hempstead, New York 16 CM Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia Conflict of interest: Nothing to report. *Correspondence to: Robert Vincent, The McGill Building, 2835 Brandywine Rd. Suite 300, Atlanta, GA 30341. E-mail: [email protected] Received 13 May 2014; Revision accepted 17 May 2014 DOI: 10.1002/ccd.25550 Published online 29 May 2014 (wileyonlinelibrary.com)
in Wiley Online Library
780
Armsby et al. C 2014 Wiley Perigiving applicants a basis on which to judge and compare programs. V odicals, Inc.
Key words: advanced training; interventional congenital catheterization
INTRODUCTION
Pediatric and Congenital Interventional Cardiology is the practice of catheter-based techniques that improve cardiac physiology and circulation through the treatment of heart disease in children and adults with congenital or acquired heart defects. Over the last decade, and since last published training guidelines for pediatric cardiac catheterization and interventional cardiology were published in 2005 [1] the field of Pediatric and Congenital Cardiac Catheterization has evolved into a predominantly interventional discipline. In most cases, it is no longer appropriate to perform a diagnostic cardiac catheterization without the ability to perform an intervention if indications for an interventional procedure are met. The knowledge base and scope of practice for Pediatric Cardiology has grown tremendously over the last few decades, and although virtually all subspecialty areas of Pediatric Cardiology have evolved into ever more complex fields, the time available for each subspecialty experience during the General Pediatric Cardiology fellowship training has not increased, and in many areas, has actually decreased. Given the greatly increased complexity and potential risks of Pediatric and Congenital Interventional Cardiac Catheterization procedures, it is no longer appropriate to expect graduating General Pediatric Cardiology fellows to be qualified in this subspecialty at the completion of their core 3-year fellowship. Advanced training programs in Pediatric and Congenital Interventional Cardiac Catheterization have been available at some institutions for a number of years; however, there is marked variation in cumulative experience, educational structure, and the scope of practice among these programs. The Society of Cardiac Angiography and Interventions recognizes the importance of advanced training in Pediatric and Congenital Interventional Cardiac Catheterization and recommends the development of guidelines and assessment tools for such programs. The Society feels that it is important for pediatric cardiologists who wish to perform cardiac catheterizations to become proficient in all aspects of cardiac catheterization through at least one additional year of advanced training. Individuals in these programs should perform procedures of gradually increasing complexity under the supervision of an attending interventional cardiologist until they become competent as the sole or primary operator.
Advanced training programs in Pediatric and Congenital Interventional Cardiac Catheterization should provide sufficient experience and advanced training for the fellow to become proficient in the applicable techniques and devices available during training, as well as competent to evaluate and learn new techniques as they emerge. By the end of the training program, the fellow should have sufficient expertise to act as an independent provider of diagnostic and interventional cardiac catheterization procedures for affected infants and children, and to act as a primary or consultant provider of these procedures in adults with congenital or acquired structural heart disease. Although newly graduated fellows should be competent, they may benefit greatly from ongoing mentorship by a senior colleague (when available) during the early years following training.
GENERAL REQUIREMENTS FOR PROGRAMS
An advanced trainee in Pediatric and Congenital Interventional Cardiac Catheterization should have successfully completed a core training program in Pediatric Cardiology as specified by the country in which they practice. A thorough understanding of the anatomy, physiology, and alternative treatment strategies for the great variety of congenital heart defects is essential to provide the best patient care; this includes an understanding of the natural history of congenital defects, which is required to determine if treatment of a defect is indicated at all. The duration of advanced training can vary, but should be sufficient to gain the experience needed and the skills required to fulfill the competencies listed below. Programs offering advanced training must have the appropriate infrastructure for training in place. In addition to the institutional requirements listed below, the program should provide trainees with exposure to, and experience with, a large number and wide variety of techniques and procedures. The case numbers of specific procedures listed below are only guidelines and may vary among training centers and individual trainees. These numbers (as with previous suggestions) [1] are based on expert consensus and have not been validated as either necessary or adequate. It is also expected that the interventional cardiology training director will utilize an effective performance evaluation tool for ongoing trainee assessment. The ability to
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Advanced Training in Interventional Congenital Heart Disease
measure the outcome of training efforts will be an increasingly important issue in the future. The Competence Assessment Tool below is meant as a guideline for trainers and trainees to consider. In the absence of formal accreditation of advanced training in Pediatric and Congenital Interventional Cardiac Catheterization, no uniform level of competence is as yet defined; however we feel the Competence Assessment Tool offers a valuable guideline to encourage and promote consistency of evaluations during the period of advanced training.
6.
7.
8. 9. 10.
INSTITUTIONAL REQUIREMENTS
In order to offer training for advanced fellows, an institution or program should have the following in place and a commitment to the training and mentorship of the trainee: 1. An experienced interventional catheterization program director: at least 5 years post-training with current certification in Pediatric Cardiology (by the American Board of Pediatrics or other country specific credentialing body), current medical licensure and appropriate medical staff appointment. An established record of teaching and research and demonstrated evidence of productivity in scholarship, including publications of original research in the field is desirable. They must have knowledge and experience with, and commitment to, pediatric and congenital interventional cardiology. 2. Sufficient annual case volume to allow for training. 3. A robust teaching environment: The institution and the program must jointly ensure the availability of adequate resources for fellows’ education. There must be space and equipment for the program, including meeting rooms, examination rooms, computers, visual and other educational aids, and work/ study space. There should be a demonstrated commitment of the institution to teaching programs (resident, fellow, nursing, other). In addition, fellows should be expected to participate in teaching within the program and institution. 4. Inpatient and outpatient facilities suitable for the treatment of children with congenital heart defects pre- and post-catheterization including intensive care units experienced in the care of all age groups treated in the catheterization laboratory. 5. A cardiac catheterization laboratory, preferably with biplane fluoroscopic and digital imaging equipment along with adequate hemodynamic monitoring and recording equipment and specialtytrained personnel. There must be a full complement
11.
781
of interventional devices (including retrieval and bail-out devices) and resuscitative equipment. A pediatric/congenital cardiac surgical program with adequate staff and facilities to appropriately respond to emergencies related to catheter interventions. Adequate non-invasive imaging facilities including echocardiography, cardiac CT, and MRI imaging with expertise in congenital heart disease. An established process for pre-catheterization review and planning of all procedures by the operators. A catheterization report system suitable for reporting congenital cardiac defects. An active local quality improvement program, including an M&M (morbidity and mortality conference). Participation in at least one national or international registry/quality improvement program related to pediatric and/or adult congenital cardiac catheterization is desirable. Research facilities, to include at a minimum: adequate personnel and resources for literature review, data collection and analysis for clinical research reviewed by an IRB.
CASE NUMBERS
Although the appropriate number of cases is arbitrary and difficult to define, during the period of advanced training the fellow should participate as primary operator or first assistant in at least 250 total cases, of which 150 should be interventional procedures and at least 25 interventional procedures should be in neonates (
