Organizational Principles to Guide and Define the Child ... · (COCATS 2) (revision of the 1995 COCATS training statement). J Am Coll Cardiol 2002;39:1242–1246. TABLE 1. Core Training

AMERICAN COLLEGE OF CARDIOLOGY FOUNDATIONAMERICAN HEART ASSOCIATION

AMERICAN ACADEMY OF PEDIATRICS

POLICY STATEMENTOrganizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children

ACCF/AHA/AAP RECOMMENDATIONS FOR

TRAINING IN PEDIATRIC CARDIOLOGY

A Report of the American College of Cardiology Foundation/AmericanHeart Association/American College of Physicians Task Force on Clinical

Competence (ACC/AHA/AAP Writing Committee to Develop TrainingRecommendations for Pediatric Cardiology)

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;

and 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; andHoward H. Weitz, MD, FACC, FACP

Training Guidelines for Pediatric Cardiology Fellowship ProgramsThomas P. Graham, Jr, MD, FACC, FAHA, FAAP, Chair; andRobert H. Beekman, III, MD, FACC, FAHA, FAAP, Co-Chair

INTRODUCTION

Pediatric cardiology is a complex, multifacetedspecialty composed of diverse clinical and aca-demic subspecialty areas. It is characterized by

rapid growth of subspecialty areas and swift in-corporation of new information from the clinicaland laboratory sciences. It is important, therefore,to define the fellowship training required tolaunch a successful career in pediatric cardiology.The following document represents the first broad-based effort to do so.

In 2000, the Society of Pediatric Cardiology TrainingProgram Directors (SPCTPD) embarked on the processof defining fellowship training guidelines. The processitself was broad-based and inclusive. All pediatric car-diology training program directors were invited tonominate members to participate in the training guide-lines task forces; in turn, each task force was comprisedof all nominated members who agreed to participate.Therefore, all training programs were provided an op-portunity to actively participate.

In 2002, the American College of Cardiology (ACC)approved and published the Revised Recommenda-tions in Adult Cardiovascular Medicine Core Cardiol-

* AHA CVDY representative† AAP representative‡ Former task force member during writing effort.This document was approved by the American College of CardiologyFoundation Board of Trustees in June 2005, by the American Heart Asso-ciation Science Advisory and Coordinating Committee in July 2005, and bythe American Academy of Pediatrics Board in July 2005.When citing this document, the American Academy of Pediatrics wouldappreciate the following citation format: Beekman RH III, Graham TP, et al.ACCF/AHA/AAP recommendations for training in pediatric cardiology: areport of the American College of Cardiology Foundation/American HeartAssociation/American College of Physicians Task Force on Clinical Com-petence (ACC/AHA/AAP Committee on Pediatric Cardiology). Pediatrics.2005;116:1256–1278.Copies: This document is available on the Websites of the American College ofCardiology (www.acc.org), the American Heart Association (www.american-heart.org), and the American Academy of Pediatrics (www.aap.org). Singlecopies 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, ResourceCenter, 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 expresspermission of the American College of Cardiology Foundation. Pleasedirect requests to [email protected]:10.1542/peds.2005-2097PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Collegeof Cardiology Foundation, the American Heart Association, Inc., and theAmerican Academy of Pediatrics.

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ogy Training.1 As the SPCTPD was concluding itstraining guideline development, plans were formalizedto use a similar process through the ACC PediatricCardiology/Congenital Heart Disease Committee andthe ACC Training Program Directors Committee. Ac-cordingly, a steering committee was developed withoriginal authors of the Pediatric Cardiology TrainingGuidelines to form a liaison with the ACC, the Amer-ican Heart Association (AHA), and the Section on Pe-diatric Cardiology and Cardiac Surgery of the Ameri-can Academy of Pediatrics (AAP) to agree on the finalguidelines and to publish them widely.

These guidelines are written with the planned goalof serving as a practical resource for directors ofpediatric cardiology training programs. We alsohope that this document will prove useful to theResidency Review Committee (RRC) for pediatrictraining programs in the revision of requirementsfor the accreditation of pediatric cardiology pro-grams. The general requirements, clinical compe-tencies, and oversight for fellows in pediatric car-diology would remain the same as outlined by theAccreditation Council for Graduate Medical Edu-cation (ACGME).

GENERAL CONSIDERATIONSThe guidelines proposed in this document address

overall recommendations for training in pediatric car-diology and important subspecialties within the field ofpediatric cardiology. Although we understand that thepediatric RRC sets minimum standards for accredita-tion of fellowship programs, this document endeavorsto define a more comprehensive set of guidelines forpediatric cardiology fellowship training. Fellowshiptraining guidelines are presented for: general pediatriccardiology (including inpatient care and consultations);echocardiography and noninvasive imaging; electro-physiology; cardiac catheterization and intervention;cardiac intensive care; adult congenital heart disease;and research participation. Each section other than gen-eral pediatric cardiology specifies “core” and “ad-vanced” training experiences. Core recommendationsare intended to be common training experiences for allpediatric cardiology trainees regardless of long-termcareer goals. Advanced recommendations are additionaltraining experiences for trainees intending to develop aclinical or academic area of special competence. Allguidelines are recommended experiences, and not ab-solute mandates, as it is recognized that each trainingprogram has unique strengths and that clinical andacademic variation across training programs providesimportant diversity for the specialty.

Table 1 summarizes the approximate time commit-ment (in months) recommended for core training inthe task force reports that follow. Variations in thesetime commitments should be allowed, as pediatriccardiology programs vary widely in size, organiza-tion, and emphasis. For example, in some programs,fellows may get considerable cardiac intensive careunit training during their general inpatient experi-

ences and not require a two- to four-month stand-alone rotation. Thus, the training guidelines mustprovide programs with flexibility to address individ-ual trainee clinical and/or research training needsduring a core fellowship of 36 months’ duration.

The training program must possess the facultyexpertise, patient volume, and inpatient/outpatientfacilities to provide meaningful trainee experiencesas outlined in this document. All faculty should beboard certified or possess suitable equivalent quali-fications. Recommendations for trainee and facultyevaluation are those outlined in the “general andspecial requirements” as published by the ACGME,and training should take place within a program thatis accredited by the ACGME.

A comment about trainee research participation isappropriate. The field of pediatric cardiology is ab-solutely dependent upon research (basic and clinical)for meaningful progress. There is a critical need forthe development of physician-scientists in our spe-cialty to assure such future progress. Therefore, it iskey that training programs begin to prepare traineesfor a successful investigative career. Such prelimi-nary research training will in most instances require18 months or more. The balancing of clinical andresearch training will continue to be a major issue fortraining programs. It is highly probable that train-ees who want to pursue a physician-scientist ca-reer will require at least four years of fellowship tobegin the academic process and to finish trainingin the clinical areas. The authors are in completeagreement with the newly published AmericanBoard of Pediatrics (ABP) Training Requirementsfor subspecialty certification concerning scholarlyactivity, meaningful accomplishments in research,scholarship oversight, and differing pathways totrain physician-scientists.

APPENDIXThe authors of this section declare they have no

relationships with industry pertinent to this topic.

REFERENCE1. Beller GA, Bonow RO, Fuster V. ACC revised recommendations for

training in adult cardiovascular medicine Core Cardiology Training II(COCATS 2) (revision of the 1995 COCATS training statement). J Am CollCardiol 2002;39:1242–1246.

TABLE 1. Core Training Recommendations

Experience Time Commitment(in months)

General experience (inpatient) 3–6Echocardiography/imaging 4–6Cardiac catheterization 3–4 (estimate*)Electrophysiology 2–3Cardiac intensive care 2–4Adult congenital heart disease 0–2 (estimate*)Research 12–18Total 36

* Task Force identified experience-based recommendations. Seeindividual section for numbers.

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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; and Kenneth G. Zahka, MD, FACC, FAAP

INTRODUCTION

The goals of pediatric cardiology traininginclude acquiring the cognitive and pro-cedural expertise required to provide high-

quality care to children with cardiovascular disease,acquiring the academic skills to make meaningfulscholarly contributions to the specialty, and, im-portantly, to develop the capacity for ongoing self-education beyond the years of formal training.

The general training of pediatric cardiology fel-lows builds on the general clinical and academicskills acquired during residency training. The pe-diatric cardiology fellow should be given broadexposure to clinical activities in pediatric car-diology inpatient and outpatient care, pediatriccardiology inpatient and outpatient consulta-tions, and in preventive cardiology. The academicskills of formal presentation, small-group teaching,literature review, data analysis, and study designare also components of the general training guide-lines.

CLINICAL TRAINING

A fundamental goal of clinical training is toacquire bedside diagnostic skill and the abilityto provide high-qualilty consultative inpatientand outpatient pediatric cardiology care. The coreskills of history-taking and physical examina-tion are the only means for correctly initiatingdiagnostic and management options appropriateto the individual patient, and these must beheavily stressed at all points of patient contact.Pediatric cardiology fellows should be observedby faculty while performing key portions of thehistory and physical examination, and to alsohave the opportunity to observe faculty performhistory-taking and physical examination, so thatmeaningful discussion of useful strategies andtechniques may develop. Consultation services,general inpatient wards, and outpatient clinics allprovide excellent opportunities for such interac-tion.

The pediatric cardiology fellow must have theopportunity to provide not only inpatient andoutpatient consultation services but also directpatient care in both inpatient and outpatientsettings. There must be a continuity of care inthe outpatient clinic so that fellows can begin to

appreciate the course of pediatric cardiac dis-ease over time and its cumulative impact on in-dividual patients and their families. The combinedtime commitment of the general inpatient and in-patient consultation services should be no less thanthree months. The continuity outpatient clinic shouldbegin early in fellowship and continue throughouttraining, preferably on a biweekly basis. Both inpa-tient and outpatient experiences should include ex-posure to the management of the adult patient withcongenital heart disease.

There are many ways for general inpatient andoutpatient practices to be organized. In the deliv-ery of high-level inpatient and outpatient care thepediatric cardiologist must demonstrate effectiveteam leadership, accurate and efficient medicalrecord keeping, sensitivity to medical ethical is-sues, an ability to communicate with and supportpatients and their families through stressful deci-sions and experiences, and show strict compliancewith federal regulatory statutes. The general inpa-tient and outpatient training environment for pe-diatric cardiology fellows must provide full oppor-tunity for observation, acquisition, and applicationof these skills by the trainee.

During the course of inpatient and outpatient ac-tivities the pediatric cardiology fellow will becomefamiliar with a core knowledge base, as outlined inTable 1, at a minimum.

DIDACTIC CONTENT

The Core Curriculum

The program should offer courses, seminars,workshops, and/or laboratory experiences to pro-vide appropriate background in basic and funda-mental disciplines related to the heart and cardiovas-cular system. A lecture series encompassing a corecurriculum in clinical and basic science topics mustbe provided for pediatric cardiology fellows. Itshould be designed so that the spectrum of topicspresented will be completed at least once in thethree years of accredited fellowship training. Pedi-atric cardiology fellows should contribute formalpresentations of selected topics in the core curric-ulum, both to strengthen their knowledge base andto develop formal presentation skills. General ar-eas to be covered in the core curriculum includethose listed in Table 1.

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Additional Conferences

Preoperative conferences with the cardiovas-cular surgical service are essential. Journal clubsare a recommended element of an academic en-vironment and provide an excellent venue forparticipatory evaluation of study design and dataanalysis. Quality assurance evaluation and mor-bidity/mortality conferences should be held pe-riodically. Multidisciplinary clinical and researchconferences are highly desirable; according tothe strengths of the institution, contributorsmight include neonatology, cardiothoracic sur-gery, adult cardiology, cardiac pathology, physiol-ogy, pharmacology, pulmonology, intensive care,cardiac anesthesiology, cardiovascular radiology,clinical genetics, molecular genetics, tissue en-gineering, stem cell biology, or developmentalbiology. In all of these conferences, pediatric car-diology fellows should be provided with activeroles appropriate to their level of knowledge andtraining.

TEACHING AND EVALUATION SKILLS

It is a fundamental responsibility in academicmedicine that those with the most experiencemust teach. The pediatric cardiology fellow willoften be the most clinically experienced houseofficer on a team of residents, interns, and/ormedical students. The fellow in that settingshould be expected to provide lectures/seminarsto the team of house officers. The pediatriccardiology fellow should also be allowed theopportunity to practice clinical leadership, or-ganizational skills, and impromptu educationalactivities as appropriate to his/her demonstratedlevel of knowledge and training. There shouldbe occasion for observation and critique ofthese skills by the attending physician as well asdemonstration of these skills to the fellow by theattending.

Pediatric cardiology fellows should developformal evaluation of trainees and training skillsduring their fellowship. To do so, they shouldparticipate in feedback to residents, students,and cardiology attendings throughout their rota-tions regarding their own educational and tech-nical progress and the progress of other teammembers. Accurate self-evaluation is the mostvaluable skill of all and should be nurtured in allphases of pediatric cardiology training.

APPENDIX

The authors of this section declare they have norelationships with industry pertinent to thistopic.

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/CTCardiac sequelae of chronic hepatic diseaseCardiac sequelae of chronic renal diseaseCardiac sequelae of HIV/AIDSCardiac sequelae of obstructive sleep apneaCardiac sequelae of oncologic therapyCardiomyopathy, heart failure, and transplantation in the

pediatric patientCardiopulmonary bypassCardiovascular pharmacologyCardiovascular physiology and anatomyCardiovascular sequelae and follow-up in Marfan, William,

DiGeorge, Turner, and Noonan syndromesCardiovascular sequelae of pregnancy and the impact of

congenital heart diseaseCardiovascular sequelae of rheumatologic diseaseCardiovascular sports medicineCare of the single ventricle patientCellular electrophysiology (e.g., action potentials and ion channels)Chest painClinical electrophysiology (e.g., mechanisms of arrhythmias,

pacemakers, ablative therapy)Coagulation and anticoagulationDiagnosis and management of arrhythmiasDiagnosis and management of elevated pulmonary vascular

resistanceDiagnosis and management of intravascular/intracardiac

thrombosisDiagnosis and management of left-to-right shunt lesionsDiagnosis and management of patent ductus arteriosus in

premature infantsDiagnosis and management of right to left shunt lesionsDiagnosis and management of valvular heart disease, including

artificial heart valvesDiagnostic evaluation of heart murmursDifferential diagnosis and management of cardiac tumorsDifferential diagnosis and management of pericardial effusion

and pericardial tamponadeEmbryonic, fetal, and postnatal cardiovascular developmentEndocarditisExercise testingFetal/neonatal/perinatal cardiovascular physiologyGenetics of cardiovascular diseases of childhoodHyperlipidemiaHypertensionKawasaki diseaseMedical ethicsNormal cardiovascular anatomy and physiology, including

exercise physiologyObesityPericarditis and pericardial effusionsPhysics of echocardiography and Doppler analysisPhysiology and natural history of congenital heart diseasePopulation healthPreventive cardiology, including prevention of adult acquired

heart diseaseQuality assurance and process improvement methodologyRationale, 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 congenitalheart disease infants of diabetic pregnancies

Rationale, expectations, and methods of screening for congenitalheart disease in the presence of neonatal emergencies such asgastroschisis, omphalocele, congenital diaphragmatic hernia,or cardiorespiratory failure leading to extracorporealmembrane oxygenation

Rheumatic feverRisk factors in childhood and adolescenceSegmental cardiac analysisStatistics and study design


Task Force 2: Pediatric Training Guidelines for Noninvasive Cardiac ImagingEndorsed 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; and

Paul M. Weinberg, MD, FACC, FAAP

INTRODUCTION

Noninvasive imaging, including echocardiog-raphy and magnetic resonance imaging(MRI), is a primary means for elucidating the

anatomy and physiology of childhood heart disease.Competence in performance and interpretation ofechocardiography and MRI is now essential to thepractice of pediatric cardiology. Depending uponone’s individual career goals, varying levels of ex-pertise may be expected to be achieved during fel-lowship training. This document defines the levels ofknowledge and expertise that pediatric cardiologytrainees should acquire in echocardiography andMRI during training, and it offers guidelines forachieving these levels of competence.

Training guidelines have been previously pub-lished for pediatric echocardiography,1 fetal echocar-diography,2 and pediatric transesophageal echocar-diography.3 Those documents were reviewed andconsidered during preparation of these guidelines.The guidelines presented here differ in some in-stances from previous recommendations becausethis task force recognizes that training programshave changed significantly over the decade since thelast guidelines were promulgated.

PEDIATRIC ECHOCARDIOGRAPHYEchocardiography, as used in this document, in-

cludes two-dimensional imaging of the heart andrelated structures, M-mode echocardiography for as-sessment of chamber size and function, color M-mode and Doppler tissue and flow mapping, pulsedand continuous-wave spectral Doppler flow analy-sis, and other variations of these basic modalitiesused to assess the structure and function of the heartand related organs, including new technologies suchas three-dimensional echocardiography as they be-come available.

Facilities and EnvironmentThe pediatric echocardiography laboratory should

serve a hospital with inpatient and outpatient facili-ties, neonatal and pediatric intensive care units, apediatric cardiac catheterization/interventional lab-oratory, and an active pediatric cardiac surgical pro-gram. The pediatric echocardiography laboratoryshould be under the supervision of a full-time pedi-atric cardiologist-echocardiographer qualified to di-rect a laboratory, and whose primary responsibilityis supervision of the laboratory. The laboratory mustperform a sufficient number of pediatric transtho-

racic, pediatric transesophageal, and fetal echocar-diograms1,4 each year to allow trainees sufficient ex-posure to both normal and abnormal examinations.

LEVELS OF EXPERTISETraining goals defined here are to enable trainees

to achieve one of two levels of expertise in echocar-diography as appropriate for career goals.

Core

• Understanding of the general physical propertiesof ultrasound and clinical ultrasound technology.

• Ability to perform and interpret transthoracicechocardiography in normal infants, children andadolescents, and in those with childhood heartdisease, with consultation as needed.

• Basic introduction to the principles of performingand interpreting transesophageal and fetal echo-cardiograms. Physicians with core expertise onlyare not expected to perform transesophageal andfetal echocardiograms independently.

Advanced

• Special expertise in performance and interpreta-tion of transthoracic echocardiography in all formsof congenital and acquired pediatric heart disease,including the adult with congenital heart disease,enabling the practitioner to function indepen-dently.

• Ability to perform and interpret transesophagealand fetal echocardiography independently.

• Ability to supervise training and performance ofsonographers, fellows, and other physicians.

TRAINING GUIDELINESCore training should be achieved by all pediatric

cardiology fellows during core clinical training, typ-ically during four to six months dedicated to echo-cardiography over the course of the standard three-year training program. This level of expertise isanticipated to be sufficient for those fellows who donot plan to pursue echocardiography as an area ofsubspecialization.

Advanced training requires an additional 9 to 12months of training and may be achieved through adedicated experience in pediatric echocardiographyafter completion of core pediatric echocardiographyinstruction. This level of training is appropriate forthose physicians who intend to be dedicated pediat-ric echocardiographers.


TRAINING GOALSSuccessful completion of each training level

should result in competence in the following specificareas.

Core

• Understanding of the physical properties of ultra-sound.

• Proper, safe, and facile use of ultrasound instru-ments.

• Knowledge of the limitations of echocardiogra-phy.

• Recognition of cardiac structures displayed byechocardiography and the correlation betweenechocardiographic images and cardiac anatomy.

• Interpretation of Doppler flow information anddeduction of cardiovascular physiology.

• Performance and interpretation of complete trans-thoracic two-dimensional and M-mode echocar-diograms, Doppler color-flow mapping, andpulsed- and continuous-wave spectral Dopplerflow analysis in normal pediatric patients and inthose with childhood heart disease, with consul-tation as needed.

• Assessment of systolic, diastolic, and regionalmyocardial function in normal pediatric patientsand those with childhood heart disease, with con-sultation as needed.

• Ability to review critically published clinical re-search in echocardiography.

AdvancedIn addition to core competencies, other goals in-

clude:

• Independent performance and interpretation ofcomplete transthoracic two-dimensional and M-mode echocardiograms, Doppler color-flow map-ping, and pulsed- and continuous-wave spectralDoppler flow analysis in normal pediatric patientsand in those with childhood heart disease.

• Independent assessment of systolic, diastolic andregional myocardial function in normal pediatricpatients and in those with congenital or acquiredheart disease, to include stress echocardiographicstudies.

• Special expertise in the performance and interpre-tation of pediatric transthoracic, pediatric trans-esophageal, and fetal echocardiography.

• Training of sonographers and junior pediatric car-diology trainees.

• Participation in basic or clinical research in echo-cardiography, including presenting original dataat one or more scientific meetings.

TRAINING METHODSEach level of training may be achieved by the

methods outlined in the following text or by compa-rable alternative methods. A summary of the recom-mended minimum number of procedures is found inTable 1.

CoreEach trainee should perform and interpret at least

150 pediatric echocardiograms, including at least 50in patients one year of age or younger, under thesupervision of the laboratory director or other qual-ified staff pediatric cardiologist-echocardio-grapher(s). Each trainee should also review at least150 additional pediatric echocardiograms.

In addition, the laboratory director or other staffpediatric cardiologist-echocardiographer(s) shouldconduct regular laboratory conferences with thetrainee(s) to present illustrative cases and to teachproper interpretation and the limitations of echocar-diography. Pathological specimens, models, or pho-tographs for echocardiographic-anatomic correlationare excellent teaching aids that should be incorpo-rated wherever possible.

Integration of echocardiography into the clinicalpractice of pediatric cardiology should be demon-strated on inpatient and outpatient rotations and atmedical-surgical management conferences.

Research training for pediatric cardiology traineesshould include active participation in reviews of scien-tific journal articles that pertain to echocardiography.

AdvancedEach advanced-level trainee should perform and

interpret at least 200 additional pediatric transtho-racic echocardiograms and review, or perform andinterpret, another 200 pediatric echocardiograms. Aswith core training, at least 50 of these should be donein infants one year of age or younger. Each traineeshould perform a significant number of echocardio-grams independently (one-third to one-half of theexams), with subsequent review and critique of theexamination by the responsible staff pediatric cardi-ologist-echocardiographer. Teaching methods out-lined in the previous text should be continued here.

Each advanced-level trainee should perform andinterpret at least 50 pediatric transesophageal echo-cardiograms, including manipulation of the trans-ducer and registration of images, under directsupervision by a dedicated pediatric cardiologist-echocardiographer. The trainee should perform intu-bation of the esophagus in at least 20 patients underthe direct supervision of a pediatric cardiologist-ech-ocardiographer or anesthesiologist experienced inthe procedure. An ideal environment for learningpediatric transesophageal echocardiography is theoperating suite during performance of intraoperative

TABLE 1. Echocardiography Training—Recommended Mini-mum Procedure Numbers

Core trainingTTE perform and interpret (�1 year of age) 150 (50)TTE review 150

Advanced training*TTE perform and interpret (�1 year of age) 200 (50)TTE review 200TEE perform and interpret 50Fetal echocardiogram 50

* Numbers are in addition to those obtained during core training.TEE � transesophageal echocardiogram; TTE � transthoracic

echocardiogram.


examinations, but the training experience should notbe limited to this venue and should include the in-tensive care unit, cardiac catheterization suite, andoutpatient examinations.

Each advanced trainee should perform and/orreview at least 50 fetal echocardiograms. Thetrainee must master the fundamental skills of de-termining fetal position, situs, cardiac anatomy,and cardiac rhythm under the supervision of adedicated pediatric cardiologist-echocardiogra-pher. The trainee should observe and participate inthe discussion of the findings with the parents bythe staff echocardiographer responsible for the ex-amination. As the trainee’s experience progresses,a significant proportion (30% to 50%) of studiesshould be performed independently, includingcases with normal and abnormal cardiac anatomyand rhythm, with supervision by a dedicated pe-diatric cardiologist-echocardiographer. Eachtrainee should understand how to recognize andapproach fetal heart failure, and he or she shouldunderstand the association of fetal heart diseasewith extracardiac structural abnormalities, syn-dromes, and chromosomal abnormalities.

Research training for pediatric cardiology traineesshould include, at a minimum, active participation inreviews of scientific journal articles that pertain toechocardiography. In addition, participation in basicor clinical research in echocardiography should beencouraged.

Each advanced-level trainee should be given re-sponsibility for participating in the training of sonog-raphers and junior pediatric cardiology fellows, ini-tially with supervision of the laboratory director andthen independently and also presenting echocardio-graphy-related teaching conferences and formal di-dactic lectures.

EVALUATIONThe laboratory director, in consultation with the

teaching staff, should evaluate each trainee in writ-ing on a regular basis. Trainees should maintain a logof all echocardiograms performed and reviewed, in-cluding the age of the patient and the diagnosis. Thelog should be reviewed regularly by both the labo-ratory director and the training program director toensure that each trainee is obtaining adequate andbalanced experience.

The evaluation should be reviewed with eachtrainee and a written copy provided. If a trainee doesnot appear to be progressing adequately during therotation, a meeting should be scheduled as soon aspossible to inform the trainee and to discuss poten-tial remedial measures. The evaluation should bebased on achievement of the expected levels of com-petence in the areas outlined in the previous text.

Direct observation of the trainee during perfor-mance of echocardiograms provides informationabout imaging skills and understanding of the ultra-sound instruments. Conferences in which echocar-diograms are presented provide an opportunity toassess skills in interpretation of images and Dopplerrecordings. The trainees’ understanding of researchdesign and methods and ability to review research

can be critically evaluated during journal club meet-ings or other venues for medical literature review.Teaching skills and effectiveness can be evaluated bydirect observation and from evaluations by sonogra-phers and more junior trainees and by performanceat teaching conferences prepared and delivered bytrainees.

Pediatric Cardiovascular Magnetic Resonance ImagingMagnetic resonance imaging (MRI) as used in this

document includes anatomic and functional cardio-vascular MRI in congenital and acquired pediatricheart disease as well as in the adult with congenitalheart disease. At present, there are no specific guide-lines for training or credentialing in pediatric cardio-vascular MRI. It is likely that the training guidelinesfor pediatric cardiovascular MRI proposed here willrequire amendment as the field evolves. Theseguidelines must be considered as goals and shouldnot be considered as requirements.

LEVELS OF EXPERTISETrainees may achieve one of two levels of expertise

in pediatric cardiovascular MRI as appropriate forcareer goals.

Core

• Familiarity with the general physical principlesupon which MRI is based.

• Ability to view and understand MR images innormal infants, children, and adolescents andthose with childhood heart disease.

• Introduction to commonly used imaging protocolsand MRI terminology.

Advanced

• Thorough understanding of clinical MRI instru-ments and the imaging protocols used for cardio-vascular imaging and physiological analysis (e.g.,quantitative analysis of ventricular function andblood flow).

• Ability to independently perform and interpret alltypes of MRI in childhood heart disease and con-genital heart disease at all ages.

• Ability to supervise training of technologists, fel-lows, and other physicians.

TRAINING GUIDELINESTraining in pediatric cardiovascular MRI should

occur within a pediatric cardiology fellowship pro-gram and/or a pediatric radiology training programaccredited by the Accreditation Council for GraduateMedical Education (ACGME). The MR laboratoryshould serve a hospital with both inpatient and out-patient facilities, neonatal and pediatric intensivecare units, a pediatric cardiac catheterization/inter-ventional laboratory, and an active pediatric cardiacsurgical program. The MRI laboratory should be un-der the supervision of a full-time cardiologist and/orradiologist qualified in cardiovascular MRI, and itmust perform a sufficient number of annual exami-nations to allow each trainee sufficient exposure toboth normal and abnormal examinations.


Core training should be achieved by all pediatriccardiology fellows during the core clinical years ofthe program. This level of expertise may be sufficientfor those fellows who plan to practice clinical pedi-atric cardiology with access to a pediatric cardiolo-gist or radiologist with special expertise in pediatriccardiovascular MRI.

Advanced training requires a minimum of sixmonths of instruction in addition to core training.This level of training is appropriate for those physi-cians who intend to have special expertise in pediat-ric cardiovascular MRI and is recommended for di-rectors of pediatric cardiovascular MRI laboratories.

TRAINING GOALSSuccessful completion of each training level

should result in competence in the following specificareas.

Core

• Physical principles of MRI and physiologic analy-sis.

• Limitations of, and contraindications to, MRI.• Recognition of cardiac structures displayed by

MRI and the correlation between MR images andcardiac anatomy.

• Basic familiarity with commonly used imagingprotocols, their clinical uses, and MRI terminol-ogy.

• Critical review of published clinical research inpediatric cardiovascular MRI.

Advanced

• Thorough understanding of MRI physics, instru-mentation, nomenclature, and safety.

• Special expertise in the performance and interpre-tation of pediatric cardiovascular MRI, includingall commonly used imaging and flow analysis pro-tocols.

• Training of technologists and junior pediatric car-diology trainees.

• Management of and quality assurance for the MRIlaboratory.

• Basic or clinical research in pediatric cardiovascu-lar MRI, including presenting original data at oneor more scientific meetings.

TRAINING METHODSEach level of training may be achieved by the

methods outlined in the following text or by compa-rable alternative methods.

CorePediatric cardiology trainees should gain exposure to

cardiovascular MRI through active review of scientific

journal articles that pertain to pediatric cardiovascularMRI, discussion with cardiologists and radiologistswho perform cardiovascular MRI, and, if possible, re-view of cardiovascular MRI examinations.

AdvancedDuring a fellowship in pediatric cardiovascular

MRI, each trainee should perform and/or interpretat least 100 cardiovascular MRI examinations in pa-tients with congenital or acquired childhood heartdisease, including adult patients with congenitalheart disease. As the trainee’s experience progresses,an increasing proportion of these examinationsshould be performed independently, with reviewand critique by the laboratory director.

Research training should include continued criticalreview of the pediatric cardiovascular MRI literatureand an opportunity to perform basic or clinical researchleading to publication or presentation of scientific data.

Each trainee should be given responsibility forparticipating in the training of technologists and jun-ior pediatric cardiology fellows, initially with super-vision of the laboratory director and subsequentlyindependently. In addition, each trainee should haveopportunities to observe and participate in the man-agement of the laboratory, especially quality im-provement initiatives.

EVALUATIONThe laboratory director, in consultation with the

teaching staff, should evaluate each trainee in writ-ing. The evaluation should be reviewed with eachtrainee and a written copy provided. The traineeshould maintain a log of all examinations performedand reviewed, including the age of the patient, diag-nosis, and role of the trainee in the examination.



REFERENCES1. Meyer RA, Hazier D, Huhta J, Smallhorn J, Snider R, Williams R. Guide-

lines for physician training in pediatric echocardiography, recommenda-tions of the Society of Pediatric Echocardiography Committee on Physi-cian Training. Am J Cardiol 1987;60164–5.

2. Meyer RA, Hagler D, Huhta J, et al. Guidelines for physician training infetal echocardiography: recommendations of the Society of PediatricEchocardiography Committee on Physician Training. J Am Soc Echocar-diogr 1990;3:1–3.

3. Fyfe DA, Ritter SB, Snider AR, et al. Guidelines for transesophagealechocardiography in children. J Am Soc Echocardiogr 1992;5:640–4.

4. Peariman AS, Gardin JM, Martin RP, et al. Guidelines for optimal phy-sician training in echocardiography: recommendations of the AmericanSociety of Echocardiography Committee for Physician Training in Echo-cardiography. Am J Cardiol 1987;60:158–61.


Task Force 3: Training Guidelines for Pediatric Cardiac Catheterizationand 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; and David F. Teitel, MD

INTRODUCTION

The purpose of this document is to recommendminimum training experiences in cardiac cathe-terization for clinical fellows in pediatric cardiol-

ogy training programs. Training guidelines in cardiaccatheterization are well-established in adult cardiovas-cular medicine,1,2 and they have been considered re-cently in pediatric cardiology as well.3,4

Pediatric cardiac catheterization is a unique spe-cialty encompassing a wide range of diagnostic andtherapeutic techniques applied to a diverse group ofcongenital and acquired cardiovascular disorders. Aphysician who performs a pediatric cardiac catheter-ization must possess the technical skills and clinicaljudgment to safely and accurately perform a thor-ough diagnostic cardiac catheterization and angio-graphic study. Furthermore, an interventional pedi-atric cardiologist must also assess the indications fora catheter intervention, including the risks of per-forming or not performing the procedure (i.e., re-quires knowledge of the natural history of the de-fect), and must skillfully perform the appropriatecatheter intervention. It is appropriate, therefore, todelineate minimal training requirements in cardiaccatheterization for pediatric cardiology trainees.

There are no studies relating training experiencesto subsequent clinical skill in pediatric cardiac cath-eterization. Therefore, the recommendations in TaskForce 3 represent the opinions of the authors. To helpguide this process, all Accreditation Council forGraduate Medical Education (ACGME)-accreditedpediatric cardiology training programs were sur-veyed in 2001 to inquire about current practices andopinions regarding fellow training in pediatric car-diac catheterization and intervention. Thirty-twoprograms responded. The responses represented theopinions of fellowship directors (n � 21), catheter-ization laboratory directors (n � 15), and divisiondirectors (n � 13) (in some programs one individualholds more than one position). This document drawson this Training Program Survey to help define train-ing guidelines in this specialty.

FACILITIES AND ENVIRONMENTTraining in cardiac catheterization should occur

within a pediatric cardiology fellowship programthat is accredited by the ACGME. The cardiac cath-eterization laboratory should serve a hospital withinpatient and outpatient facilities, neonatal and pe-diatric intensive care units, and an active pediatriccardiac surgical program. The pediatric cardiac cath-

eterization laboratory should be under the supervi-sion of a full-time pediatric cardiologist, whose pri-mary responsibility is supervision of the laboratory.The laboratory must perform a sufficient number ofcardiac catheterizations and interventional proce-dures to provide each trainee with an acceptableexperience.

The cardiac catheterization program must have aregular teaching conference in which diagnostic data(hemodynamic and angiographic) and therapeuticoutcomes are formally discussed. In addition, eachprogram that provides advanced interventional train-ing must have a regular morbidity and mortalityconference in which all adverse outcomes of catheterinterventions are systematically reviewed. Partici-pants in this conference should include cardiologyfaculty, clinical fellows, and preferably pediatric car-diothoracic surgeons and cardiac anesthesiologists.Active participation in these conferences by all clin-ical cardiology fellows, particularly those at advancedlevels, is essential to clinical training that emphasizesquality outcomes.

LEVELS OF EXPERTISEIn this report we discuss core training for all fel-

lows, and advanced training for fellows desiring spe-cial expertise in cardiac catheterization and interven-tional cardiology. The core training is recommendedfor all clinical fellows during their core clinical expe-rience. It is intended to be sufficient for fellows whodo not plan a career in interventional pediatric car-diology, but who may be required to perform simplediagnostic studies and to interpret catheterizationand angiographic data in their clinical practices.(Cardiologists who provide “diagnostic only” cathe-terization services must coordinate the care closelywith interventional cardiologists and surgeons at re-ferral centers to minimize the need for repeat cathe-terization procedures.) The advanced training pro-vides expertise in both diagnostic and interventionalcatheterization procedures, and it is intended toqualify a fellow to embark upon a career in cardiaccatheterization and intervention.

Core Training: Goals and MethodsCore training in cardiac catheterization refers to the

training experiences recommended for all clinicalcardiology fellows, regardless of specific careergoals. In the Training Program Survey, there wasunanimous support for core training in cardiac cath-eterization for all clinical fellows. The goal of such


core training is to introduce fellows to the field ofcardiac catheterization and the risks and benefits ofcatheter-based procedures, to teach basic diagnosticcatheterization skills, and to provide a basic knowl-edge of hemodynamics, angiography, and radiationsafety. A core curriculum in pediatric cardiac cathe-terization should include the topics and experiencesoutlined in Table 1.

The core training should involve each clinical fel-low in a minimum of 100 cardiac catheterizations, atleast 20 of which include an interventional compo-nent (Table 2). These experiences should familiarizethe fellow to the indications for cardiac catheteriza-tion and intervention, femoral vessel access tech-niques, basic catheter manipulations, hemodynamicmeasurements and calculations, and angiographicinterpretations. Participation by the fellow as eitherthe primary operator or the primary assistant is sat-isfactory involvement. A log book should be main-tained by the fellow to document the experience andoutcomes of catheterization.

Advanced Training: Goals and MethodsAdvanced training in cardiac catheterization refers

to the training recommended for pediatric cardiol-ogy fellows who intend to pursue a career in pedi-atric cardiac catheterization and interventional car-diology. Therefore, the advanced training goal is toprepare the trainee to independently perform diag-nostic and therapeutic catheter procedures with ex-cellent outcomes. Prerequisite to these advancedtraining experiences is the successful completion ofcore training. Advanced training should involveeach fellow in a minimum of 200 catheterizationprocedures, at least 100 of which are interventional.The minimum recommended numbers of proceduresare specified in Table 3 (and are in addition to thoseobtained during the core training). The proceduretypes and numbers in Table 3 are recommendedguidelines, not mandates, as it is understood thatsome qualified programs may not perform everyprocedure. Participation by the fellow as either the

primary operator or the primary assistant is satisfac-tory involvement.

A minimum number of procedures is necessary,but this is not sufficient to prepare a trainee for acareer in cardiac catheterization and intervention.Also important to a successful career, and perhapsmore crucial, are technical facility and good clinicaljudgment. During advanced training the traineemust acquire sophisticated skills in complex cathetermanipulations, wire and sheath exchanges, deviceimplantation techniques, and retrievals. Further-more, good clinical judgment regarding the indica-tions for and against intervention require a thoroughknowledge of the natural history of congenital car-diac defects,5,6 and of the medical, catheter, and sur-gical options available for treatment. It is the respon-sibility of the training program director to assure thateach advanced trainee graduates with the technicalskills, clinical judgment, and cognitive knowledge topursue an independent career in pediatric cardiaccatheterization.

A log book is to be maintained by the advancedfellow to document the nature and outcome of eachdiagnostic and interventional procedure he or sheparticipated in throughout training. The fellowshould also participate actively in regular cardiaccatheterization teaching and morbidity conferenceswhere outcomes and complications of interventionalprocedures are thoroughly discussed (see the previ-ous text). Finally, it is strongly recommended that theadvanced fellow participate in at least one clinicalresearch project related to cardiac catheterizationand/or interventional cardiology.

Advanced training in pediatric cardiac catheteriza-tion requires a dedicated 12-month experience, at aminimum. Some fellowship programs may be able tooffer the recommended advanced training experi-ences during a 3- or 3.5-year training program. Nev-ertheless, even in those programs additional trainingprovides the fellow an opportunity to enhance tech-nical skills and clinical judgment in this very com-plex specialty. The authors of this document believethat the highest-quality training is obtained during afourth-year experience. Three or 3.5 years of trainingmay be satisfactory for some individuals if all ad-vanced training guidelines are achieved, and partic-

TABLE 1. Recommended Body of Knowledge Covered Dur-ing Core Training

• Indications for and risks of cardiac catheterization andangiography

• Indications for and risks of therapeutic catheter procedures• Interpretation of pressure waveforms• Interpretation of O2 saturation data• Fick principle and shunt calculations• Vascular resistance calculations• Cardiac angiography: basic techniques/angles/interpretation• Radiation safety

TABLE 2. Core Training—Recommended Minimum CaseNumbers*

Total cardiac catheterizations 100Interventional procedures 20

Type of interventionBalloon septostomy† 5Other Not specified

* Numbers represent the median response from the Training Pro-gram Survey.† Fluoroscopic orechocardiographic guidance.

TABLE 3. Advanced Training—Recommended MinimumCase Numbers*

Total cardiac catheterizations 200Interventional procedures 100

Type of interventionBalloon septostomy† 5Transseptal puncture 10Pulmonary valve dilation 10 (5 newborns)Aortic valve dilation 10 (5 newborns)Pulmonary artery dilation 10Pulmonary artery stent 10Coarctation dilation 10Coarctation stent 5Collateral occlusion 10Ductus arteriosus occlusion 10Atrial septal defect occlusion 10

* Numbers represent the median response from the Training Pro-gram Survey.† Fluoroscopic or echocardiographic guidance.


ularly if the fellow’s next postgraduate position canbe anticipated to provide ongoing mentoring forcomplex interventions.

REFERENCES1. Pepine CJ, Babb JD, Brinker JA, et al. Guidelines for training in adult

cardiovascular medicine Core Cardiology Training Symposium (CO-CATS). Task Force 3: Training in Cardiac Catheterization and Interven-tional Cardiology J Am Coll Cardiol 1995;25:14–16

2. Hirshfeld JW, Banas JS, Cowley M, et al. American College of Cardiologytraining statement on recommendations for the structure of an optimaladult interventional cardiology training program J Am Coll Cardiol 1999;34:2141–47

3. Ruiz CE, Mullins CE, Rocchini AP, et al. Core curriculum for the trainingof pediatric invasive/interventional cardiologists: report of the Societyfor Cardiac Angiography and Interventions Committee on PediatricCardiology Training Standards. Cath Cardiovasc Diag 1996;37:409–24

4. Benson L, Coe Y, Houde C, Human D, Paquet M. Training standards forpediatric cardiac catheterization and interventional cardiology Can J Car-diol 1998;14:907–10

5. Nadas AS, Ellison RC, Weidman WH. Report from the Joint Study on theNatural History of Congenital Heart Defects. Circulation 1977;56 SupplI:I1–87

6. O’Fallon WM, Weidman WH. Long-term follow-up of congenital aorticstenosis, pulmonary stenosis, and ventricular septal defect Report fromthe Second Joint Study on the Natural History of Congenital HeartDefects (NHS-2). Circulation 1977;87 Suppl I:I1–126

Task Force 4: Recommendations for Training Guidelines in PediatricCardiac 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; and Edward P. Walsh, MD, FACC

INTRODUCTION

The field of clinical cardiac electrophysiologyhas rapidly expanded over the past 30 years.Advances in the diagnosis and treatment of

pediatric cardiac rhythm disorders, and the increas-ing trend in medicine in general to develop criteria orguidelines for competence and training in specificfields, have led to the need to develop guidelines fortraining in pediatric clinical cardiac electrophysiol-ogy (CCEP).

The American College of Cardiology (ACC),American Heart Association (AHA), and HeartRhythm Society (formerly NASPE) have addressedtraining guidelines in adult CCEP.1–3 The extensivebody of literature regarding adult CCEP training andbasic electrophysiology (EP) knowledge provides animportant background and should be applied in anappropriately modified form to pediatric CCEPtraining.4–21 Recognizing the considerable differ-ences in the pediatric and adult cardiology popula-tions, guidelines that are unique to the pediatric andcongenital heart disease population must be devel-

oped. Canadian recommendations for training in pe-diatric EP have been published.22 It should be recog-nized that pediatric patients are unique, as recog-nized by the separate training programs and boardcertification for pediatricians and internists, and foradult and pediatric cardiologists. In addition, thepediatric electrophysiologist will have experienceand expertise in groups unique to pediatric cardiacelectrophysiology, including the fetus with in uteroarrhythmias, the child with a structurally normalheart and supraventricular tachycardia, ventriculartachycardia, or other arrhythmias, the child with pre-operative or postoperative arrhythmias after surgeryfor congenital heart disease, and the adult with con-genital heart disease, both in the pre- and postoper-ative states. This unique group of adults with con-genital heart disease is best served by those with acombined knowledge of congenital heart disease andage-specific disease processes, whether this be pro-vided by a combination of pediatric and adult cardi-ologists or single individuals with broad training ordual training in pediatric and adult cardiology.

APPENDIX. Author Relationships With Industry and Others

Name Consultant ResearchGrant

ScientificAdvisory

Board

Speakers’Bureau

SteeringCommittee

Stock Holder Other

Dr. Robert H. Beekman III None None None None None NoneDr. William E. Hellenbrand • AGA None • AGA • AGA None NoneDr. Thomas R. Lloyd None None None None None NoneDr. 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, NMTDr. Jonathan J. Rome None • Gore, Inc. None None None NoneDr. David F. Teitel None None None None None None


FACILITIES AND ENVIRONMENTTraining should be obtained in an Accreditation

Council for Graduate Medical Education (ACGME)-accredited pediatric cardiology training program.Recommendations for catheter ablation facilitieshave been published.2,9 Pediatric catheterization lab-oratory facilities should be available with the appro-priate EP equipment to perform EP studies and cath-eter ablation. These facilities should ensure a safe,sterile, and effective environment for invasive EPstudies and implantation of pacemakers and arrhyth-mia control devices. In many settings, the operatingroom can be used for the pacing/arrhythmia controldevices. Although experience at outside institutions,including adult programs, may be valuable, no morethan two to four months of the one-year advancedtraining should be spent at other institutions. In par-ticular, added experience in pacemaker and implant-able cardioverter-defibrillator (ICD) implantation, aswell as in ventricular tachycardia studies, may beacquired at a certified adult CCEP program, pro-vided that it is within the previously noted timeframe.

At least one board-certified pediatric cardiologistwith advanced CCEP skills should be identified asthe director of the core and advanced Electrophysi-ology Training Program. Because there is currentlyno pediatric EP examination, consideration shouldbe given for one pediatric EP faculty member to takethe NASPExAM, or its successor examination. Foradvanced training of fellows, at least one facultymember should be skilled in the implantation ofpacemakers and ICDs.

LEVELS OF EXPERTISEIn this report we discuss core training for all fel-

lows and advanced training for fellows desiring spe-cial expertise in pediatric CCEP. The core training isrecommended for all clinical fellows during theircore clinical experience. It is intended to be sufficientfor fellows who do not plan a career in EP. Theadvanced training provides expertise in both diagnos-tic and therapeutic EP and it is intended to qualify afellow to embark upon a career in pediatric CCEP.Within the advanced level are two tracks related toexpertise in pacemaker/ICD care: track 1 physiciansprescribe and follow patients who require pacemak-er/ICD care; track 2 physicians will also be skilled indevice implantation.

Core Training: Goals and MethodsCore EP training is required of all trainees to be a

competent pediatric cardiologist. The goal is to en-able all trainees to be skilled in electrocardiographic(ECG) interpretation, including standard, ambula-tory (Holter), exercise ECGs, and transtelephonicECGs.

Additionally, the trainee should understand theindications for and the use of noninvasive diagnostictechniques including exercise testing, 24-h ambula-tory and event monitors, and tilt table testing andshould have a general understanding of their inter-pretation. All trainees should be able to properlyinterpret cardiac arrhythmias and manage arrhyth-

mias in the acute care setting. There should be anunderstanding of the use of non-pharmacologicmethods and pharmacologic agents to treat arrhyth-mias, including drug interactions and proarrhythmicpotential. The trainee should understand the indica-tions for the selection of patients for specialized elec-trophysiologic studies, including ablation. In addi-tion, the trainee should obtain a basic understandingof the indications for, and the information obtainedfrom, invasive EP studies. This should include anunderstanding of the use of information obtainedfrom these testing modalities for the management ofthe patient’s clinical condition. The trainee shouldhave skills in the interpretation of basic EP informa-tion obtained from electrophysiology study (EPS).

Participation in at least 10 EPS cases includingcatheter placement and analysis of electrophysi-ologic tracings are needed to acquire these skills. Thetrainee should understand the evaluation of patientswith syncope, palpitations, chest pain, and irregularheart rhythms. All trainees should understand theindications for pacemaker placement, know the dif-ferences in pacing modes, understand and be able toperform basic pacemaker interrogation, reprogramand troubleshoot pacemakers, recognizing basic mal-functions such as capture failure, sensing malfunc-tions, and battery end of service characteristics. Par-ticipation by the trainee in at least 20 pacemakerevaluations is recommended to develop these skills.The trainee should receive instruction in the inser-tion, management, and follow-up of temporary pace-makers, including measurement of pacing and sens-ing thresholds. He or she should understand thegeneral indications for consideration of the use ofarrhythmia control devices (ICDs and anti-tachycar-dia devices) and know when to refer these patientsfor more advanced EP evaluation. The trainee shouldunderstand the indications and techniques for elec-tive and emergency cardioversion. Four elective di-rect current cardioversions are required.

The core training to obtain the previously de-scribed skills and knowledge should occur in the firstthree years of pediatric cardiology training and beequivalent to two to three months of concentratedstudy, but may be acquired throughout the threeyears as needed to obtain designated competenceskills (Table 1).

Advanced Training (Year 4 � Year 5): Goals andMethods

The goal of advanced training is to enable the pe-diatric electrophysiologist to perform, interpret, andtrain others to conduct and interpret specific proce-dures at a high skill level. Tables 2 and 3 describe thecompetence skills necessary for advanced-level train-ing. The recommended minimum procedures aresummarized in Table 4 for both core and advancedtraining.

Advanced-level skills involve understanding theevaluation and management of common arrhyth-mias, from the fetus to young adult. In addition,advanced understanding of complex arrhythmiamanagement, especially in the postoperative periodafter repair of congenital heart defects and in special


groups such as long QT syndrome, Brugada syn-drome, and right ventricular dysplasia, should beattained. Evaluation and management of the patientwith all forms of syncope should be accomplished,including the performance of tilt table testing whenappropriate. In those programs that employ tilt test-ing, participation in at least 10 procedures in a pedi-atric or adult laboratory is advisable. A thoroughunderstanding of pathophysiology and therapy ofsyncope and tilt testing should be required of alltrainees. Advanced-level trainees should develop thecognitive skills to evaluate the patient with a familyhistory of sudden cardiac arrest or death. Skill andexperience should be encouraged in pediatric EPSinterpretation and use of the EP data to make man-agement and therapeutic decisions. Experience withesophageal EPS should be obtained with participa-tion in 10 procedures. The indications, risks, andbenefits of these procedures should be known.

Advanced-level trainees will develop technicaland cognitive skills and experience in the perfor-mance of invasive diagnostic and therapeutic CCEP.At least 75 diagnostic intracardiac EPS should beperformed, of which at least 10 should be patientswith ventricular tachycardia. At least 40 of thesediagnostic procedures must be in patients who are 12years of age or younger, and at least 10 should be inpatients with repaired or palliated congenital heartdisease. In addition, participation in at least 40 cath-eter ablation procedures is required. The diagnosticportion of a catheter ablation procedure may be usedto satisfy the requirement for participation in 75 di-agnostic procedures. Participation should includescrubbing for the case, catheter manipulation, anal-ysis, review of tracings, and generation of a report.

Advanced understanding of pacemaker indica-

tions, optimal pacemaker choices, and follow-up ofpacemaker patients should be obtained. The HeartRhythm Society has recommended two tracks forthose caring for pacemaker patients. Track 1 involveselectrophysiologists who will be involved in pre-scribing and following pacemaker and ICD patients.Track 2 individuals prescribe, implant, and followpatients with pacemakers and ICDs. In both tracks,advanced understanding of pacemaker and ICD in-dications, optimal pacemaker choices, and evalua-tion or follow-up of 75 pacemaker/ICD patientsshould be obtained. In addition, attendance—includ-ing intraoperative testing of 35 pacemaker or ICDimplants (20 new, 10 revisions, 5 ICDs)—is required.To implant pacemakers and ICDs, direct participa-tion in a total of at least 50 pacemaker and deviceimplants is required, of which a reasonable numbershould be complex devices including ICDs. As newtechnology develops, the number of device implantsnecessary to achieve competence may change. Par-ticipation should include scrubbing for the surgery,catheter manipulation, participation in intraopera-tive testing, and generation of a report. As the skillsfor implanting devices in smaller children are spe-cific to pediatric EP, at least 15 of these implantationprocedures should be in children less than 12 yearsof age. Also, experience with implantation in patientswith repaired congenital heart disease is essential.

Advanced-level pediatric electrophysiologistsshould have all the skills noted in the previous text,but they may or may not perform the implantation ofpacemakers and ICDs. If the pediatric clinical cardiacelectrophysiologist does not actually perform these

TABLE 1. Core Competence Skills

• Interpretation of ECGs, Holters, exercise testing, and eventmonitors with arrhythmia recognition

• Recognition of developmental changes in cardiac rates andrhythm with age and of “normal” variants of rhythm

• Management of arrhythmias in the acute care setting,including uses of pharmacologic agents, cardioversion withesophageal or intracardiac pacing, and direct currentcardioversion

• Management of common chronic arrhythmias such as infantsupraventricular tachycardia

• Evaluation of the patient with documented arrhythmia,symptoms of arrhythmia (palpitations, increased or decreasedheart rate, irregular heart rhythm), and syncope orpresyncope

• Treatment of patients with all forms of syncope• Evaluation of patients with long QT syndrome or family

history of sudden death and management of these patients• Knowledge of indications for use of noninvasive EP testing• Knowledge of indications for invasive EP studies and general

understanding of information obtained from EPS, includinginterpretation of basic EP information

• Knowledge of indications for catheter ablation, understandingof procedure and complications of procedure

• Knowledge of indications for pacing, anti-tachycardia device,and ICD placement

• Knowledge of pacing modes, basic pacemaker interrogation,reprogramming, and trouble-shooting for loss of capture,under or over sensing, battery end of life

• Temporary transvenous and transcutaneouspacing• Evaluation of EP literature

TABLE 2. Advanced EP Clinical Competence Skills

Advanced competence skills include core basic skills plus:• Management of all types of cardiac arrhythmias in all ages

from the fetus to young adult• Evaluation and management of patients with specific

arrhythmia syndromes including long QT syndrome,Brugada syndrome, and right ventricular dysplasia

• Evaluation of patients with family history of suddencardiac death

• Management of complex arrhythmias, especially inpostoperative congenital heart disease patients

• Evaluation of patient with syncope including, whenappropriate, performance of tilt table testing withappropriate interpretation and management of patient

• Performance of esophageal EPS• Knowledge of the indications, risks, and benefits of EPS/

catheter ablation• Interpretation and use of EPS data• Technical and cognitive skills to perform EPS/catheter

ablation, using current mapping technology and techniques• Advanced knowledge of selection of pacemaker type,

programming, follow-up, and trouble-shooting• Advanced knowledge of pacemakers and implantable

cardioverter-defibrillators• Intraoperative evaluation and programming of pacemakers

and ICDs

TABLE 3. Advanced EP Research Competence Skills

• Evaluation of EP literature• Development of clinical research skills• Completions of EP project which results in an abstract and/or

manuscript• Grant submission is encouraged


procedures, they should participate in the intraoper-ative evaluation and postoperative care. Advanced-level training is expected for any pediatric electro-physiologist who implants pacemakers and ICDs.An additional one to two years after the generalcardiology training program is required to achieveadvanced-level training. Supplementary trainingmay be required to achieve track 2 implantation com-petence. Part of this experience with implantationmay be gained in an outside program or an affiliatedadult CCEP training program. Until specific pediat-ric pacemaker and ICD certification is available, con-sideration should be given for advanced traineesimplanting pacemakers and ICDs to take the NASPEexamination.

Specific Program Content (Core and Advanced Levels)Trainees will be expected to develop an appropri-

ate level of knowledge and experience in the follow-ing areas:

• Basic cellular and whole organ EP related to nor-mal physiology and cardiac arrhythmias in all pe-diatric and adult congenital patients.

• Pharmacologic principles underlying the use ofantiarrhythmic drugs and the effects of variousconditions encountered in pediatrics on the use ofthose drugs (prematurity, developmental biologicchanges, including those in volume of distribu-tion, hepatic and renal clearance, drug interac-tions, and congestive heart failure).

• Management of pediatric and adult patients withcongenital heart disease and cardiac arrhythmias;knowledge of presentation and natural history ofthe variety of arrhythmias encountered in pediat-ric electrophysiology practice; understanding ofthe effects of various management strategies on

the physiology and psychology of the pediatricand congenital heart patient.

• Expertise in the use of the ECG and other nonin-vasive specialized testing, including ambulatorymonitoring, transtelephonic monitoring, exercisestress testing, and tilt table testing to evaluatecardiac arrhythmias and symptoms.

• An understanding of the indications, contraindi-cations, and potential risks and benefits of intra-cardiac EPS and esophageal EPS. Core-level train-ees should have a general understanding of theinformation provided by EPS and recognize basicinformation provided such as site of heart block,identification of mechanism of the arrhythmia,and location of accessory pathways or focal ar-rhythmia sites. Advanced-level trainees shouldhave experience with esophageal EPS for the treat-ment and evaluation of arrhythmias. Advancedtrainees should also develop an advanced under-standing of intracardiac EPS interpretation anduse of the data for management. In addition, ad-vanced trainees should develop the advanced cog-nitive and technical skills to perform EPS.

• Proficiency in the use of esophageal, temporarypostoperative epicardial wire, and intracardiacEPS for diagnosis and treatment should beachieved. This includes the ability to manipulatecatheters, knowledge of EP equipment and cathe-ters, and ability to perform the full spectrum ofprogrammed electrical stimulation and intracar-diac mapping and to interpret the results.

• Advanced trainees should develop the full spec-trum of cognitive and technical skills in all typesof catheter ablation in children and young adultswith congenital heart disease. Advanced traineesshould develop skills in the indications for and

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 generalPC training*

ECG interpretation 500† 1,500Ambulatory ECG interpretation 50 200Exercise ECG 10 40Tilt table tests 2 10Transesophageal EPS/temporary postoperative

epicardial wire study5 10

Intracardiac EPS 10 75‡Intracardiac EPS 12 years of age or less 40Intracardiac EPS in repaired congenital heart

disease10

Catheter ablation 5 40Catheter ablation 12 years of age of age or less 20Catheter ablation in repaired congential heart

disease10

DC cardioversion 4 10Pacemaker � ICD

Evaluations/follow-up 20 50Intraoperative evaluation pacemakers and

devices35 (20 new, 10 revisions, 5 ICDs)

Track 2: implant pacemaker and complexdevices

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 withother 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.


potential complications of catheter ablation andshould be prepared to treat any of these compli-cations. During the four years of training, the ad-vanced trainee should develop skills in trans-septal perforation by participating in at least 10transseptal procedures. Trainees should have ex-posure to and develop skills in manipulation ofablation catheters for antegrade ablation; retro-grade (transaortic) ablation experience is alsohighly desirable.

Core-level trainees should have a basic knowledgeand understanding of the use of pacemakers andICDs in pediatric and congenital heart patients. Inaddition, the core trainee should develop an under-standing of pacemakers and skills in evaluation ofpacemaker problems that may occur. Advanced-level trainees should have advanced knowledge inthe evaluation and management of pacemakers andICDs. In addition, advanced trainees will participatein implantation (either intraoperative evaluation oractual implant depending on whether track 1 or 2 ischosen) of pacemakers and ICDs, and provide expertunderstanding and management of implanted pace-makers and ICDs. In addition, advanced-level train-ees should have an understanding and experience inusing pacemakers and ICDs for noninvasive EPS andinternal cardioversion. All levels should have skillsin introducing temporary transvenous pacemakers.All levels should have experience with transcutane-ous pacing. Both levels should have the skill to usetransthoracic temporary postoperative epicardialwires for the recording of electrograms. Advancedtrainees should have knowledge and experience inusing these wires to convert arrhythmias.

Core-level trainees should have a basic under-standing of the indications for and use of cardiacsurgery to treat arrhythmias. Advanced level train-ees should provide expert mapping and other EPknowledge at the surgical procedure.

Specific formal instruction topics should be cov-ered in a core lecture series and in a journal clubformat. There should be regularly scheduled confer-ences regarding EPS interpretation, application ofthe EPS to the patient’s clinical management, andconferences on interpretation of standard and ambu-latory ECGs.

EVALUATION AND DOCUMENTATION OFCOMPETENCE

The program director is expected to maintain ad-equate records of each individual’s training experi-

ences and performance of various procedures forappropriate documentation for levels 1 or 2. Thetrainees should maintain records of participation inthe form of a log book containing clinical informa-tion, procedure performed, and outcomes, listingany complications encountered. Finally, formal writ-ten evaluations should occur at least every threemonths.

Track 2 will develop skills in implantation of pace-makers and ICDs, including extraction.

REFERENCES1. American College of Cardiology, American Heart Association, American

Academy of Pediatrics. ACP/ACC/AHA Task Force on Clinical Privilegesin Cardiology Clinical competence in insertion of a temporary transvenousventricular pacemaker. J Am Coll Cardiol 1994;23:1254–7

2. Scheinman M. Catheter ablation for cardiac arrhythmias, personnel, andfacilities: North American Society of Pacing and Electrophysiology AdHoc Committee on Catheter Ablation. Pacing Clin Electrophysiol 1992;15:715–21

3. American Academy of Pediatrics, American College of Cardiology,American Heart Association. Clinical competence in invasive cardiacelectrophysiological studies: ACP/ACC/AHA Task Force on ClinicalPrivileges in Cardiology. J Am Coll Cardiol 1994;23:1258–61

4. Tracy CM, Akhtar M, DiMarco JP, Packer DL, Weitz HH. ACC/AHAclinical competence statement on invasive electrophysiology studies,catheter ablation, and cardioversion A report of the American Collegeof Cardiology/American Heart Association/American College of Phy-sicians-American Society of Internal Medicine Task Force on ClinicalCompetence. Circulation 2000;102:2309–20

5. Akhtar M, Williams SV, Achord JL, et al. Clinical competence in inva-sive cardiac electrophysiological studies. Circulation 1994;89:1917–20

6. Alpert JS, Arnold WJ, Chaitman BR, et al. Guidelines for training inadult cardiovascular medicine Core Cardiology Training Symposium(COCATS). Task Force 1: training in clinical cardiology. J Am CollCardiol 1995;25:4–9

7. Dreifus LS, Fisch C, Griffin JC, Gillette PC, Mason JW, Parsonnet V.Guidelines for implantation of cardiac pacemakers and antiarrhythmiadevices. Circulation 1991;84:455–67

8. Fisch C, Hancock EW, McHenry PL, Selzer A, Yurchak PM. Task forceII: training in electrocardiography. J Am Coll Cardiol 1986;7:1201–4

9. Fisher JD, Cain ME, Ferdinand KC, et al. Catheter ablation for cardiacarrhythmias: clinical applications, personnel and facilities. J Am CollCardiol 1994;24:828–33

10. Flowers NC, Abildskov JA, Armstrong WF, et al. Recommended guide-lines for training in adult clinical cardiac electrophysiology. J Am CollCardiol 1991;18:637–40

11. Francis GS, Williams SV, Achord JL, et al. Clinical competence ininsertion of a temporary transvenous ventricular pacemaker. Circulation1994;89:1913–16

12. Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE 2002guideline update for implantation of cardiac pacemakers and antiar-rhythmia devices: summary article A report of the American College ofCardiology/American Heart Association Task Force on Practice Guide-lines (ACC/AHA/NASPE Committee to Update the 1998 PacemakerGuidelines). J Cardiovasc Electrophysiol 2002;13:1183–99

13. Knoebel S, Crawford M, Dunn M, et al. Guidelines for ambulatoryelectrocardiography. Circulation 1989;79:206–15

14. Knoebel S, Williams SV, Achord JL, et al. Clinical competence in am-bulatory electrocardiography. Circulation 1993;88:337–41

APPENDIX. Author Relationships With Industry and Others

Name Consultant ResearchGrant

ScientificAdvisory Board

Speakers’Bureau

SteeringCommittee

StockHolder

Other

Dr. Victoria L. Vetter None None None None None NoneDr. Michael J. Silka None None None None None NoneDr. George F. Van Hare None • Medtronic None None None None • Support for fellow

training—MedtronicDr. Edward P. Walsh None None None None None None


15. Mitchell LB, Dorian P, Gillis A, Kerr C, Klein G, Talajic M. Standards fortraining in adult clinical cardiac electrophysiology. Can J Cardiol 1996;12:476–81

16. Scheinman M, Akhtar M, Brugada P, et al. Teaching objectives forfellowship programs in clinical electrophysiology. Pacing Clin Electro-physiol 1988;11:989–96

17. Yurchak PM, Williams SV, Achord JL, et al. Clinical competence inelective direct current (DC) cardioversion: a statement for physiciansfrom the AHA/ACC/ACP Task Force on Clinical Privileges in Cardi-ology. Circulation 1993;88:342–5

18. Zipes DP, DiMarco JP, Gillette PC, Jackman WM, Myerburg RJ, Rahim-toola SH. Guidelines for clinical intracardiac electrophysiological andcatheter ablation procedures. J Am Coll Cardiol 1995;26:555–73

19. Hayes DL, Naccarelli GV, Furman S, Parsonnet V. NASPE Pacemaker

Training Policy Conference Group Training requirements for perma-nent pacemaker selection, implantation, and follow-up Pacing Clin Elec-trophysiol 1994;17:6–12

20. Josephson ME, Maloney JD, Barold SS, et al. Guidelines for training inadult cardiovascular medicine Core Cardiology Training Symposium(COCATS). Task force 6: training in specialized electrophysiology, car-diac pacing and arrhythmia management. J Am Coll Cardiol 1995;25:23–6

21. Kennedy HL, Goldberger AL, Graboys TB, Hancock EW. Guidelines fortraining in adult cardiovascular medicine Core Cardiology TrainingSymposium (COCATS). Task force 2: training in electrocardiography,ambulatory electrocardiography and exercise testing. J Am Coll Cardiol1995;25:10–3

22. Gow RM, Beland M, Guiffre M, Hamilton R. Standards for training inpediatric electrophysiology. Can J Cardiol 1998;14:902–10

Task Force 5: Requirements for Pediatric Cardiac Critical Care

Thomas Kulik, MD, Chair; Therese M. Giglia, MD, FACC;Keith C. Kocis, MD, FACC, FAAP; Larry T. Mahoney, MD, FACC; Steven M. Schwartz, MD;

Gil Wernovsky, MD, FACC, FAAP; and David L. Wessel, MD, FAHA

INTRODUCTION

Although pediatric cardiac critical care, as adistinct field of interest, is a relatively recentdevelopment, treating critically ill patients

has always been a substantial part of clinical pediat-ric cardiology. In addition, even pediatric cardiolo-gists who do not provide primary care for criticallyill patients will be asked to consult on such patients.It therefore seems appropriate to specify whatknowledge and skills relevant to the care of criticallyill patients should be taught in a pediatric cardiologyfellowship program.

FACILITIES AND ENVIRONMENTNot all pediatric cardiac training programs have a

separate pediatric cardiac intensive care unit (ICU),and in some training programs the primary care ofhemodynamically compromised cardiac patients isprovided by physicians other than pediatric cardiol-ogists. However, this should not preclude traineesfrom attaining the specified requirements throughinteraction with pediatric cardiologists, pediatric in-tensivists, neonatologists, pediatric cardiac surgeons,and other practitioners. Because the advanced prac-titioner must be board eligible or board certified inpediatric cardiology, it is implied that the pediatriccardiology training be done in an AccreditationCouncil for Graduate Medical Education (ACGME)-approved training program. The additional ninemonths of advanced training specified below shouldtake place in an institution in which at least 250pediatric cardiac procedures per year (this number isby consensus of the authors), utilizing cardiopulmo-nary bypass, are performed.

LEVELS OF EXPERTISEIn formulating the core training requirements, it

was expected that all board-certified pediatric cardi-ologists should be proficient in the following: 1) theevaluation and (at least) initial stabilization of thehemodynamically compromised pediatric patientwith heart disease; and 2) consultation with sur-

geons, pediatric intensivists, neonatologists, and oth-ers regarding the medical, and preoperative andpostoperative management of pediatric patients withheart disease.

It is unrealistic to expect all pediatric cardiac train-ees to be expert (and stay expert) in the most ad-vanced aspects of pediatric cardiac critical care. Inmany centers the critical care management of pedi-atric cardiac patients is provided primarily by pedi-atric intensivists, neonatologists, or pediatric cardiacsurgeons, rather than by cardiologists. However,given that most pediatric cardiologists will occasion-ally be responsible for situations such as those pre-viously noted, it is important that they can provideappropriate care until consultation with those moreexperienced in pediatric cardiac intensive care can beobtained. In some cases the pediatric cardiologistmay be the only source of expertise (e.g., in under-standing the limitations of echocardiography in de-lineating the anatomy/physiology of a hemodynam-ically compromised postoperative patient). Hence, itis important that the pediatric cardiologist be famil-iar with critical care-related issues, often specific to agiven cardiac lesion, when providing consultation inthe context of the critically ill patient. Thus, corerequirements apply to all trainees seeking board cer-tification in pediatric cardiology.

Advanced requirements, which are more compre-hensive, apply to practitioners who will undertakeprimary responsibility for the comprehensive man-agement of critically ill pediatric patients with con-genital or acquired heart disease.

These documents specify training guidelines inpediatric cardiac critical care for pediatric cardiologytrainees. The advanced guidelines specify trainingrequirements only for practitioners who are boardeligible/board certified in pediatric cardiology.These guidelines do not address what might be asuitable course of training for cardiac critical care forpractitioners with primary training in a disciplineother than pediatric cardiology.


CORE TRAINING: GOALS AND METHODS

General RequirementsAt the end of the pediatric cardiology fellowship,

the board-eligible pediatric cardiologist should reli-ably be able to do the following:

1) Evaluate and treat neonates and infants withcritical structural cardiac disease. Evaluation andtreatment includes:a) Establishing an accurate anatomic diagnosis

and ascertaining the relevant cardio-pulmo-nary physiology.

b) Providing appropriate medical therapy to sta-bilize the patient (provide for adequate oxy-gen delivery and organ perfusion).

c) Knowing what medical and surgical treat-ments are appropriate for the condition andwhat the short- and long-term outcomes ofthese therapies are.

In particular, the trainee should have sufficienttraining and experience to be efficient in manag-ing these patients:• Neonates and infants with ductal-dependent

left and right-sided obstructive lesions.• Neonates with d-transposition of the great ar-

teries.• Neonates with total anomalous pulmonary

venous connection with obstruction.• Infants with anomalous origin of the left cor-

onary artery.2) Evaluate and treat neonates, infants, and older

patients with other forms of critical cardiacdisease.

In particular, the trainee should have sufficienttraining and experience to be efficient in evalu-ating and treating these patients:• Patients with primary myocardial dysfunc-

tion.• Patients with acutely compromised cardiopul-

monary status due to myocarditis or cardio-myopathy (including that due to rheumaticfever, Kawasaki disease, and so on).

• Patients with acutely symptomatic arrhyth-mias.

• Patients with acutely compromised cardiopul-monary status due to endocarditis.

• Patients with pericardial effusion.• Patients having a hypercyanotic episode (“tet

spell”).• Neonates and infants with increased pulmo-

nary vascular resistance, with or withoutstructural abnormality of the heart.

3) Provide care, or consultation for those providingprimary care, for cardiac patients with illness ofnon-cardiac origin.

For example, a cyanotic patient with respira-tory syncitial virus pneumonitis requires caresomewhat different than a patient with a normalheart.

4) Provide consultation for those caring for postop-erative cardiac patients.

In particular, the pediatric cardiologist shouldbe able to do the following:

• Provide interpretation of diagnostic studies,such as echocardiograms and heart catheter-ization, including clearly delineating the lim-itations of such studies.

• Diagnose and treat acutely symptomatic ar-rhythmias.

• Provide consultation regarding therapies tomaximize oxygen delivery and cardiac out-put.

• Provide consultation regarding pharmaco-logic and other therapies for patients with“single ventricle” physiology.

• Provide consultation regarding therapy forpatients with increased pulmonary vascularresistance.

SPECIFIC AREAS OF KNOWLEDGE ANDCOMPETENCE

The following section lists certain areas of specialimportance.

1. Cardiopulmonary physiology, especially as it ap-plies to cardiac patients in the ICU setting.a) Determinants of, and means of influencing,

oxygen delivery, cardiac output, and vascularresistance.

b) The physiology of the patient with a singleventricle, including determinants of, andmeans of influencing, systemic arterial oxy-gen saturation, systemic perfusion, and myo-cardial work.

c) The physiology of the patient with a ductal-dependent left-sided obstructive lesion, in-cluding determinants of, and means of influ-encing, systemic arterial oxygen saturation,systemic perfusion, and myocardial work.

d) The physiology of the patient with a fixedrestriction of pulmonary blood flow, includ-ing determinants of, and means of influenc-ing, systemic arterial oxygen saturation, sys-temic perfusion, and myocardial work.

e) The physiology associated with d-transposi-tion of the great arteries.

f) The physiology of cardiopulmonary interac-tion, including how mechanical ventilation af-fects cardiac output.

2. Cardiovascular pharmacology.The trainee should learn the actions, mecha-

nisms of action, side effects, and clinical use of:a) Inotropic agents (e.g., digoxin, adrenergic

agonists, phosphodiesterase inhibitors).b) Vasodilators/antihypertensive agents (e.g., al-

pha adrenergic antagonists, angiotensin-con-verting enzyme inhibitors, calcium channelantagonists, beta adrenergic antagonists).

c) Commonly used antiarrhythmic drugs (e.g.,digoxin, procainamide, lidocaine, amioda-rone).

d) Inhaled nitric oxide.e) Prostaglandin E1.f) Neuromuscular blocking agents (e.g., pancu-

ronium, succinylcholine).g) Analgesics and sedatives (e.g., morphine, fen-

tanyl, ketamine, benzodiazepines).


h) Anticoagulants (unfractionated and low mo-lecular weight heparin, warfarin).

i) Diuretics (e.g., furosemide, chlorothiazide).j) Prostacyclin and other pulmonary vaso-

dilators.3. The relationship between cardiac structure, func-

tion, and clinical state.The trainee should learn:a) How cardiac structural abnormalities (e.g.,

obstruction of the atrial septum in hypoplasticleft heart syndrome) affect cardiopulmonaryfunction, physiology, and hence the clinicalstate of the patient.

b) Methods (e.g., echocardiography, invasivepressure measurements, arterial blood gasanalysis, magnetic resonance imaging) to de-termine and measure cardiac structure, func-tion, and physiology in the ICU patient, andthe limitations of these techniques.

c) Indications for remedy of structural lesions (inboth unoperated and operated patients), andappropriate means of therapy (surgical, cath-eter-based intervention).

4. Diagnosis and therapy of arrhythmias, especiallythose occurring in ICU patients.

In particular, the trainee should be familiarwith the use of atrial and ventricular pacingleads or transesophageal electrocardiography fordiagnosing and treating arrhythmias, and thediagnosis and therapy of junctional ectopictachycardia.

5. Airway management skills.6. Provision of analgesia and sedation.7. Conduct of cardiopulmonary resuscitation.8. Commonly used modes of mechanical ventila-

tion and their application in patients with heartdisease.

9. Common complications that occur in cardiac pa-tients in the ICU, and how they may be pre-vented and treated.The trainee should be familiar with factors thatpredispose to common postoperative complica-tions (e.g., catheter-related sepsis, pathologicalthrombosis, surgically-induced heart block), ap-propriate diagnostic techniques, and therapy forthese complications.

10. Familiarity with extracorporeal membrane oxy-genation and other cardiac support systems.

11. Indications for, and general principles, for pro-viding “end-of-life” or “palliative” care.

REQUIRED TRAINING PERIOD FOR CORETRAINING

In training programs where pediatric cardiologyfellows provide primary care of pediatric cardiacpatients in the ICU (generally programs that have aseparate cardiac ICU), a minimum of two months’full-time experience in the ICU is recommended. Forprograms where pediatric cardiology fellows act asconsultants for cardiac patients in the intensive caresetting, at least four months’ experience providingsuch consultation is recommended.

Trainees will be evaluated by the appropriate su-pervising faculty, and both written and oral feedback

will be provided to the trainee. Written evaluations,addressing specific areas of competence, will be de-veloped at each training site.

ADVANCED TRAINING: GOALS AND METHODSAdvanced training in pediatric cardiac intensive

care is intended to prepare practitioners who willundertake primary responsibility for the comprehen-sive management of critically ill patients with con-genital or acquired heart disease. Because this disci-pline stands at the nexus of pediatric cardiology andpediatric critical care, some physicians with primarytraining in fields other than pediatric cardiologywork in this area. This document describes an appro-priate advanced practitioner training program onlyfor physicians board eligible or board certified inpediatric cardiology; it does not specify what anappropriate training program should be for thosetrained in other disciplines (e.g., critical care medi-cine [CCM] or pediatric anesthesiology).

GENERAL REQUIREMENTS1. The advanced practitioner must be board certi-

fied/board eligible in pediatric cardiology.2. Advanced practitioners must have (at least) nine

months of clinical training beyond the core train-ing as outlined in the previous text. (This excludespractitioners doubly boarded in pediatric cardiol-ogy and pediatric CCM.) Practitioners with train-ing in (only) pediatric cardiology are thereforeexpected, in addition to having three years ofpediatric cardiology training, to have one monthof training in anesthesia, four months’ experiencepredominantly in general pediatric CCM, and atleast four months’ experience caring for pediatriccardiac patients in the ICU setting (a total of 9months).The practitioner must have sufficient experience in

managing term and pre-term neonates both preop-eratively and postoperatively.

SPECIFIC AREAS OF KNOWLEDGE ANDCOMPETENCE

Specific requirements for advanced training in-clude all of those for core training (listed in theprevious text), as well as the following:

1. Mechanical ventilation.a) Indications for and utilization of commonly

employed modes of mechanical ventilation, aswell as more advanced modes of ventilation(e.g., high-frequency oscillatory ventilation).

b) Optimal ways of providing gas exchange forpatients with congenital heart disease, takinginto account factors such as the effect of air-way pressure on venous return, the impact offiO2 on pulmonary vascular resistance, arte-rial O2 saturation, and systemic perfusion.

c) Pulmonary toxicity related to barotrauma, vo-lutrauma, and high levels of inspired oxygen,and how to minimize such toxicity.

2. Indications for, application of, and complicationsrelated to mechanical support for the failing car-diopulmonary system. Current systems that pro-vide such support include extracorporeal life


support, ventricular support devices, and intra-aortic balloon pumps. Expertise in at least oneform of mechanical support should result fromadvanced-level training.

3. Performance of invasive procedures often re-quired in managing critically ill cardiac patients.These procedures include advanced techniquesfor intravascular access (e.g., subclavian vein andinternal jugular venous cannulation), insertion ofchest tubes, pericardiocentesis, and so on.

4. Utilization of more advanced cardiovascularpharmacologic therapy (e.g., esmolol for therapyof hypertension, vasopressin for therapy of hy-potension).

5. Advanced skills in evaluation and treatment ofarrhythmias (e.g., utilization of epicardial elec-trodes and transesophageal leads for diagnosisand treatment of rhythm abnormalities, use ofpharmacologic agents to treat arrhythmias, andso on).

6. Advanced management of pulmonary hyperten-sion.

7. Diagnosis and treatment of less frequently en-countered/more complex postoperative compli-cations, including lesion-specific complications.Such complications include significant residualcardiac lesions, paralyzed hemi-diaphragm(s),large airway obstruction, compartment syn-drome following femoral arterial cannulation forcardiopulmonary bypass, prolonged chest tubedrainage, and so on. The practitioner should befamiliar with indications for invasive evaluation

(e.g., heart catheterization or bronchoscopy) andinvasive therapy (e.g., additional cardiac sur-gery, interventional catheterization, tracheos-tomy).

8. Evaluation and management of multisystem or-gan failure.

9. Postoperative management of orthotopic hearttransplant patients, and management of acuterejection.

10. Diagnosis and management of renal failure, in-cluding indications for renal replacement ther-apy.

11. Diagnosis and management of forms of neuro-logical dysfunction, sometimes seen in patientswith critical heart disease (seizures, stroke,global ischemia, increased intracranial pressure).

12. Available means of providing nutritional sup-port, and the most appropriate means for a givenpatient.

13. Transfusion management, and recognition andtreatment of common transfusion-related com-plications.

APPENDIXDr. David L. Wessel declared that he had the fol-

lowing relationships with industry relevant to thistopic—Pfizer (consultant and research grant); INOTherapeutics (consultant and scientific advisoryboard). The other authors of this report declared thatthey have no relationships with industry pertinent tothis topic.

Task Force 6: Training in Transition of Adolescent Care and Care of theAdult With Congenital Heart Disease

Daniel J. Murphy, Jr, MD, FACC, FAAP, Chair; and Elyse Foster, MD, FACC, FAHA

INTRODUCTION

The number of adults with congenital heart dis-ease (CHD) has increased significantly over thepast 20 years. Palliative surgery and, more re-

cently, non-surgical and medical interventions havepermitted even those with the most complex lesionsto reach adulthood. The recent Bethesda Conferenceestimated that there are approximately 420,000 CHDpatients in the U.S., based on models that excludesimple congenital lesions such as bicuspid aorticvalve, small atrial or ventricular septal defect, andmild pulmonary stenosis. Of those patients, approx-imately three-fourths have lesions that are moder-ately complex and one-fourth have lesions of greatcomplexity.

Establishing an adequate system for the care ofthese individuals is a challenging task that can bestbe accomplished through an integrative approachthat draws on the skills and knowledge base of bothpediatric and medical (adult) cardiologists within anadult CHD center. Many adults with CHD continue

to be cared for by pediatric cardiologists, who arewell trained to deal with the often complex problemsassociated with CHD, but are generally unpreparedto manage unique problems of adults with CHD,including long-term complications and adult healthcare issues such as pregnancy and overlay of ac-quired disease. Thus, basic knowledge of issuesunique to adults with CHD as well as knowledge ofthe indications for referral to a specialized adultCHD (ACHD) center is required of all pediatric car-diologists.

The American College of Cardiology (ACC) haspublished training guidelines for Adult Cardiovas-cular Medicine Core Cardiology Training II (CO-CATS 2) which include recommendations regardingcare of adult patients with CHD. These recommen-dations were developed with the recognition thatappropriate training and education for adult cardi-ologists is currently deficient in CHD, but that even-tually the numbers and complexity of such adultpatients will demand that many be cared for in adultsettings by cardiologists with an internal medicine-


adult cardiology background.1 It will be at least adecade or more before the graduates of adult cardi-ology training programs are sufficiently numerousand adequately trained to staff specialized adult con-genital centers as recommended in the 32nd Be-thesda Conference.2 Medical/pediatric residentswith double boards in adult and pediatric cardiologywould provide excellent training to care for thesepatients. Meanwhile, for the foreseeable future, sig-nificant numbers of adults will need to receive all ora part of their cardiac care from pediatric cardiolo-gists with training in adult issues.

Even if in the future the majority of adults withCHD are cared for in specialized ACHD centers,staffed primarily by specially trained adult cardiol-ogists, there are compelling reasons for the pediatriccardiology training curriculum to address issues re-lating to ACHD. The Bethesda Conference recom-mended that such centers maintain a liaison withpediatric cardiology programs for purposes of pa-tient care, education, and support. For example, assurgical treatments evolve, the postoperative coursechanges, requiring new forms of surveillance andfollow-up; the lessons learned from adolescents willshape the care of adults with CHD, and only closecoordination between pediatric cardiologists andspecialists in ACHD will optimize that care.

This report suggests an approach to the training ofpediatric cardiologists. These guidelines will empha-size the importance of preparing young patients withCHD for transition to adult care, the need for pedi-atric cardiologists to understand the outcomes ofCHD in the adult patient, and will serve as a guidefor pediatric cardiologists who will participate di-rectly in the care of adults with CHD.

LEVELS OF TRAINING

Core Training (Level 1)

We differentiate three levels of training and ex-pected expertise in the care of adults with CHD. Coretraining represents the level of knowledge appropri-ate for all trainees in pediatric cardiology and indi-cates the knowledge content that each graduate ofsuch a program should acquire. This level of knowl-edge should be tested in the Subspecialty Certifica-tion Examination in Pediatric Cardiology and willprovide the graduate with sufficient expertise to carefor adolescents with CHD and prepare them for tran-sition to ACHD care. In addition to the basic scienceand clinical knowledge included in every pediatriccardiology curriculum, certain additional knowledgeareas should be included:

• general knowledge• natural history of cardiac defects• postoperative residua, long-term issues• understanding care in the adult setting• transition issues• adolescent medicine

• outpatient experience• lectures as part of core curriculum• indications for and access to local/regional expert

consultation• adolescent and young adult medical care issues• contraception, gynecologic issues, pregnancy• physical activity, sports, and activity counseling• education, health and general• insurability• employment• psychosocial issues

Advanced Training (Level 2): Special Expertise inAdults With CHD

The COCATS 2 guidelines for adult cardiologyfellows suggest at least one year of concentratedexposure for those trainees who wish to care inde-pendently for adult patients with CHD. Certainknowledge areas should be included:

Basic Science

Pathophysiology of acquired heart disease with astrong emphasis on heart failure, arrhythmias, andcoronary atherosclerosis.

Adult Medical Care Issues

• coronary artery disease, hypertension, lipid man-agement, chronic obstructive pulmonary disease

• contraception, gynecologic issues, managementduring pregnancy and delivery

• physical activity, sports, and activity counseling• education, health and general• insurability• employment• psychosocial issues• palliative care

In addition to didactic materials, training shouldinclude the following activities and aims:

• Participation in a regular (at least weekly) clinicorganized for the care of adults with CHD—atleast 10 patients per week; and participation in theperioperative care of adult patients with CHD in-cluding direct observation of surgical repair.

• Program requirements.

To train effectively at level 2, a pediatric cardiol-ogy program should include at least one facultymember with a career commitment to the care ofadult patients with CHD.

Advanced Training (Level 3): Advanced Expertise inAdults With CHD

The COCATS 2 guidelines recommend an addi-tional year of continued participation in clinical prac-tice relating to ACHD to achieve advanced level 3training. In addition to the guidelines for advancedlevel 2 training, level 3 should include active partic-ipation in clinical and/or laboratory research in


conjunction with clinical activities and direct partic-ipation in additional cardiac catheterization andechocardiographic procedures in adults with CHD.1



REFERENCES

1. Skorton DJ, Garson A. Training in the care of adult patients with con-genital heart disease. Cardiol Clin 1993;11:717–720

2. Child JS, Collins-Nakai RL, Alpert JS. Task force 3: workforce descriptionand educational requirements for the care of adults with congenital heartdisease. J Am Coll Cardiol 2001;37:1183–1187

Task Force 7: Training Guidelines for Research in Pediatric Cardiology

D. Woodrow Benson, Jr, MD, PhD, Chair; H. Scott Baldwin, MD, FACC, FAHA;Larry T. Mahoney, MD, FACC, FAHA; and Tim C. McQuinn, MD, FAAP

Historically, pediatric cardiology has been adynamic clinical field where a rapid transferof knowledge from the research laboratory

to the bedside occurred regularly. Conversely, manyproblems on which laboratory effort was focusedwere first identified at the bedside. This pattern con-tinues today, and there is every reason to believe itwill accelerate in the future. Research in pediatriccardiology is defined in broad terms because it isanticipated that future advances in the care of pedi-atric patients with cardiovascular disease will gobeyond current practice and come from diverse areasof biomedical science. If the pediatric cardiologist isto maintain clinical competence and improve clinicalknowledge in step with the progress of biomedicalscience, it is crucial that he or she thoroughly under-stands the concepts, methods, and pitfalls of theresearch process. It is important that every pediatriccardiology trainee participate directly in research astraining that is limited to practical experience canteach only the status quo, and the status quo cannotimprove patient care. The guidelines that follow arebased in part on recommendations published in 1995and revised in 20021,2 and a Task Force Report onPediatric Cardiovascular Diseases.3

In addition to direct involvement in research, ev-ery trainee should gain practical experience in re-view of published data, research design, data analy-sis, and logical deduction. The research experienceplays a unique role in developing the skills in con-tinuing self-education essential to all pediatric cardi-ologists. Trainees contemplating a career in investi-gative cardiology bear a special responsibility toprepare effectively to advance understanding in thebroad area of clinical, translational, and basic cardio-vascular science as well as population science, be-havioral science, quality of care, and outcomes re-search.

Because the research experience is such an integralcomponent, pediatric cardiology training should becarried out in institutions in which the opportunityto participate in research is available. The trainingsite should be one that provides an atmosphere ofintellectual inquiry and support of the investiga-tional process.

GENERAL STANDARDSThe training institution must have staff and facil-

ities for research. Opportunities for research for the

trainees should be available not only within the clin-ical cardiology division, but also within biomedicalscience, epidemiological, or other clinical programsof the institution. Availability of expertise in cardiacdevelopment, cardiovascular genetics, epidemiol-ogy, outcome evaluation, biostatistics, populationscience, behavioral science, quality of care, outcomesresearch, and biomedical ethics should be readilyavailable. There should be a critical mass of investi-gators, and it is expected that cardiovascular inves-tigation be well represented. Not all investigatorsneed to be clinical cardiologists, but at least onefull-time faculty member from each training pro-gram should have demonstrated skill and researchproductivity as an investigator.

DURATION OF RESEARCH TRAININGFor trainees planning careers in education and

patient care, the core research training should in-clude substantial research time devoted to a specificresearch project or projects. In most cases, this willencompass a full 12 months of the training period.For those planning a career with a major emphasison investigation, an additional one to two years be-yond the core research training, working directlywith an experienced funded mentor, is needed inmost cases.

CONTENT OF TRAINING PROGRAMResearch training is an important part of the core

instruction of every trainee. Those planning a sub-stantive commitment to clinical, translational, or ba-sic cardiovascular research, as well as populationscience, behavioral science, quality of care, and out-comes research, will need advanced research train-ing.

Core Research TrainingIt is anticipated that in most instances core re-

search training will be devoted to a specific project orprojects with a clinical or translational research fo-cus. Such research training must be carried out underthe supervision of an experienced investigator andaccording to approved principles of biomedical eth-ics and institutional rules for patient protection. Itmust be recognized that such research is difficultbecause of the complexity of achieving valid scien-


tific conclusions while working with a diverse pop-ulation and simultaneously protecting the interestsof each patient. Advanced educational activities asoutlined by the American Board of Pediatrics maymeet the core research training objectives when ap-propriately planned, supervised, and evaluated byfaculty with expertise in this area.

Components of Core Research TrainingWith appropriate mentoring, the trainee should

develop skills in at least the following areas:

1. Literature study, to ascertain the exact state ofknowledge before undertaking new investigation.

2. Formulation of hypothesis and specific goals, en-suring that the hypothesis is testable, that thegoals are appropriate, and that statistical power isachievable.

3. Development of the research plan and the proto-col, including study design, recruitment of sub-jects, ethical considerations, informed consent andprotection of privacy, data collection modes, fulldescription of procedures, and institutional ap-proval of human investigation, where appropri-ate.

4. Data collection, including preparation of dataforms.

5. Development of analytic methods or proceduralskills, as required, and particularly the handlingof artifacts, missing data, outliers, and statisticalinference.

6. Presentation of results, preferably both oral andwritten, emphasizing that no investigation is com-plete until it is reported in peer-reviewed journals.

7. Risk-benefit analysis, regarding both patient (sub-ject) risk and benefit and societal risk and benefit.

8. Health policy implications of research.

In the case of multiple center clinical trials, partic-ipation in the full range of special activities outlinedhere is required. The clinician lacking expertise inthese areas may be unable to interpret critical reportsbearing directly on his or her practice. New datamight be accepted uncritically or important advancesrecognized tardily. The training program shouldprovide frequent opportunities for faculty and train-ees to review and analyze small- and large-scaleclinical and basic research reports in depth. Coreresearch training in the eight skill areas in the previ-ous text could be most easily obtained as part of amaster’s program in Clinical Investigation, PublicHealth, or some other structured program.

Advanced Research TrainingTrainees preparing for research careers in pediatric

cardiology need an extensive foundation in scientificinvestigation. Some trainees may have obtained ex-tensive research preparation in combined MD/PhDprograms, but may lack the special skills appropriateto their personal research goals. These may be ob-tained during a postdoctoral research fellowship oras part of the cardiology traineeship. Advanced re-search training should be a mentored investigational

experience with a productive and active scientist,MD or PhD, working in the appropriate fields ofclinical, epidemiological, genetic, developmental, orbiomolecular investigation as well as population sci-ence, behavioral science, quality of care, and out-comes research.

Trainees who aim for a career in investigative car-diology but who have not had the opportunity toobtain a PhD or equivalent training prior to embark-ing on their cardiology traineeships should have theopportunity and be encouraged to obtain the essen-tial coursework and laboratory experience necessaryfor a productive research career. Several types ofindividual or institutional research training grantsare important resources to support such training.

The advanced research training previously out-lined constitutes only the beginning of the educationof an independent cardiovascular investigator. Indi-viduals who pursue this path will require additionalresearch mentoring as junior faculty, and compensa-tion during the prolonged period of research trainingand mentoring should be sufficient to allow a sub-stantial time commitment to this training. To preparefor a successful investigative career, mentored train-ing during and following fellowship of two to fiveyears is usually necessary. Current models to sup-port young faculty during these critical times of ca-reer development include the American Heart Asso-ciation Scientist Development Grant and theNational Heart, Lung, and Blood Institute K08 or K23awards.

The fundamental demonstration of successfultraining for a pediatric cardiology investigator is suc-cessful competition for external funding obtained viapeer-reviewed mechanisms. Advanced researchtraining plans should be formulated with this goal inmind.

EVALUATIONEvaluation of a trainee’s research progress and

research skills should be subjective as well as objec-tive, based on agreed-upon criteria and standards,and should be ongoing throughout the training pe-riod. Each trainee’s competence and understandingshould be documented at the completion of training.The American Board of Pediatrics requirements forresearch oversight should guide the evolution pro-cess.

Trainees should be strongly encouraged to publishsubstantive results, thereby providing an evaluationby peer-reviewed journals.

FLEXIBILITYIt must be appreciated that the education of future

investigative cardiologists is a continuing processand that they usually remain in an educational insti-tution where they are immersed in clinical cardiol-ogy. They often have unique demands that mightrequire altering the sequence and exposure of clinicaltraining, consistent with their previous clinical expe-rience. Therefore, the program director should beafforded latitude in the assignment of responsibili-ties for the three years of training while guaranteeing


full clinical competence. Blocked research time of 12to 18 months with clinical duties limited to one-halfday per week plus weekend and night call duringthis time is highly desirable.

SUMMARYIt is vital to the future intellectual health of cardio-

vascular medicine and the welfare of pediatric pa-tients with cardiovascular disease that all future pe-diatric cardiologists be familiar with the principlesand tools of research. Training in research requiresthe intense involvement of productive and estab-lished investigators. Those trainees preparing for acareer in investigative cardiology require a carefullydeveloped but flexible educational plan that will per-mit them to be successful in their research careersover an extended period.

APPENDIX

Dr. D. Woodrow Benson declared that he had thefollowing relationships with industry relevant to this

topic—stock ownership in Medtronic, Guidant, andProctor & Gamble. The other authors of this reportdeclared that they have no relationships with indus-try pertinent to this topic.

REFERENCES

1. Sonnenblick EH, Ryan TI, Starke RD. Task force 7: training in cardiovas-cular research. J Am Coll Cardiol 1995;25:25–28

2. Roberts R, Alexander RW, Loscalzo J, Williams RS. Task force 7: trainingin cardiovascular research. Available at: http://www.acc.org/clinical/training/cocats2.pdf2002. Accessed August 10, 2004.

3. NHLBI Task Force Report on Pediatric Cardiovascular Diseases. Avail-able at: http://www.nhlbi.nih.gov/resources/docs/pediatric_cvd.pdf.Accessed August 10, 2004.

All policy statements from the American Academy ofPediatrics automatically expire 5 years after publication unlessreaffirmed, revised, or retired at or before that time.


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Organizational Principles to Guide and Define the Child ... · (COCATS 2) (revision of the 1995 COCATS training statement). J Am Coll Cardiol 2002;39:1242–1246. TABLE 1. Core Training