Happy New Year to all the Pediatric and Congenital Heart Disease Council members, and welcome to 2016! As we welcome in the New Year, it is clear that our council has much work to do. As many of you know, ASE has four strategic goals to achieve over the next few years.
Goal 1: Attract all users of CV ultrasound by creating quality and value
Goal 2: Promote the value of CV ultrasound to be well-known by patients, payers and health care providers
Goal 3: Facilitate the development and application of novel CV ultrasound technology
Goal 4: Create a governance structure that is representative of our membership and supports an efficient and effective organization
With these goals in mind, the PCHD Steering Committee will be meeting in April for a retreat to discuss how our council can help meet these goals and how these goals impact the PCHD community. We plan to have several in-depth discussions on a variety of topics.
With regard to attraction of all users of CV ultrasound, we plan to work on ways in which the pediatric cardiology community can help facilitate high quality imaging and reporting amongst our non-cardiology colleagues who perform point of care echocardiography. This may include MOC activities, quality assurance activities, and strategies to teach echocardiography in the pediatric ICU, pediatric emergency department, and neonatal ICU settings. Many practitioners in these areas are already using point of care echocardiography but issues such as image quality, equipment, archiving, and reporting remain quite variable. It is clear that point of care echocardiography is here to stay and that the PCHD community should help rather than hinder these efforts.
As for the promotion of CV ultrasound, we have less struggles than our adult colleagues who compete with cardiac CT, cardiac magnetic resonance imaging, and nuclear imaging. Most of our patients and referring physicians have a fairly good understanding of the benefits of echocardiography. Still, we need to determine how best to share images and reporting with families, patients, and referring health care providers so that they are clearly understood. We need to educate the pediatric community about appropriate use criteria in the non-congenital heart disease population and even start to consider how often to image patients with acquired and congenital heart disease (similar to our adult colleagues). Importantly, we can help educate the community at-large about the limitations of pediatric echocardiography as well.
One area of great interest to our community is how we quantify valve dysfunction in the pediatric population. The methods used in the adult population to quantify valve disease are often difficult to use in infants and children. This is true for a variety of reasons including faster heart rates, lack of cooperation, complex heart disease states, and better capacity of the young heart to compensate for disease. Despite being a mainstay diagnostic tool for almost 40 years, we have not established definitive criteria for valve regurgitation or valve stenosis in children. We can use the aortic valve as an example. Adult methods of quantitating aortic regurgitation include such measures as proximal isovelocity surface area (PISA). PISA is typically not applicable in children because it is difficult to obtain, and the assumptions required to measure it accurately (central jet, circular orifice) are often not present. Vena contracta (the narrowest portion of the color Doppler jet of regurgitation) can be used but its effective cross-sectional area is dependent on patient size, and there are no z-scores to determine its significance based on body surface area. Methods using pulsed wave Doppler such as regurgitant volume and regurgitant fraction depend on the heart rate being maintained during the measurements and accuracy of annulus measurement (potential error particularly in infants with small valves). In pediatric echocardiography laboratories, some use jet cross-sectional area, jet width, jet width to left ventricular outflow tract width ratio, jet length into ventricle, and/or assessment of diastolic reversal in the aorta. Thus, in children, severity of aortic regurgitation often differs amongst institutions and observers in the same institution. Our goal in the retreat is to try to determine how to standardize these evaluations; this will be no small feat I can assure you!
In addition to this initiative, we will be discussing future guideline projects. The Pediatric TEE guidelines were published in 2005. Much has changed since then including new probes (micro-mini, 3D) and views; thus, an update of these guidelines is warranted. We will also consider updating the fetal echocardiography guidelines which were last published in 2004. As I have discussed in previous reports from the chair, a guideline on imaging of congenital coronary artery anomalies is in its early phases.
With regard to application of novel CV technology, we will discuss more standardized views for 3D imaging (guideline soon to be published!) and to improve dataset manipulation specific to congenital heart disease. We will also continue to work on normal values for myocardial deformation imaging across vendors. Three dimensional printing is gaining favor in the CHD community to help with surgical planning, and this is also an area ripe for investigation in a multicenter fashion.
As you see, we will have plenty of topics to discuss and I look forward to reporting back to you after the retreat. In the meantime, thank you for your continued support. Please do not hesitate to contact me with ideas you might have to enhance your experience as a member of the Council on Pediatric and Congenital Heart Disease. Stay warm!
Meryl S. Cohen, MD, FASE, FACC, FAHA is a Professor of Pediatrics at University of Pennsylvania Perelman School of Medicine, and Medical Director of the Echocardiography Laboratory and Program Director for the Cardiology Fellowship Program at The Children’s Hospital of Philadelphia. She is the Chair of the Council on Pediatric and Congenital Heart Disease Steering Committee.