Pediatric and Congenital Echocardiography: How Far Have We Gone, and What Is Ahead?

Leo Lopez, MD, FASE, Chair of the Council on Pediatric and Congenital Heart Disease

The American Society of Echocardiography (ASE) Council on Pediatric and Congenital Heart Disease (PCHD) is one of few entities representing the community of healthcare providers specializing in pediatric and congenital echocardiography. Over the past couple of years, efforts by leaders in this ASE community have resulted in significant accomplishments, primarily in four areas that have been identified by the PCHD Council leadership as priorities for this community: research, training, quality, and education. In addition, many of these initiatives have involved new collaborative activities with other stakeholders in pediatric and congenital cardiology, all in an effort to provide integrated and comprehensive care for patients with PCHD.

In order to identify the most significant research topics in pediatric and congenital echo, a survey was conducted last year among leaders in the Council, and a gap analysis of the results highlighted the need for increased research efforts in valve function, ventricular function, and new technologies in the PCHD patient population. Because PCHDs are relatively rare, research studies with meaningful results related to outcomes are difficult to realize without multi-center studies involving large sample sizes. Developing the infrastructure to address the priorities identified in the gap analysis within a multi-center environment is a major challenge, particularly as it relates to proprietary image formats and analytic tools, image transfer and storage, data anonymization, legal and compliance issues, and funding. A major accomplishment by the Council to address these issues has involved the development of the Technology in Pediatric and Congenital Echo Think Tank, which occurred at ASE 2014 in Portland, Oregon, and at the Annual Scientific Sessions of the European Association of Cardiovascular Imaging (EACVI) in Vienna, Austria, in December 2014. During these forums, North American and European leaders in pediatric and congenital echo met with representatives from industry to identify areas where the two groups of stakeholders can collaborate to advance the field. The Think Tanks have definitely been productive, and both groups have expressed a desire to continue meeting in these forums on an annual or bi-annual basis. ASE, in conjunction with its IRT partners, is now planning to host the third event in Boston this June.

Advances in echo technology as well as the advent of cardiac magnetic resonance imaging and computed tomography have had significant impact on training in pediatric cardiac noninvasive imaging. As a result, the previous guidelines for this training have been updated, and a new document has recently been published outlining guidelines for core and advanced 4 th year training in noninvasive imaging. Most of the PCHD Council leadership participated in vetting the document, and the new standards have definitely accounted for the evolving landscape of pediatric and congenital cardiac imaging. Because of the heterogeneity in local imaging expertise at different institutions offering advanced 4 th year imaging fellowships, there is also significant variability in the application, interview, and selection process at these centers, often leading to significant confusion and stress for fellows applying for these positions. In response to the need for structure within this process, the PCHD Council has recently developed a recommended timeline for the application, interview, and selection process for these positions. Although the document does not represent a mandate for all programs offering advanced training positions, the timeline does provide a structured schedule for all centers that wish to collaborate in the process. Lastly, the PCHD Council instituted a mentorship program at ASE 2014 pairing fellows who received a travel grant or presented an oral abstract with established leaders within the community in an effort to provide individual guidance and support on issues related to the practice of pediatric and congenital echo during ASE 2014.

Quality improvement in pediatric cardiac noninvasive imaging is a growing priority in the PCHD community, particularly in this era of increased clinical demands and limited resources. In collaboration with the American College of Cardiology (ACC), members of the PCHD Council have recently participated in the publication of the first document on pediatric appropriate use criteria (AUC) for outpatient pediatric transthoracic echo. Using the RAND methodology to identify the most common indications for an outpatient echocardiogram and classify them as “appropriate,” “may be appropriate,” or “rarely appropriate,” the AUC document is the first step in optimizing resource utilization as it relates to echo. Other collaborative efforts with the ACC have involved the development quality metrics specific to pediatric cardiac noninvasive imaging, including metrics to assess image quality, adherence to a comprehensive protocol, and diagnostic accuracy within an echo laboratory. These metrics are currently being vetted locally (as part of a research project funded by the Intersocietal Accreditation Commission [IAC]) and nationally (though an open comment review process within ACC). Of interest to the pediatric and congenital echo community is a recent proposal within IAC to amend the process of accreditation for pediatric transesophageal echo, an initiative promoted by representatives from the Society of Pediatric Echocardiography (SOPE) and supported by members of the PCHD Council. This proposal is currently undergoing an open comment review process within IAC.

Within the realm of education, publications of guidelines and standards are crucial initiatives for the pediatric and congenital echo community, and leaders in the PCHD Council have been pivotal in the development of these documents. For example, ASE published guidelines for multimodality imaging of patients after tetralogy of Fallot repair in 2014, and upcoming documents include guidelines for imaging atrial septal defects and patent foramen ovale (in collaboration with the Society for Cardiac Angiography and Intervention) as well as expert recommendations for 3-dimensional echocardiography in the setting of PCHD (in collaboration with EACVI). Work with colleagues in Maternal and Fetal Medicine has also resulted in the publication of a scientific statement on fetal cardiology from the American Heart Association (AHA) with endorsement by ASE. In addition, ASE has recently published a statement on fetal echo screening. The objective of this statement is to engage in a “concerted, cross-discipline, multi-organizational effort to provide teaching, resources, and accreditation in fetal screening” in order to increase the surprisingly low detection rates for congenital heart diseases in the United States, and several members of the PCHD Council are currently developing educational modules to address this gap. Another deficiency within the pediatric and congenital echo community involves the ability to easily obtain relevant Continuing Medical Education (CME) and Maintenance of Certification (MOC) points in an online infrastructure. In collaboration with members of the PCHD Council, ASE has recently developed a CME/MOC educational module with clinical cases involving congenital heart diseases which is now available on ASE’s educational website, . Through major efforts by other members of the PCHD Council, in conjunction with the ASE education committee, another educational tool, which will also appear as a section of ASEUniversity, will allow access to recordings of past ASE sessions on specific congenital heart diseases, and will be provided with a CME designation. This activity will be released in the summer of 2015.

In summary, members of the ASE Council on PCHD have been tremendously active over the past couple of years to develop and establish initiatives to improve the practice and efficacy of pediatric congenital echo, and these efforts have focused primarily on research, training, quality, and education. Aside from the commitment to excellence and dedication to safe and effective care that have pervaded all of these activities, most have also involved collaboration with other stakeholders of pediatric and congenital echo, including representatives from industry, PCHD colleagues from Europe, other organizations (such as ACC, IAC, AHA, and SOPE), and healthcare providers in Maternal and Fetal Medicine, all in an effort to provide comprehensive and effective care to patients with PCHD.

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Apr 21, 2018 | Posted by in CARDIOLOGY | Comments Off on Pediatric and Congenital Echocardiography: How Far Have We Gone, and What Is Ahead?

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