Lynne Brown, BA, RDCS, FASE

“As sonographers, we are always learning something new. If we don’t, we get left behind! During my career the application of echocardiography has grown exponentially. One area that has changed dramatically is pediatrics and congenital heart disease. This month’s communication is dedicated to the rapidly developing specialty of adult congenital cardiology.” — Elizabeth McIlwain, Council Chair

Over the past 50 years, the study of cardiac sonography has changed dramatically- from the days of M-mode, to the use of two-dimensional imaging, and more recently the development of three- and four-dimensional echocardiography. In this time period, the treatment for congenital heart disease (CHD) has also evolved, leading to improved patient outcomes for reparative and palliative operative procedures. As pre- and post-operative assessments continue to improve, the number of patients living into adulthood with CHD has increased, and as recently as the year 2000, it has been reported that there are more adult patients living with CHD than pediatric patients. In the US, it is estimated that there are approximately 3 million citizens affected with CHD, with one million over the age of 18 years. Historically, these patients would have continued their care with their pediatric cardiologist throughout their lives, but with improved surgical techniques and post-operative care, they are surviving into adulthood and are requiring diagnosis and treatment of adult cardiac issues (for example, the development of coronary artery disease in addition to the repaired CHD). The specialty of adult congenital cardiology has emerged in response to this increased number of CHD patients and has become an important facet in the training of cardiac sonographers.

Traditionally, cardiac sonography programs have focused on adult cardiology and the issues facing an aging population. Most educational topics were centered on acquired heart disease and cardiac issues that are typically brought on by aging. Congenital heart disease may have been acknowledged, taught in an introductory course, or taught in the curriculum without dedicated pediatric clinical or adult congenital heart disease rotations. For many educational programs, it may be difficult to find clinical rotations for students, due to a small number of sites performing specialized congenital heart disease exams. The lack of clinical rotation sites results in many sonographers receiving their congenital heart disease clinical instruction through on-the-job training or independent study. Today, there is a need for sonographers with experience and training in CHD to assist cardiologists with their adult congenital patients. This should no longer be reserved for specialists but be added to a comprehensive echocardiography curriculum to prepare new graduates to image congenital heart defects and post-operative procedures in both pediatric and adult patients.

One way that pediatric and adult congenital cardiac sonographers can help to promote this is for sites that perform CHD echocardiograms to become clinical sites for educational programs (see Mitchell & Korcarz for detailed information for how to become a clinical site). Providing students “real” clinical hands-on experience with imaging CHD helps them understand that imaging CHD is very different from imaging acquired heart disease. To be an effective CHD cardiac sonographer, students need at least a basic understanding of the underlying pathology, anatomy, and physiology pre-repair, as well as of the surgical techniques used to correct it. Complex heart defects have not only anatomical implications but physiological effects that continue even after repair. Very often these patients will require serial monitoring and follow-up, and students must be prepared to “tailor the exam to answer the clinical question.” Many of these exams will require creative and even off-axis views to demonstrate the pathology and repair (e.g., conduit, baffle, etc.). Only real-time hands-on experience in echocardiography laboratories that perform CHD exams will provide students the knowledge to tailor the exam to answer the clinical question.

Many sonography programs now provide embryology and pediatric echocardiography training as part of their core curriculum. Recently the Commission on Accreditation of Allied Health Education Programs (CAAHEP) has added specific learning concentrations for cardiovascular technology (CVT) and diagnostic medical sonography (DMS) programs. With the addition of these learning concentrations and focused clinical education requirements in the study of CHD, students will be well prepared for the challenges of a changing population needing cardiac testing and care. Directors of programs in which it is not feasible to have dedicated rotations or become accredited in the pediatric/CHD concentrations are encouraged to seek out adult congenital cardiologists, pediatric cardiologists, and registered congenital/pediatric sonographers as guest lecturers to supplement their curriculums.

In conclusion, the addition of a dedicated CHD course of study to the cardiac sonographer curriculum will better prepare graduates as well as equip future sonographers to care for all adult patients who may enter their clinics and hospitals.

Resources for learning about congenital heart disease.

Formal educational programs:

http://www.caahep.org/Find-An-Accredited-Program/ . Search under “cardiovascular technology” and under the concentration: “pediatric Echocardiography” from the dropdown menu.

http://www.caahep.org/Find-An-Accredited-Program/ . Search under the profession name: “diagnostic medical sonographer” and the concentration: “pediatric cardiac” from the dropdown menu.

Websites with educational information:

http://asecho.org/pediatricsneonatalcongenital/ has information on the latest guidelines for performing pediatric echocardiography.

http://www.sopeonline.org . Society of Pediatric Echocardiography.