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Journal of the American College of Cardiology Vol. 46, No. 7, 2005 2005 by the American College of Cardiology Foundation, the American Heart Association, Inc.,and the American Academy of Pediatrics

ISSN 0735-1097/05/$30.00doi:10.1016/j.jacc.2005.07.014

P

ACCF/AHA/AAP Recommendations for Trainingin Pediatric Cardiology

A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians

Task Force on Clinical Competence (ACC/AHA/AAP Writing Committee

ublished by Elsevier Inc.

to Develop Training Recommendations for Pediatric Cardiology)

AUTHORS

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ntroduction: Training Guidelines for Pediatricardiology Fellowship Programshair: Thomas P. Graham, JR, MD, FACC, FAHA,

FAAP, Nashville, TNo-Chair: Robert H. Beekman III, MD, FACC, FAHA,

FAAP, Cincinnati, OH

ask Force 1: General Experiences and Traininghair: Hugh D. Allen, MD, FACC, FAHA, FAAP,

Columbus, OH. Timothy Bricker, MD, FACC, FAAP, Houston, TX

ichael D. Freed, MD, FACC, FAHA, FAAP,Boston, MA

oger A. Hurwitz, MD, FACC, FAAP, Indianapolis, INim C. McQuinn, MD, FAAP, Charleston, SCichard M. Schieken, MD, FACC, FAHA, FAAP,

Richmond, VAilliam B. Strong, MD, FACC, FAAP, Augusta, GA

enneth G. Zahka, MD, FACC, FAAP, Cleveland, OH

ask Force 2: Pediatric Training Guidelines foroninvasive Cardiac Imaginghair: Stephen P. Sanders, MD, FACC, Durham, NCteven D. Colan, MD, FACC, Boston, MAimothy M. Cordes, MD, FACC, FAAP,

Indianapolis, INary T. Donofrio, MD, FACC, FAAP, Washington, DCregory J. Ensing, MD, FACC, Ann Arbor, MIal Geva, MD, FACC, Boston, MAhomas R. Kimball, MD, FACC, FAAP,

Cincinnati, OHavid J. Sahn, MD, MACC, FAAP, Portland, ORorman H. Silverman, MD, FACC, FAHA,

Stanford, CAark S. Sklansky, MD, FACC, Los Angeles, CA

aul M. Weinberg, MD, FACC, FAAP,Philadelphia, PA

ask Force 3: Training Guidelines for Pediatricardiac Catheterization and Interventional Cardiologyhair: Robert H. Beekman III, MD, FACC, FAAP,

Cincinnati, OH T

illiam E. Hellenbrand, MD, FACC, New York, NYhomas R. Lloyd, MD, FACC, Ann Arbor, MI

ames E. Lock, MD, FACC, FAAP, Boston, MAharles E. Mullins, MD, FACC, FAHA, FAAP,

Houston, TXonathan J. Rome, MD, FACC, Philadelphia, PAavid F. Teitel, MD, San Francisco, CA

ask Force 4: Recommendations for Traininguidelines in Pediatric Cardiac Electrophysiologyhair: Victoria L. Vetter, MD, FACC, FAHA,

Philadelphia, PAichael J. Silka, MD, FACC, Los Angeles, CAeorge F. Van Hare, MD, FACC, FAAP,

Palo Alto, CAdward P. Walsh, MD, FACC, Boston, MA

ask Force 5: Requirements for Pediatricardiac Critical Carehair: Thomas Kulik, MD, Ann Arbor, MIherese M. Giglia, MD, FACC, New Hyde Park, NYeith C. Kocis, MD, FACC, FAAP, Chapel Hill, NCarry T. Mahoney, MD, FACC, FAHA, Iowa City, IAteven M. Schwartz, MD, Cincinnati, OHil Wernovsky, MD, FACC, FAAP, Philadelphia, PAavid L. Wessel, MD, FAHA, Boston, MA

ask Force 6: Training in Transition ofdolescent Care and Care of the Adult Withongenital Heart Diseasehair: Daniel J. Murphy, JR, MD, FACC, FAAP,

Palo Alto, CAlyse Foster, MD, FACC, FAHA, San Francisco, CA

ask Force 7: Training Guidelines for Research inediatric Cardiologyhair: D. Woodrow Benson, JR, MD, PHD,

Cincinnati, OH. Scott Baldwin, MD, FACC, FAHA, Nashville, TNarry T. Mahoney, MD, FACC, FAHA, Iowa City, IA

im C. McQuinn, MD, FAAP, Charleston, SC

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1379JACC Vol. 46, No. 7, 2005 ACCF/AHA/AAP Recommendations for Training in Pediatric CardiologyOctober 4, 2005:13789

STEERING COMMITTEEThomas P. Graham, JR, MD, FACC, FAHA, FAAP, Chair

Robert H. Beekman III, MD, FACC, FAHA, FAAP, Co-Chair

TDVW

ichael D. Freed, MD, FACC, FAHA, FAAPohn W. Hirshfeld, JR, MD, FACC, FAHAhomas Kulik, MD

ohn D. Kugler, MD, FACC, FAAP*

Mark A. Creager, MD,

GJCH

*AHA CVDY representative; AAP representative

Former Task Force member during writing effort

im C. McQuinn, MD, FAAPavid J. Sahn, MD, MACC, FAAPictoria L. Vetter, MD, FACC, FAHAilliam B. Moskowitz, MD, FACC, FAAP

TASK FORCE MEMBERS

FACC, FAHA, Chair

ohn W. Hirshfeld, JR, MD, FACC, FAHAeverly H. Lorell, MD, FACC, FAHAeno Merli, MD, FACP

eorge P. Rodgers, MD, FACCohn D. Rutherford, MB, CHB, FACC, FAHAynthia M. Tracy, MD, FACC, FAHA

oward H. Weitz, MD, FACC, FACP

This document was approved by the American College of Cardiology Foundation Board of Trustees in June 2005, by themerican Heart Association Science Advisory and Coordinating Committee in July 2005, and by the American Academyf Pediatrics Board in July 2005.When citing this document, the American College of Cardiology Foundation would appreciate the following citation

ormat: Beekman RH III, Graham TP, et al. ACCF/AHA/AAP recommendations for training in pediatric cardiology: aeport of the American College of Cardiology Foundation/American Heart Association/American College of Physiciansask Force on Clinical Competence (ACC/AHA/AAP Committee on Pediatric Cardiology). J Am Coll Cardiol005;46:1378403.Copies: This document is available on the Websites of the American College of Cardiology (www.acc.org), the Americaneart Association (www.americanheart.org), and the American Academy of Pediatrics (www.aap.org). Single copies of this

ocument may be purchased for $10.00 each by calling 1-800-253-4636 or by writing to the American College ofardiology, Resource Center, 9111 Old Georgetown Road, Bethesda, Maryland 20814-1699.Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not

ermitted without the express permission of the American College of Cardiology Foundation. Please direct requests toopyright_permissions@acc.org.

http://www.acc.orghttp://www.americanheart.orghttp://www.aap.orgmailto:copyright_permissions@acc.org

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Journal of the American College of Cardiology Vol. 46, No. 7, 2005 2005 by the American College of Cardiology Foundation, the American Heart Association, Inc.,and the American Academy of Pediatrics

ISSN 0735-1097/05/$30.00doi:10.1016/j.jacc.2005.07.025

P

NTRODUCTION

raining Guidelines forediatric Cardiology Fellowship Programs

homas P. Graham, JR, MD, FACC, FAHA, FAAP, Chair

ublished by Elsevier Inc.

obert H. Beekman III, MD, FACC, FAHA, FAAP, Co-Chair

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ediatric cardiology is a complex, multifaceted specialty com-osed of diverse clinical and academic subspecialty areas. It isharacterized by rapid growth of subspecialty areas and swiftncorporation of new information from the clinical and labo-atory sciences. It is important, therefore, to define the fellow-hip training required to launch a successful career in pediatricardiology. The following document represents the first broad-ased effort to do so.

In 2000, the Society of Pediatric Cardiology Trainingrogram Directors (SPCTPD) embarked on the process ofefining fellowship training guidelines. The process itself wasroad-based and inclusive. All pediatric cardiology trainingrogram directors were invited to nominate members toarticipate in the training guidelines task forces; in turn, eachask force was comprised of all nominated members whogreed to participate. Therefore, all training programs wererovided an opportunity to actively participate.In 2002, the American College of Cardiology (ACC) approved

nd published the Revised Recommendations in Adult Cardio-ascular Medicine Core Cardiology Training (1). As thePCTPD was concluding its training guideline development,lans were formalized to use a similar process through the ACCediatric Cardiology/Congenital Heart Disease Committee and

he ACC Training Program Directors Committee. Accordingly,steering committee was developed with original authors of theediatric Cardiology Training Guidelines to form a liaison with

he ACC, the American Heart Association (AHA), and theection on Pediatric Cardiology and Cardiac Surgery of themerican Academy of Pediatrics (AAP) to agree on the final

uidelines and to publish them widely.These guidelines are written with the planned goal of

erving as a practical resource for directors of pediatricardiology training programs. We also hope that thisocument will prove useful to the Residency Review Com-ittee (RRC) for pediatric training programs in the revision

f requirements for the accreditation of pediatric cardiologyrograms. The general requirements, clinical competencies,nd oversight for fellows in pediatric cardiology wouldemain the same as outlined by the Accreditation Councilor Graduate Medical Education (ACGME).

ENERAL CONSIDERATIONS

he guidelines proposed in this document address overall

ecommendations for training in pediatric cardiology and p

mportant subspecialties within the field of pediatric cardi-logy. Although we understand that the pediatric RRC setsinimum standards for accreditation of fellowship pro-

rams, this document endeavors to define a more compre-ensive set of guidelines for pediatric cardiology fellowshipraining. Fellowship training guidelines are presented for:eneral pediatric cardiology (including inpatient care andonsultations); echocardiography and noninvasive imaging;lectrophysiology; cardiac catheterization and intervention;ardiac intensive care; adult congenital heart disease; andesearch participation. Each section other than general pedi-tric cardiology specifies core and advanced training expe-iences. Core recommendations are intended to be commonraining experiences for all pediatric cardiology traineesegardless of long-term career goals. Advanced recommen-ations are additional training experiences for traineesntending to develop a clinical or academic area of specialompetence. All guidelines are recommended experiences,nd not absolute mandates, as it is recognized that eachraining program has unique strengths and that clinical andcademic variation across training programs provides im-ortant diversity for the specialty.Table 1 summarizes the approximate time commitment

in months) recommended for core training in the task forceeports that follow. Variations in these time commitmentshould be allowed, as pediatric cardiology programs varyidely in size, organization, and emphasis. For example, in

ome programs, fellows may get considerable cardiac inten-ive care unit training during their general inpatient expe-iences and not require a two- to four-month stand-aloneotation. Thus, the training guidelines must provide pro-rams with flexibility to address individual trainee clinicalnd/or research training needs during a core fellowship of6 months duration.The training program must possess the faculty expertise,

atient volume, and inpatient/outpatient facilities to provideeaningful trainee experiences as outlined in this docu-ent. All faculty should be board certified or possess

uitable equivalent qualifications. Recommendations forrainee and faculty evaluation are those outlined in thegeneral and special requirements as published by theCGME, and training should take place within a program

hat is accredited by the ACGME.A comment about trainee research participation is appro-

riate. The field of pediatric cardiology is absolutely depen-

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1381JACC Vol. 46, No. 7, 2005 Graham, Jr. and Beekman IIIOctober 4, 2005:13801 Introduction: Training Guidelines for Pediatric Cardiology Fellowship Programs

ent upon research (basic and clinical) for meaningfulrogress. There is a critical need for the development ofhysician-scientists in our specialty to assure such futurerogress. Therefore, it is key that training programs begin torepare trainees for a successful investigative career. Suchreliminary research training will in most instances require

able 1. Core Training Recommendations

ExperienceTime Commitment

(in months)

eneral experience (inpatient) 36chocardiography/imaging 46ardiac catheterization 34 (estimate*)lectrophysiology 23ardiac intensive care 24dult congenital heart disease 02 (estimate*)esearch 1218otal 36

Task Force identified experience-based recommendations. See individual section forumbers.

8 months or more. The balancing of clinical and research s

raining will continue to be a major issue for trainingrograms. It is highly probable that trainees who want toursue a physician-scientist career will require at least fourears of fellowship to begin the academic process and tonish training in the clinical areas. The authors are inomplete agreement with the newly published Americanoard of Pediatrics (ABP) Training Requirements for

ubspecialty certification concerning scholarly activity,eaningful accomplishments in research, scholarship over-

ight, and differing pathways to train physician-scientists.

EFERENCE

. Beller GA, Bonow RO, Fuster V. ACC revised recommendations fortraining in adult cardiovascular medicine. Core Cardiology Training II(COCATS 2) (revision of the 1995 COCATS training statement).J Am Coll Cardiol 2002;39:12426.

PPENDIX

he authors of this section declare they have no relation-

hips with industry pertinent to this topic.

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Journal of the American College of Cardiology Vol. 46, No. 7, 2005 2005 by the American College of Cardiology Foundation, the American Heart Association, Inc.,and the American Academy of Pediatrics

ISSN 0735-1097/05/$30.00

P

ASK FORCES

ask Force 1: General Experiences and Trainingugh D. Allen, MD, FACC, FAHA, FAAP, Chair, J. Timothy Bricker, MD, FACC, FAAP,ichael D. Freed, MD, FACC, FAHA, FAAP, Roger A. Hurwitz, MD, FACC, FAAP,

im C. McQuinn, MD, FAAP, Richard M. Schieken, MD, FACC, FAHA, FAAP,

ublished by Elsevier Inc.

illiam B. Strong, MD, FACC, FAAP, Kenneth G. Zahka, MD, FACC, FAAP

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NTRODUCTION

he goals of pediatric cardiology training include acquiringhe cognitive and procedural expertise required to provideigh-quality care to children with cardiovascular disease,cquiring the academic skills to make meaningful scholarlyontributions to the specialty, and, importantly, to develophe capacity for ongoing self-education beyond the years oformal training.

The general training of pediatric cardiology fellows buildsn the general clinical and academic skills acquired duringesidency training. The pediatric cardiology fellow should beiven broad exposure to clinical activities in pediatric cardiol-gy inpatient and outpatient care, pediatric cardiology inpa-ient and outpatient consultations, and in preventive cardiol-gy. The academic skills of formal presentation, small-groupeaching, literature review, data analysis, and study design arelso components of the general training guidelines.

LINICAL TRAINING

fundamental goal of clinical training is to acquire bedsideiagnostic skill and the ability to provide high-qualiltyonsultative inpatient and outpatient pediatric cardiologyare. The core skills of history-taking and physical exami-ation are the only means for correctly initiating diagnosticnd management options appropriate to the individualatient, and these must be heavily stressed at all points ofatient contact. Pediatric cardiology fellows should bebserved by faculty while performing key portions of theistory and physical examination, and to also have thepportunity to observe faculty perform history-taking andhysical examination, so that meaningful discussion ofseful strategies and techniques may develop. Consulta-ion services, general inpatient wards, and outpatientlinics all provide excellent opportunities for such inter-ction.

The pediatric cardiology fellow must have the opportu-ity to provide not only inpatient and outpatient consulta-ion services but also direct patient care in both inpatientnd outpatient settings. There must be a continuity of caren the outpatient clinic so that fellows can begin to appre-iate the course of pediatric cardiac disease over time and itsumulative impact on individual patients and their families.he combined time commitment of the general inpatient

nd inpatient consultation services should be no less than l

hree months. The continuity outpatient clinic should beginarly in fellowship and continue throughout training, pref-rably on a biweekly basis. Both inpatient and outpatientxperiences should include exposure to the management ofhe adult patient with congenital heart disease.

There are many ways for general inpatient and outpatientractices to be organized. In the delivery of high-levelnpatient and outpatient care the pediatric cardiologist mustemonstrate effective team leadership, accurate and efficientedical record keeping, sensitivity to medical ethical issues,

n ability to communicate with and support patients andheir families through stressful decisions and experiences,nd show strict compliance with federal regulatory statutes.he general inpatient and outpatient training environment

or pediatric cardiology fellows must provide full opportu-ity for observation, acquisition, and application of thesekills by the trainee.

During the course of inpatient and outpatient activitieshe pediatric cardiology fellow will become familiar with aore knowledge base, as outlined in Table 1, at a minimum.

IDACTIC CONTENT

he Core Curriculum

he program should offer courses, seminars, workshops,nd/or laboratory experiences to provide appropriate back-round in basic and fundamental disciplines related to theeart and cardiovascular system. A lecture series encompass-

ng a core curriculum in clinical and basic science topicsust be provided for pediatric cardiology fellows. It should

e designed so that the spectrum of topics presented will beompleted at least once in the three years of accreditedellowship training. Pediatric cardiology fellows shouldontribute formal presentations of selected topics in theore curriculum, both to strengthen their knowledge basend to develop formal presentation skills. General areaso be covered in the core curriculum include those listedn Table 1.

dditional Conferences

reoperative conferences with the cardiovascular surgicalervice are essential. Journal clubs are a recommendedlement of an academic environment and provide an excel-

ent venue for participatory evaluation of study design and

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1383JACC Vol. 46, No. 7, 2005 Allen et al.October 4, 2005:13824 Task Force 1: General Experiences and Training

ata analysis. Quality assurance evaluation and morbidity/ortality conferences should be held periodically. Multidis-

iplinary clinical and research conferences are highly desir-

Table 1. Core Knowledge Base

Anatomy and physiology of congenital heart defectsventricular septal defect)

Cardiac, autonomic and noncardiac causes of syncopCardiac 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 inCardiopulmonary bypassCardiovascular pharmacologyCardiovascular physiology and anatomyCardiovascular sequelae and follow-up in Marfan, WCardiovascular sequelae of pregnancy and the impactCardiovascular sequelae of rheumatologic diseaseCardiovascular sports medicineCare of the single ventricle patientCellular electrophysiology (e.g., action potentials andChest painClinical electrophysiology (e.g., mechanisms of arrhyCoagulation and anticoagulationDiagnosis and management of arrhythmiasDiagnosis and management of elevated pulmonary vDiagnosis and management of intravascular/intracardDiagnosis and management of left-to-right shunt lesDiagnosis and management of patent ductus arteriosDiagnosis and management of right to left shunt lesDiagnosis and management of valvular heart disease,Diagnostic evaluation of heart murmursDifferential diagnosis and management of cardiac tumDifferential diagnosis and management of pericardialEmbryonic, fetal, and postnatal cardiovascular develoEndocarditisExercise testingFetal/neonatal/perinatal cardiovascular physiologyGenetics of cardiovascular diseases of childhoodHyperlipidemiaHypertensionKawasaki diseaseMedical ethicsNormal cardiovascular anatomy and physiology, incluObesityPericarditis and pericardial effusionsPhysics of echocardiography and Doppler analysisPhysiology and natural history of congenital heart diPopulation healthPreventive cardiology, including prevention of adultQuality assurance and process improvement methodoRationale, expectations, and methods of screening fo

chromosome 21, 18, or 13Rationale, expectations, and methods of screening foRationale, expectations, and methods of screening fo

emergencies such as gastroschisis, omphalocele, cofailure leading to extracorporeal membrane oxygen

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

ble; according to the strengths of the institution, o

ontributors might include neonatology, cardiothoracic sur-ery, adult cardiology, cardiac pathology, physiology, phar-acology, pulmonology, intensive care, cardiac anesthesiol-

tetralogy of Fallot, hypoplastic left heart syndrome,

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genital heart disease in neonates with trisomy of

genital heart disease infants of diabetic pregnanciesgenital heart disease in the presence of neonataltal diaphragmatic hernia, or cardiorespiratory

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1384 Sanders et al. JACC Vol. 46, No. 7, 2005Task Force 2: Pediatric Training Guidelines for Noninvasive Cardiac Imaging October 4, 2005:13848

enetics, tissue engineering, stem cell biology, or develop-ental biology. In all of these conferences, pediatric cardi-

logy fellows should be provided with active roles appropri-te to their level of knowledge and training.

EACHING AND EVALUATION SKILLS

t is a fundamental responsibility in academic medicine thathose with the most experience must teach. The pediatricardiology fellow will often be the most clinically experi-nced house officer on a team of residents, interns, and/oredical students. The fellow in that setting should be

xpected to provide lectures/seminars to the team of housefficers. The pediatric cardiology fellow should also bellowed the opportunity to practice clinical leadership,rganizational skills, and impromptu educational activitiess appropriate to his/her demonstrated level of knowledge

ark S. Sklansky, MD, FACC, Paul M. Weinberg, MD

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ritique of these skills by the attending physician as well asemonstration of these skills to the fellow by the attending.Pediatric cardiology fellows should develop formal

valuation of trainees and training skills during theirellowship. To do so, they should participate in feedbacko residents, students, and cardiology attendingshroughout their rotations regarding their own educa-ional and technical progress and the progress of otheream members. Accurate self-evaluation is the mostaluable skill of all and should be nurtured in all phasesf pediatric cardiology training.

doi:10.1016/j.jacc.2005.07.015

PPENDIX

he authors of this section declare they have no relation-

nd training. There should be occasion for observation and ships with industry pertinent to this topic.

ask Force 2: Pediatric Traininguidelines for Noninvasive Cardiac Imaging

ndorsed by the American Society of Echocardiography and theociety of Pediatric Echocardiographytephen P. Sanders, MD, FACC, Chair, Steven D. Colan, MD, FACC,imothy M. Cordes, MD, FACC, FAAP, Mary T. Donofrio, MD, FACC, FAAP,regory J. Ensing, MD, FACC, Tal Geva, MD, FACC, Thomas R. Kimball, MD, FACC, FAAP,avid J. Sahn, MD, MACC, FAAP, Norman H. Silverman, MD, FACC, FAHA,

, FACC, FAAP

NTRODUCTION

oninvasive imaging, including echocardiography andagnetic resonance imaging (MRI), is a primary means for

lucidating the anatomy and physiology of childhood heartisease. Competence in performance and interpretation ofchocardiography and MRI is now essential to the practicef pediatric cardiology. Depending upon ones individualareer goals, varying levels of expertise may be expected toe achieved during fellowship training. This documentefines the levels of knowledge and expertise that pediatricardiology trainees should acquire in echocardiography and

RI during training, and it offers guidelines for achievinghese levels of competence.

Training guidelines have been previously published forediatric echocardiography (1), fetal echocardiography (2),nd pediatric transesophageal echocardiography (3). Thoseocuments were reviewed and considered during prepara-ion of these guidelines. The guidelines presented here differn some instances from previous recommendations becausehis task force recognizes that training programs havehanged significantly over the decade since the last guide-

EDIATRIC ECHOCARDIOGRAPHY

chocardiography, as used in this document, includes two-imensional imaging of the heart and related structures,-mode echocardiography for assessment of chamber size

nd function, color M-mode and Doppler tissue and flowapping, pulsed and continuous-wave spectral Doppler

ow analysis, and other variations of these basic modalitiessed to assess the structure and function of the heart andelated organs, including new technologies such as three-imensional echocardiography as they become available.

acilities and Environment

he pediatric echocardiography laboratory should serve aospital with inpatient and outpatient facilities, neonatal andediatric intensive care units, a pediatric cardiac catheteriza-ion/interventional laboratory, and an active pediatric cardiacurgical program. The pediatric echocardiography laboratoryhould be under the supervision of a full-time pediatricardiologist-echocardiographer qualified to direct a laboratory,nd whose primary responsibility is supervision of the labora-ory. The laboratory must perform a sufficient number of

ediatric transthoracic, pediatric transesophageal, and fetal

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1385JACC Vol. 46, No. 7, 2005 Sanders et al.October 4, 2005:13848 Task Force 2: Pediatric Training Guidelines for Noninvasive Cardiac Imaging

chocardiograms (1,4) each year to allow trainees sufficientxposure to both normal and abnormal examinations.

EVELS OF EXPERTISE

raining goals defined here are to enable trainees to achievene of two levels of expertise in echocardiography asppropriate for career goals.

ore

Understanding of the general physical properties ofultrasound and clinical ultrasound technology.Ability to perform and interpret transthoracic echocardi-ography in normal infants, children and adolescents, andin those with childhood heart disease, with consultationas needed.Basic introduction to the principles of performing andinterpreting transesophageal and fetal echocardiograms.Physicians with core expertise only are not expectedto perform transesophageal and fetal echocardiogramsindependently.

dvanced

Special expertise in performance and interpretation oftransthoracic echocardiography in all forms of congenitaland acquired pediatric heart disease, including the adultwith congenital heart disease, enabling the practitioner tofunction independently.Ability to perform and interpret transesophageal andfetal echocardiography independently.Ability to supervise training and performance of sonog-raphers, fellows, and other physicians.

RAINING GUIDELINES

ore training should be achieved by all pediatric cardiologyellows during core clinical training, typically during four toix months dedicated to echocardiography over the course ofhe standard three-year training program. This level ofxpertise is anticipated to be sufficient for those fellows whoo not plan to pursue echocardiography as an area ofubspecialization.

Advanced training requires an additional 9 to 12 monthsf training and may be achieved through a dedicatedxperience in pediatric echocardiography after completionf core pediatric echocardiography instruction. This level ofraining is appropriate for those physicians who intend to beedicated pediatric echocardiographers.

RAINING GOALS

uccessful completion of each training level should result inompetence in the following specific areas.

ore

Understanding of the physical properties of ultrasound.Proper, safe, and facile use of ultrasound instruments.

Knowledge of the limitations of echocardiography. t

Recognition of cardiac structures displayed by echocar-diography and the correlation between echocardiographicimages and cardiac anatomy.Interpretation of Doppler flow information and deduc-tion of cardiovascular physiology.Performance and interpretation of complete transtho-racic two-dimensional and M-mode echocardiograms,Doppler color-flow mapping, and pulsed- and continuous-wave spectral Doppler flow analysis in normal pediatricpatients and in those with childhood heart disease, withconsultation as needed.Assessment of systolic, diastolic, and regional myocardialfunction in normal pediatric patients and those withchildhood heart disease, with consultation as needed.Ability to review critically published clinical research inechocardiography.

dvanced

n addition to core competencies, other goals include:

Independent performance and interpretation of completetransthoracic two-dimensional and M-mode echocardio-grams, Doppler color-flow mapping, and pulsed- andcontinuous-wave spectral Doppler flow analysis in nor-mal pediatric patients and in those with childhood heartdisease.Independent assessment of systolic, diastolic and regionalmyocardial function in normal pediatric patients and inthose with congenital or acquired heart disease, to in-clude stress echocardiographic studies.Special expertise in the performance and interpretation ofpediatric transthoracic, pediatric transesophageal, andfetal echocardiography.Training of sonographers and junior pediatric cardiologytrainees.Participation in basic or clinical research in echocardiog-raphy, including presenting original data at one or morescientific meetings.

RAINING METHODS

ach level of training may be achieved by the methodsutlined in the following text or by comparable alternativeethods. A summary of the recommended minimum num-

er of procedures is found in Table 1.

ore

ach trainee should perform and interpret at least 150ediatric echocardiograms, including at least 50 in patientsne year of age or younger, under the supervision of theaboratory director or other qualified staff pediatricardiologist-echocardiographer(s). Each trainee should alsoeview at least 150 additional pediatric echocardiograms.

In addition, the laboratory director or other staff pediatricardiologist-echocardiographer(s) should conduct regularaboratory conferences with the trainee(s) to present illus-

rative cases and to teach proper interpretation and the

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1386 Sanders et al. JACC Vol. 46, No. 7, 2005Task Force 2: Pediatric Training Guidelines for Noninvasive Cardiac Imaging October 4, 2005:13848

imitations of echocardiography. Pathological specimens,odels, or photographs for echocardiographic-anatomic

orrelation are excellent teaching aids that should be incor-orated wherever possible.Integration of echocardiography into the clinical practice

f pediatric cardiology should be demonstrated on inpatientnd outpatient rotations and at medical-surgical manage-ent conferences.Research training for pediatric cardiology trainees should

nclude active participation in reviews of scientific journalrticles that pertain to echocardiography.

dvanced

ach advanced-level trainee should perform and interprett least 200 additional pediatric transthoracic echocardio-rams and review, or perform and interpret, another 200ediatric echocardiograms. As with core training, at least0 of these should be done in infants one year of age orounger. Each trainee should perform a significant num-er of echocardiograms independently (one-third to one-alf of the exams), with subsequent review and critique ofhe examination by the responsible staff pediatricardiologist-echocardiographer. Teaching methods out-ined in the previous text should be continued here.

Each advanced-level trainee should perform and interprett least 50 pediatric transesophageal echocardiograms, in-luding manipulation of the transducer and registration ofmages, under direct supervision by a dedicated pediatricardiologist-echocardiographer. The trainee should performntubation of the esophagus in at least 20 patients under theirect supervision of a pediatric cardiologist-echocardiographerr anesthesiologist experienced in the procedure. An idealnvironment for learning pediatric transesophageal echocar-iography is the operating suite during performance of

ntraoperative examinations, but the training experiencehould not be limited to this venue and should include thentensive care unit, cardiac catheterization suite, and outpa-ient examinations.

Each advanced trainee should perform and/or review ateast 50 fetal echocardiograms. The trainee must master theundamental skills of determining fetal position, situs,ardiac anatomy, and cardiac rhythm under the supervision

able 1. Echocardiography TrainingRecommended Minimumrocedure Numbers

ore trainingTTE perform and interpret

(1 year of age)150 (50)

TTE review 150dvanced 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.

f a dedicated pediatric cardiologist-echocardiographer. t

he trainee should observe and participate in the discussion ofhe findings with the parents by the staff echocardiographeresponsible for the examination. As the trainees experiencerogresses, a significant proportion (30% to 50%) oftudies should be performed independently, includingases with normal and abnormal cardiac anatomy andhythm, with supervision by a dedicated pediatricardiologist-echocardiographer. Each trainee should un-erstand how to recognize and approach fetal heartailure, and he or she should understand the associationf fetal heart disease with extracardiac structural abnor-alities, syndromes, and chromosomal abnormalities.Research training for pediatric cardiology trainees should

nclude, at a minimum, active participation in reviews ofcientific journal articles that pertain to echocardiography.n addition, participation in basic or clinical research inchocardiography should be encouraged.

Each advanced-level trainee should be given responsibilityor participating in the training of sonographers and juniorediatric cardiology fellows, initially with supervision of the

aboratory director and then independently and also pre-enting echocardiography-related teaching conferences andormal didactic lectures.

VALUATION

he laboratory director, in consultation with the teachingtaff, should evaluate each trainee in writing on a regularasis. Trainees should maintain a log of all echocardiogramserformed and reviewed, including the age of the patientnd the diagnosis. The log should be reviewed regularly byoth the laboratory director and the training programirector to ensure that each trainee is obtaining adequatend balanced experience.

The evaluation should be reviewed with each trainee andwritten copy provided. If a trainee does not appear to berogressing adequately during the rotation, a meetinghould be scheduled as soon as possible to inform the traineend to discuss potential remedial measures. The evaluationhould be based on achievement of the expected levels ofompetence in the areas outlined in the previous text.

Direct observation of the trainee during performance ofchocardiograms provides information about imaging skillsnd understanding of the ultrasound instruments. Conferencesn which echocardiograms are presented provide an opportu-ity to assess skills in interpretation of images and Dopplerecordings. The trainees understanding of research design andethods and ability to review research can be critically evalu-

ted during journal club meetings or other venues for medicaliterature review. Teaching skills and effectiveness can bevaluated by direct observation and from evaluations by sonog-aphers and more junior trainees and by performance at

eaching conferences prepared and delivered by trainees.

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1387JACC Vol. 46, No. 7, 2005 Sanders et al.October 4, 2005:13848 Task Force 2: Pediatric Training Guidelines for Noninvasive Cardiac Imaging

EDIATRIC CARDIOVASCULARAGNETIC RESONANCE IMAGING

agnetic resonance imaging (MRI) as used in this docu-ent includes anatomic and functional cardiovascular MRI

n congenital and acquired pediatric heart disease as well asn the adult with congenital heart disease. At present, therere no specific guidelines for training or credentialing inediatric cardiovascular MRI. It is likely that the traininguidelines for pediatric cardiovascular MRI proposed hereill require amendment as the field evolves. These guide-

ines must be considered as goals and should not beonsidered as requirements.

EVELS OF EXPERTISE

rainees may achieve one of two levels of expertise inediatric cardiovascular MRI as appropriate for career goals.

ore

Familiarity with the general physical principles uponwhich MRI is based.Ability to view and understand MR images in normalinfants, children, and adolescents and those with child-hood heart disease.Introduction to commonly used imaging protocols andMRI terminology.

dvanced

Thorough understanding of clinical MRI instrumentsand the imaging protocols used for cardiovascular imag-ing and physiological analysis (e.g., quantitative analysisof ventricular function and blood flow).Ability to independently perform and interpret all typesof MRI in childhood heart disease and congenital heartdisease at all ages.Ability to supervise training of technologists, fellows, andother physicians.

RAINING GUIDELINES

raining in pediatric cardiovascular MRI should occurithin a pediatric cardiology fellowship program and/or aediatric radiology training program accredited by theccreditation Council for Graduate Medical Education

ACGME). The MR laboratory should serve a hospitalith both inpatient and outpatient facilities, neonatal andediatric intensive care units, a pediatric cardiac catheter-zation/interventional laboratory, and an active pediatricardiac surgical program. The MRI laboratory should bender the supervision of a full-time cardiologist and/oradiologist qualified in cardiovascular MRI, and it musterform a sufficient number of annual examinations to allowach trainee sufficient exposure to both normal and abnor-al examinations.Core training should be achieved by all pediatric cardiol-

gy fellows during the core clinical years of the program. t

his level of expertise may be sufficient for those fellowsho plan to practice clinical pediatric cardiology with access

o a pediatric cardiologist or radiologist with special exper-ise in pediatric cardiovascular MRI.

Advanced training requires a minimum of six months ofnstruction in addition to core training. This level of trainings appropriate for those physicians who intend to havepecial expertise in pediatric cardiovascular MRI and isecommended for directors of pediatric cardiovascular MRIaboratories.

RAINING GOALS

uccessful completion of each training level should result inompetence in the following specific areas.

ore

Physical principles of MRI and physiologic analysis.Limitations of, and contraindications to, MRI.Recognition of cardiac structures displayed by MRI and thecorrelation between MR images and cardiac anatomy.Basic familiarity with commonly used imaging protocols,their clinical uses, and MRI terminology.Critical review of published clinical research in pediatriccardiovascular MRI.

dvanced

Thorough understanding of MRI physics, instrumenta-tion, nomenclature, and safety.Special expertise in the performance and interpretation ofpediatric cardiovascular MRI, including all commonlyused imaging and flow analysis protocols.Training of technologists and junior pediatric cardiologytrainees.Management of and quality assurance for the MRIlaboratory.Basic or clinical research in pediatric cardiovascular MRI,including presenting original data at one or more scien-tific meetings.

RAINING METHODS

ach level of training may be achieved by the methodsutlined in the following text or by comparable alternativeethods.

ore

ediatric cardiology trainees should gain exposure to car-iovascular MRI through active review of scientific journalrticles that pertain to pediatric cardiovascular MRI, discus-ion with cardiologists and radiologists who perform car-iovascular MRI, and, if possible, review of cardiovascularRI examinations.

dvanced

uring a fellowship in pediatric cardiovascular MRI, each

rainee should perform and/or interpret at least 100 cardio-

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1388 Beekman III et al. JACC Vol. 46, No. 7, 2005Task Force 3: Training Guidelines for Pediatric Cardiac Catheterization and Interventional Cardiology October 4, 2005:138890

ascular MRI examinations in patients with congenital orcquired childhood heart disease, including adult patientsith congenital heart disease. As the trainees experiencerogresses, an increasing proportion of these examinationshould be performed independently, with review and cri-ique by the laboratory director.

Research training should include continued critical reviewf the pediatric cardiovascular MRI literature and an op-ortunity to perform basic or clinical research leading toublication or presentation of scientific data.Each trainee should be given responsibility for participat-

ng in the training of technologists and junior pediatricardiology fellows, initially with supervision of the labora-ory director and subsequently independently. In addition,ach trainee should have opportunities to observe andarticipate in the management of the laboratory, especiallyuality improvement initiatives.

VALUATION

he laboratory director, in consultation with the teachingtaff, should evaluate each trainee in writing. The evaluation

harles E. Mullins, MD, FACC, FAHA, FAAP, Jonath

erforming the procedure (i.e., requires knowledge of the

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rovided. The trainee should maintain a log of all examina-ions performed and reviewed, including the age of the patient,iagnosis, and role of the trainee in the examination.

doi:10.1016/j.jacc.2005.07.016

EFERENCES

. Meyer RA, Hazier D, Huhta J, Smallhorn J, Snider R, Williams R.Guidelines for physician training in pediatric echocardiography, recom-mendations of the Society of Pediatric Echocardiography Committeeon Physician Training. Am J Cardiol 1987;60:1645.

. Meyer RA, Hagler D, Huhta J, et al. Guidelines for physician trainingin fetal echocardiography: recommendations of the Society of PediatricEchocardiography Committee on Physician Training. J Am Soc Echo-cardiogr 1990;3:13.

. Fyfe DA, Ritter SB, Snider AR, et al. Guidelines for transesophagealechocardiography in children. J Am Soc Echocardiogr 1992;5:6404.

. Peariman AS, Gardin JM, Martin RP, et al. Guidelines for optimalphysician training in echocardiography: recommendations of the Amer-ican Society of Echocardiography Committee for Physician Training inEchocardiography. Am J Cardiol 1987;60:15861.

PPENDIX

he authors of this section declare they have no relation-

hould be reviewed with each trainee and a written copy ships with industry pertinent to this topic.

ask Force 3: Training Guidelines for Pediatricardiac Catheterization and Interventional Cardiology

ndorsed by the Society for Cardiovascular Angiography and Interventionsobert H. Beekman III, MD, FACC, FAAP, Chair, William E. Hellenbrand, MD, FACC,homas R. Lloyd, MD, FACC, James E. Lock, MD, FACC, FAAP,

an J. Rome, MD, FACC, David F. Teitel, MD

NTRODUCTION

he purpose of this document is to recommend minimumraining experiences in cardiac catheterization for clinicalellows in pediatric cardiology training programs. Traininguidelines in cardiac catheterization are well-established indult cardiovascular medicine (1,2), and they have beenonsidered recently in pediatric cardiology as well (3,4).

Pediatric cardiac catheterization is a unique specialtyncompassing a wide range of diagnostic and therapeuticechniques applied to a diverse group of congenital andcquired cardiovascular disorders. A physician who per-orms a pediatric cardiac catheterization must possess theechnical skills and clinical judgment to safely and accuratelyerform a thorough diagnostic cardiac catheterization andngiographic study. Furthermore, an interventional pediat-ic cardiologist must also assess the indications for a catheterntervention, including the risks of performing or not

atural history of the defect), and must skillfully performhe appropriate catheter intervention. It is appropriate,herefore, to delineate minimal training requirements inardiac catheterization for pediatric cardiology trainees.

There are no studies relating training experiences toubsequent clinical skill in pediatric cardiac catheterization.herefore, the recommendations in Task Force 3 represent

he opinions of the authors. To help guide this process, allccreditation Council for Graduate Medical Education

ACGME)-accredited pediatric cardiology training pro-rams were surveyed in 2001 to inquire about currentractices and opinions regarding fellow training in pediatricardiac catheterization and intervention. Thirty-two programsesponded. The responses represented the opinions of fel-owship directors (n 21), catheterization laboratory direc-ors (n 15), and division directors (n 13) (in somerograms one individual holds more than one position).his document draws on this Training Program Survey to

elp define training guidelines in this specialty.

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1389JACC Vol. 46, No. 7, 2005 Beekman III et al.October 4, 2005:138890 Task Force 3: Training Guidelines for Pediatric Cardiac Catheterization and Interventional Cardiology

ACILITIES AND ENVIRONMENT

raining in cardiac catheterization should occur within aediatric cardiology fellowship program that is accredited byhe ACGME. The cardiac catheterization laboratory shoulderve a hospital with inpatient and outpatient facilities,eonatal and pediatric intensive care units, and an activeediatric cardiac surgical program. The pediatric cardiacatheterization laboratory should be under the supervisionf a full-time pediatric cardiologist, whose primary respon-ibility is supervision of the laboratory. The laboratory musterform a sufficient number of cardiac catheterizations andnterventional procedures to provide each trainee with ancceptable experience.

The cardiac catheterization program must have a regulareaching conference in which diagnostic data (hemody-amic and angiographic) and therapeutic outcomes areormally discussed. In addition, each program that providesdvanced interventional training must have a regular mor-idity and mortality conference in which all adverse out-omes of catheter interventions are systematically reviewed.articipants in this conference should include cardiology

aculty, clinical fellows, and preferably pediatric cardiotho-acic surgeons and cardiac anesthesiologists. Active partici-ation in these conferences by all clinical cardiology fellows,articularly those at advanced levels, is essential to clinicalraining that emphasizes quality outcomes.

EVELS OF EXPERTISE

n this report we discuss core training for all fellows, anddvanced training for fellows desiring special expertise inardiac catheterization and interventional cardiology. Theore training is recommended for all clinical fellows duringheir core clinical experience. It is intended to be sufficientor fellows who do not plan a career in interventionalediatric cardiology, but who may be required to performimple diagnostic studies and to interpret catheterizationnd angiographic data in their clinical practices. (Cardiolo-ists who provide diagnostic only catheterization servicesust coordinate the care closely with interventional cardi-

logists and surgeons at referral centers to minimize theeed for repeat catheterization procedures.) The advancedraining provides expertise in both diagnostic and interven-ional catheterization procedures, and it is intended toualify a fellow to embark upon a career in cardiac cathe-erization and intervention.

able 1. Recommended Body of Knowledge Covered Duringore Training

Indications for and risks of cardiac catheterization and angiographyIndications for and risks of therapeutic catheter proceduresInterpretation of pressure waveformsInterpretation of O2 saturation dataFick principle and shunt calculationsVascular resistance calculationsCardiac angiography: basic techniques/angles/interpretation

Radiation safety *

ore Training: Goals and Methods

ore training in cardiac catheterization refers to the trainingxperiences recommended for all clinical cardiology fellows,egardless of specific career goals. In the Training Programurvey, there was unanimous support for core training inardiac catheterization for all clinical fellows. The goal ofuch core training is to introduce fellows to the field ofardiac catheterization and the risks and benefits ofatheter-based procedures, to teach basic diagnostic cathe-erization skills, and to provide a basic knowledge of hemody-amics, angiography, and radiation safety. A core curriculumn pediatric cardiac catheterization should include the topicsnd experiences outlined in Table 1.

The core training should involve each clinical fellow in ainimum of 100 cardiac catheterizations, at least 20 ofhich include an interventional component (Table 2).hese experiences should familiarize the fellow to the

ndications for cardiac catheterization and intervention,emoral vessel access techniques, basic catheter manipula-ions, hemodynamic measurements and calculations, andngiographic interpretations. Participation by the fellow asither the primary operator or the primary assistant isatisfactory involvement. A log book should be maintainedy the fellow to document the experience and outcomes ofatheterization.

dvanced Training: Goals and Methods

dvanced training in cardiac catheterization refers to theraining recommended for pediatric cardiology fellows whontend to pursue a career in pediatric cardiac catheterization

able 2. Core TrainingRecommended Minimumase Numbers*

otal cardiac catheterizations 100Interventional procedures 20

Type of interventionBalloon septostomy 5Other Not specified

Numbers represent the median response from the Training Program Survey.Fluoroscopic or echocardiographic guidance.

able 3. Advanced TrainingRecommended Minimumase Numbers*

otal 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 Program Survey.Fluoroscopic or echocardiographic guidance.

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1390 Beekman III et al. JACC Vol. 46, No. 7, 2005Task Force 3: Training Guidelines for Pediatric Cardiac Catheterization and Interventional Cardiology October 4, 2005:138890

nd interventional cardiology. Therefore, the advancedraining goal is to prepare the trainee to independentlyerform diagnostic and therapeutic catheter procedures withxcellent outcomes. Prerequisite to these advanced trainingxperiences is the successful completion of core training.dvanced training should involve each fellow in a minimumf 200 catheterization procedures, at least 100 of which arenterventional. The minimum recommended numbers ofrocedures are specified in Table 3 (and are in addition tohose obtained during the core training). The procedureypes and numbers in Table 3 are recommended guidelines,ot mandates, as it is understood that some qualifiedrograms may not perform every procedure. Participation byhe fellow as either the primary operator or the primaryssistant is satisfactory involvement.

A minimum number of procedures is necessary, but thiss not sufficient to prepare a trainee for a career in cardiacatheterization and intervention. Also important to a suc-essful career, and perhaps more crucial, are technicalacility and good clinical judgment. During advanced train-ng the trainee must acquire sophisticated skills in complexatheter manipulations, wire and sheath exchanges, devicemplantation techniques, and retrievals. Furthermore, goodlinical judgment regarding the indications for and againstntervention require a thorough knowledge of the naturalistory of congenital cardiac defects (5,6), and of theedical, catheter, and surgical options available for treat-ent. It is the responsibility of the training program

irector to assure that each advanced trainee graduates withhe technical skills, clinical judgment, and cognitive knowl-dge to pursue an independent career in pediatric cardiacatheterization.

A log book is to be maintained by the advanced fellow toocument the nature and outcome of each diagnostic and

nterventional procedure he or she participated in throughoutraining. The fellow should also participate actively in regularardiac catheterization teaching and morbidity conferenceshere outcomes and complications of interventional proce-

t is strongly recommended that the advanced fellow participaten at least one clinical research project related to cardiacatheterization and/or interventional cardiology.

Advanced training in pediatric cardiac catheterizationequires a dedicated 12-month experience, at a minimum.ome fellowship programs may be able to offer the recom-ended advanced training experiences during a 3- or

.5-year training program. Nevertheless, even in thoserograms additional training provides the fellow an oppor-unity to enhance technical skills and clinical judgment inhis very complex specialty. The authors of this documentelieve that the highest-quality training is obtained during aourth-year experience. Three or 3.5 years of training maye satisfactory for some individuals if all advanced traininguidelines are achieved, and particularly if the fellows nextostgraduate position can be anticipated to provide ongoingentoring for complex interventions.

doi:10.1016/j.jacc.2005.07.017

EFERENCES

. Pepine CJ, Babb JD, Brinker JA, et al. Guidelines for training in adultcardiovascular medicine. Core Cardiology Training Symposium(COCATS). Task Force 3: Training in Cardiac Catheterization andInterventional Cardiology. J Am Coll Cardiol 1995;25:146.

. Hirshfeld JW, Banas JS, Cowley M, et al. American College ofCardiology training statement on recommendations for the structure ofan optimal adult interventional cardiology training program. J Am CollCardiol 1999;34:21417.

. Ruiz CE, Mullins CE, Rocchini AP, et al. Core curriculum for thetraining of pediatric invasive/interventional cardiologists: report of theSociety for Cardiac Angiography and Interventions Committee onPediatric Cardiology Training Standards. Cath Cardiovasc Diag 1996;37:40924.

. Benson L, Coe Y, Houde C, Human D, Paquet M. Training standardsfor pediatric cardiac catheterization and interventional cardiology. CanJ Cardiol 1998;14:90710.

. Nadas AS, Ellison RC, Weidman WH. Report from the Joint Study onthe Natural History of Congenital Heart Defects. Circulation 1977;56Suppl I:I187.

. OFallon WM, Weidman WH. Long-term follow-up of congenitalaortic stenosis, pulmonary stenosis, and ventricular septal defect. Report

ures are thoroughly discussed (see the previous text). Finally,from the Second Joint Study on the Natural History of CongenitalHeart Defects (NHS-2). Circulation 1993; 87 Suppl I:I1126.

PPENDIX. Author Relationships With Industry and Others

Name ConsultantResearch

Grant

ScientificAdvisory

BoardSpeakers

BureauSteering

Committee Stock Holder Other

r. Robert H. Beekman III None None None None None Noner. William E. Hellenbrand AGA None AGA AGA None Noner. Thomas R. Lloyd None None None None None Noner. James E. Lock None None None None None NMT Royalties greater

than 10%Cook, NMT

r. Charles E. Mullins NuMED Inc. NMT

None None AGA None Boston Scientific Proctor fordevicesAGA, NMT

r. Jonathan J. Rome None Gore, Inc. None None None Noner. David F. Teitel None None None None None None

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1391JACC Vol. 46, No. 7, 2005 Vetter et al.October 4, 2005:13915 Task Force 4: Recommendations for Training Guidelines in Pediatric Cardiac Electrophysiology

ask Force 4: Recommendations for Traininguidelines in Pediatric Cardiac Electrophysiology

ndorsed by the Heart Rhythm Societyictoria L. Vetter, MD, FACC, FAHA, Chair, Michael J. Silka, MD, FACC,

eorge F. Van Hare, MD, FACC, FAAP, Edward P. Walsh, MD, FACC

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NTRODUCTION

he field of clinical cardiac electrophysiology has rapidlyxpanded over the past 30 years. Advances in the diagnosisnd treatment of pediatric cardiac rhythm disorders, and thencreasing trend in medicine in general to develop criteria oruidelines for competence and training in specific fields,ave led to the need to develop guidelines for training inediatric clinical cardiac electrophysiology (CCEP).The American College of Cardiology (ACC), Americaneart Association (AHA), and Heart Rhythm Society

formerly NASPE) have addressed training guidelines indult CCEP (13). The extensive body of literature regard-ng adult CCEP training and basic electrophysiology (EP)nowledge provides an important background and shoulde applied in an appropriately modified form to pediatricCEP training (421). Recognizing the considerable dif-

erences in the pediatric and adult cardiology populations,uidelines that are unique to the pediatric and congenitaleart disease population must be developed. Canadianecommendations for training in pediatric EP have beenublished (22). It should be recognized that pediatricatients are unique, as recognized by the separate trainingrograms and board certification for pediatricians and in-ernists, and for adult and pediatric cardiologists. In addi-ion, the pediatric electrophysiologist will have experiencend expertise in groups unique to pediatric cardiac electro-hysiology, including the fetus with in utero arrhythmias,he child with a structurally normal heart and supraventric-lar tachycardia, ventricular tachycardia, or other arrhyth-ias, the child with preoperative or postoperative arrhyth-ias after surgery for congenital heart disease, and the adultith congenital heart disease, both in the pre- and postop-

rative states. This unique group of adults with congenitaleart disease is best served by those with a combinednowledge of congenital heart disease and age-specificisease processes, whether this be provided by a combina-ion of pediatric and adult cardiologists or single individualsith broad training or dual training in pediatric and adult

ardiology.

ACILITIES AND ENVIRONMENT

raining should be obtained in an Accreditation Councilor Graduate Medical Education (ACGME)-accredited

ediatric cardiology training program. Recommendations t

or catheter ablation facilities have been published (2,9).ediatric catheterization laboratory facilities should bevailable with the appropriate EP equipment to perform EPtudies and catheter ablation. These facilities should ensure

safe, sterile, and effective environment for invasive EPtudies and implantation of pacemakers and arrhythmiaontrol devices. In many settings, the operating room can besed for the pacing/arrhythmia control devices. Althoughxperience at outside institutions, including adult programs,ay be valuable, no more than two to four months of the

ne-year advanced training should be spent at other insti-utions. In particular, added experience in pacemaker andmplantable cardioverter-defibrillator (ICD) implantation,s well as in ventricular tachycardia studies, may be acquiredt a certified adult CCEP program, provided that it isithin the previously noted time frame.At least one board-certified pediatric cardiologist with

dvanced CCEP skills should be identified as the director ofhe core and advanced Electrophysiology Training Program.ecause there is currently no pediatric EP examination,onsideration should be given for one pediatric EP facultyember to take the NASPExAM, or its successor exami-

ation. For advanced training of fellows, at least one facultyember should be skilled in the implantation of pacemakers

nd ICDs.

EVELS OF EXPERTISE

n this report we discuss core training for all fellows anddvanced training for fellows desiring special expertise inediatric CCEP. The core training is recommended for alllinical fellows during their core clinical experience. It isntended to be sufficient for fellows who do not plan a careern EP. The advanced training provides expertise in bothiagnostic and therapeutic EP and it is intended to qualifyfellow to embark upon a career in pediatric CCEP.ithin the advanced level are two tracks related to expertise

n pacemaker/ICD care: track 1 physicians prescribe andollow patients who require pacemaker/ICD care; track 2hysicians will also be skilled in device implantation.

ore Training: Goals and Methods

ore EP training is required of all trainees to be a competentediatric cardiologist. The goal is to enable all trainees to bekilled in electrocardiographic (ECG) interpretation, in-luding standard, ambulatory (Holter), exercise ECGs, and

ranstelephonic ECGs.

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1392 Vetter et al. JACC Vol. 46, No. 7, 2005Task Force 4: Recommendations for Training Guidelines in Pediatric Cardiac Electrophysiology October 4, 2005:13915

Additionally, the trainee should understand the indica-ions for and the use of noninvasive diagnostic techniquesncluding exercise testing, 24-h ambulatory and event mon-tors, and tilt table testing and should have a generalnderstanding of their interpretation. All trainees should beble to properly interpret cardiac arrhythmias and managerrhythmias in the acute care setting. There should be annderstanding of the use of non-pharmacologic methodsnd pharmacologic agents to treat arrhythmias, includingrug interactions and proarrhythmic potential. The traineehould understand the indications for the selection ofatients for specialized electrophysiologic studies, includingblation. In addition, the trainee should obtain a basicnderstanding of the indications for, and the informationbtained from, invasive EP studies. This should include annderstanding of the use of information obtained fromhese testing modalities for the management of the patientslinical condition. The trainee should have skills in thenterpretation of basic EP information obtained from elec-rophysiology study (EPS).

Participation in at least 10 EPS cases including catheterlacement and analysis of electrophysiologic tracings areeeded to acquire these skills. The trainee should under-tand the evaluation of patients with syncope, palpitations,hest pain, and irregular heart rhythms. All trainees shouldnderstand the indications for pacemaker placement, knowhe differences in pacing modes, understand and be able toerform basic pacemaker interrogation, reprogram androubleshoot pacemakers, recognizing basic malfunctions

able 1. Core Competence Skills

Interpretation of ECGs, Holters, exercise testing, and event monitorswith arrhythmia recognition

Recognition of developmental changes in cardiac rates and rhythmwith age and of normal variants of rhythm

Management of arrhythmias in the acute care setting, including uses ofpharmacologic agents, cardioversion with esophageal or intracardiacpacing, and direct current cardioversion

Management of common chronic arrhythmias such as infantsupraventricular tachycardia

Evaluation of the patient with documented arrhythmia, symptoms ofarrhythmia (palpitations, increased or decreased heart rate, irregularheart rhythm), and syncope or presyncope

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, understanding ofprocedure and complications of procedure

Knowledge of indications for pacing, anti-tachycardia device, andICD placement

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

Temporary transvenous and transcutaneous pacing Evaluation of EP literature

uch as capture failure, sensing malfunctions, and battery

nd of service characteristics. Participation by the traineen at least 20 pacemaker evaluations is recommended toevelop these skills. The trainee should receive instructionn the insertion, management, and follow-up of temporaryacemakers, including measurement of pacing and sensinghresholds. He or she should understand the general indi-ations for consideration of the use of arrhythmia controlevices (ICDs and anti-tachycardia devices) and know wheno refer these patients for more advanced EP evaluation.he trainee should understand the indications and tech-iques for elective and emergency cardioversion. Four elec-ive direct current cardioversions are required.

The core training to obtain the previously described skillsnd knowledge should occur in the first three years ofediatric cardiology training and be equivalent to two to threeonths of concentrated study, but may be acquired through-

ut the three years as needed to obtain designated compe-ence skills (Table 1).

dvanced Training (Year 4 Year 5):oals and Methods

he goal of advanced training is to enable the pediatriclectrophysiologist to perform, interpret, and train others toonduct and interpret specific procedures at a high skillevel. Tables 2 and 3 describe the competence skills neces-ary for advanced-level training. The recommended mini-um procedures are summarized in Table 4 for both core

nd advanced training.Advanced-level skills involve understanding the evalua-

ion and management of common arrhythmias, from theetus to young adult. In addition, advanced understandingf complex arrhythmia management, especially in the post-

able 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, andright ventricular dysplasia

Evaluation of patients with family history of sudden cardiac death Management of complex arrhythmias, especially in postoperative

congenital heart disease patients Evaluation of patient with syncope including, when appropriate,

performance of tilt table testing with appropriate interpretation andmanagement 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

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1393JACC Vol. 46, No. 7, 2005 Vetter et al.October 4, 2005:13915 Task Force 4: Recommendations for Training Guidelines in Pediatric Cardiac Electrophysiology

perative period after repair of congenital heart defects andn special groups such as long QT syndrome, Brugadayndrome, and right ventricular dysplasia, should be at-ained. Evaluation and management of the patient with allorms of syncope should be accomplished, including theerformance of tilt table testing when appropriate. In thoserograms that employ tilt testing, participation in at least 10rocedures in a pediatric or adult laboratory is advisable. Ahorough understanding of pathophysiology and therapy ofyncope and tilt testing should be required of all trainees.dvanced-level trainees should develop the cognitive skills

o evaluate the patient with a family history of suddenardiac arrest or death. Skill and experience should bencouraged in pediatric EPS interpretation and use of theP data to make management and therapeutic decisions.xperience with esophageal EPS should be obtained witharticipation in 10 procedures. The indications, risks, andenefits of these procedures should be known.Advanced-level trainees will develop technical and cog-

itive skills and experience in the performance of invasiveiagnostic and therapeutic CCEP. At least 75 diagnostic

ntracardiac EPS should be performed, of which at least 10hould be patients with ventricular tachycardia. At least 40f these diagnostic procedures must be in patients who are2 years of age or younger, and at least 10 should be inatients with repaired or palliated congenital heart disease.n addition, participation in at least 40 catheter abla-ion procedures is required. The diagnostic portion of aatheter ablation procedure may be used to satisfy the

able 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

able 4. Core and Advanced Training: Recommended Minimum

Level of Training

raining time

CG interpretationmbulatory ECG interpretationxercise ECGilt table testsransesophageal EPS/temporary postoperative epicardial wire study

ntracardiac EPSntracardiac EPS 12 years of age or lessntracardiac EPS in repaired congenital heart diseaseatheter ablationatheter ablation 12 years of age of age or lessatheter ablation in repaired congential heart diseaseC cardioversionacemaker ICDEvaluations/follow-upIntraoperative evaluation pacemakers and devicesTrack 2: implant pacemaker and complex devices

4 to 6 months of this training could be obtained during a regular 3-year pediatric cardiologay be performed throughout three-year fellowship. The diagnostic portion of an ablatio

equirement for participation in 75 diagnostic procedures.articipation should include scrubbing for the case, catheteranipulation, analysis, review of tracings, and generation ofreport.Advanced understanding of pacemaker indications, opti-al pacemaker choices, and follow-up of pacemaker pa-

ients should be obtained. The Heart Rhythm Society hasecommended two tracks for those caring for pacemakeratients. Track 1 involves electrophysiologists who will benvolved in prescribing and following pacemaker and ICDatients. Track 2 individuals prescribe, implant, andollow patients with pacemakers and ICDs. In bothracks, advanced understanding of pacemaker and ICDndications, optimal pacemaker choices, and evaluation orollow-up of 75 pacemaker/ICD patients should bebtained. In addition, attendanceincluding intraoperativeesting of 35 pacemaker or ICD implants (20 new, 10evisions, 5 ICDs)is required. To implant pacemakersnd ICDs, direct participation in a total of at least 50acemaker and device implants is required, of which aeasonable number should be complex devices includingCDs. As new technology develops, the number of devicemplants necessary to achieve competence may change.articipation should include scrubbing for the surgery,atheter manipulation, participation in intraoperative test-ng, and generation of a report. As the skills for implantingevices in smaller children are specific to pediatric EP, at

east 15 of these implantation procedures should be inhildren less than 12 years of age. Also, experience withmplantation in patients with repaired congenital heartisease is essential.Advanced-level pediatric electrophysiologists should have

ll the skills noted in the previous text, but they may or mayot perform the implantation of pacemakers and ICDs. Ifhe pediatric clinical cardiac electrophysiologist does not

eriences

Pediatric Cardiology Training Advanced Pediatric EP Training

2 to 3 months equivalent 12 months or more post generalPC training*

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1394 Vetter et al. JACC Vol. 46, No. 7, 2005Task Force 4: Recommendations for Training Guidelines in Pediatric Cardiac Electrophysiology October 4, 2005:13915

ctually perform these procedures, they should participate inhe intraoperative evaluation and postoperative care.dvanced-level training is expected for any pediatric elec-

rophysiologist who implants pacemakers and ICDs. Andditional one to two years after the general cardiologyraining program is required to achieve advanced-levelraining. Supplementary training may be required to achieverack 2 implantation competence. Part of this experienceith implantation may be gained in an outside program or

n affiliated adult CCEP training program. Until specificediatric pacemaker and ICD certification is available,onsideration should be given for advanced trainees im-lanting pacemakers and ICDs to take the NASPE exam-nation.

PECIFIC PROGRAM CONTENTCORE AND ADVANCED LEVELS)

rainees will be expected to develop an appropriate level ofnowledge and experience in the following areas:

Basic cellular and whole organ EP related to normalphysiology and cardiac arrhythmias in all pediatric andadult congenital patients.Pharmacologic principles underlying the use of antiar-rhythmic drugs and the effects of various conditionsencountered in pediatrics on the use of those drugs(prematurity, developmental biologic changes, includingthose in volume of distribution, hepatic and renal clear-ance, drug interactions, and congestive heart failure).Management of pediatric and adult patients with con-genital heart disease and cardiac arrhythmias; knowledgeof presentation and natural history of the variety ofarrhythmias encountered in pediatric electrophysiologypractice; understanding of the effects of various manage-ment strategies on the physiology and psychology of thepediatric and congenital heart patient.Expertise in the use of the ECG and other noninvasivespecialized testing, including ambulatory monitoring,transtelephonic monitoring, exercise stress testing, andtilt table testing to evaluate cardiac arrhythmias andsymptoms.An understanding of the indications, contraindications,and potential risks and benefits of intracardiac EPS andesophageal EPS. Core-level trainees should have a gen-eral understanding of the information provided by EPSand recognize basic information provided such as site ofheart block, identification of mechanism of the arrhyth-mia, and location of accessory pathways or focal arrhyth-mia sites. Advanced-level trainees should have experiencewith esophageal EPS for the treatment and evaluation ofarrhythmias. Advanced trainees should also develop anadvanced understanding of intracardiac EPS interpreta-tion and use of the data for management. In addition,advanced trainees should develop the advanced cognitive

and technical skills to perform EPS. a

Proficiency in the use of esophageal, temporary postop-erative epicardial wire, and intracardiac EPS for diagno-sis and treatment should be achieved. This includes theability to manipulate catheters, knowledge of EP equip-ment and catheters, and ability to perform the fullspectrum of programmed electrical stimulation and in-tracardiac mapping and to interpret the results.Advanced trainees should develop the full spectrum ofcognitive and technical skills in all types of catheterablation in children and young adults with congenitalheart disease. Advanced trainees should develop skills inthe indications for and potential complications of cath-eter ablation and should be prepared to treat any of thesecomplications. During the four years of training, theadvanced trainee should develop skills in transseptalperforation by participating in at least 10 transseptalprocedures. Trainees should have exposure to and de-velop skills in manipulation of ablation catheters forantegrade ablation; retrograde (transaortic) ablation ex-perience is also highly desirable.

Core-level trainees should have a basic knowledge andnderstanding of the use of pacemakers and ICDs inediatric and congenital heart patients. In addition, theore trainee should develop an understanding of pace-akers and skills in evaluation of pacemaker problems

hat may occur. Advanced-level trainees should havedvanced knowledge in the evaluation and managementf pacemakers and ICDs. In addition, advanced traineesill participate in implantation (either intraoperative

valuation or actual implant depending on whether trackor 2 is chosen) of pacemakers and ICDs, and provide

xpert understanding and management of implantedacemakers and ICDs. In addition, advanced-level train-es should have an understanding and experience in usingacemakers and ICDs for noninvasive EPS and internalardioversion. All levels should have skills in introducingemporary transvenous pacemakers. All levels should havexperience with transcutaneous pacing. Both levelshould have the skill to use transthoracic temporaryostoperative epicardial wires for the recording of elec-rograms. Advanced trainees should have knowledge andxperience in using these wires to convert arrhythmias.

Core-level trainees should have a basic understandingf the indications for and use of cardiac surgery to treatrrhythmias. Advanced level trainees should providexpert mapping and other EP knowledge at the surgicalrocedure.Specific formal instruction topics should be covered in a

ore lecture series and in a journal club format. There shoulde regularly scheduled conferences regarding EPS interpre-ation, application of the EPS to the patients clinicalanagement, and conferences on interpretation of standard

nd ambulatory ECGs.

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1395JACC Vol. 46, No. 7, 2005 Vetter et al.October 4, 2005:13915 Task Force 4: Recommendations for Training Guidelines in Pediatric Cardiac Electrophysiology

VALUATION ANDOCUMENTATION OF COMPETENCE

he program director is expected to maintain adequateecords of each individuals training experiences and perfor-ance of various procedures for appropriate documentation

or levels 1 or 2. The trainees should maintain records ofarticipation in the form of a log book containing clinicalnformation, procedure performed, and outcomes, listingny complications encountered. Finally, formal written eval-ations should occur at least every three months.Track 2 will develop skills in implantation of pacemakers

nd ICDs, including extraction.

doi:10.1016/j.jacc.2005.07.018

EFERENCES

1. American College of Cardiology, American Heart Association, Amer-ican Academy of Pediatrics. ACP/ACC/AHA Task Force on ClinicalPrivileges in Cardiology. Clinical competence in insertion of a tem-porary transvenous ventricular pacemaker. J Am Coll Cardiol 1994;23:12547.

2. Scheinman M. Catheter ablation for cardiac arrhythmias, personnel,and facilities: North American Society of Pacing and Electrophysiol-ogy Ad Hoc Committee on Catheter Ablation. Pacing Clin Electro-physiol 1992;15:71521.

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;23:125861.

4. Tracy CM, Akhtar M, DiMarco JP, Packer DL, Weitz HH. ACC/AHA clinical competence statement on invasive electrophysiologystudies, catheter ablation, and cardioversion. A report of the AmericanCollege of Cardiology/American Heart Association/American Collegeof Physicians-American Society of Internal Medicine Task Force onClinical Competence. Circulation 2000;102:230920.

5. Akhtar M, Williams SV, Achord JL, et al. Clinical competence ininvasive cardiac electrophysiological studies. Circulation 1994;89:191720.

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;25:49.

7. Dreifus LS, Fisch C, Griffin JC, Gillette PC, Mason JW, Parsonnet V.Guidelines for implantation of cardiac pacemakers and antiarrhythmia

8. Fisch C, Hancock EW, McHenry PL, Selzer A, Yurchak PM. Taskforce II: training in electrocardiography. J Am Coll Cardiol 1986;7:12014.

9. Fisher JD, Cain ME, Ferdinand KC, et al. Catheter ablation forcardiac arrhythmias: clinical applications, personnel and facilities.J Am Coll Cardiol 1994;24:82833.

0. Flowers NC, Abildskov JA, Armstrong WF, et al. Recommendedguidelines for training in adult clinical cardiac electrophysiology. J AmColl Cardiol 1991;18:63740.

1. Francis GS, Williams SV, Achord JL, et al. Clinical competence ininsertion of a temporary transvenous ventricular pacemaker. Circula-tion 1994;89:19136.

2. Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE2002 guideline update for implantation of cardiac pacemakers andantiarrhythmia devices: summary article. A report of the AmericanCollege of Cardiology/American Heart Association Task Force onPractice Guidelines (ACC/AHA/NASPE Committee to Update the1998 Pacemaker Guidelines). J Cardiovasc Electrophysiol 2002;13:118399.

3. Knoebel S, Crawford M, Dunn M, et al. Guidelines for ambulatoryelectrocardiography. Circulation 1989;79:20615.

4. Knoebel S, Williams SV, Achord JL, et al. Clinical competence inambulatory electrocardiography. Circulation 1993;88:33741.

5. Mitchell LB, Dorian P, Gillis A, Kerr C, Klein G, Talajic M.Standards for training in adult clinical cardiac electrophysiology. CanJ Cardiol 1996;12:47681.

6. Scheinman M, Akhtar M, Brugada P, et al. Teaching objectives forfellowship programs in clinical electrophysiology. Pacing Clin Elec-trophysiol 1988;11:98996.

7. 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 inCardiology. Circulation 1993;88:3425.

8. Zipes DP, DiMarco JP, Gillette PC, Jackman WM, Myerburg RJ,Rahimtoola SH. Guidelines for clinical intracardiac electrophysiologicaland catheter ablation procedures. J Am Coll Cardiol 1995;26:55573.

9. Hayes DL, Naccarelli GV, Furman S, Parsonnet V, NASPE Pace-maker Training Policy Conference Group. Training requirements forpermanent pacemaker selection, implantation, and follow-up. PacingClin Electrophysiol 1994;17:612.

0. Josephson ME, Maloney JD, Barold SS, et al. Guidelines for trainingin adult cardiovascular medicine. Core Cardiology Training Sympo-sium (COCATS). Task force 6: training in specialized electrophysi-ology, cardiac pacing and arrhythmia management. J Am Coll Cardiol1995;25:236.

1. Kennedy HL, Goldberger AL, Graboys TB, Hancock EW. Guide-lines for training in adult cardiovascular medicine. Core CardiologyTraining Symposium (COCATS). Task force 2: training in electro-cardiography, ambulatory electrocardiography and exercise testing.J Am Coll Cardiol 1995;25:103.

2. Gow RM, Beland M, Guiffre M, Hamilton R. Standards for training

devices. Circulation 1991;84:45567. in pediatric electrophysiology. Can J Cardiol 1998;14:90210.

PPENDIX. Author Relationships With Industry and Others

Name ConsultantResearch

GrantScientific

Advisory BoardSpeakers

BureauSteering

CommitteeStock

Holder Other

r. Victoria L. Vetter None None None None None Noner. Michael J. Silka None None None None None Noner. George F. Van Hare None Medtronic None None None None Support for fellow

trainingMedtronicr. Edward P. Walsh None None None None None None

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1396 Kulik et al. JACC Vol. 46, No. 7, 2005Task Force 5: Requirements for Pediatric Cardiac Critical Care October 4, 2005:13969

ask Force 5: Requirementsor Pediatric Cardiac Critical Carehomas Kulik, MD, Chair, Therese M. Giglia, MD, FACC, Keith C. Kocis, MD, FACC, FAAP,arry T. Mahoney, MD, FACC, Steven M. Schwartz, MD, Gil Wernovsky, MD, FACC, FAAP,