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Task
Force 9: Training in the Care of Adult Patients With
Congenital Heart Disease
David
J. Skorton, MD, FACC - Chairman
Melvin D. Cheitlin, MD, FACC
Michael D. Freed, MD, FACC
Arthur Garson, Jr., MD, MPH, FACC
William W. Pinksy, MD, FACC
David J. Sahn, MD, FACC
Carole A. Warnes, MD, MRCP
The care of the patient with congenital heart disease
has long been the province of pediatric cardiologists
and cardiovascular surgeons. With advances in surgical
and medical management, increasing numbers of patients
with congenital heart disease are surviving into adulthood.
These patients often present complex combinations of
problems that may be unfamiliar to those who undergo
a traditional medical (internal medicine) cardiology
training program. Medical cardiologists are expert in
the care of patients with acquired diseases of the heart
and circulation, but currently most have little training
in congenital heart disease, particularly in complex
disorders. This report suggests an initial approach
to the more systematic training of medical cardiologists
in the recognition and care of adults with congenital
heart disease.
We differentiate two levels of training and expected
expertise in the care of adult patients with congenital
heart disease:
Level 1 training represents the level of knowledge appropriate
for all trainees in medical cardiology and indicates
the knowledge content that each graduate of such a program
should acquire. This level of knowledge should be tested
in the Subspecialty Certification Examination in Cardiovascular
Diseases and will provide the graduate with sufficient
expertise to recognize and evaluate common congenital
heart disorders in adults. However, for trainees with
level 1 expertise, consultation with a pediatric cardiologist
or level 2-trained clinician will be advisable when
major management decisions are made about patients.
Level 2 training represents the level of knowledge
needed by those graduates who wish to make a commitment
to this field and who wish to become competent in
the care of the entire range of adult patients with
congenital heart disease.
Level
1: Basic Training for all Medical Cardiology Fellows
All medical cardiology trainees should be exposed to
a core of information regarding adults with congenital
heart disease. The goal of level 1 training is for all
graduates to be able to recognize and evaluate common,
simple congenital heart lesions. These graduates should
consider consultation and collaborative patient management
with a level 2-trained specialist or pediatric cardiologist
when major management decisions are made for adults
with congenital heart disease and for periodic discussions
of ongoing care.
We suggest that at least 3 h of formal lectures within
the core curriculum of the training program be devoted
to congenital heart disease in adults. Table 1 indicates
the content suggested for these 3 h, covering key basic
and clinical aspects of these disorders.
Table 1: Level 1 Training in Congenital Heart Disease
in Adults
- Basic
science: anatomy, pathology, physiology and genetic
counseling
- Natural
history, clinical recognition and care of patients
with common defects presenting in adulthood
- Postoperative
residua and sequelae
- Indications
for and access to local regional expert consultation
In addition to the didactic material in the core curriculum,
trainees ideally should be exposed to adult patients
with congenital heart disease on a regular basis. This
could be done in the context of ongoing weekly case
conferences already present in the medical cardiology
training program. For example, at least one of the patients
discussed in case conferences each month could be an
adult with congenital heart disease. In addition, involvement
in an ongoing congenital heart disease clinic or seeing
older children or adolescents with a pediatric cardiology
colleague, or both, is encouraged.
During rotations in electrocardiography, echocardiography,
nuclear cardiology and the cardiac catheterization laboratory,
and when being trained in other imaging techniques (magnetic
resonance imaging, computed tomography), trainees should
be exposed to the evaluation of congenital heart disease
with these diagnostic modalities. Didactic material
for these rotations should include consideration of
the adult with congenital heart disease.
Level
2: Special Expertise in Adults With Congenital Heart
Disease
At least 1 year of concentrated exposure is necessary
for those trainees who wish to care independently for
adult patients with congenital heart disease. Table
2 indicates the knowledge areas that should be covered
during this year.
Table 2: Level 2 Training in Congenital Heart Disease
in Adults
In
addition to didactic materials, the training should include
the following activities and aims:
- Attending
a regular (at least weekly) clinic organized for the
care of adults with congenital heart disease.
- Participation
in formal rotations in pediatric cardiology, including
exposure to neonates and children with congenital
heart disease.
- Gaining
familiarity with the range of diagnostic and therapeutic
methods, including direct experience in echocardiography
and cardiac catheterization.
- Participation
in the perioperative care of patients with congenital
heart disease (preferably in adults), including direct
observation of surgical repair.
Program
Requirements
Two basic requirements are indicated for a program to
train effectively at level 2:
- The
presence of associated formal programs in pediatric
cardiology and cardiovascular surgery.
- At
least one faculty member with a career commitment
to the care of adult patients with congenital heart
disease; preferably this faculty member would have
received level 2 training.
Because relatively few centers in the United States
have amassed a sufficient number of adult patients with
congenital heart disease followed in an organized manner,
regionalization of training in the care of the complex
congenital heart disease patient is necessary.
The specific numbers of patients and procedures that
will be required to develop expertise in this discipline
have not been well defined. It may be helpful to note
that the several currently active multidisciplinary
programs training clinicians in this area typically
have well delineated populations of at least 500 adult
patients, and have regularly scheduled clinics encompassing
10 to 20 patients/week, including diagnostic procedures.
The level 2 trainee should be involved with the care
of a minimum of 10 patients/week.
Reference
- Skorton
DJ, Garson A Jr. Training in the care of adult patients
with congenital heart disease. Cardiol Clin
1993;11:717-20.
Copyright © 1995 American College
of Cardiology
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