Session VI: Training in Congenital Cardiac Anesthesia
By Scott G. Walker, MD
Director, Congenital Cardiac Anesthesia, Riley Hospital for Children, Indianapolis, IN
and Asif Padiyath, MBBS
Clinical Fellow, Cardiothoracic Anesthesiology, The Children’s Hospital of Philadelphia, Philadelphia, PA
Session VI took place during the breakout sessions for the workshops and featured a review of training in congenital cardiac anesthesia in the United States and the United Kingdom. The session was moderated by Dr. Rania K. Abbasi (Riley Hospital for Children, Indianapolis, IN), who began by introducing the first speaker, Dr. Viviane Nasr (Boston Children’s Hospital).
Topic: Advanced Congenital Cardiac Anesthesia Training in the United States
Speaker: Viviane G. Nasr, MD, Boston Children’s Hospital
Dr. Nasr began with a review of the current state of congenital cardiac anesthesia (CCA) training in the US. This was done by examining the training pathways represented within her own congenital cardiac anesthesia group at Boston Children’s Hospital (BCH). The most common route is that of a pediatric anesthesia fellowship followed by a CCA fellowship. The second pathway is that of an adult cardiac anesthesia fellowship. Others have done additional training in pediatric critical care, pediatric cardiac critical care, or even pediatric cardiology. This has created a diverse mix of training backgrounds within CCA groups. Part of the mission of the CCAS is to promote education by creating guidelines for residency and fellowship training in congenital heart disease. Evidence of this can be seen in the trainee membership of the Society, which has grown from below 50 at its inception in 2005 to 234 in January of 2020.
The history of CCA training begins in the 1970s, before which no special training was in place. Since then, centers have slowly adopted specialized training models with early programs at Boston Children’s Hospital, Children’s Hospital of Philadelphia, the Texas Heart Institute, and the University of California. In 1997, core pediatric anesthesia fellowships became accredited by the ACGME. In 2005, the CCAS was formed. In 2006, adult cardiac anesthesia fellowships became ACGME accredited, followed by congenital heart surgery in 2007. In 2010, a proposal was published for training in CCA1.
Three potential pathways were suggested, each concluding with nine months in “core” CCA training: (1) a 12-month adult cardiothoracic anesthesia fellowship followed by three months of non-cardiac pediatric anesthesia; (2) a 12-month pediatric anesthesia fellowship followed by the nine-month core CCA training, plus three months of CCA electives (with rotations in perfusion and echocardiography recommended); and (3) an 18-month combined program, with the first nine months in general pediatric anesthesia.
In 2012, the Pediatric Anesthesia Leadership Council (PALC) and the CCAS proposed case requirements for CCA training, which included 100 bypass and 50 non-bypass cases, with 50% of bypass cases under one year of age and 25% less than one month of age. In 2014, the PALC and CCAS recommended that CCA training be included as one of the proposed advanced second year fellowships and that it be 12 months in duration, thus negating the proposed eighteen-month combined program proposal. In 2018, milestones for fellowship training in CCA were published as a CCAS consensus statement2.
Dr. Nasr reviewed a recent CCAS/SPA survey that showed that currently there are 19 CCA fellowship programs in the US., offering a total of 25 positions nationwide, with 15 positions filled in 2019. There is effectively no government funding of training beyond the PGY-5 year, so CCA fellowships must be funded in other ways. Seven programs are self-funded with fellows not required to provide any attending responsibilities. Other programs either require attending work as funding for the fellowship or allow it as an additional source of fellow income.
From 2014-2019, 62 fellows graduated from 12-month CCA programs, with 82% coming from a background of pediatric anesthesia training. About 10% did adult cardiac first and about 8% did pediatric anesthesia and pediatric critical care. Fifty percent of fellows went on to jobs that included both pediatric and pediatric cardiac anesthesia, with 27% getting jobs doing strictly pediatric cardiac anesthesia. The remainder do a mix that might include adult cardiac and/or pediatric critical care. Current recommendations for CCA training include a didactic curriculum, minimum case numbers, milestones, and scholarly activity requirements.
A CCAS trainee interest group has been formed to formalize goals and objectives. In addition, a workforce-manpower survey has been issued by Dr. Nasr and others to gather data to guide future needs assessments. Didactic components were proposed in the 2010 DiNardo article1, and can be delivered through lectures, CCAS online educational content, OPENPediatrics, and institutional cardiac surgery/cath lab conferences. Numerous textbooks are also available for fellows.
For clinical training, it is recommended that elective rotations be offered in addition to the core cardiac OR and cath lab experience. These can include cardiac ICU, perfusion, and echocardiography. A recent review article by Nasr et al proposes a detailed list of cases with minimum numbers3. Milestones proposed by the CCAS consensus statement2 are based on the six ACGME core competencies and define the progression of fellows through five levels of expertise. While scholarly activity is not currently a formal requirement for CCA fellowship training, many programs have made it a requirement and a recent survey indicates that recent graduates have consistently contributed to scholarly work including book chapters, manuscripts, and newsletters.
What is on the horizon for CCA training? Dr. Nasr suggests that the next step is ACGME accreditation of CCA fellowship programs. This has already happened for both adult cardiac anesthesia and congenital cardiac surgery. While there is still no board certification for adult cardiac anesthesia, congenital cardiac surgery began board certification two years after achieving accreditation status for their fellowship programs. The CCAS, together with the SPA, has formed a working group to explore the issue of CCA training. This group has representation from large and smaller programs as well as mixed adult and pediatric programs. The goal is to standardize fellowship training, consider accreditation, and make workforce assessments and predictions.
- DiNardo et al. Anesth Analg 2010:100;1121
- Nasr et al. Anesthesia & Analgesia. 2018:126(1);198-207
- Nasr et al. J Cardiothorac Vasc Anesth. 2019:33(7);1828-34
Topic: Advanced Congenital Cardiac Anaesthesia Fellowship Training in the United Kingdom
Speaker: Tim Murphy, MBBS, FRCA, Bristol Children’s Hospital, UK
In this session, Dr. Tim Murphy from Bristol Children’s Hospital discussed the training pathways available in the United Kingdom (UK) for a trainee in Pediatric Cardiac Anaesthesiology. This session followed the talk on training pathways available in the United States (US) by Dr. Viviane Nasr from Boston Children’s Hospital.
The session started with an introduction of the University Hospital at Bristol where Dr. Murphy practices. It is the largest provider of tertiary and quaternary level medical care in the South West of England. Bristol Children’s Hospital building is physically connected to the adult hospital and has 182 beds. They have a mixed intensive care unit for children with 18 beds where paediatric cardiac patients are admitted post-operatively. The cardiac surgical program at the Bristol Children’s Hospital performs approximately 450-500 surgical cases per year.
Dr. Murphy went on to describe the variety of definitions that determines the training requirement for a consultant post in the UK for an anaesthetist caring for patients with congenital heart disease. Similar to many centers in the US, this definition can vary depending on the institution that one practices. In the UK as well, the anaesthesia needs of children and adults with congenital heart disease are cared for by; 1) a pediatric anaesthetist with cardiac training who cares for only children; 2) adult cardiac anaesthetist who cares for children; or 3) a congenital cardiac anaesthetist who is comfortable with all ages. There is also variation among institutions on whether you start functioning as a cardiac anaesthetist straightaway following your training or after one has established themselves as a consultant anaesthetist for several years.
In 2016, the National Heart Service in the UK published a consensus document of standards and specifications for cardiac centers that care for patients with congenital diseases (https://www.england.nhs.uk/wp-content/uploads/2018/08/Congenital-heart-disease-standards-and-specifications.pdf). This document specifies the need to have “immediate and documented availability of specialized cardiac paediatric anaesthetists with full training (in accordance with the Royal College of Anaesthetists’ Guidelines and Paediatric Intensive Care Society Standards) and competence in managing paediatric cardiac cases including “a specialist paediatric cardiac on-call rota which is separate from the intensive care rota”.
This publication does not specify the training requirements needed for such a consultant post. The Royal College of Anaesthetists has a guidance statement that specifies that “for trainees looking to a post with a major/exclusive interest in paediatric cardiac surgery an individual advanced training programme will need to be prospectively agreed and early discussions with the RCoA Training Department and Chair of the Training Committee will be essential.”
Dr. Murphy went on to say that recently there have been calls for setting standards in paediatric cardiac anaesthesia, but none have ever been established. It is yet to be determined which governing body will set the standards for this training, whether it will be the Royal College of Anaesthetists, Association of Paediatric Anaesthetists, British Congenital Cardiac Association or Congenital Cardiac Anaesthesia Network.
Next, he described the current training pathway a medical school graduate in the UK system undergoes to become a consultant anaesthetist. This consists of two years of core level training and two years of intermediate level training at which time one becomes eligible to take the final FRCA exam.
Following this, and prior to becoming a consultant anesthetist, one undergoes three years of additional advanced level training which consists of access to specialist training if that is desired. This includes training in general paediatric anaesthesia. As such, prior to becoming a consultant paediatric anaesthetist in the UK, one needs to undergo a minimum of seven years of post-medical school training. A fellowship in paediatric cardiac anaesthesia follows the seven years of training and is of varying length depending on the institution.
Dr. Murphy then went on to quote three publications in the past 15 years that have reviewed training pathways in different countries.
- White MC, Murphy TW. Postal Survey of Training in Pediatric Cardiac Anesthesia in the United Kingdom. Paediatr Anaesth. 2007 May;17(5):421-5. (From the UK)
- DiNardo JA1, Andropoulos DB, Baum VC. Special Article: A Proposal for Training in Pediatric Cardiac Anesthesia. Anesth Analg. 2010 Apr 1;110(4):1121-5. (From the US)
- Baehner T, Dewald O, Heinze I, Mueller M, Schindler E, Schirmer U5, Baumgarten G, Hoeft A, Ellerkmann RK. The Provision of Pediatric Cardiac Anesthesia Services in Germany: Current Status of Structural and Personnel Organization. Paediatr Anaesth. 2017 Aug;27(8):801-809 (From Germany)
Dr. Murphy, in his paper published in 2007 in the Paediatric Anaesthesia journal, surveyed consultants from centers across the UK on the duration of training in paediatric, adult cardiac, and paediatric cardiac anaesthesia. In this study, the respondents who were consultant cardiac anaesthetists received on average 2.5 years of combined training in general paediatric anaesthesia specific to paediatric cardiac anaesthesia, PICU, or adult cardiac anaesthesia following their core number.
He went on to also say that for a well-rounded experience in paediatric cardiac anaesthesia, in addition to the surgical cases, one needs to have training in echocardiography and providing anaesthesia in remote settings such as CT/MRI/other imaging, cardiac catheterization lab, and electrophysiology lab.
Dr. Murphy then described the current structure within his department at the Bristol Children’s Hospital. There are six consultants within his department. Most of them have training in paediatric anaesthesia with some members with adult cardiac anaesthesia training and additional congenital cardiac anaesthesia training.
Currently in the UK, there are a few established fellowship training programs in congenital cardiac anaesthesia. They are offered at the following institutions:
- Great Ormond Street. Two 18-month posts (12 months anaesthetics, 6 months Cardiac Intensive Care Unit)
- Freeman Hospital, Newcastle. Two 12-month posts
- Ad hoc arrangements in some institutions (e.g. Royal Brompton Hospital, Evelina Children’s Hospital)
He concluded his presentation with the following statements; currently there are no nationally-defined standards for training in paediatric cardiac anaesthesia in the UK; there are too few consultants in the specialty to define hard and fast rules that work for every individual and department; one cannot gain necessary training during current conventional core training and specialty training years – but it is unclear at this point if it implies additional need for a fellowship; at present, there are multiple pathways into the specialty.
He offered some advice at the end of his presentation to a future trainee in this specialty;
- One needs to identify potential aptitude early.
- Customized supported packages for individuals based on knowledge, skills, attitudes and progress, and personal preferences are important.
- Accept that some enter the specialty as a trainee but do not end up as consultants.
- Support for one another at all stages of career, especially for complex cases, is essential.