Fellowship Programs

Training Objectives

General Objective:
To learn the principles and practice of Pediatric Interventional Cardiology (PIC). These include general topics in PIC such as: preparation of cases, attendance to pre‐catherization clinics, post-catherization care and preparation of heart catherization reports. The candidate will acquire knowledge of pertinent risks and benefits of each intervention and obtain informed consent from families. In addition, the fellow will gain awareness of occupational hazards and radiation safety as pertaining to the field on Interventional Cardiology. The fellow will learn a team approach to care delivery with constant interactions with other members of the Cardiac Team. More specifically, the fellow will present the results of the heart catherization to the members of the Cardiac Team and conjointly devise further care plans.

Specific objectives are to provide exposure in the following areas:

1. Obtaining vascular access (venous, arterial) in various sites including femoral, jugular, radial, transhepatic in children of all ages either by palpation and landmarks or using ultrasound guidance
2. Performing diagnostic heart catherizations (right and left heart) in children of all ages including hemodynamic assessment, evaluation of cardiac output and intracardiac shunts, assessment of pulmonary hypertension and manipulation of pulmonary vascular bed in the cath lab. The candidate will be versed in all aspects of a heart catherization including catheter selection and manipulation, titration of anticoagulation including post cath hemostasis, generating diagnostic angiograms including appropriate selection of projections.
3. Performing interventional procedures including:
   1. balloon dilation (with or without stent implantation) of semilunar valves, pulmonary arteries, aorta, systemic and pulmonary veins
   2. device occlusion of atrial septal defects, patent foramen ovale, patent ductus arteriosus, Fontan fenestration
   3. device of coil occlusion of abnormal vessels or collaterals
   4. retrieval of embolized foreign bodies
   5. percutaneous implantation of pulmonary valves
   6. balloon atrial septostomies (bedside or in the cath lab)
   7. endomyocardial biopsies
   8. management of complications that can arise from any of the above complications
4. Research: All fellows are expected to participate in at least one research project, with the goal of publishing in a major peer‐reviewed journal. Fellows are also encouraged to take advantage of the many opportunities to contribute to multi‐disciplinary research projects ongoing with other departments.
5. Teaching: Fellows are expected to teach resident rounds whenever appropriate. This could include general teaching rounds with all the residents and more specifically core pediatric cardiology fellows. With respect to procedures, the fellow is primarily responsible for all interventional procedures with the help of the overseeing interventional cardiologist. When appropriate, the fellow will be involved in the hands on teaching of core pediatric cardiology fellows.

Program Description

The fellowship program trains pediatric cardiologists in non-invasive cardiac imaging to be able to function independently in high volume echocardiography laboratories and cardiac MRI programs, while being comfortable with the non-invasive diagnosis of the whole breadth of fetal and pediatric cardiac pathology. The wide variety of cardiac pathology encountered at the Montreal Children’s Hospital provides fellows in our program with unparalleled exposure to the state of the art of pediatric echocardiography, fetal cardiology and cardiac magnetic resonance imaging (MRI).

Our fellows are already graduated pediatric cardiologists with a core knowledge of transthoracic echocardiography (TTE). During the fellowship they refine their TTE skills including functional tissue Doppler assessment and strain imaging; develop expertise in transesophageal echocardiography (TEE) both in the operating room and during interventional procedures in the catheterization laboratory; acquire expertise in fetal cardiology; and, acquire expertise in cardiac magnetic resonance imaging (MRI).

Cardiac Magnetic Resonance has become part of the common armamentarium available to the cardiologist for investigation in congenital heart disease. The cardiac MRI aspect of our one-year imaging fellowship naturally evolves from the basic requirements of core pediatric cardiology training with the goal of achieving level II training where at the end, the trainee will be able to work independently in the field of congenital cardiac magnetic resonance.

The training both for echocardiography and MRI is longitudinal and under one-to-one supervision.

There are four cardiologists with formal advanced training in pediatric echocardiography and fetal cardiology: Dr. Tíscar Cavallé-Garrido, Dr. Claudia Renaud, Dr. Luc Jutras and Dr. Wadi Mawad, the last two with also formal level III training in pediatric cardiac MRI. In addition, there are four senior echocardiography technologists in the laboratory with an important role in teaching image acquisition, particularly in fetal echocardiography.

The emphasis of the fellowship is to provide high-level personalized training. All imaging techniques performed by the fellow are directed / assessed one by one by staff and are tailored to their starting skill level and progression in training. Fellows are given full flexibility and priority in choosing to image certain cases to ensure proper exposure to all pathology. Fellows are encouraged to work with all attending imaging cardiologists to maximize the exposure to different approaches. In order to allow fellows to reach adequate volumes, they are always given priority to choose cases. There are no scheduling conflicts with core cardiology trainees in our program. Maternal Fetal Medicine fellows rotate in fetal cardiology during the last months of the academic year when the emphasis of our program has shifted towards a more intensive MRI exposure.

Since some of our fellows are international graduates with no previous experience in our hospital, the first month of fellowship is spent on cardiology in-patient and consultation service under the supervision of the staff cardiologist on call. This allows the trainee to become familiar with the hospital structure and functioning as well as the modus operandi of the Division of Cardiology. The remaining months in the fellowship are spent as detailed below. The proposed schedule is flexible to adapt to the educational needs of individual trainees. In addition, there is home call duty throughout the year, in accordance with the residents’ union agreement.

Schedule

Program Requirements

Program Highlights

1. High-volume exposure to the echocardiographic imaging of the whole breadth of fetal and pediatric cardiac pathology
2. Training is one to one with direct supervision at all times.
3. Four dedicated cardiac staff echocardiographers
4. Experienced, dedicated, senior echocardiography technicians devoted to teaching
5. The Division of Pediatric Cardiology at the Montreal Children’s Hospital is a pioneer in Cardiac Magnetic Resonance. It was one of the first to fully integrate Cardiac Magnetic Resonance in its armamentarium for investigation of congenital heart disease with the first level III trained pediatric cardiologist in Canada since 1994.
6. All scans are planned, executed and analyzed by two level III MRI trained pediatric cardiologists.
7. MRI case load and historical database is varied and representative of the wide range of disease.
8. Equipment and software are current and the object of regular upgrades.
9. The environment is pleasant and is highly conducive to learning.