Fellowship Pediatrics Cardiology
 


​​Paediatric Cardiology 

Paediatric Cardiology is a highly specialised subspecialty of Paediatrics.  The importance emerges from the high incidence of congenital and acquired disorders of the cardiovascular system found in children.  Its importance at the present time is also because of the paucity of Paediatric Cardiologists in the country.  The growing clinical need for this intensive field has led to the establishment of a fellowship program in Paediatric Cardiology.  The primary goal of the program is to prepare individuals for a career in academic Paediatric Cardiology.  Individuals are chosen for the program that will pursue creative, scholarly endeavours to advance the science and practice of Paediatric Cardiology.

Goals and objectives 

The Fellowship Program in Paediatric Cardiology is structured to enable the trainee to become competent in all the diagnostic and therapeutic areas of clinical Paediatric Cardiology so that s/he is capable of becoming a consultant.  The candidate is supposed to achieve the following

Subject Knowledge 

  • Embryology, anatomy and physiology of cardiovascular system 
  • Fetal circulation and neonatal adaptation 
  • Pathology of congenital and acquired cardiac diseases 
  • Hemodynamic and clinical manifestations of congenital and acquired heart diseases 
  • Arrhythmias and their management 
  • Investigational tools of heart diseases in children: ECG, radiography, echocardiography, cardiac catheterisation, MRI and MRA, CT angiography. 
  • Medical, surgical and intensive care management of different cardiac diseases 
  • Basics of Interventional cardiac catheterisation

Skills with objectives at the end of each year 

The candidate will have to maintain a log book of the number of cases done under each level of competence as specified.  Supervision would be done by the faculty with whom the candidate is rotating. 

Level of competence 

Observer 2.Assistant 3.Under supervision 4.Independent 

Skills / Procedure

  • Year 1  Year 2  Year 3 
  • Level of competence (and patient numbers) 
  • History, Examination    4  4  4
  • Journal club, M&M    4  4  4
  • Student/Resident teaching   4  4  4
  • Consults     3  3  3/4 
  • Acute Emergencies    2/3  3/4  4
  • Ward Management    3  3/4  4
  • ECG Taking     3/4(50)  4 (25)  4
  • ECG Interpretation    3 (50)  4 (25)  4 (25) 
  • Temp Pacemaker Insertion/Rx  1  2  3 
  • Transthoracic Echocardiography  2/3 (200) 3/4 (200) 4 (100) 
  • Transesophageal Echocardiography  1(25)  2/3 (25) 3/4 (25) 
  • Fetal Echocardiography   1 (20)  2 (20)  2/3 (20)
  • Diagnostic Cardiac Catheterisation  2 (50)  2/3 (50) 3 (50) 
  • Interventional Catheterisation   1(15)  2 (20)  2 (20)

Research/Scholarship 

  • Fellow is expected to have gained basic knowledge of prospective and retrospective clinical studies 
  • Be familiar with methods of statistical analysis of clinical data 
  • Have at least one  publications in PMDC recognised journals. 

Attitude and behaviour 

  • Fellow has to inculcate tender handling of neonates, infants and children 
  • Communication skills 
  • Parental counseling 
  • Amicable relationship with medical, nursing and paramedical staff 

Responsibilities 

The responsibilities of the candidate will increase with seniority and this would be informed to him at the time of joining the program in written form. 

Duration of training 

This is a three year training program and the purpose of training during the three year fellowship is to provide a foundation for understanding normal and abnormal cardiovascular conditions, with a focus on the pathophysiology of cardiovascular disease, to learn the skills of non-invasive and invasive procedures as well as to prepare them to provide optimal care and consultation for paediatric patients with cardiovascular disease.

Eligibility 

  • MBBS or equivalent degree approved by PM&DC 
  • One year of house job or internship 
  • Four years Paediatric training/residency 
  • FCPS (Paediatrics) 

Evaluation of fellows 

Fellows will be evaluated as follows 

  • Continuous assessment of rotations in clinics (in-campus and off-campus) 
  • Continuous assessment during bedside rounds and electrocardiography 
  • Assessment during Echocardiography, Cardiac Catheterisation and Cardiac Intensive Care 
  • Evaluation of presentation and participation in Cath-Surgical rounds, Journal Club, Morbidity and Mortality and Grand Rounds 
  • Assessment of presentations in clinical meetings 
  • Formal MCQ test once in six months 
  • Debriefing once in six months by the Program Director
  • Evaluation forms would be filled out at the end of each rotation and each presentation. 

Content and organisation 

Process of training 

General Cardiology (10 months) 

This would consist of the time spent in clerking patients, ward rounds, day to day management, consults on patients from other service and management of emergencies.  This would also include On-Campus clinics with the Full Time and Non Full Time Paediatric Cardiologists as well as one clinic per week Off Campus with Prof Kalimuddin Aziz. 

Echocardiography (7 months) 

Transthoracic Echocardiography of in-patients and out-patients, in PCICU and Transesophageal echocardiogram in the operating room or cath lab.  The candidate would be expected to participate in at least 200 echo's per year. 

Cardiac Catheterisation (7 months) 

This would be for diagnostic Cardiac Catheterisation and Interventional Cardiac Catheterisation at different level of competence.  The candidate would be expected to participate in at least 150 cardiac catheterisations and 55 Interventions in the Cath Lab. 

Cardiac Surgery (2 months) 

Rotation in Surgery would be participation in clinics, observation in OR and post op care. 

Cardiac Intensive Care (2 months)

Training in post operative care.

Adult Cardiology (3 months)

Train in ECG, dobutamine stress echo, Transesophageal echo, tilt table test, exercise tolerance test, electrophysiological studies, pacemaker clinics, Ct angiography and Cardiac MR.

External Rotation (2 months)

This is extramural training which should be done at the Children's Hospital, Lahore  The funding for the external rotation would be arranged by the candidate. 

Clinical, teaching and administrative responsibilities 

  • Teach Medical Students, Paediatric Residents, Nurses and Paramedical Staff 
  • Conduct Cath-Surgical rounds 
  • Present mortality and morbidity audits 
  • CME/Scholarship/Research Component 
  • Cath rounds once a week 
  • Journal club once in 2 months 
  • Grand Round once in 2 months 
  • Echo Case of the month 
  • Morbidity and Mortality once a month 
  • One publications of clinical data in a journal approved by the PMDC 
  • Participation in National Conferences and Interventional Workshops. 

External rotation (During the Year 3 of training) 

Objectives: 

  • To have an optimal exposure to the case mix seen in a government general hospital like rheumatic fever and rheumatic heart disease 
  • To widen the exposure to different cardiologists and hospital settings 

Names of the Institutions 

  • Children's Hospital or Punjab Institute of Cardiology, Lahore (mandatory) 
  • Karolinska Institute, Stockholm , Sweden (optional) 

Typical time frame rota 

First year
General Paediatric Cardiology (wards)  5 months
Echocardiography      3 months
Cardiac Caths       3 months 

Second year 
General Paediatric Cardiology    2 months
Echocardiography      2 months
Cardiac Caths       1 month
Paediatric Cardiac Surgery     2 months
Paediatric Cardiac ICU     2 months
Adult Cardiology      2 months 

Third year 
General Paediatric Cardiology    3 months
Echocardiography      2 months
Pacemaker clinics (Adult Cardiology)   1 month
Cardiac Caths       3 months
External rotation      2 months

  • Fellow should plan work carefully to ensure that there is time to attend the educational conferences. 
  • Fellow should fill out the faculty assessment form at the end of the rotation, review the faculty's written assessment of the fellow's performance and discuss. 

Goals of cardiac catheterisation rotation 

  • Understand indications for invasive hemodynamic, interventional or electrophysiological study 
  • Understand the risks of cardiac catheterisation 
  • Learn to explain the procedure clearly including the extent of the risks and the expected benefits.  Obtain informed consent and articulate in the medical record the indications for the study 
  • Develop clear plans for the conduct of the procedure before entering the laboratory 
  • Understand the influence of anaesthesia on the collection of data 
  • Understand the techniques of minimising blood loss and appropriate anticoagulation 
  • Understand all aspects of the equipment necessary to perform the study.  This includes the operation of all recording and measurement equipment 
  • Understand the physics of radiation and all the techniques to minimise radiation to the operator and the patient 
  • Develop a working knowledge to the various types of wires and catheters and the techniques of catheter manipulation 
  • Learn the techniques of pressure and blood flow measurement including the engineering principles behind the measurement.  Learn to rapidly interpret the data during the catheterisation and make the appropriate calculations from the data 
  • Learn the appropriate techniques of angiography including the value of specific injections, the camera angles and the techniques of obtaining diagnostic images.  Learn the interpretation of angiograms and the language used to generate a report 
  • Learn the basic techniques of interventional catheterisation including valvuloplasty, balloon septostomy and coil occlusion 
  • Understand the gathering and interpretation of intracardiac electrocardiograms.  Learn the basic techniques of RF ablation and device management 
  • Recognise complications and manage them effectively to minimise the harm to the patient 
  • Generate a complete report, reviewed with the faculty on a timely basis 
  • Understand the medical economics of cardiac catheterisation including the cost of the supplies and the procedure 
  • Learn to present the data clearly and provide opinion about the data and its utility for patient management 
  • Work effectively with the technical staff, nurses and anaesthesiologists.  Provide an environment where everyone participates for the benefit of the patient 

Goals of non-invasive rotation 

  • Understand indications for echocardiography including fetal, transthoracic and transesophageal echocardiography. Understand the indications for exercise testing including treadmill and bicycle studies with metabolic gas collection or echocardiography. Understand the indications for ECG, ambulatory ECG, event monitoring and tilt table testing. Understand the indications for nuclear scans to assess pulmonary blood flow and myocardial perfusion. Understand the indications for cardiac MRI and MRA. 
  • Understand the risks of transesophageal echocardiography and exercise testing. 
  • Learn to explain the indication for the tests clearly to the child as well as the family.  Include how you will use the information gathered by the test.  Obtain informed consent and articulate in the medical record the indications for TEE, exercise testing and tilt testing. 
  • Develop clear plans for the conduct of the test before beginning the test. 
  • Understand all aspects of the equipment necessary to perform the study.  This includes the operation of all imaging and electrocardiographic equipment. Understand the physics of ultrasound and magnetic resonance for both imaging and flow. 
  • Learn to perform a complete and orderly echocardiogram including the report in a timely manner. Use each study as foundation for further learning about the specific cardiovascular problem. 
  • Learn the techniques of fetal echocardiography.  Develop an understanding of the natural history fetal structural disease and arrhythmias. Use your understanding of the pre and post natal course to counsel or prepare the parents.  Learn the management of fetal arrhythmias. 
  • Learn the techniques and interpretation of transesophageal echocardiography.  Learn to minimise airway compression and the duration of the study while maximising the useful information. 
  • Learn the interpretation of heart rate and blood pressure changes with exercise.  Interpret ECG changes accurately and learn to manage acute arrhythmias. Understand all aspects of metabolic gas collection.  Learn the technique and interpretation of stress echocardiography. 
  • Learn to interpret MRI and MRA, CT angiography,  anatomic, functional and flow studies. 
  • Learn to accurately diagnose hypertrophy, abnormal conduction, abnormal repolarisation and arrhythmias from each of the non-invasive modalities. 
  • Explain the results of the studies to the child and the family clearly. 
  • Work effectively with the technicians. 
  • Understand the medical economics of each of these studies. 

Goals of inpatient rotation 

  • Learn the common and usual presentations of heart disease in infants, children, adolescents and young adults.  Learn a methodical approach to the use of the history, physical examination and testing to make an accurate diagnosis and assessment of the child's cardiovascular condition. 
  • Understand the role of other services and consultation to maximise the benefit to the child. 
  • Understand the natural history of the child's disease. 
  • Articulate a clear diagnosis and, when this is not possible, develop differential diagnoses and a plan to accurately determine the problem. 
  • Understand the appropriate use of blood testing and radiology. 
  • Know the indications for medical management including pharmacologic and nutritional options. 
  • Know the indications, risks and benefits of each of the surgical approaches to cardiovascular problems. 
  • Understand post-operative care including the clinical assessment of the child, the interpretation of hemodynamic monitoring data, ventilator management, pharmacologic management and issues of blood loss and clotting. 
  • Explain the nature of the problem and your plan clearly to the child and the family. 
  • Work effectively with the nursing, social work, nutrition, child life, and respiratory therapy.  Involve the Paediatric residents and medical students in the decisions about management and teach them about the child's disease. 
  • Keep accurate and complete medical records.  Complete all medical record tasks in a timely manner. 
  • Understand the medical economics of each aspect of the hospitalisation 
  • Learn from the faculty and the literature about the pathophysiology, natural history and treatment of each child. Use evidence based medicine to guide your therapeutic recommendations. 

Goals of ambulatory rotation 

  • Learn to methodically approach the common reasons for ambulatory referral. Use the history and physical examination as the primary assessment tool.  Learn the limitations of clinical evaluation and the appropriate use of testing. 
  • Understand the natural history of cardiovascular abnormalities and the appropriate timing for and use of medical or surgical intervention. 
  • Learn the basis of recommendations about activity, SBE prophylaxis, and follow-up intervals. 
  • Inform the family (and the child where applicable) of your findings and recommendations.  Anticipate their questions and concerns. 
  • Communicate with the referring primary care provider in a timely manner.  Keep appropriate medical records. 
  • Understand the medical economics of each aspect of the ambulatory visit. 
  • Learn from the faculty and the literature about the pathophysiology, natural history and treatment of each child. Use evidence based medicine to guide your therapeutic recommendations. 
  • External rotation in Paediatric Cardiology 
  • Elective rotation is designed to provide a trainee a wider clinical exposure particularly experience of working with different consultants.  It is meant to cover deficits in patient population and disease spectrum seen by different hospitals.  It gives the trainee an opportunity to explore research interests or future directions in his career.  The rotation can be broad based or selective.  The following are the objectives of the rotation: 
  • Learn the common, usual and unusual presentations of heart disease in infants, children, adolescents and young adults; 
  • Learn to methodically approach the common reasons for ambulatory referral. Use the history and physical examination as the primary assessment tool; 
  • Learn the importance as well as limitations of clinical evaluation and the appropriate use of testing; 
  • Understand the role of other services and consultations; 
  • Understand the medical economics of each aspect of patient care including inpatient management, echocardiography and diagnostic and therapeutic cardiac catheterisation; 
  • Gain experience in the diagnosis and management of acquired heart diseases eg. Rheumatic fever and its sequelae; 
  • Understand the natural history of cardiovascular abnormalities and the appropriate timing for and use of medical or surgical intervention. 

Duration of elective rotation 

The trainee is allowed 2 calendar months of elective rotation in the third year of the training.  S/he is expected to maintain 90% attendance, report to the elective supervisor, maintain a log book of experience and get an evaluation formed filled and duly signed by the elective supervisor.

Responsibility and conduct 

The trainee is expected work with full responsibility in patient care areas, exhibit professionalism and maintain high demeanor and conduct.

Institutions for Elective Rotation 

Department of Paediatric Cardiology, Children's Hospital, Lahore 

Teaching Faculty 

Full-time Faculty 
Two full time Paediatric Cardiologists would be pivotal to the program.  They would be helped by Adult Cardiologists, Paediatric Intensivists and Paediatric Cardiac surgeons.

Professor 

Dr Mehnaz Atiq
FCPS (Paediatrics), FCPS (Paediatric Cardiology), Fellowship in Interventional Cardiology
Section Head of Paediatric Cardiology, Department of Paediatricsand Child Health

Associate Professors

Dr Mohammad Hamid
Paediatric Cardiac Anaesthetists 

Dr Anwar-ul-Haque
DABP; FAAP
Director PICU

Assistant Professors

Dr Babar Hasan
DABP. FAAP
Paediatric Cardiologist

Dr Muneer Amanullah
FRCS (General Surgery); FRCS (Cardiothoracic Surgery)
Paediatric Cardiac Surgeon​

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How to Apply