The Division of Pediatric Cardiology, based at the Montreal Children's Hospital (MCH) which is part of the McGill University Health Centre (MUHC), offers a 1‐year Pediatric Interventional Cardiology Fellowship Program.
The fellowship program provides exposure to all areas of diagnostic and interventional heart catheterization procedures. The fellowship consists of integrated exposure to clinical care, research, and teaching. The Montreal Children's Hospital is a 154 inpatient beds institution that has a busy Cardiac Program that offers a full range of cardiac care. In 2015, the MUHC moved to the new Glen site that provides tertiary and quaternary cardiac care from fetal to adult life. The facility features key adjacencies for the Fetal Maternal unit and between the pediatric and adult interventional platforms (operating room and heart cathetertization laboratory).
Heart catheterizations are performed in a new, dedicated state of the art biplane laboratory that offers advanced imaging capabilities including rotational angiography. The laboratory is also fully equipped for complex electrophysiology applications including 3D mapping. Between 100‐120 catheterization procedures are done yearly at our institution.
Interventions are carried out under the supervision of Dr. Adrian Dancea and, occasionally, Dr. Giuseppe Martucci from the immediately adjacent Royal Victoria Hospital (RVH). Occasionally, the fellow will also participate in structural heart catheterization cases in the biplane lab at the RVH under the supervision of either Dr. Dancea or Dr. Martucci.
Program length: 1 year
Average number of trainees per year: 1
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:
- 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
- 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.
- Performing interventional procedures including:
- balloon dilation (with or without stent implantation) of semilunar valves, pulmonary arteries, aorta, systemic and pulmonary veins
- device occlusion of atrial septal defects, patent foramen ovale, patent ductus arteriosus, Fontan fenestration
- device of coil occlusion of abnormal vessels or collaterals
- retrieval of embolized foreign bodies
- percutaneous implantation of pulmonary valves
- balloon atrial septostomies (bedside or in the cath lab)
- endomyocardial biopsies
- management of complications that can arise from any of the above complications
- 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.
- 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.
The Advanced Training in Pediatric Cardiac Non-Invasive Imaging Fellowship Program gives future echocardiographers the experience, tools and confidence to efficiently function in and/or lead high-volume echocardiographic academic or community laboratories, while being truly comfortable with the breadth of all echocardiographic procedures, techniques and protocols. The fellowship provides an integrated experience of clinical care, research, and teaching. All activities take place at the Montreal Children’s Hospital (MCH) of the McGill University Health Centre (MUHC).
Program length: 1 year
Average number of trainees per year: 1
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.
|8-9 AM||Handover Rounds||Cardiology Service||Grand Rounds||Echo Teaching Rounds||Fetal Diagnosis and Treatment Group Rounds|
|AM||Cardiology Service||Cardiology Service||Cardiology Service||Research|
|Cardiology Service||MRI Scanning||Cardiology Service||
|8-9 AM||Handover Rounds||Fetal Echo||Grand Rounds||Echo Teaching Rounds||Fetal Diagnosis and Treatment Group Rounds|
|AM||Research||Fetal Echo||Fetal Echo||Research|
|Fetal Echo||MRI Scanning||Fetal Echo||
|8-9 AM||Handover Rounds||
TEE (OR/cath lab)
|Grand Rounds||Echo Teaching Rounds||Fetal Diagnosis and Treatment Group Rounds|
|AM||MRI Reporting||MRI Reporting||
TEE (OR/cath lab)
TEE (OR/cath lab)
TEE (OR/cath lab)
In order to ensure balance between the requirements of service and education, the imaging fellowship concentrates on fetal echocardiography for the first 6 months with formal teaching in MRI teaching and longitudinal exposure as an active observer. In the second half of the fellowship, the trainee is invited to take an active role in the echo lab with a focus on transesophageal echo and independent but supervised interpretation of studies and report generation of transthoracic echocardiograms. In addition, the trainee will gradually participate in the planning of MRI examinations as they apply to specific patients, participate in the scanning, interpret the studies using available display and analysis software, then generate a comprehensive and concise report. Every single study performed is reviewed by the staff one-to-one with the trainee, who receives specific feedback and teaching related to each individual case from image acquisition to interpretation and reporting.
The fellow is expected to attend Handover Rounds on Monday mornings and is responsible for case presentations, including imaging, if he/she has been on call on the previous weekend. As call is directly supervised by the staff cardiologist, all echocardiograms performed after hours and on weekends are reviewed by the staff with the trainee, who receives immediate feedback.
The fellow is expected to attend Monday Journal Club presentations by staff. In addition, he/she is assigned to review ahead of time and present the echocardiograms and MRIs of all patients listed for discussion in Monday pm Cardiosurgical Conference.
The fellow is expected to attend and participate in Echo Teaching Rounds on Thursdays. This formal teaching activity with an emphasis on fetal echocardiography and cardiac function occurs year-round and given by cardiology staff or fellows with attendance of all cardiology staff and echocardiography technologists.
The fellow is expected to attend the Fetal Diagnosis and Treatment Group meetings that are held every other Friday. These are multidisciplinary rounds where the management of fetuses with congenital malformations is discussed. Maternal-fetal medicine specialists form the Royal Victoria, Jewish General and St. Mary’s Hospitals, neonatologists, geneticists, fetal cardiologists and other pediatric and surgical specialists participate in these discussions. The role of our fellow is to prepare and present the fetal cardiology cases including review of fetal echocardiographic images, diagnosis, prognosis, surgical options and perinatal management. This is carried out under the supervision of the fetal cardiologist(s) in attendance.
Eight 2 to 3-hour private MRI tutorials with Dr. Luc Jutras are provided during the first 3 months of the fellowship. The list of topics includes basic MRI physics, pulse sequences, image analysis and application to a broad range of congenital and acquired heart conditions. These tutorials are also given year-round to Radiology, Adult Cardiology and Cardiac Surgery trainees and are therefore available would the trainee need a refresher. Impromptu sessions are also organized to discuss specific topics at the trainee’s request.
In order to facilitate personal learning the fellow has access to a number of textbooks and up to date electronic resources. These include a collection of educational CDs on Fetal Cardiology with recorded presentations by world experts in the field.
Opportunities exist for the fellow to teach other trainees, including pediatric intensive care residents while in their transthoracic echocardiography rotation and maternal-fetal medicine fellows in their fetal echocardiography rotation. Moreover, he/she is expected to participate in formal teaching rounds for pediatric residents and neonatal intensive residents once or twice per year, under the supervision of a staff.
MRI simulations using volunteers are planned to allow exploration of the image planning, pulse sequences, trouble shooting in a more relaxed setting. Again, all scans are performed under the direct and constant supervision of cardiologists with level III training in Cardiac Magnetic Resonance. Exchanges are therefore constant and direct. We have also started exploring novel techniques like 3D printing as there is a mounting interest in the Pediatric Cardiology community and as it may soon become a routine part of surgical planning as 3D display techniques have been in the last decade.
A year-round lecture series of non-medical expert roles for pediatric subspecialty trainees has recently been established at the Montreal Children’s Hospital. Our fellow’s attendance is voluntary.
The fellow is scheduled to cover ward and consultation services during the first month of the fellowship under the supervision of one of the staff cardiologists. In addition, there is home call duty throughout the year, in accordance with the residents’ union agreement.
The fellow is expected to elaborate and start the implementation of a research project in imaging with the mentor(s) of their choosing. Protected time is reserved for this purpose.
- High-volume exposure to the echocardiographic imaging of the whole breadth of fetal and pediatric cardiac pathology
- Training is one to one with direct supervision at all times.
- Four dedicated cardiac staff echocardiographers
- Experienced, dedicated, senior echocardiography technicians devoted to teaching
- 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.
- All scans are planned, executed and analyzed by two level III MRI trained pediatric cardiologists.
- MRI case load and historical database is varied and representative of the wide range of disease.
- Equipment and software are current and the object of regular upgrades.
- The environment is pleasant and is highly conducive to learning.