Paediatric Cardiology CESR Portfolio Guide

Able to function successfully within NHS organisational and management systems

• Aware of, and adheres to, the GMC professional requirements
• Aware of public health issues including population health, social determinants of health and global health perspectives
• Demonstrates effective clinical leadership
• Demonstrates promotion of an open and transparent culture
• Keeps up to date through learning and teaching
• Demonstrates engagement in career planning
• Demonstrates capabilities in dealing with complexity and uncertainty
• Aware of the role and processes for commissioning
• Aware of the need to use resources wisely

Able to deal with ethical and legal issues related to clinical practice

• Aware of national legislation and legal responsibilities, including safeguarding vulnerable groups
• Behaves in accordance with ethical and legal requirements
• Demonstrates ability to offer apology or explanation when appropriate
• Demonstrate ability to lead the clinical team in ensuring that ethical and legal factors are considered openly and consistently

Communicates effectively and is able to share decision making, while maintaining appropriate situational awareness, professional behaviour and professional judgement

• Communicates clearly with patients and carers in a variety of settings
• Communicates effectively with clinical and other professional colleagues
• Identifies and manages barriers to communication
• Demonstrates effective consultation skills including effective verbal and non-verbal interpersonal skills
• Shares decision making by informing the patient, prioritising the patient’s goals and wishes, and respecting the patient’s beliefs, concerns and expectations
• Shares decision making with children and young people
• Applies management and team working skills appropriately, including influencing, negotiating, re-assessing priorities and effectively managing complex, dynamic situations

Is focussed on patient safety and delivers effective quality improvement in patient care

• Makes patient safety a priority in clinical practice
• Raises and escalates concerns where there is an issue with patient safety or quality of care
• Demonstrates commitment to learning from patient safety investigations and complaints
• Shares good practice appropriately
• Contributes to and delivers quality improvement
• Understands basic Human Factors principles and practice at individual, team, organisational and system levels
• Understands the importance of non-technical skills and crisis resource management
• Recognises and works within limit of personal competence
• Avoids organising unnecessary investigations or prescribing poorly evidenced treatments

Carries out research and manages data appropriately

• Manages clinical information / data appropriately
• Understands principles of research and academic writing
• Demonstrates ability to carry out critical appraisal of the literature
• Understands the role of evidence in clinical practice and demonstrates shared decision making with patients
• Understands public health epidemiology and global health patterns
• Demonstrates appropriate knowledge of research methods, including qualitative and quantitative approaches in scientific enquiry
• Demonstrates appropriate knowledge of research principles and concepts and the translation of research into practice
• Follows guidelines on ethical conduct in research and consent for research
• Recognises potential of applied informatics, genomics, stratified risk and personalised medicine and seeks advice for patient benefit when appropriate

Acts as a clinical teacher and clinical supervisor

• Delivers effective teaching and training to medical students, junior doctors and other healthcare professionals
• Delivers effective feedback with action plan
• Able to supervise less experienced trainees in their clinical assessment and management of patients
• Able to supervise less experienced trainees in carrying out appropriate practical procedures
• Able to act as a clinical supervisor to doctors in earlier stages of training

Diagnoses and manages acute and chronic structural congenital and paediatric heart disease in general, developing knowledge and ability to contribute to the patient / family centred care of this life-long disease process including awareness of comorbidities and end of life care

• Demonstrates theoretical knowledge of morphology, genetics/genomics, pathophysiology and natural history across the spectrum of congenital heart disease
• Applies knowledge of the wide range of conditions and comorbidities that can be found in conjunction with congenital heart disease to practise
• Recognises the signs and symptoms suggestive of congenital heart disease in children
• Able to assess, investigate and instigate appropriate management in patients presenting with signs and symptoms of congenital heart disease
• Able to assess, investigate and instigate appropriate management in critically ill children with cardiovascular collapse
• Able to conduct paediatric cardiac outpatient reviews
• Demonstrates ability to counsel patients and families about specific congenital cardiac defects, explaining possible treatment options and prognosis
• Appropriately manages patients pre and post cardiac surgery and cardiac catheterisation
• Provides cardiology input and advice on patients under the care of other specialities including patients in intensive care
• Able to perform and report echocardiograms to diagnose abnormalities in cardiac structure or function
• Demonstrates appropriate us and interpretation of ECG based investigations
• Refers patients appropriately for TOE, cardiac MRI and CT
• Able to perform cardiac catheterisation and angiography under supervision
• Able to prepare and present patients at congenital heart disease MDT discussions
• Safely prescribes drugs commonly used in patients with congenital heart disease
• Appropriately advises and refers children with congenital heart disease for support with feeding and nutrition
• Appropriately advises on lifestyle factors and promotes healthy behaviours to minimise risk of future comorbidities
• Able to identify patients with indications for cardiac transplantation and initiate appropriate investigations
• Identifies when ongoing treatment may not be in the patient’s best interest. Able to counsel and refer patients to the palliative care service appropriately
• Provides cardiology advice to referring teams transferring patients to cardiac centres
• Provides advice on patients with congenital heart disease undergoing non cardiac treatment
• Supports patients transitioning from paediatric to young adult services

Diagnose and manage acute and chronic functional and acquired heart disease in fetal life and childhood

• Demonstrates theoretical knowledge of pathophysiology and natural history across the spectrum of acquired heart disease in children
• Able to assess, investigate and instigate management of children presenting with signs and symptoms of acquired heart disease
• Demonstrates knowledge of the role of advanced echo techniques including tissue Doppler imaging, speckle tracking, myocardial deformation imaging and dysynchrony studies to serially assess cardiac function in children with functional heart disease
• Demonstrates knowledge of the natural history of functional heart disease in utero and how this differs from postnatal disease
• Able to advise patients with CHD on precautions to reduce the risk of acquired heart disease
• Manages patients with acquired heart disease in clinic
• Provides cardiology input and advice to patients under shared care and patients in intensive care with acquired heart disease
• Provides cardiology advice to referring teams transferring patients to cardiac centres
• Able to perform and report echocardiograms to diagnose abnormalities in cardiac function and coronary abnormalities associated with acquired heart disease in children
• Recognises the signs and symptoms of chronic and acute heart failure in children
• Refers patients appropriately for TOE, cardiac MRI and CT
• Safely prescribes drugs commonly used in children with acquired heart disease
• Able to advise and refer children with chronic functional heart disease for support with feeding and nutrition
• Able to identify patients with indications for cardiac transplantation and initiate appropriate investigations
• Demonstrates understanding of the indications for ECMO and VAD support in patients with severely impaired cardiac function
• Identifies when ongoing treatment may not be in the patient’s best interest. Able to counsel and refer patients to the palliative care service appropriately
• Supports patients transitioning from paediatric to young adult services

Diagnose and manage acute and chronic heart rhythm abnormalities in fetal life, childhood, and in adults with congenital heart disease, including knowledge of pacing

• Able to review patients with suspected heart rhythm disease in the outpatient setting
• Demonstrates theoretical knowledge of pathophysiology of arrhythmias
• Demonstrates instigation of appropriate investigations to determine the cause of symptoms of heart rhythm disease
• Able to interpret non-invasive ECG monitoring including ambulatory monitors and exercise tests
• Able to identify major abnormalities on invasive cardiac event recorders
• Conducts discussions with young people and families on the options available to manage paediatric arrhythmia
• Instigates treatment for arrhythmias including DC Cardioversion
• Demonstrates knowledge of the diagnosis and principles of management of fetal arrhythmia
• Demonstrates knowledge and application of national guidance and evidence-based medicine in arrhythmia treatment
• Demonstrates theoretical knowledge of pharmacotherapy of arrhythmia including side effects and appropriate monitoring in both children and adults with CHD
• Safely prescribes rhythm control drugs
• Refers appropriately to Electro-Physiology services for invasive event recorders, pacemakers and EP or ablation therapy
• Demonstrates knowledge of invasive investigation and treatment options for paediatric arrhythmia including procedural risk
• Able to manage arrhythmias in the acutely unwell patient (including referral for ECMO when appropriate)
• Able to assess, investigate and instigate management in patients with arrhythmias following cardiac surgery, including the use of postoperative pacing
• Identifies and is able to instigate management in patients with complications of Implantable Cardiac Devices
• Able to assess, investigate and instigate management in patients at risk of arrhythmic events due to family history of Inherited Cardiac Conditions
• Able to prepare and present patients at cardiac genetics MDT discussions

Participate in and contribute to the acute and chronic care of adult patients with congenital heart disease (ACHD) including during pregnancy

• Recognise signs and symptoms suggestive of congenital heart disease in adults
• Instigate appropriate investigation and management in patients with signs and symptoms of congenital heart disease
• Appropriately refer newly diagnosed adults with congenital heart disease to specialist services including inherited cardiac conditions/cardio-genetics where appropriate
• Initiate management in patients with known congenital heart disease during acute cardiac presentations
• Provide advice on patients with congenital heart disease undergoing non cardiac treatment
• Manage patients in adult congenital heart disease clinics under supervision
• Prepare and present patients at congenital heart disease multidisciplinary team meetings
• Apply knowledge of the epidemiology, anatomy and pathophysiology of common congenital heart abnormalities to practice
• Support patients transitioning from paediatric to young adult services under supervision
• Provide contraceptive advice and pre-pregnancy counselling for patients with congenital cardiac conditions under supervision
• Manage patients with congenital heart disease during pregnancy under supervision
• Investigate and instigate management in pregnant patients presenting with cardiac symptoms
• Safely prescribe in pregnant and breast-feeding patients

Working with a complex multidisciplinary team, including community and network provision of patient centred care

• Demonstrates engagement in discharge planning
• Understands the role of the paediatric cardiologist in congenital heart disease management including presentation of evidence for decision making and the requirement for accurate documentation and communication
• Demonstrates participation in the wider network MDT including working with paediatricians with expertise in cardiology, other referring paediatricians including community paediatrics
• Demonstrates high quality verbal and written communication
• Demonstrates the ability to manage appropriate technology for presentation of multi modal cardiac imaging, including the use of remote technology

Provide an arrhythmia service including ablation and device therapy for paediatric and CHD patients

• Accept electrophysiology referrals from the general paediatric cardiology service, and reviews patients and / or non-invasive monitoring
• Perform appropriate further invasive investigation
• Medically manage with pharmacotherapy where appropriate
• Discuss in cardiac genetics MDT for management
• Routine EPS and ablation for AVRT/AVNRT
• Trans-septal puncture in adults and older children
• Focal Cryotherapy
• Understand when to perform VT ablation in children
• Understand strengths and weaknesses of electro-anatomic (3D) and magnetic mapping systems
• Manage a paediatric implantable device service including basic interrogation and programming of devices in children and adults with CHD
• Understand when to consider, and to perform, an electrophysiology study +/- ablation
• Understand indications for and complications of, device implantation including epicardial and transvenous, both temporary and permanent
• Understand the issues specific to device use in the growing infant and child
• Understand indications for lead extractions
• Implant a standard trans-venous pacemaker device in an adult or older child
• Be a competent second operator at Implantable Cardioverter Defibrillator implantation in an adult or older child

Provide a complex structural interventions service for paediatric and CHD patients

• Demonstrates knowledge of the indication, risks / benefits of the full range of diagnostic and therapeutic paediatric and adult congenital cardiac catheterisation procedures
• Correctly interprets complementary intra-procedural imaging investigations such as TOE
• Holds valid IRMER accreditation and practices in a way that minimises radiation exposure to the patient and staff at all times
• Ensures appropriate patient listing, pre-procedural assessment and obtain fully informed consent using a suitable level of language
• Able to undertake diagnostic and less complex interventional procedures (e.g. angioplasty, valvoplasty, ASD, PDA and collateral occlusion) including balloon atrial septostomy and pericardiocentesis in an emergency setting
• Able to lead or assist in more complex interventional procedures (e.g. stenting, percutaneous valve implantation and hybrid procedures) with senior supervision
• Recognises potentially serious complications during cardiac catheterisation (eg device embolisation, vascular perforation) and know standard approaches to urgently address these
• Communicates effectively with the multi-professional team – lead comprehensive pre-procedural brief, communicate clearly during the procedure, concisely document procedure findings and lead team debrief
• Provides appropriate post-procedural care, including identification and management of potential complications, explanation of catheter findings to the patient / family and appropriate discharge / follow-up recommendations

Provide a comprehensive imaging service for paediatric and CHD patients (this could be echocardiographic and / or cross-sectional imaging)

• Advanced Echocardiography
• Able to perform and report transthoracic and transoesophageal echocardiography independently across a full range of congenital cardiac pathology and recommend further investigation and management
• Provides expert advice on the use of echo imaging techniques to plan surgical and intervention approaches in patients with complex CHD
• Able to acquire and post-process 3D echo data-sets to diagnose and plan the management of children with CHD
• Provides expert advice on the use of, advanced echo imaging techniques (e.g. Speckle tracking myocardial deformation imaging) to diagnose and manage patients with cardiomyopathies
• Identifies patients in need of additional cross-sectional imaging with MRI and CT
• Demonstrates knowledge and understanding of the advantages and disadvantages of different imaging modalities (CMR, CT, TOE) and utilises them appropriately in the clinical setting
• Able to perform and interpret intra-operative imaging for children undergoing cardiac surgery and plan further management in collaboration with surgical colleagues
• Able to perform 2D TTE and TOE echocardiography to guide catheter interventions
• Recognises indications for, perform and report bubble contrast studies, strain imaging and dyssynchrony studies
• Is able to confidently demonstrate transthoracic and transoesophageal echo imaging at cardiac MDTs
• Prepares children to safely undergo transoesophageal echocardiography under GA
• Utilises novel imaging techniques, emerging evidence base and established guidelines appropriately
• Able to lead an imaging service through full competence to perform, supervise and teach techniques in transthoracic and TOE
• Supervise an echo service encompassing TOE, 3D echo techniques, LV strain assessment, stress echocardiography and contrast echo techniques
• Cardiac MRI (CMR) and congenital CT
• Demonstrates knowledge of basic MR physics
• Refers appropriately for CMR and congenital CT
• Able to triage referrals for cardiac MRI and Congenital CT
• Is able to perform, report and utilise congenital CT to plan the management of children with CHD
• Is able to perform, report, and utilise cardiac MRI to diagnose and risk stratify patients followed up after surgery for CHD
• Is able to perform, report and utilise CMR to assess ventricular function and diagnose children with acquired heart disease
• Provides advice on MR safety to referring clinicians
• Is able to confidently demonstrate CMR and Congenital CT data at cardiac MDTs

Provide a fetal diagnostic and management service for pregnancies affected by CHD

• Able to perform detailed fetal echocardiography and diagnosis congenital heart disease in utero
• Demonstrates understanding of the limitations of fetal echocardiography
• Complies with national safety standards for ultrasound in pregnancy
• Able to perform detailed echocardiographic assessment of fetal arrhythmias to allow appropriate treatment
• Demonstrates knowledge of the natural history of congenital heart defects in utero understands how this differs from postnatal lesions and communicates this appropriately
• Understands the risks and natural history of fetal arrhythmias, demonstrates knowledge of the drugs used to treat fetal arrhythmias and their safe use in pregnancy and communicates this appropriately
• Demonstrates knowledge of the postnatal management and outcome of cardiac lesions
• Demonstrates knowledge of the risk factors for congenital heart disease, the indications for referral to fetal cardiology and appropriate timing of fetal echo
• In collaboration with obstetric and fetal medicine and neonatal teams formulates plans for delivery and immediate postnatal care of babies with prenatal diagnosis of CHD and fetal arrhythmias
• Able to lead multidisciplinary team meetings to discuss cases including those in which postnatal outcome is uncertain
• Demonstrates knowledge of the legal framework around termination of pregnancy
• Able to provide evidence-based counselling with clear explanation of diagnosis, management and pregnancy options for patients with prenatal diagnosis of CHD
• Demonstrates understanding of the associations between fetal cardiac abnormalities and chromosomal and genetic abnormalities and refers to other specialists such as clinical genetics as necessary
• Demonstrates an awareness of the psychological impact of prenatal diagnosis of CHD and difficulties for patients in decision making, facilitating additional support from within team, awareness of available parent support groups and referral to psychology as appropriate

Manage all aspects of the heart failure service, including transplant assessment and on-going follow up

• Recognises the signs and symptoms of HF in children
• Able to generate a differential diagnosis for heart failure in children and initiate medical management
• Is able to appropriately adjust medical treatment in children with established HF
• Demonstrates knowledge of the pathophysiology of HF through its application to treatment
• Utilises investigations appropriately to establish an accurate diagnosis (including imaging, genetic evaluation, metabolic assessment, endomyocardial biopsy, and cardiac catheterisation)
• Is able to interpret the results of arrhythmia testing, exercise testing, biomarker levels, non-invasive imaging, and cardiac catheterisation to plan treatment
• Safely prescribes diuretics, antiarrhythmics, inotropic and lusitropic agents, anticoagulation, angiotensin-converting enzyme inhibitors, beta-blockers in children with HF
• Demonstrates knowledge and understanding of the utility of non-medical therapies in the HF management, including the creation of an interatrial communication in patients supported by extracorporeal membrane oxygenation (ECMO), cardiac resynchronization therapy and arrhythmia management
• Demonstrates knowledge of MCS application including ECMO, ventricular assist device (VAD) support in the treatment of end-stage HF as a bridge to transplantation and potentially as a bridge to recovery or as destination therapy in selected groups
• Demonstrates knowledge of the indications and contraindications for heart transplantation
• Understands the process of assessment of donor suitability including matching criteria, importance of human leucocyte antibodies and blood group status
• Demonstrates knowledge of outcomes of heart transplantation including complications
• Demonstrates knowledge of the physiology of the denervated, transplanted heart
• Safely prescribes immunosuppressive medications and demonstrates knowledge of side effects and interactions
• Demonstrates knowledge of Blood group (ABO) and Human leucocyte antibodies mismatch transplantation and complications
• Is able to recognise and initiate investigation and treatment for post-transplant rejection
• Demonstrates knowledge of the evidence base as it relates to heart transplant in children
• Demonstrates knowledge of the evidence base as it relates to HF in children. Applies the emerging evidence base and guidelines to develop heart failure service
• Has observed surgical procedures for organ procurement and implantation, ventricular assist device implantation and extracorporeal membrane oxygenation deployment
• Provides evidence-based counselling with a clear explanation of diagnosis and management options for patients with heart failure

Provide a comprehensive diagnosis and treatment service for patients with pulmonary hypertension

• Demonstrates theoretical knowledge of the pathophysiology of pulmonary hypertension
• Demonstrates knowledge of the potential sources of error when calculating PVR from data obtained by cardiac catheterisation
• Demonstrates knowledge and application of international guidance and evidence-based medicine in pulmonary hypertension investigation and treatment
• Is able to identify patients at risk of developing pulmonary hypertension
• Understands the clinical utility and limitations of genetic testing and the principles of family screening
• Recognises the signs and symptoms suggestive of pulmonary hypertension in children and adolescents
• Instigates appropriate investigations to establish causes and contributors in children with pulmonary hypertension
• Utilises imaging (Echo, MRI, CT, Angiography) to diagnose and risk stratify patients with known and suspected pulmonary hypertension
• Refers patients with known or suspected pulmonary hypertension appropriately for right heart catheterisation
• Is able to interpret and interrogate data obtained from right heart catheterisation in patients with known or suspected pulmonary hypertension
• Able to Supports patients transitioning from paediatric to adult pulmonary hypertension services
• Instigates appropriate management of children with pulmonary hypertension during acute presentations
• Is able to conduct outpatient consultations for children with known or suspected pulmonary hypertension
• Provides management advice to other specialities caring for patients with pulmonary hypertension including on the ITU and in cooperation with primary and intermediate care
• Provides advice on patients with pulmonary hypertension undergoing non-cardiac procedures under general anaesthesia
• Manages patients with pulmonary hypertension in cooperation with primary and intermediate care
• Is able to identify patients for referral to transplant services
• Demonstrate theoretical knowledge of pharmacology of targeted therapy for pulmonary hypertension
• Safely prescribes oral, subcutaneous and IV pulmonary arterial hypertension medication
• Able to confidently present haemodynamic and imaging data of with pulmonary hypertension at cardiac MDTs
• Demonstrates knowledge of the evidence base as it relates to pulmonary hypertension in children

Provide a comprehensive adult congenital heart disease service

• Diagnose, assess and manage adults presenting with new diagnoses of Adult Congenital Heart Disease
• Manage patients with known congenital heart disease transitioning from paediatric to adult care
• Perform transoesophageal echocardiography in Adult Congenital Heart Disease patients and interpret results to manage care
• Understand indications and interpret MRI to investigate Adult Congenital Heart Disease patients in conjunction with imaging specialists
• Understand indications and interpret CT to investigate Adult Congenital Heart Disease patients in conjunction with imaging specialists
• Manage heart failure in Adult Congenital Heart Disease patients
• Manage acute arrhythmias in Adult Congenital Heart Disease patients
• Manage pulmonary hypertension in Adult Congenital Heart Disease patients in collaboration with National PH Centres
• Lead the Adult Congenital Heart Disease Multidisciplinary Team
• Diagnose and manage the long-term sequelae of native, repaired and palliated Adult Congenital Heart Disease lesions
• Perform transthoracic echocardiography in Adult Congenital Heart Disease patients and interpret results to manage care
• Identify Adult Congenital Heart Disease patients with indications for cardiac transplantation. Investigate, counsel and refer patients appropriately
• Identify Adult Congenital Heart Disease patients who would benefit from supportive and palliative care, refer and share care appropriately
• Manage services for pregnant patients with congenital heart disease in cooperation with general cardiologists, obstetricians, obstetric anaesthetists, haematologists, midwives and Inherited Cardiac Conditions/genetic specialists
• Undertake pre-pregnancy counselling in patients with pre-existing or newly diagnosed congenital heart disease including risks to mother and fetus and risk of recurrence
• Coordinate care plans for pregnant patients with established or newly diagnosed congenital cardiac conditions in conjunction with maternity services and general cardiology
• Identify, investigate, counsel and refer patients appropriately for surgical and catheter interventions
• Contribute to the care of the peri-operative Adult Congenital Heart Disease patient in theatre, intensive care and the ward
• Manage Adult Congenital Heart Disease patients post procedure in conjunction with the procedural team
• Supervise the management of congenital cardiac patients in the postpartum period
• Assist with diagnostic catheterisation and intervention in the Adult Congenital Heart Disease patient if appropriately trained to do so

Provide a comprehensive inherited cardiac conditions service

• Demonstrates knowledge and application of international guidance and evidence-based medicine in ICC investigation and treatment, including family screening
• Applies knowledge of the epidemiology, anatomy and pathophysiology of common ICC to practice
• Understands clinical utility and limitation of genetic testing and the principles of family screening
• Recognise signs and symptoms suggestive of ICC in children and adolescents
• Able to assess and instigate appropriate investigation and management in patients with signs and symptoms of ICC
• Appropriately refers newly diagnosed children with ICC to specialist services
• Initiates management in patients with ICC during acute cardiac presentations
• Provides advice on patients with ICC undergoing non cardiac treatment
• Manages patients in specialist ICC clinics under supervision
• Able to prepare and present patients at ICC MDTs
• Supports patients transitioning from paediatric to young adult ICC services under supervision
• Appropriately requests and interprets ECG and imaging based investigations
• Able to assess, investigate and instigate management in patients at risk of arrhythmic events including identifying patients who may be indicated cardiovascular implanted electronic devices (CIEDs)
• Able to identify and instigate management in ICC patients with complications of CIEDs
• Demonstrates safe prescribing of rhythm control, heart failure and anticoagulant drugs
• Able to advise patients with ICC on safety and legality of driving

Currency Window

Evidence of your recent practice will be given more weight to reflect current capabilities and we suggest that approximately 50% of your evidence for a curriculum outcome is drawn from within the last five years of clinical practice (WTE).

Evidence Volume

around 100 electronically uploaded documents