As part of our educational curriculum, we provide a robust offering of the formal didactic conferences listed below. While most of the conferences are focused entirely on fellow education, others serve as “work conferences” during which fellows present and discuss patients for the purposes of clinical care. We strongly feel that meaningful learning occurs in both environments and strive for appropriate balance.
The pediatric cardiology fellowship at UAMS/ACH provides diverse options for mentored research. Resources available to fellows include database projects (using the Pediatric Health Information System [PHIS] and National Birth Defects Prevention Study [NBDPS], to name a few), unique opportunities in fetal cardiology (including the use of fetal magnetocardiography, available at only several centers worldwide), and bench research through the Arkansas Children’s Research Institute (ranked among the top pediatric research institutes for NIH funding). Fellows frequently win awards for abstracts presented at national and international meetings; many graduating fellows have gone on to have successful careers as independent investigators at academic institutions nationwide.
Recent fellow publications:
- Purifoy ET, Spray BJ, Riley JS, Prodhan P, Bolin EH. Effect of Trisomy 21 on Postoperative Length of Stay and Non-cardiac Surgery After Complete Repair of Tetralogy of Fallot. Pediatr Cardiol. 2019 ec; 40(8):1627-1632. PMID: 31494702.
- Dalby ST, Tang X, Daily JA, Sukumaran S, Collins RT, Bolin EH. Effect of pericardial effusion on outcomes in children admitted with systemic lupus erythematosus: a multicenter retrospective cohort study from the United States. Lupus. 2019 Mar; 28(3):389-395. PMID: 30744520.
- Shivaram P, Angtuaco S, Ahmed A, Daily J, Grigsby DF, Li L, Craft M, Danford D, Kutty S. Age-Related Changes in Inferior Vena Cava Dimensions among Children and Adolescents with Syncope. J Pediatr. 2019 04; 207:49-53.e3. PMID: 30580976.
- Kosiv KA, Gossett JM, Bai S, Collins RT 2nd. Congenital Heart Surgery on In-Hospital Mortality in Trisomy 13 and 18. Pediatrics. 2017;140(5):e20170772. doi:10.1542/peds.2017-0772
Recent fellow presentations:
- Cobb, Harrison. Cutting Balloon Angioplasty on Branch Pulmonary Artery Stenosis In Congenital Heart Disease, oral presentation at PICS-AICS in Sept 2019.
- Schoeneberg, Laura. Utility of Cardiac MRI in Children After out of Hospital Arrest, oral presentation at North American Society for Cardiovascular Imaging annual meeting, Sept 2019.
- Crawford, Richard. Mortality Among Children with Heart Disease and Adenovirus Pneumonia Adenovirus, oral presentation at American Academy of Pediatrics Nov 2019.
- Arthur, Lindsay. Transthoracic Echocardiography is an Inadequate Imaging Modality in Senning and Mustard Survivors, oral presentation at North American Society for Cardiovascular Imaging annual meeting, Sept 2019.
Recent fellow awards:
- Katya Kosiv, best abstract, Fetal Cardiology
- Eric Purifoy, travel award ACC
Link to UAMS SARA lab: https://obgyn.uams.edu/research/sara-research-centers/
Link to ACRI: https://www.archildrens.org/research/research
Link to NBDPS: http://www.nbdps.org/
Link to PHIS: https://www.childrenshospitals.org/phis
The Cardiovascular Surgery program at Arkansas Children’s Hospital performs over 300 pump cases per year. The program is led by Brian Reemtsen, M.D., who holds the Log-a-Load for Kids of Arkansas Endowed Chair for Pediatric Cardiovascular Surgery. Dr. Reemtsen and fellow cardiothoracic surgeon Dr. Lawrence Greiten work alongside a team of 5 cardiac anesthesiologists and a robust OR staff to provide the full spectrum of pediatric heart surgeries, including complete repairs, palliative surgeries, mechanical support, and transplantation. The facility includes two dedicated cardiovascular surgical ORs and two hybrid suites. Our team’s volumes and outcomes are provided below:
The Fetal Heart Center at Arkansas Children’s Hospital performs approximately 1000 fetal echocardiograms per year and is staffed by six physicians, two nurses, and six fetal cardiac sonographers. We collaborate with the Arkansas Fetal Diagnosis and Management Group within UAMS, which includes Maternal-Fetal Medicine Obstetricians as well as Neonatologists. We utilize multidisciplinary clinics and monthly meetings with these groups to discuss and plan patient management and receive post-natal follow-up information.
The Fetal Heart Center serves as a bridge for families into the Arkansas Children’s Care Network. As Arkansas Children’s Hospital is the only congenital cardiac surgical center in the state, the fetal cardiac patients identified by our practice as needing timely cardiac evaluations are typically delivered at UAMS and then transferred to ACH for further medical management and surgical care.
Cardiology Fellows within our section begin learning about fetal cardiology as soon as they begin their fellowship. Monthly fetal conferences are held for the education of the Pediatric Cardiology Fellows, Maternal-Fetal Medicine Fellows, and Neonatology Fellows. Elective rotations in our Fetal Clinic are available during the fellowship, with the opportunity for hands-on scanning.
In the Cardiac Electrophysiology lab at ACH, Dr. Srikant Das provides full-spectrum pediatric and adult congenital cardiac electrophysiology services, with an average of ~170 procedures annually. This includes:
- Performing and interpreting electrophysiology studies
- Radiofrequency ablations
- Cryoablations (only program with this capability in the state of Arkansas)
- Pacemaker, defibrillator, and other cardiac device implantation
- Drug challenge studies
Despite a large proportion of complex adult congenital EP procedures and combination (cath and EP/device) procedures, our performance and outcome measures meet or exceed the standards reported in the IMPACT Registry (Improving Pediatric and Adult Congenital Treatments). For example, the snapshot below shows the mean fluoroscopy time is consistently less than half of the national average, as Dr. Das maximizes fluoroless techniques.
Technologies/Products utilized in our Electrophysiology Program:
- Insertion of smallest loop recorder (LINQ)
- Subcutaneous-ICDs (among national leaders in adopting this technology)
- Leadless cardiac pacemaker implant (MICRA Transcatheter Pacing System, the world’s smallest pacemaker)
- MRI compatible cardiac pacemakers and devices
- Intracardiac echocardiography for EP procedures
- Irrigation catheter ablations
- Ablations with IMPELLA pump support
- Novel Safesept wire technique for transseptal punctures
The ACH EP lab has demonstrated an excellent track record in treating adult congenital and pediatric patients with complex dysrhythmias. For example, our team performed successful ablation on an infant with preexcitation-induced cardiomyopathy. The patient had been dependent on an implanted Berlin BiVAD heart pump, but after ablation, cardiac function normalized and transplant was avoided. The Berlin BiVAD was explanted (world’s first report of such).
Outpatient /Non-invasive electrophysiology services:
- Electrophysiology and cardiac devices clinic (weekly)
- Adult congenital arrhythmia and device clinic (monthly)
- Outreach/regional arrhythmia clinics
- Management of ~ 300 cardiac device patients
- Review, interpretation, and recommendation for all Holters and event monitors
Cardiac Catheterization Laboratory
The Cardiac Catheterization Laboratory at Arkansas Children’s Hospital performs 400 cases per year, with more than half of these involving transcatheter interventions for congenital heart disease. Categorical cardiology fellows have the opportunity to work side-by-side with our three interventional pediatric cardiologists without competing with other learners. Fellows gain firsthand experience in state-of-the-art interventions for a wide variety of patients, from the Abbott Piccolo device for closure of patent ductus arteriosus in premature infants to transcatheter valve implantations using the Medtronic Melody or Edwards Sapien valves for adult patients with congenital heart disease. Our cath lab team also works with our cardiothoracic surgery team to perform hybrid procedures for more complex interventions.
In addition to offering a full range of transcatheter interventions, the cath lab provides cardiology fellows the opportunity to gain valuable diagnostic experience in hemodynamic evaluations for patients with pulmonary hypertension as well as pediatric heart transplant recipients. The cath lab is also the focal point of a major construction project due to be completed this year, during which two new angiographic suites will be installed, including a Hybrid OR suite to facilitate greater collaboration between the cath lab and surgical teams. ACH will be the first pediatric cath lab in the world to utilize Siemens Artis Icono technology.
For our categorical pediatric cardiology fellows, the cardiology consult service is their primary opportunity to play the role of a consulting subspecialist. As the only pediatric cardiology group in the state, consult questions come from throughout our region, including within our own hospital walls and as far as our neighboring states. The wide scope of questions is both the greatest challenge and the greatest strength of this core rotation. Fellows develop an increasing degree of autonomy as they progress throughout their training, but always have the backup and supervision of an attending cardiologist.
- The consult fellow and attending are charged with interpretation of all in-house electrocardiograms ordered by non-cardiologists, as well as any outside electrocardiograms sent for formal reading, so proficiency in pediatric ECG interpretation is gained quickly.
- The consult team also evaluates urgent outpatients, such as a neonate with a worrisome heart murmur, who might otherwise be poorly served waiting for the next available clinic visit.
- Consult calls frequently come from other inpatient units, including Arkansas Children’s 104-bed level 4 Neonatal Intensive Care Unit, our 26-bed Pediatric Intensive Care Unit, and our level 1 trauma center Emergency Department.
A typical day for the consult fellow might include evaluating a “new blue” cyanotic newborn in the NICU, examining and counseling several outpatients whose cardiac evaluations were deemed urgent, answering a handful of referring pediatrician calls about cardiology patients with possibly concerning new symptoms and cardioverting a 28-year-old in the ED with palliated complex single ventricle heart disease and recurrent atrial dysrhythmias. The consult service is the rotation where the fellow gets to meld together his/her experience from all other sub-subspecialty rotations, to help pediatricians and other specialists formulate a thoughtful cardiac plan of care.
Cardiovascular Inpatient Service
The Cardiovascular Inpatient Service at the Arkansas Children’s Hospital Heart Center consists of a 31-bed CVICU that is strategically located adjacent to the two dedicated cardiac ORs. The new cath labs will also be collocated here when construction is complete by the end of 2020. The CVICU is separated into an intensive care team and an intermediate team.
The CVICU manages patients with all forms of pediatric and congenital cardiac disease:
- Pre- and postoperative care
- Cardiac transplantation
- Medical management
- Cardiac arrhythmias
- Heart failure with all modalities mechanical support (ECMO, all types of VADs)
At the foundation of the Heart Center’s CVICU is our multi-disciplinary team model. Cardiologists and cardiac intensivists work collaboratively with surgeons, nurse practitioners, medical students, nurses, respiratory therapists, dieticians, occupational therapists, physical therapists, and case managers. Each member of the team is integral to providing comprehensive care to our patients and their families. On a given day, two dedicated teams provide clinical care:
- The Intensive Care Team includes an attending physician, 1-2 fellows (cardiology, pediatric ICU, neonatal ICU, and CV anesthesia), and advanced nurse practitioners. There is 24/7 in-house coverage in the CVICU by an attending cardiac intensivist.
- The Intermediate Team includes an attending cardiologist and advanced nurse practitioners, as well as cardiology fellows intermittently. This team manages the transition from intensive care to discharge readiness, in addition to moderate acuity hospitalization of cardiac patients.
Residents and medical students are able to participate in elective rotations with either inpatient team.
Quality and safety are high priorities for the inpatient service. We support an extremely robust Quality and Safety improvement process internally. Furthermore, both the inpatient services are benchmarked to national standards with our peers in the country through our active participation in the Pediatric Cardiac Critical Care Consortium (PC4) and Pediatric Acute Care Cardiology Collaborative (PAC3).
The inpatient service faculty provide an enriching learning experience for all learners with bedside teaching, didactics, and case-based lectures. The CVICU also provides advanced training opportunities through two CVICU fellowship-training positions offered annually.
Categorical cardiology fellows are an integral part of both the CVICU and intermediate teams. The expectations and roles of the cardiology fellows typically start with first year fellows serving as the primary provider for a group of patients and progress to 3rd year fellows running rounds and managing the entire team.
The Echocardiography Laboratory at Arkansas Children’s Hospital Systems (ACH) is an IAC accredited full-service, state of the art program providing all facets of congenital cardiac imaging. We perform nearly 10,000 transthoracic echocardiograms, 400 transesophageal, and 900 fetal echocardiograms per year.
Our teaching philosophy for training fellows is that echocardiography is a foundational tool with which the cardiology fellows builds their knowledge base in congenital heart disease. Echocardiography interpretation skills are important in the majority of pediatric cardiology roles the fellow will choose. Therefore, our aim is to provide the trainee with the opportunity to become an exceptional echocardiographer by the end of the categorical fellowship and be prepared to fully function as an imaging pediatric cardiologist.
The Echo lab at ACH maintains advanced equipment and first-rate ultrasound technology for the performance of 2, 3 and 4 Dimensional, Doppler and strain imaging from transthoracic and transesophageal modalities. A diverse brand of full-size ultrasound units is used daily including: GE Vivid-E95, Voluson-E8 and Vivid-IQ; Philips iE33, EPIQ-7C and CX- 50.
Our interpretation and reporting platform is Syngo Dynamics. This system also houses the cardiac catheterization data, such that echocardiograms and catheterization studies can be retrieved simultaneously for comparison. Stand-alone desktop software systems including GE QLab and Philips EchoPAC are available for offline advanced 3D and myocardial deformation/strain evaluation.
The echocardiography lab at Arkansas Children’s is located within the Cardiology Clinic area. The sonographer arena, the physician reading room, the fetal reading and telemedicine room, and 6 echo exam rooms are immediately adjacent to the main clinic space. The NICU is on the floor directly above the cardiology clinic, and the cardiac intensive care unit is 2 floors directly above the clinic, making the lab optimally positioned for portable studies.
We additionally perform echocardiograms at Arkansas Children’s Northwest (ACNW) and Arkansas Children’s Jonesboro Cardiology clinic. These studies are read at our main campus in Little Rock.
ACH has a network of 28 hospitals within the State of Arkansas that rely on us for interpretation of pediatric echocardiograms. Studies performed at these hospitals and clinics are digitally transmitted to the PACs system at the Arkansas Children’s campus in Little Rock and are interpreted and reported same day by our cardiologists.
Fellow education in echocardiography at Arkansas Children’s provides the learner with an advanced level of knowledge, skills, and training that mirrors the expectations for a fourth year trained pediatric echocardiography fellow as outlined by the American Society of Echocardiography.
The UAMS/ACH Heart Center offers advanced fellowships in Cardiac Intensive Care and Advanced Imaging (Fetal Echo, TEE, CT, and MRI). For more information on these fellowships please contact:
Markus Renno, M.D., M.P.H.
Director of Advanced Imaging Fellowship
Parthak Prodhan, M.D.
Director of Cardiac Intensive Care Fellowship
Adult Congenital Heart Disease Program
Arkansas Children’s Hospital established its Adults with Congenital Heart Disease (ACHD) Program in 2010. The program has grown substantially each year and is now following more than 2250 patients from throughout the state and region.
Arkansas has a large population of adults with congenital heart disease, many of whom underwent surgical interventions many years ago and are only now able to reestablish care with a congenital cardiology specialist. Our ACHD cardiologists work closely with community cardiologists from around the state to optimize medical management and thoughtfully consider the role of further intervention. We offer patients a comprehensive array of ACHD Program Services.
In addition to excellent patient care, our goal is to train pediatric cardiology fellows in the management of adults with congenital heart disease in both the outpatient and inpatient settings. Our fellows prepare and present complex ACHD patients in the weekly surgical conference. They get an opportunity to analyze the data, understand the nuances of adult cardiology, and help in formulating a management plan.
Cross-Sectional Cardiac Imaging Program
The cardiac MRI and cardiac CT programs at Arkansas Children’s Hospital collectively perform over 300 studies annually, the vast majority for complex congenital heart disease. As the only congenital heart disease program in the state, we serve patients across the spectrum of age and disease complexity. This routinely includes adults who have had operations in childhood that are no longer commonly performed, offering fellows a rich opportunity to learn about the history of congenital heart surgery.
Rooted in a tradition of close collaboration between the pediatric cardiology and pediatric radiology sections, the cross-sectional cardiac imaging team has benefited from the complementary strengths of both specialties. Similarly, categorical cardiology fellows have the opportunity to learn from attendings with diverse backgrounds and expertise.
Beginning partway through their first year of fellowship, cardiology fellows are coached on how to review and present advanced cardiac imaging to the faculty during surgical case management conferences. Graduating cardiology fellows consistently report this as a strength of our program when they move on to the next phase of their careers.
Advanced 3D+ Cardiac Visualization Laboratory
Arkansas Children’s Hospital employs state of the art technologies for advanced visualization of complex cardiac anatomy in three or more dimensions. Thanks to generous donations from local families who support the Pediatric Heart Center, the 3D cardiac print laboratory utilizes a full color 3D resin printer to create life-size cardiac models for planning the most complex cardiac operations. After clinical use, the models are stored in a library alongside their clinical narratives, enabling trainees to learn from each case for years to come.
Cardiology fellows have the opportunity during their training to participate in the planning, image acquisition, segmentation, and production of 3D models. One recent fellow presented her work on 3D modeling at a national conference (view the presentation here).
In some instances, augmented 3D or 4D reality caries one or more advantages over 3D printing. In these cases, EchoPixel enables the advanced imaging and surgical teams to review complex anatomy for surgical planning. Cardiology fellows are always welcome to join in these high-level discussions and are free to utilize this technology at their leisure to help them understand the relationships of complex cardiovascular structures in their patients.