PICS-AICS face-off: Who should care for adult CHD patients?

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BOSTON—Turf and training issues may create tension between pediatric cardiologists and interventionalists, raising the question: Should pediatric cardiologists treat adult congenital heart disease (CHD) patients? A debate on July 27 at this year’s Pediatric and Adult Interventional Cardiac Symposium (PICS-AICS) ultimately concluded that the ideal situation could be a joint partnership between the pediatric cardiologist and interventionalist in the cath lab.

“Comorbid conditions frequently plague adults and need to be understood,” Thomas J. Forbes, MD, director of the cardiac cath lab at the Children’s Hospital of Michigan in Detroit, suggested during the debate. Forbes, a pediatric cardiologist, said that there must be a complete understanding of the patient's condition and patient’s history.

Forbes said that the high level of care provided by pediatric cardiologists to the adult patient supports the argument that pediatric cardiologists should be treating this patient population, adding, “If it ain’t broke, don’t fix it.

“Adult interventional cardiologists equals attention deficit,” said Forbes. He said that the amount of cases and number of interruptions that adult interventionalists endure during procedure may indicate trouble focusing. Forbes concluded that pediatric cardiologists should be the ones to treat adult CHD patients.

On the other side of the argument, John D. Carroll, MD, medical director of the Cardiac and Vascular Center at the University of Colorado Hospital in Denver, said, “Pediatric interventional cardiologists are extremely skilled, and have my respect and admiration, as I love performing procedures with them. However, they should not be caring for this adult subset of patients on their own.”

Different training paths at the beginning of medical school make these two specialties very different, and usually there is “no significant mixing of pediatric or adult interventional care," said Carroll, who offered that both programs have very rigid training associated with them.

Citing the American Board of Internal Medicine, Carroll suggested that physicians must show objective documentation that they are trained in certain specialties, procedures and patient populations to be considered knowledgeable to perform procedures in certain patients.

"The medical literature is loaded with references addressing the strong opinion [that] children are not little adults,” Carroll said. And in the same manner, “Adults are not big children.”

Carroll urged that this issue is not just knowing about the procedure, but it also must center on understanding conditions such as atrial septal defect (ASD) or closure of the patent foramen ovale (PFO). “Procedures are very different in these patient populations,” Carroll offered. "There is a whole different approach to dealing with the vessels of a 90-year-old compared with those of an18-year-old."

He suggested that the Med-Ped training program guide of 2010 could be the solution to these types of underlying problems. Med-Ped training enables a physician to be board certified in both disciplines—pediatric cardiology and intervention—and have a skill set and experience in objective testing.

However, Carroll said that pediatric cardiologists should be present in the majority of interventions for adult CHD patients, such as complex adult CHD or coarctation of the aorta, among others.

While Carroll acknowledged the turf issues between these two fields, he said that this should be a partnership, not circumvention.

Training pathways are different; however, there are also procedural differences that could require special vascular access and navigation issues in adults, said Carroll.

“The expertise of pediatric interventional cardiology is important for some adults,” Carroll concluded. “Join us and don’t circumvent adult physicians.”