Heynric B. Grotenhuis

Bakcgroung: Training in pediatric and congenital echocardiography has progressed substantially over the past two decades, supported by structured recommendations in North America and Europe. However, while North American training pathways are generally more standardized and closely linked to accreditation and certification, European training remains heterogeneous. Differences in healthcare systems, regulatory frameworks, institutional organization, supervision, case exposure, and access to advanced imaging may result in unequal acquisition of competencies, with potential implications for patient care. The aim of this expert consensus document is to update European standards for training in pediatric and congenital echocardiography and to promote harmonization through a competency-based framework that complements, rather than replaces, national regulatory systems and existing certification pathways. Methods: Developed by the Imaging Working Group of the Association for European Paediatric and Congenital Cardiology (AEPC), in collaboration with the Congenital Heart Disease Shared Interest Group of the European Association of Cardiovascular Imaging (EACVI), the document defines three progressive levels of expertise: Basic, Advanced, and Specialized/Tertiary. Each level is characterized by specific competencies, indicative procedural experience, and expected professional responsibilities. Building on previous European recommendations and the recent joint statement addressing laboratory organization and service governance, this document focuses specifically on the educational pathway, progressive acquisition of clinical competencies, and assessment of individual practitioners. Results: The proposed framework emphasizes comprehensive training across the lifespan of congenital heart disease, including competencies bridging pediatric and adult cardiology. It incorporates contemporary imaging modalities, including three-dimensional echocardiography, myocardial deformation imaging, transesophageal and fetal echocardiography, and emerging blood speckle tracking and artificial intelligence applications. Minimum requirements for training centres, structured assessment, quality assurance, continuous professional development, research activity, and multidisciplinary collaboration are also addressed. Procedural volumes are proposed as indicative benchmarks to support training and assessment, not as stand-alone evidence of competence or universally mandatory thresholds. Conclusions: This consensus document provides a shared European reference framework designed to reduce unwarranted variability in training, facilitate professional mobility, promote competency-based progression, and ensure that pediatric and congenital echocardiography remain aligned with current clinical practice and technological innovation.

This document has been developed to provide a practical guide for the application of speckle tracking echocardiography (STE) in paediatric and congenital heart diseases. In the present document, the following topics are reviewed and discussed: (i) the basic principles of STE, its potential applications, and limitations in the paediatric population; (ii) normal paediatric reference values for STE; and (iii) the use of STE in various congenital and acquired heart diseases. The potential role of routine STE in the management and follow-up of paediatric and congenital heart disease is explored, with practical examples illustrating how STE can provide additional insights beyond conventional echocardiographic parameters. Limitations regarding clinical interpretation, prognostic value, the lack of standardized timing for measurements, and the absence of universally accepted thresholds for STE-derived strain parameters are also highlighted. Overall, this document is intended to serve as a comprehensive guide to (i) orient clinicians regarding the strengths and limitations of STE in paediatric and congenital heart disease; (ii) identify specific clinical scenarios where STE may be particularly informative; and (iii) encourage future research and multicentre collaborative studies. By providing both practical guidance and a framework for further investigation, the document aims to support standardized use of STE, improve patient care, and foster the integration of this technique into routine paediatric and congenital cardiology practice.

Although echocardiography remains the primary imaging modality for assessing Fontan palliation, a standardized systematic approach for evaluating the univentricular heart throughout the different stages of palliation has yet to be established. This document aims to provide a narrative review and practical guide for the echocardiographic assessment of the univentricular heart at various phases of Fontan palliation. Additional objectives include highlighting the potential of advanced three-dimensional (3D) and four-dimensional (4D) imaging modalities, as well as outlining a systematic strategy for detecting thromboembolic complications. We propose a sequential framework for echocardiographic evaluation, encompassing key anatomical and functional components of the univentricular heart. This includes the atrial septum and pulmonary veins, ventricular function, atrioventricular valve, aorta and neo-aorta, sub-aortic region, aortic arch, and pulmonary arteries. Furthermore, we detail the assessment of pulmonary blood supply at different stages of palliation, including the modified Blalock–Taussig–Thomas (mBTT) shunt, Sano conduit, Glenn procedure, and total cavo-pulmonary connection (TCPC). A comprehensive analysis of potential thrombus formation sites is provided, along with diagnostic pitfalls. Additionally, we outline methods for screening for extracardiac clots following Glenn and TCPC procedures. This document serves as a practical guide for the systematic echocardiographic evaluation of the univentricular heart across all stages of Fontan palliation, offering guidance for clinical practice. It also explores the capabilities of emerging 3D and 4D echocardiographic techniques in univentricular heart assessment and provides an in-depth review of thromboembolic complications, emphasizing key diagnostic challenges.

Cross-sectional cardiac imaging including cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMR) allows three-dimensional imaging of intracardiac and extracardiac structures. This study was undertaken to better understand current European practice of pediatric cardiology cross-sectional imaging, in addition to how training is undertaken in different centers. A structured detailed 64-question survey focusing on cross-sectional imaging was circulated to all Imaging Working Group members of the 95 AEPC affiliated centers. Consultants from 42 centers (44%) from 25 different European countries completed the survey, between 7th July 2024 and 28th October 2024. Ninety percent of centers have been performing pediatric CCT for > 10 years, with median 135 scans/year. Comparatively, 84% of centers have been performing CMR for > 10 years, with a median 200 scans/year. CCT was performed by a pediatric radiologist, whereas CMR was more often performed by a pediatric cardiologist, but frequently both modalities were undertaken by a combination of pediatric cardiologists and radiologists. Less than two-third of centers surveyed train fellows in CMR or CCT. Many fellows travel abroad to obtain specialist training. Just over half of the centers surveyed have institutional guidelines for pediatric CCT/CMR, with the majority agreeing that provision of European (AEPC-led) guidelines for pediatric CCT/CMR would be helpful. Across Europe there is significant variation in how CCT/CMR is performed and how pediatric cardiologists are trained in cross-sectional imaging. This survey highlights the current state of cross-sectional imaging in Europe, challenges faced, but also explores potential solutions to standardize European cross-sectional imaging.

Fetal cardiovascular magnetic resonance imaging (MRI) has emerged as a complementary modality for prenatal imaging in suspected congenital heart disease. Ongoing technical improvements extend the potential clinical value of fetal cardiovascular MRI. Ascertaining equivocal prenatal diagnostics obtained with ultrasonography allows for appropriate parental counseling and planning of postnatal surgery. This work summarizes current acquisition techniques and clinical applications of fetal cardiovascular MRI in the prenatal diagnosis and follow‐up of fetuses with congenital heart disease.Level of Evidence: 3Technical Efficacy: Stage 3

Hypertrophic Cardiomyopathy (HCM) is an inherited myocardial disease characterised by left ventricular hypertrophy, which carries an increased risk of life-threatening arrhythmias and sudden cardiac death. The age of presentation and the underlying aetiology have a significant impact on the prognosis and quality of life of children with HCM, as childhood-onset HCM is associated with high mortality risk and poor long-term outcomes. Accurate cardiac assessment and identification of the HCM phenotype are therefore crucial to determine the diagnosis, prognostic stratification, and follow-up. Cardiac magnetic resonance (CMR) is a comprehensive evaluation tool capable of providing information on cardiac morphology and function, flow, perfusion, and tissue characterisation. CMR allows to detect subtle abnormalities in the myocardial composition and characterise the heterogeneous phenotypic expression of HCM. In particular, the detection of the degree and extent of myocardial fibrosis, using late-gadolinium enhanced sequences or parametric mapping, is unique for CMR and is of additional value in the clinical assessment and prognostic stratification of paediatric HCM patients. Additionally, childhood HCM can be progressive over time. The rate, timing, and degree of disease progression vary from one patient to the other, so close cardiac monitoring and serial follow-up throughout the life of the diagnosed patients is of paramount importance. In this review, an update of the use of CMR in childhood HCM is provided, focussing on its clinical role in diagnosis, prognosis, and serial follow-up.

The Fontan operation was introduced in 1968. For congenital malformations, where biventricular repair is unsuitable, the Fontan procedure has provided a long-term palliation strategy with improved outcomes compared to the initially developed procedures. Despite these improvements, several complications merely due to a failing Fontan circulation, including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein-losing enteropathy, hepatic dysfunction, plastic bronchitis, and thrombo-embolism, may occur, thereby limiting the life-expectancy in this patient cohort. This review provides an overview of the most common complications of Fontan circulation and the currently available treatment options.