A Standardized Curriculum for Transitioning Knowledge Requirements from the Adult to the Pediatric Cath Lab By Riyanna Day George Burch Norman Leqakowailutu A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah April 25, 2025 ⅱ THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Riyanna Day George Burch Norman Leqakowailutu This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Tanya Nolan, EdD Chair, School of Radiologic Sciences ______________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA ______________________________ Dr. Robert Walker, PhD Director of MSRS ⅲ THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Riyanna Day George Burch Norman Leqakowailutu This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date April 25, 2025 ______________________ ____________________________________ Riyanna Day April 25, 2025 ______________________ ____________________________________ George Burch April 25, 2025 ______________________ ____________________________________ Norman Leqakowailutu ⅳ Abstract Transitioning from the adult to pediatric cardiac catheterization lab presents a unique set of challenges for cath lab technologists. This study focused on identifying the knowledge gaps, procedural differences, and technical skills needed to support cath lab technologists making that transition. This study aimed to develop a standardized curriculum that prepares adult-trained technologists for the pediatric environment. Using a comprehensive literature review as the research methodology, this study pulled together over 76 peer-reviewed articles, professional guidelines, and real-world case studies from the last 10 years. The focus was on five common cath lab procedures: Atrial septal defect (ASD) closure, patent ductus arteriosus (PDA) occlusion, Ventricle Septal Defect (VSD) closure, balloon valvuloplasty, and angioplasty/stenting. Findings showed apparent gaps in areas like congenital heart anatomy, radiation safety tailored to kids, pediatric sedation, emergency protocols, and specialized equipment use. Adult trained cath lab technologists don't get the exposure they need to be confident or effective in the pediatric setting. A big part of the challenge is the shift in communication styles, smaller anatomy, and stricter safety protocols, especially around radiation and sedation. This review led to the creation of a curriculum designed around three core themes: procedural adaptations, pediatric-specific technical knowledge, and foundational education on congenital heart defects. The curriculum aims to help cath lab technologists feel more comfortable, reduce complications, and standardize care across pediatric cath labs. ⅴ Acknowledgements Thank you to all that helped us with the research, studying, and helping proof read our paper. A special thank you to the Weber State Cardiac Specialist program for the dedicated time and help with our paper. Another special thank you to Chris Steeleman MS, R.T.(R)(CI)(ARRT), RCIS, FACVP, AACC Assistant Professor, for guiding us through this paper and helping us whenever we needed. ⅵ Table of Contents Background ...................................................................................................................................... 3 Statement of the Problem ................................................................................................................. 7 Purpose of the Study ........................................................................................................................ 8 Research Questions .......................................................................................................................... 8 Nature of the Study .......................................................................................................................... 9 Definition of Key Terms ................................................................................................................ 10 Summary ........................................................................................................................................ 11 General Literature Review ............................................................................................................. 12 Current Approaches to Cardiac Catheterization Laboratory Training ........................................... 12 Procedural Differences: Adult versus Pediatric Catheterization.................................................... 14 Equipment and Technical Adaptations for Pediatric Catheterization ............................................ 15 Curriculum Development for Technologist Transition .................................................................. 18 Pediatric Cardiac Catheterization Examination Overview ............................................................ 20 Examination Matrix and Task List: Structure and Relationship .................................................... 20 Examination Matrix ....................................................................................................................... 21 Duties and Tasks ............................................................................................................................ 22 Conducting Pre-Procedural Activities (15%)................................................................................. 22 Conducting Diagnostic Procedures (45%) ..................................................................................... 23 Conducting Interventional Procedures (30%) ................................................................................ 26 Responding to Emergency Procedures and Protocols (5%) ........................................................... 29 Conducting Post-Procedural Activities (5%) ................................................................................. 31 Summary ........................................................................................................................................ 33 Research Methods and Design ....................................................................................................... 36 Data Collection, Processing, and Analysis .................................................................................... 36 Assumptions................................................................................................................................... 36 Limitations ..................................................................................................................................... 37 Delimitations .................................................................................................................................. 37 Summary ........................................................................................................................................ 38 Synthesis of Findings ..................................................................................................................... 39 Procedural Adaptations for Pediatric Catheterization .................................................................... 40 Equipment and Technical Considerations...................................................................................... 40 Educational Framework ................................................................................................................. 41 Results ............................................................................................................................................ 41 Evaluation of Findings ................................................................................................................... 43 Summary ........................................................................................................................................ 44 Introduction .................................................................................................................................... 44 Implications.................................................................................................................................... 45 Recommendations .......................................................................................................................... 48 Future Directions ........................................................................................................................... 49 ⅶ Conclusions ........................................................................................................................50 Appendix A: Diagnostic Patient Preparation Reference Tool ...........................................59 Appendix B: Diagnostic Procedure and Balloon Atrial Septostomy Reference................60 Appendix C: Patent Ductus Arteriosus Closure Reference Tool .......................................61 Appendix D: Atrial Septal Defect Closure and Ventricle Septal Defect Closure .............62 Appendix E: Aortic Valve Stenosis Reference Tool .........................................................63 Appendix F: Competency Assessment Checklist/HR Handout .........................................64 ⅷ List of Tables Table 1. RCIS/RCPS Elimination Matrix…………………………….………………………22 ⅸ List of Figures Figure 1. RCIS/RCPS Elimination Matrix ……………..…………………………………………….22 1 Chapter 1: Introduction Interventional catheterization has become the preferred treatment for pediatrics within the last twenty years.1 Due to the rising popularity of the pediatric catheterization lab and its procedures, many cath lab technologists trained exclusively in adult treatments are transitioning to the pediatric cath lab. This transition from adult to pediatric practice poses unique challenges for cath lab technologists. The main challenge is that this professional shift remains largely undocumented and unsupported. Unlike other allied health transitions, there is little structured guidance to prepare cath lab technologists for the specialized demands of pediatric care. This gap is particularly significant given the growing complexity and volume of congenital heart interventions. Congenital heart disease (CHD) affects nearly 1% of all live births, with most patients now surviving into adulthood due to significant advances in medical care.2 This demographic shift has prompted increased attention to the transition of CHD patients from pediatric to adult-centered healthcare systems. However, far less attention has been given to the parallel transition required of cath lab technologists moving from adult to pediatric settings. This professional shift demands the acquisition of specialized knowledge beyond standard adult cardiovascular training, particularly in regard to the procedural and anatomical nuances unique to pediatric interventions. The care design for CHD has evolved over the past few decades. Today, it is expected that most individuals born with CHD, even those with complex heart conditions, will survive to adulthood.3 This progress has driven the development of structured transition programs aimed at helping adolescent patients move from pediatric to adult healthcare systems. The evolving patient care landscape has created a need for healthcare professionals who can effectively bridge pediatric and adult cardiac care, this need is especially apparent in the cath lab. As academic 2 centers and training facilities develop formal transition programs for patients, they simultaneously face staffing challenges in specialized areas like the cardiac catheterization laboratory, where procedural knowledge differs significantly between adult and pediatric populations. Cardiac catheterization technologists, commonly known as cath lab technologists, are allied health professionals who assist interventionist cardiologists in diagnosing and treating cardiovascular conditions. Their role includes everything from patient preparation, equipment operation, procedural assistance, and post-procedure care.4 While basic certification requires completion of an associate degree or certificate program in invasive cardiovascular technology, specialized training for pediatric procedures often requires additional training and are not always covered in standard programs.5 Current pathways to becoming a cath lab technologist focus on adult cardiac procedures, with very little education specific to pediatric catheterization. The Intersocietal Accreditation Commission standards require technologists to obtain at least 15 hours of continuing education relevant to acquired and/or congenital heart disease every three years, indicating minimal recognition of the knowledge gap.5 However, this requirement does not addresses the comprehensive knowledge needed to transition successfully to pediatric cath lab settings. The transition from adult to pediatric cath lab settings presents significant challenges for technologists. Beyond procedural knowledge, pediatric cardiac catheterization requires understanding different radiation safety parameters, contrast dose calculations, sedation protocols, and equipment specifications scaled for children of varying sizes.17 Additionally, the psychological approach to pediatric patients differs substantially from adult care, requiring specialized communication skills with patients and parents alike. 3 The literature reveals a significant gap in formalized transition pathways for cardiac catheterization professionals. While transition programs for patients have been extensively studied and implemented,6 parallel programs for healthcare professionals remain underdeveloped. This gap is concerning given the specialized knowledge required for common pediatric interventions described and the potential impact on patient outcomes when procedures are performed by technologists transferring over without adequate pediatric training. As the field of congenital heart disease continues to evolve, increasing survival rates and technological advancements, the need for specialized training for these cath lab technologists becomes critical. Addressing this knowledge gap represents an important frontier in optimizing care for any cath lab technologist that transfers from adult to pediatric settings. Background The transition of cath lab technologists, from adult to pediatric catheterization labs is becoming more relevant as the need for pediatric trained staff grows. It is also an emerging concern as a workforce development issue within interventional cardiology. According to recent data from the Society for Cardiovascular Angiography and Interventions (SCAI), approximately 30% of pediatric cath labs are facing staffing shortages that directly impact scheduling procedures and patient care delivery.7 This staffing shortage occurs amid an expansion of pediatric interventional capabilities. The total number of pediatric catheterization laboratories has increased by 15% over the past decade.8 Despite this growth, most training programs still don't include pediatric specific education in the core curriculum. The American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACCF/AHA/SCAI) competency guidelines highlights the distinct technical competencies required for pediatric interventional procedures, 4 noting that "skills utilized in an adult catheterization laboratory may not fully transfer to the pediatric domain without significant additional training".9 This acknowledgement has sparked more focus on developing a structured training curriculum for adult cath lab technologists seeking to contribute within pediatric settings. The differences between pediatric and adult catheterization procedures extend well beyond equipment dimensions. Pediatric patients have different cardiovascular physiology, which directly impacts everything from procedural planning, equipment selection, and choices to risk management strategies. Children typically demonstrate higher resting heart rates, lower blood pressures, and different oxygen consumption metrics compared to adults, necessitating specialized monitoring parameters during interventional procedures accordingly. Additionally, the cardiovascular system demonstrates greater vessel elasticity but increased sensitivity to hemodynamic compromise during interventional manipulations, which adds another layer of complexity during key moments like balloon inflation in valvuloplasty procedures. In pediatrics, congenital heart disease (CHD) is often the predominant indication for pediatric valvuloplasty procedures, which is a completely different procedural context compared to the acquired valvular disease typically encountered in adult settings. Recent studies have shown that understanding the complex 3D anatomy associated with congenital heart defects represents a significant learning curve for technologists transitioning from adult practice. Competency assessment tools reveal that mastery of anatomical variations typically requires 6-9 months to become proficient in this area.10 The equipment used in pediatric cath procedures is another area that requires substantial training for adult cath lab technologists. A detailed analysis of pediatric catheterization equipment published in the Journal of Invasive Cardiology found that approximately 85% of devices used in pediatric valvuloplasty differ from those in the adult counterparts in critical dimensions or 5 operating parameters.11 These differences include smaller equipment sizes, and different design characteristics tailored for the unique requirements of pediatric intervention. Imaging systems represent a key difference between adult and pediatric catheterization labs. While single plane fluoroscopy is common in adult settings, approximately 92% of pediatric labs utilize biplane imaging due to its ability to better visualize complex congenital anatomy while reducing contrast load and radiation exposure.12 Radiation safety takes on greater importance in pediatrics, given children’s increased sensitivity to ionizing radiation and longer projected lifespans. The Image Gently Alliance emphasizes the application of ALARA (As Low As Reasonably Achievable) principles tailored to pediatric care.12 Cath lab technologists must be proficient in pediatric-specific techniques such as collimation, frame rate optimization, and virtual collimation. Research examining procedural workflow in pediatric catheterization laboratories highlights significant differences in team members and communication compared to adult settings. Pediatric procedures typically involve a larger multidisciplinary team, including dedicated pediatric anesthesiologists, which creates more complex communication requirements for cath lab technologists.13 A time-motion analysis of pediatric valvuloplasty procedures demonstrated that technologists in pediatric settings spend approximately 32% more time coordinating with anesthesia staff than similar adult procedures, reflecting the increased importance of coordinated sedation management in younger patients.14 Pediatric-specific emergency protocols differ from adult protocols, with greater emphasis on ventilation support and modified medication dosing based on weight-based calculations unfamiliar to many adult practitioners.14 These differences highlight the need for structured emergency simulation training as part of the transition process for cath lab technologists entering pediatric practice. 6 The specialized knowledge and skills required for pediatric catheterization procedures have prompted the development of a curriculum for cath lab technologists transitioning between adult and pediatric settings. The Pediatric & Congenital Cardiac Catheterization Quality & Outcomes Assessment Committee has established consensus recommendations for training and competency assessment explicitly addressing the needs of technologists entering pediatric practice.15 These include congenital heart defect anatomy and physiology, pediatric medication dosing calculations, age-specific communication strategies, pediatric emergency response protocols, and specialized equipment operation.15 The current literature illustrates a critical need for structured transitions for cath lab technologists moving from adult to pediatric catheterization laboratories. As the complexity of pediatric interventional procedures continues to increase, adequate staffing with properly trained technologists represents a significant healthcare challenge. The specialized knowledge and skills required for pediatric valvuloplasty procedures differ substantially from adult practice, necessitating dedicated training programs that address these procedural variations.11 This research area is particularly important given the projected increase in pediatric interventional procedures. The American Academy of Pediatrics projects a dramatic increase in pediatric procedures over the next decade, creating additional pressure on an already constrained specialized workforce.16 Developing evidence-based transition programs for experienced adult cath lab technologists represents a promising strategy for addressing this workforce challenge while maintaining procedural quality and patient safety standards. Statement of the Problem The increasing complexity of pediatric interventional cardiology procedures requires cardiac catheterization laboratory technologists to have highly specialized knowledge and skills. However, structured educational programs tailored to technologists—especially those 7 transitioning from adult to pediatric practice—remain limited. This training gap can lead to procedural inefficiencies, increased radiation exposure, and potentially compromised patient outcomes. Pediatric cases present unique challenges, including smaller, more fragile vasculature and different physiological parameters, requiring careful technique and precise radiation management. Children’s increased sensitivity to ionizing radiation, combined with their longer life expectancy, results in significantly higher lifetime risk from exposure—yet most training programs provide limited emphasis on pediatric-specific radiation safety protocols. Recent competency framework research has identified key knowledge domains that adult-trained technologists often lack when entering pediatric environments.8 These include understanding congenital heart defect anatomy, operating specialized pediatric equipment, and applying pediatric-specific radiation safety techniques. These knowledge gaps are particularly evident in procedures such as valvuloplasty and stenting, where approximately 85% of the devices differ from adult equivalents in size or functional characteristics.9 Additionally, pediatric interventions often involve complex congenital lesions and hybrid procedures that demand advanced sterile techniques and close collaboration with surgical teams—elements that are rarely covered in traditional training pathways. Workforce shortages in pediatric settings further stress the urgency of addressing this gap, with nearly 30% of pediatric catheterization labs reporting staffing difficulties that impact procedural scheduling and patient care.7 As pediatric volumes continue to grow, the absence of a standardized, evidence-based transition curriculum poses a significant challenge. Addressing this gap through focused education and clearly defined core competencies is essential to ensure cath lab technologists are prepared to safely and effectively support pediatric interventional procedures. 8 Purpose of the Study The purpose of this literature review is to systematically analyze and synthesize current literature on procedural techniques, equipment specifications, and clinical competencies that differentiate adult and pediatric cardiac catheterization laboratories, with the goal of developing a comprehensive transition curriculum for cath lab technologists moving from adult to pediatric settings. This review will examine peer-reviewed clinical studies, professional guidelines, and existing educational frameworks published within the last ten years across cardiovascular technology programs and healthcare institutions to identify best practices that address the specialized knowledge and skill gaps experienced by technologists during transition to pediatrics. Research Questions The pediatric catheterization lab is a unique and complicated space. A proposed curriculum to train any cath lab technologist in this challenging space will cut down on complications and allow for a more standardized level of care. Pediatrics need to be understood by Cath Lab personnel throughout the world. Identifying the most common procedures, radiation standards, and equipment will allow cath lab technologists to be more prepared to enter a pediatric space. Research questions that can be addressed throughout this thesis includes: Q1. What are the key competencies required for cardiac catheterization technologists transitioning from adult to pediatric settings? Q2. How does the absence of a structured pediatric cardiac catheterization training program impact procedural efficiency, radiation safety, and patient outcomes? Q3. What educational strategies are most effective in preparing technologists for pediatric cardiac catheterization procedures? 9 Q4. What pediatric cardiac catheterization procedures are unfamiliar to technologists trained only in adult settings? Q5. How does pediatric catheterization differ from adult procedures in terms of required technical skills, radiation safety, and equipment handling? Nature of the Study This comprehensive review presents literature that supports building a curriculum for transitioning adult cath lab technologists to the pediatric cath lab and includes an overview of all relevant research. This study utilizes a detailed literature review on the current state of pediatric cath labs and literature available on pediatric cath lab procedures in order to propose a standardized curriculum for a cath lab technologist transitioning. This thesis seeks to improve the understanding of the pediatric cath labs and pediatric treatment centers by compiling a thorough literature review and case study analysis. This research will highlight important technical procedures commonly performed in the pediatric cath lab, the weaknesses of informal and non-standardized cath lab treatment, and the proposed curriculum's role in the pediatric cath lab. By collecting information on the most common pediatric procedures, this research contributes to new understanding and proposes a new curriculum for pediatric cath lab technologists transferring from the adult cath lab. Significance of the Study The development of a curriculum for cath lab technologists transitioning from adult to pediatric settings addresses a significant education gap in cardiovascular technology training. Currently, most cath lab technologists receive education primarily focused on adult patients, with limited exposure to the specialized knowledge required for pediatric cardiac catheterization. According to a survey done by the American College of Cardiology (ACC) in 2023, 52% of cath lab technologists reported needing extra qualifications beyond their basic education to work 10 effectively in catheterization laboratories.9 This education deficit becomes even more pronounced when technologists transition to pediatric settings, where unique considerations in equipment, procedures, and patient care require specialized knowledge that is overlooked in traditional cardiovascular technology programs. Definition of Key Terms ASD: Atrial Septal Defect - A condition in which there is a hole between the top two chambers of the heart.18 VSD: Ventricular Septal Defect - A congenital heart condition where there is a hole in the septum separating the two lower chambers or ventricles of the heart.12 CHD: Congenital Heart Disease - A variety of heart and great vessel abnormalities that originate during fetal development and can be identified at different stages of life, from prenatal periods to adulthood.14 TGA: Transposition of the Great Arteries - is a congenital cardiac defect caused by an embryological discordance between the aorta and pulmonary trunk or by both atrioventricular and ventriculoarterial discordance—a condition often termed "double discordance."13 PDA: Patent Ductus Arteriosus - a condition where a blood vessel (known as a ductus arteriosus) that naturally closes after birth fails to close and too much blood is directed toward the lungs of a baby.18 Balloon AngioPlasty: Balloon angioplasty, also known as percutaneous transluminal angioplasty, is a minimally invasive procedure used to open narrowed or blocked arteries, often caused by atherosclerosis. During the procedure, a catheter with a deflated balloon at its tip is inserted into the affected artery.19 Balloon Valvuloplasty: Requiring valvuloplasty procedures where small balloons are inflated to stretch narrowed heart valves.18 11 Transcatheter Valve Implantation: also known as TAVI is a procedure in which a valve is implanted using a thin, flexible tube known as a catheter.20 PFO: Patent Foramen Ovale - A patent foramen ovale (PFO) is a small hole between the heart’s two upper chambers, the right atrium and the left atrium.21 Percutaneous BAS: Balloon Atrial Septostomy - A balloon or stent is used to create an opening between the atrial septum to create a larger interatrial connection to keep blood flowing.2 Summary This thesis offers a detailed literature review on the most commonly performed pediatric catheterization procedures, the equipment utilized in the pediatric cath lab, and the radiation precautions utilized that differ from the adult cath lab. Gaining a clear understanding of the complex and challenging nature of the pediatric cath lab will improve care for pediatric patients. The main goal of this thesis is to propose a structured curriculum in order to standardize pediatric care and provide cath lab technologists with the necessary training and requirements. Chapter 2: Literature Review Documentation The literature search for this review was conducted using multiple electronic databases including PubMed, Medline, EBSCO database, Weber State Stewart Library Onesearch, and Google Scholar. Search terms included combinations of "pediatric cardiac catheterization," "cath lab technologist training," "adult to pediatric transition," "congenital heart defects," "pediatric interventional cardiology," "cardiac catheterization curriculum," “paediatric catheterization,” and "pediatric cath lab equipment." Additionally, professional organization websites including the Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology (ACC), and European Association of Percutaneous Cardiovascular Interventions 12 (EAPCI) were searched for relevant guidelines and educational resources. Inclusion criteria focused on English-language, peer-reviewed articles published within the last five years (20202025), with a small number of seminal works from earlier dates included for historical context. Of the 77 sources identified for this review, 63 (82%) were publications within the last 5 years and 5 sources were hospital websites without peer review (6%). This is due to needing sources from varying hospitals and their standards on training and guidelines for pediatric cath labs. General Literature Review The purpose of this literature review is to break down the current research evidence regarding the transition of cath lab technologists from adult to pediatric settings. It focuses on comparing procedural techniques, equipment specifications, and required competencies. This review is organized into four major thematic sections: (1) current training methods to cardiac catheterization labs, (2) key procedural differences between adult and pediatric catheterization, with specific focus on congenital defect interventions including ASD, PDA, valve stenosis, and balloon angioplasty. (3) Equipment and technical adaptations required for pediatric patients, and (4) curriculum development frameworks for specialized transition training. This structure reflects the progressive nature of knowledge required for successful transition from adult to pediatric practice, beginning with foundational concepts and advancing to practical curriculum design considerations. Current Approaches to Cardiac Catheterization Laboratory Training Formal education and training for cardiac catheterization laboratory technologist has focused predominantly on adult patients, with limited structured pathways for specialization in pediatrics. The European Association of Percutaneous Cardiovascular Interventions (EAPCI) has developed a comprehensive core curriculum for the cardiac catheterization laboratory that addresses 13 technical aspects of knowledge by "providing a competencies matrix for use in educational development or introduction of new staff in the cath lab".22 This curriculum framework states that "much of the work in the cath lab can be captured by tasks and responsibilities that must be entrusted to individuals"22 the curriculum states the importance of integration from other domains but never specifies what those domains are. While this framework provides valuable guidance for general catheterization laboratory training, it does not specifically address the unique considerations for pediatric practice or the transition between adult and pediatric environments. The curriculum is organized into nine core themes including fundamentals of cardiovascular pathophysiology, procedure and technique, radiation and imaging, cardiovascular risk factors, assessment and planning of care, pharmacology, person-centered care, physical well-being, and quality evaluation.22 These domains provide a useful organizational structure that could be adapted for specialized pediatric transition training. Existing fellowship programs in pediatric cardiac care demonstrate the comprehensive nature of training required for this specialized environment. Phoenix Children's Hospital's Cardiovascular Intensive Care Unit (CVICU) Fellowship features a twelve-month curriculum "designed to combine didactic lectures and clinical experience in Cardiology and Pediatric Critical Care Medicine".23 This program includes dedicated rotations in cardiac catheterization, varying from four weeks for critical care-trained fellows to a combined four weeks of catheterization/electrophysiology for cardiology-trained fellows.23 This model is designed for physician training, the structured rotation approach with progressive responsibility could be adopted for technologist transition education. The fellowship model demonstrates the principle of more authority and responsibility under appropriate supervision, which represents a best practice for clinical education across 14 disciplines.23 For technologists transitioning from adult to pediatric settings, a similar approach with structured mentorship and progressive responsibility is appropriate, with special attention to "the supervision of attending physicians to learn the necessary skills"23 specific to the pediatric environment. Procedural Differences: Adult versus Pediatric Catheterization Cardiac catheterization laboratories serving pediatric populations address a fundamentally different spectrum of cardiac conditions than adult-focused facilities. While adult catheterization mostly addresses acquired issues such as coronary artery disease and valve disorders relating to aging and lifestyle factors, pediatric catheterization primarily addresses congenital defects present from birth. Labs operate during standard business hours with 24/7 emergency on-call services, which reflects the unique and often unpredictable demands of pediatric cardiac care. The patient population served by pediatric cath labs include those with "structural and congenital cardiovascular defects, cardiomyopathy, post heart transplant, peripheral vascular disease, coronary artery disease, and myocardial infarction"8, demonstrating a broader and more complex spectrum of conditions than typically encountered in adult cath labs. According to trends in Ochsner Health,18 three of the most common conditions treated in pediatric settings are: ASD, PDA, and Valve Stenosis. These congenital conditions represent a significant departure from the primary focus of adult cath labs, requiring cath lab technologists to develop specialized knowledge of embryological development, congenital defect manifestations, and age-appropriate procedural modifications tailored to pediatric patients. Pediatric interventional procedures are performed using "non-surgical transcatheter treatment" approaches requiring specialized delivery systems and devices designed specifically for pediatric anatomy.11 15 The Centers for Disease Control and Prevention reports that "every year 40,000 babies are born with congenital heart defects",11 highlighting a clear and ongoing demand for specialized cardiac catheterization services. Unlike adult procedures that largely focus on diagnosing and treating acquired coronary disease, pediatric catheterization often addresses structural defects through minimally invasive approaches where "a cardiologist accesses the heart by inserting a thin plastic tube called a catheter into a patient's blood vessels in the leg or neck".11 Another important procedural difference in pediatric catheterization involves anesthesia protocols. Unlike adult procedures that frequently use conscious sedation, pediatric procedures often require general anesthesia for younger patients. As noted in Ochsner Health's description, "Most young children do go under general anesthesia for the procedure, while teenagers tend to be awake".11 This adds another layer of complexity to pediatric care, requiring the cath lab team to be proficient in pediatric anesthesia monitoring and support protocols not commonly used in adult cath labs. Equipment and Technical Adaptations for Pediatric Catheterization The equipment and technical considerations for pediatric cardiac catheterization differ from adult settings, requiring specialized knowledge and skills for safe and effective practice. Pediatric cath labs specialize in imaging systems that address unique challenges of imaging smaller cardiac structures while minimizing radiation exposure. Imaging in pediatric cath labs initiate special dose tracking systems to reduce radiation exposure to pediatric patients along with a Cannon Alphenix Biplane – an imaging apparatus outfitted with two cameras that rotate simultaneously, leading to better visibility of the tiniest hearts.18 These biplane devices allows simultaneous imaging from multiple angles at the same time, which 16 reduces procedure time and contrast medium requirements while enhancing visualization of complex congenital anomalies. The heightened radiation sensitivity of pediatric patients requires specialized protocols for dose minimization. Several equipment design challenges exist specifically for pediatric cardiac catheterization laboratories. The most obvious difference is that "adult laboratories are optimized to provide adequate image quality over a relatively narrow weight range (i.e. most adults weigh between 50 and 150 kg), whereas the pediatric laboratory encounters patients who range from a very small weight range".24 This big variation in pediatric patient sizes necessitates equipment with exceptional flexibility in imaging parameters and radiation dose management. Beyond imaging, pediatric cath labs need to incorporate child friendly environments such as "monitors where patients can watch cartoons and other kid-friendly videos... while being prepped in the room for procedures",18 which can create a less intimidating environment for younger patients. These psychological comfort measures represent important aspects of pediatric care not emphasized in adult settings. For equipment, specialization of pediatric catheterization extends to the entire procedure, including catheters, guidewires, and interventional devices scaled appropriately for smaller cardiovascular structures. Technologists transitioning from adult to pediatric settings will need to develop familiarity with these specialized tools and their applications for all procedures including congenital heart defect interventions. While selecting appropriate equipment needed for the exact procedure, comparing them to the adult cath lab supports learning. As with adult procedures, vascular sheaths are placed in the patients femoral and jugular vessels.27 However, french sizes vary in size, are usually shorter in the femoral or jugular arteries, and can even extend from the groin to the heart to perform interventions.27 Pediatric catheters differ due to 17 shape and purpose of the procedure. Most common catheter french sizes in pediatrics are 3-4F and are used to investigate structural abnormalities.27 Balloon tipped wedge catheters are the most commonly used catheter to obtain pressures and oxygen saturations in the pulmonary arteries and require carbon dioxide gas during advancement and navigation.27 This difference in gas allows the balloon to advance with ease and carbon dioxide is soluble in blood. This prevents the risk of air embolism in pediatric patients if the balloon is ruptured. For angiography, a balloon tipped side hole catheter, such as the Berman catheter, allows flow directed injections, which performs angiography of the structures investigated.27 During angiography, the balloon can be inflated to occlude the vessel distally, which can give a better angiogram with contrast injections. Similarly to the adult cath lab, pigtail catheters are used for left ventricle and aortic angiography.27 However, these catheters such as the Judkins and multipurpose catheters are smaller sizes with shorter lengths and curves. Many catheter products that seem familiar to adult cath lab procedures, have been adapted for pediatric cardiology. For contrast injections during all pediatric procedures, power injector protocols are common due to image quality, vascular attenuation, and dosing restrictions.28 Curriculum Development for Technologist Transition Designing an effective curriculum for technologists transitioning from adult to pediatric cath labs requires careful consideration of the specific knowledge and skill sets that pediatric care requires. While there is limited literature specifically addressing this transition for technologists, ideas can be pulled together from related training models to guide the development. The European Association of Percutaneous Cardiovascular Interventions (EAPCI) Core Curriculum for cath lab professionals provides a valuable foundation that could be adapted for pediatric transition training even though it is not pediatric specific.22 This curriculum addresses 18 "the technical aspects of knowledge... by providing a competencies matrix for use in educational development or introduction of new staff in the cath lab".26 The nine core themes identified in this curriculum – ranging from procedural technique to person-centered care – provide a comprehensive framework that could be adapted to address the specific requirements of pediatric practice. Educational strategies used in care setting transitions can also provide useful guidance for technologist transition curricula. Research on pediatric-to-adult healthcare highlights the importance of programs that should be "longitudinal in nature, be patient focused, and be co produced by patients, caregivers, and care team members".29 These same principles– structured progression, team involvement, and mentorship–can be applied effectively to support technologists moving into pediatric roles. Technological innovations can also play a role in supporting transitions between care settings. Studies on smartphone applications for adolescents transitioning to adult healthcare have shown improvements in knowledge of medical conditions (21% improvement), healthcare system navigation (15.3% improvement), provider identification (32% improvement), and resource awareness (19.3% improvement).9, 31 Similar digital solutions could support technologist transitions through on-demand guidance to pediatric-specific procedural guides, equipment specifications, and reference materials. The Phoenix Children's Hospital CVICU Fellowship curriculum offers a model for specialized training through rotational experiences with progressive responsibility. This model could be adapted for technologist transition education, incorporating structured experiences in "Cardiac Catheterization" and other relevant areas with appropriate supervision.7 The principle that "as the fellow progresses through the training experience, they assume graduated authority and 19 increasing responsibility" with continuous access to expert consultation, this can provide a valuable model for technologist transition training.7 Foundational pediatric cardiac knowledge should also be incorporated, as exemplified by training at Boston Children’s Hospital. Topics such as "cardiac history exam, pediatric chest radiography," and other diagnostic modalities.30 Gaining an understanding of the unique elements involved in pediatric cardiac assessment such as "auscultation and characterization of cardiac murmurs" and recognition of "features of pathologic versus benign murmurs" offers essential contextual knowledge for cath lab procedures.30 The interdisciplinary nature of pediatric cath lab practice must be emphasized. The UF Health Shands Hospital Pediatric Cardiac Catheterization Lab highlight that "multidisciplinary, comprehensive care of patients and families is provided by medicine, nursing, social work services, case management, pastoral care, food & nutritional services, pharmacy, rehab services, cardiopulmonary services, and other health care providers".8 A well-rounded transition curriculum should prepare technologists to work collaboratively within the multifaceted care model. Pediatric Cardiac Catheterization Examination Overview Pediatric cardiac catheterization is a specialized field that requires a deep understanding of congenital heart disease, pediatric physiology, and age-specific procedural techniques. Unlike adult cardiac catheterization, which primarily focuses on coronary artery disease and structural heart interventions, pediatric procedures focus on diagnosing and treating congenital heart defects.31 Training for the treatment of pediatric CHD requires knowledge of the types of procedures performed, arrhythmias, normal and abnormal pediatric hemodynamics and 20 physiology, blood gas analysis, signs of patient decompensation, emergency management, and types of equipment that may be needed in emergencies.25 The following is a proposed Pediatric Cardiac Catheterization Examination designed to evaluate the knowledge and skills required for cath lab technologists transitioning to pediatric cath labs. The exam structure is adapted from adult catheterization credentialing but has been adjusted to reflect the unique nature of pediatric catheterization labs. The proposed examination matrix has a distribution of topics, including pre-procedural preparation, diagnostic procedures, and interventional procedures. Examination Matrix and Task List: Structure and Relationship The relationship between the Examination Matrix and Task List ensures that the examination remains practical, competency-based, and reflective of clinical responsibilities. The matrix provides a structured framework, while the task list defines the procedural and decision-making skills required for safe and effective patient care. Together, the Matrix and List create a comprehensive assessment model that evaluates both technical expertise and critical thinking in pediatric cardiac catheterization. Each section of the examination covers critical competencies in pediatric catheterization: PreProcedural Activities (15%) emphasize pediatric-specific sedation, anesthesia planning, radiation safety, and psychological preparation for children and families.25 Diagnostic Procedures (45%) carry the greatest weight, reflecting the importance of shunt detection, hemodynamic assessments, congenital defect imaging, and radiation minimization strategies. Interventional Procedures (30%) include structural heart interventions such as ASD, VSD, and PDA closure, balloon valvuloplasty, transcatheter valve implantation, and emergency interventions like balloon atrial septostomy. Emergency Response (5%) assesses the ability to manage pediatric 21 cardiac crises, airway management, and Pediatric Advanced Life Support (PALS) protocols. Post-Procedural Activities (5%) focus on pediatric hemostasis, complication management, caregiver education, and coordinated ICU/NICU transfers.33 Utilization of this proposed examination would ensure that professionals working in pediatric catheterization possess the expertise to provide safe, effective, and developmentally appropriate care for infants, children, and adolescents undergoing cardiac procedures. The following sections provide a detailed breakdown of each content category, defining key competencies and comparisons to adult catheterization. Examination Matrix The Examination Matrix or Registered Cardiovascular Pediatric Specialist (RCPS) Matrix visualized below, serves as a blueprint for the Pediatric Cardiac Catheterization Examination, outlining the emphasis placed on different skill areas and how it differentiates from the RCIS matrix. Each content category is assigned a percentage, reflecting its importance in clinical practice. This distribution ensures that the examination accurately assesses the core competencies required for professionals working in pediatric cardiac catheterization. The increased emphasis on pre-procedural and diagnostic activities reflects the complexity of congenital heart disease (CHD) management, while interventional procedures, emergency protocols, and post-procedural care are weighted to align with their practical significance. 22 Duties and Tasks The Task List defines the specific activities that a Registered Pediatric Cardiovascular Invasive Specialist is expected to perform in the pediatric cardiac catheterization lab. These tasks represent the day-to-day responsibilities of practitioners, from pre-procedure preparation to postprocedural care. The examination questions are directly linked to this task list, ensuring that candidates are assessed on real-world, job-relevant skills. The content of the examination is informed by a Job Task Analysis (JTA), which outlines the core responsibilities and knowledge areas expected of a Registered Cardiovascular Invasive Specialist. The CCI conducts a JTA every five years for all nine of its certification exams to ensure alignment with current industry practices. Examination material is developed in collaboration with cardiovascular subject matter experts and validated through statistical analysis conducted by professionals with advanced expertise in Industrial and Organizational Psychology.77 23 Conducting Pre-Procedural Activities (15%) Pre-procedural activities in pediatric cardiac catheterization differ significantly from those in adult catheterization due to variations in patient size, physiological considerations, and psychological needs.34 While both require preparation of the procedure room, the pediatric setting demands additional specialized equipment, catheter sizes, and radiation safety measures to accommodate smaller patients and minimize radiation exposure. Pediatric patients are more sensitive to radiation, necessitating techniques such as pulsed fluoroscopy, collimation, and shielding to reduce cumulative dose, whereas adult procedures focus more on general ALARA (As Low As Reasonably Achievable) principles.34 Patient preparation is also more complex in pediatrics, as it includes sedation or anesthesia planning and psychological preparation for both the child and family. Unlike adults, who can often undergo catheterization under mild sedation or local anesthesia, pediatric patients, especially neonates and infants, frequently require deep sedation or general anesthesia to minimize movement and distress.35 This requires careful assessment of pediatric-specific anesthetic agents such as ketamine, dexmedetomidine, or fentanyl/midazolam combinations, tailored to the child's age, weight, and hemodynamic status.35 In contrast, adult patients typically require less intensive anesthesia planning, as many can tolerate procedures with conscious sedation and local anesthetics. The review and validation of patient or procedure information also differ in focus. For pediatric patients, congenital heart disease (CHD) history, pre-procedure imaging (e.g., echocardiography, cardiac MRI), and hemodynamic parameters play a crucial role in planning interventions. Given the complexity of CHD, pre-procedural imaging is often more detailed, guiding both diagnostic and therapeutic decisions. Adult pre-procedural validation, on the other hand, primarily revolves 24 around coronary artery disease assessment, medication reconciliation, and general risk stratification.25 Additionally, obtaining informed consent in pediatrics is more intricate, as it requires engagement with parents or guardians, with additional considerations for assent from older children.25A reference tool for everything that should be completed for diagnostic patient preparation in pediatrics can be found in Appendix A.25,27,34,35 Overall, while the fundamental goals of pre-procedural preparation—ensuring patient safety, procedural success, and risk minimization—are shared between pediatric and adult catheterization, pediatric cases demand greater attention to anesthesia, radiation safety, congenital heart disease complexity, and psychological preparation.25 Conducting Diagnostic Procedures (45%) Diagnostic procedures in pediatric cardiac catheterization differ significantly from those in adults due to the unique hemodynamic considerations, congenital heart disease complexity, and anatomical variations in children. While both pediatric and adult catheterization focus on monitoring vital signs, assessing cardiac pressures, and utilizing imaging modalities such as intracardiac echocardiography (ICE), intravascular ultrasound (IVUS), and optical coherence tomography (OCT), pediatric cases require additional considerations for age-dependent vital sign norms, shunt calculations, and congenital anatomy.36 Pediatric catheterization places greater emphasis on right and left heart catheterization for congenital defect assessment, angiographic imaging for vessel anomalies, and radiation safety protocols tailored to smaller and more radiosensitive patients.36 Vital sign monitoring is more complex in pediatric patients due to the wide variability in normal ranges based on age and weight. Heart rate, blood pressure, and respiratory rate differ significantly from neonates to adolescents, requiring specialized monitoring to detect 25 hemodynamic instability.37 In adults, vital signs remain relatively stable across patients, with most variations related to preexisting cardiovascular disease rather than developmental physiology.37 One of the biggest differences between pediatric and adult diagnostic catheterization is the high frequency of congenital heart disease evaluations in pediatrics. Pediatric cardiac catheterization often involves shunt detection, oxygen saturation runs, and Qp:Qs calculations to assess intracardiac and extracardiac shunts, whereas adult procedures primarily focus on ischemic heart disease, valve dysfunction, and pressure gradients.25 The pediatric workflow frequently includes angiographic imaging of complex vascular structures such as the aorta, pulmonary arteries, and venous return systems, which are rarely imaged in adult patients unless there is a vascular anomaly.25 Additionally, balloon occlusion testing for preoperative planning is a routine pediatric assessment, particularly for single-ventricle physiology, whereas in adults, occlusion testing is more commonly performed in the context of tumor embolization or vascular trauma.25 Both pediatric and adult catheterization labs employ advanced imaging modalities such as ICE, IVUS, and OCT, but pediatric cases require greater precision in identifying congenital anomalies and assessing vessel growth potential.36 Pediatric imaging must account for smaller vessel diameters, complex anatomical variations, and the need for long-term monitoring of repaired defects.25 Adult catheterization, on the other hand, predominantly uses imaging to guide coronary interventions, peripheral vascular procedures, and structural heart evaluations. Radiation safety is a higher priority in pediatric catheterization, as children are more susceptible to radiation-induced complications due to their developing tissues and longer life expectancy. Techniques such as pulsed fluoroscopy, collimation, and dose minimization protocols are strictly enforced.34 While radiation safety is important in adults, pediatric patients require stricter 26 adherence to ALARA (As Low As Reasonably Achievable) principles, with a focus on alternative imaging strategies such as MRI or echocardiography when possible.34 Pharmacologic considerations also differ, as pediatric patients require weight-based dosing of cardiovascular medications, including inotropes, vasodilators, and prostaglandins. Unlike adults, who often have preexisting conditions requiring chronic medication management, pediatric patients may have more acute and developmental considerations, such as the use of prostaglandin E1 (PGE1) to maintain ductal patency in neonates with duct-dependent congenital heart disease.38 Vascular access techniques are significantly different in pediatric patients. While both pediatric and adult procedures commonly utilize femoral, radial, and jugular access, pediatric cases may require umbilical vein access in neonates or modified techniques for small vessel cannulation.40 Pediatric providers must also carefully balance access site selection with future surgical and interventional needs, particularly in cases of staged palliation for complex congenital heart disease.40 A reference tool for everything that should be included in a diagnostic procedure is in Appendix B.25,27,34,35 Overall, pediatric diagnostic catheterization is more focused on congenital anatomy, hemodynamic assessments, and radiation safety, whereas adult catheterization prioritizes ischemic disease, coronary evaluations, and structural interventions. The increased weight of diagnostic procedures in pediatric catheterization reflects the greater complexity of CHD evaluations, the need for meticulous hemodynamic assessments, and the reliance on catheterization for both diagnosis and interventional planning.43 27 Conducting Interventional Procedures (30%) Interventional procedures in pediatric cardiac catheterization differ significantly from those in adults due to the focus on congenital heart disease (CHD), developmental physiology, and the need for long-term procedural planning.39 While both pediatric and adult catheterization labs perform device implants, balloon interventions, and stent placements, pediatric interventions primarily address structural heart defects, congenital obstructions, and duct-dependent circulation, whereas adult interventions are more focused on coronary artery disease, atherosclerosis, and acquired valvular dysfunction.39,42 The slightly lower weight of interventional procedures in pediatrics (30% vs. 33% in adults) reflects the greater emphasis on diagnostic catheterization in congenital cases, as well as the higher reliance on surgical interventions for complex congenital defects.41,42 Device implantation is a shared component between pediatric and adult catheterization, but the indications and technical considerations differ. Adults commonly receive pacemakers, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices for ischemic cardiomyopathy, atrioventricular block, and arrhythmias related to aging and structural heart disease.44 In pediatrics, device implants must be tailored to smaller anatomical structures, growth considerations, and congenital arrhythmia syndromes.45 Epicardial lead placement, which is rarely needed in adults, is more common in pediatrics due to smaller venous anatomy limiting transvenous lead options.45 A key distinction in pediatric interventional catheterization is the frequent need for emergency balloon atrial septostomy (BAS) in neonates with transposition of the great arteries (TGA)48. This procedure, performed via the Rashkind technique, is life-saving in newborns with cyanotic CHD who require an atrial-level shunt for oxygenated blood mixing. No adult equivalent exists, 28 as atrial septostomy is rarely indicated outside of palliative settings for refractory heart failure or pulmonary hypertension. A reference tool for everything that should be included in Balloon Atrial Septostomy should be included in Appendix B.25,27,34,35 Pediatric catheterization also involves a greater emphasis on congenital defect closures. Patent ductus arteriosus (PDA) closure, atrial septal defect (ASD) closure, ventricular septal defect (VSD) closure, and patent foramen ovale (PFO) closure are routine pediatric interventions performed with devices such as the Amplatzer septal occluder.26 In contrast, ASD and PFO closure in adults are less common and typically reserved for stroke prevention or right heart strain. VSD closure in adults is rare, as most congenital VSDs either close spontaneously in childhood or are surgically repaired in infancy.51A reference tool for Atrial Septal Defect Closure and Ventricle Septal Defect Closure can be found in Appendix D.25,27,34,35 Balloon valvuloplasty is another common pediatric intervention performed for pulmonary, aortic, and mitral valve stenosis.53 This technique is often preferable to surgery in neonates and infants with congenital valve stenosis, it is a minimally invasive alternative to surgical valvotomy.53 In contrast, adult balloon valvuloplasty is primarily used for calcific aortic stenosis in patients who are not surgical candidates for valve replacement.54 Stent placement in pediatric catheterization is primarily performed for congenital vascular stenosis, such as coarctation of the aorta and pulmonary artery stenosis. Unlike adults, where stents are primarily used in coronary and peripheral arteries, pediatric cases require growthadapted stent selection, with some stents designed to be expanded over time.56 Similarly, transcatheter valve implantation, such as the Melody valve for pulmonary valve replacement, is widely used in pediatrics but is distinct from adult transcatheter aortic valve replacement (TAVR), which is primarily used for degenerative valve disease.57 29 Another key pediatric intervention is ductal stenting in duct-dependent congenital heart disease. Some neonates with conditions such as hypoplastic left heart syndrome (HLHS) or pulmonary atresia rely on a patent ductus arteriosus for systemic or pulmonary blood flow.59 In these cases, stenting the ductus arteriosus can serve as a bridge to surgical palliation, a concept that does not exist in adult practice. Pediatric interventional procedures also include percutaneous coronary interventions for congenital coronary anomalies. Unlike adults, where coronary interventions focus on atherosclerotic plaque removal, pediatric coronary interventions address anomalous coronary artery origins, fistulas, or Kawasaki disease-related stenoses.60 Mechanical circulatory support in pediatrics includes extracorporeal membrane oxygenation (ECMO), ventricular assist devices (VADs), and Impella RP, but differs from adults in that pediatric support is often needed for congenital heart failure, myocarditis, or bridge to transplant, whereas adult use is primarily related to ischemic cardiomyopathy and cardiogenic shock.61,63 Lastly, while both pediatric and adult catheterization involve pericardiocentesis and thrombectomy, the etiologies differ. In adults, pericardiocentesis is often required for malignant or post-myocardial infarction pericardial effusions, whereas in pediatrics, it is more often related to postoperative effusions or congenital pericardial disorders.62 Thrombectomy in adults is mostly performed for deep vein thrombosis (DVT) or acute coronary thrombosis, while in pediatrics, it is more frequently used for catheter-related thrombosis or thrombotic complications of congenital heart disease.64 In summary, pediatric interventional catheterization focuses on congenital defect management, valve and shunt modifications, and growth-adapted interventions, whereas adult interventions primarily address ischemic, degenerative, and acquired cardiovascular diseases. The slightly 30 lower emphasis on interventional procedures in pediatrics (30% vs. 33% in adults) reflects the greater reliance on catheterization for diagnostic evaluations and the ongoing role of surgical interventions in pediatric CHD management.42 Responding to Emergency Procedures and Protocols (5%) Emergency response in pediatric cardiac catheterization differs from adult catheterization due to developmental physiology, the prevalence of congenital heart disease (CHD), and the specialized resuscitation protocols required for neonates and children. While both pediatric and adult catheterization teams must respond to cardiac arrest, shock, arrhythmias, and hemodynamic instability, pediatric emergencies often involve cyanotic crises, low cardiac output syndrome, and congenital anatomical complexities.47 Additionally, airway management and sedation reversal are more critical in pediatric settings due to the frequent use of deep sedation and general anesthesia, whereas adult emergencies are often related to ischemic events and preexisting cardiovascular conditions.47 One of the key differences in emergency response is the type of cardiac events encountered. In adult catheterization, the most common emergencies include ST-elevation myocardial infarction (STEMI), acute pulmonary edema, limb ischemia, and stroke, reflecting the high prevalence of atherosclerosis and thromboembolic disease.49 Pediatric catheterization, in contrast, frequently involves cyanotic episodes in infants with CHD, low cardiac output syndrome following interventional procedures, and tamponade due to small pericardial space constraints.50 Additionally, children are more prone to bradyarrhythmias and congenital arrhythmia syndromes, which require specialized pediatric ACLS (PALS) protocols different from adult ACLS guidelines.50 31 The operation and maintenance of emergency equipment also vary between pediatric and adult settings. While both require defibrillators, code carts, suction, and airway management tools, pediatric cases demand age-specific resuscitation equipment, including smaller endotracheal tubes, specialized defibrillator energy settings, and pediatric-specific medication dosing.50 In adults, emergency response primarily focuses on coronary reperfusion strategies, thrombolytic therapy, and cardiogenic shock management with advanced mechanical support such as intraaortic balloon pumps (IABP) or Impella devices.52 In contrast, pediatric cases require rapid management of hypoxia, acidosis, and congenital cardiac anomalies, sometimes necessitating ECMO (extracorporeal membrane oxygenation) support in critically ill neonates and children.28 Additionally, sedation-related emergencies are more frequent in pediatric catheterization due to age-dependent responses to anesthesia and sedation agents. Children, especially neonates and infants, have immature hepatic and renal clearance mechanisms, increasing their risk for delayed sedation recovery, apnea, and airway compromise.50 Therefore, pediatric emergency response protocols emphasize sedation reversal agents (e.g., flumazenil for benzodiazepines, naloxone for opioids) and airway protection strategies,50 whereas in adults, sedation emergencies are less common due to greater procedural tolerance and the routine use of conscious sedation rather than deep anesthesia. While both pediatric and adult emergency response protocols include Advanced Cardiovascular Life Support (ACLS), pediatric cases follow the Pediatric Advanced Life Support (PALS) algorithm, which incorporates age-based resuscitation techniques, pediatric-specific drug dosages, and recognition of congenital heart lesions that may alter traditional resuscitation strategies.50 For example, a child with a single ventricle physiology or a systemic-to-pulmonary 32 shunt may require modified resuscitation approaches, such as maintaining ductal patency with prostaglandin E1 (PGE1) infusion rather than conventional ACLS interventions.38 The slightly lower emphasis on emergency protocols in pediatric catheterization (5% vs. 6% in adults) reflects the fact that pediatric cath lab procedures are often planned rather than urgent,42 whereas in adult cath labs, emergent STEMI interventions are a common indication for catheterization. However, when pediatric emergencies do occur, they require a highly specialized, age-specific response that accounts for developmental physiology, congenital heart defects, and unique resuscitation challenges.50 Conducting Post-Procedural Activities (5%) Post-procedural activities in pediatric cardiac catheterization differ significantly from those in adults due to smaller vascular structures, developmental considerations, congenital heart disease (CHD) complexities, and the involvement of families in post-procedure care.55 While both pediatric and adult post-procedural management focuses on hemostasis, complication monitoring, patient education, and care transition, pediatric cases require specialized vascular closure techniques, vigilant monitoring for developmental complications, and family-centered education.55 The lower weight of post-procedural activities in pediatric catheterization (5% vs. 9% in adults) reflects the fact that pediatric patients often require extended inpatient observation post-procedure,42 reducing the immediate need for extensive post-procedural management within the cath lab setting. Hemostasis management is more challenging in pediatric patients due to smaller arterial and venous vessels, lower blood volume, and the limited availability of closure devices specifically designed for infants and young children.55 While adults often benefit from vascular closure devices (e.g., Angio-Seal, Perclose), pediatric patients, especially neonates, frequently require 33 manual compression due to the risk of vessel trauma or thrombosis from closure devices. In contrast, adults have larger, more robust vessels, making closure device application more straightforward.55 Post-procedural complication management also differs between pediatric and adult patients. Adults are more prone to ischemic complications, such as stroke or acute limb ischemia, whereas pediatric patients are at higher risk for hematomas, vascular thrombosis, and hypoxia due to their smaller vessel size and immature cardiopulmonary physiology.50 Arrhythmias, a common concern in both populations, may have different etiologies and management strategies in pediatric patients, particularly those with congenital conduction system abnormalities or prior surgical interventions affecting conduction pathways.58 Patient education in pediatrics is inherently different from that in adults, as it involves both the child (when age-appropriate) and their caregivers.55 Unlike adults, who can directly manage their own post-procedural care, pediatric discharge instructions must be tailored to parents and guardians, covering topics such as activity restrictions, wound care, medication adherence, and follow-up for congenital interventions.55 Additionally, pediatric patients undergoing interventional procedures for CHD may require long-term follow-up and staged surgical planning, requiring caregivers to be actively engaged in ongoing medical decision-making.55 Finally, the reporting and transfer of care process in pediatric catheterization differs due to the frequent need for post-procedural ICU or NICU monitoring. Many pediatric patients, especially neonates and infants, require direct transfer from the cath lab to intensive care settings, whereas most adult patients return to general cardiac recovery units or step-down telemetry units.55 Additionally, pediatric cardiac catheterization often involves multidisciplinary coordination 34 between pediatric cardiologists, intensivists, and congenital heart surgeons to determine the next steps in patient management.55 Overall, while both pediatric and adult post-procedural care emphasize hemostasis, complication monitoring, and education, pediatric cases require specialized vascular management, heightened family involvement, and more complex care transitions.55 The lower weight assigned to postprocedural activities in pediatric catheterization (5% vs. 9%) reflects the fact that many pediatric patients remain under inpatient monitoring post-procedure, reducing the need for extensive immediate post-cath management in the cath lab itself.42,55 Summary This literature review has explored the current evidence regarding the transition of cath lab technologists from adult to pediatric settings, with a particular focus on procedural differences, equipment adaptations, and curriculum development approaches. The review highlights the significant distinctions between adult and pediatric cardiac catheterization, including the higher prevalence of congenital heart defects in pediatric populations, the need for specialized equipment to accommodate smaller anatomies, and unique procedural considerations such as pediatric-specific anesthesia protocols and radiation safety measures. Existing curriculum frameworks, particularly the EAPCI Core Curriculum for catheterization laboratory professionals, offer valuable structures that could be adapted for pediatric specific transition training.22 The CVICU Fellowship model at Phoenix Children's Hospital, which emphasizes rotational experiences and graduated responsibility, presents another effective approach that could be modified for technologist education.23 In addition, research on healthcare transitions – although primarily centered on patients – underscores the importance of structured, 35 longitudinal programs supported by mentorship and accessible resources, which are equally relevant for professional role transitions. Although educational intervention case studies do not specifically address technologist transitions, they offer valuable models that could inform curriculum design. Models based on the rotational experience approach with graduated responsibility, as demonstrated in fellowship programs, provide an effective structure for specialized training. Technological support tools have proven its effectiveness in supporting transitions across healthcare settings and could be adapted for technologist education. Despite these contributions, there remains a notable gap in the literature specifically addressing the transition of technologists from adult to pediatric catheterization settings through documented case studies. Further research is necessary to identify the specific challenges encountered, successful adaptation strategies, and learning approaches employed by technologists who have successfully made this transition. This gap reinforces the need for the proposed study to develop a comprehensive case-informed curriculum tailored for cath lab technologists transitioning from adult to pediatric settings, incorporating learning approaches that build on the limited existing literature. Chapter 3: Research Method Current pathways to becoming a cath lab technologist focus on adult cardiac procedures, with very little education specific to pediatric catheterization. The transition from adult to pediatric cath lab settings presents significant challenges for technologists. Beyond procedural knowledge, pediatric cardiac catheterization requires understanding different radiation safety parameters, contrast dose calculations, sedation protocols, and equipment specifications scaled for children of varying sizes.17 Additionally, the psychological approach to pediatric patients differs 36 substantially from adult care, requiring specialized communication skills with patients and parents alike. The literature reveals a significant gap in formalized transition pathways for cardiac catheterization professionals. While transition programs for patients have been extensively studied and implemented,6 parallel programs for healthcare professionals remain underdeveloped. This gap is concerning given the specialized knowledge required for common pediatric interventions described and the potential impact on patient outcomes when procedures are performed by technologists transferring over without adequate pediatric training. As the field of congenital heart disease continues to evolve, increasing survival rates and technological advancements, the need for specialized training for these cath lab technologists becomes critical. Addressing this knowledge gap represents an important frontier in optimizing care for any cath lab technologist that transfers from adult to pediatric settings. The following chapter will set up the literature review as a guideline for cath lab technologists trained in the adult cath labs transitioning to the Pediatric Cath Lab. Research Methods and Design This comprehensive literature review will be structured using the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines.46 The goal is to gather comprehensive literature to support the proposal of a curriculum for any cath lab technologist transitioning to a pediatric cath lab. Data Collection, Processing, and Analysis All research information and studies will be gathered using Weber State Universities Meta Search, Elicit research AI database, PubMed online database, and Google Scholar. These platforms will be used to search for key terms like “Cath Lab and pediatrics”, “common pediatric 37 procedures”, “paediatric catheterization laboratory” and more. The goal is to find the most up to date information on all procedures performed worldwide, providing essential knowledge for the Cath Lab personnel and the treatments offered in pediatric catheterization labs. Assumptions In studying the transition of cath lab technologists from adult to pediatric care, a few assumptions are made to help guide the research. First, it’s presumed that the current literature on pediatric catheterization and professional transition is credible, reliable and relevant to this topic. This includes academic sources, peer-reviewed articles and established clinical guidelines that provide valuable insights on the necessary skills required, obstacles, and challenges involved in the transition. Second, it’s assumed that the authors of these sources have maintained objectivity, ensuring their conclusions are free of bias. Lastly, it’s assumed that findings from past studies on similar healthcare transitions can be applied to cath lab technologists transitioning from adult to pediatric care. These assumptions help establish a foundation for analyzing existing knowledge while also recognizing potential limitations in the sources used. Limitations Limitations of this comprehensive literature review include the use of published peer reviewed research papers including pediatric information from hospital websites. As this specific literature review has not been conducted, limitations arise in locating step by step guidance of pediatric Cath lab procedures world wide. This challenge also includes comparing adult catheterization equipment to pediatric equipment globally. The availability of research focused on pediatric invasive cardiologists and fellows is not limited through sources, but it is limited on cath lab technologists scope of practice. 38 This review is limited to studies published within the last 10 years, with the exception of five studies. All studies that are sourced only include the english language, which may exclude valuable data published in other languages. Potential study biases for these studies involve equipment costs, availability geographically, preferences, technological advancements, and facilities. Since Pediatric Cath Labs are rare throughout the world, there is a lack of standardized guidelines and cohesion between institutions. Training of cath lab technologists typically follows local protocols and varies depending on individual hospital policies. Delimitations When developing a curriculum for transitioning from the adult cath lab to the pediatric cath lab, it is important to consider key delimitations. An initial consideration is the time frame; the majority of included studies are from 2015-2025, with the exception of five articles. Another defined boundary that was established in this literature review is the patient population. The primary focus is on children ages 0-18. Treatments specific to neonatal populations and continued congenital heart care into adulthood have been excluded from the scope of this curriculum. Finally, this study is limited to procedures that are commonly performed in the pediatric cath lab. While there are many rare cases and disorders encountered in practice, they will not be discussed in this curriculum. By outlining these delimitations, the proposed curriculum can explain all of the necessary skills and tools that cardiovascular invasive specialists will need to efficiently succeed in a pediatric cath lab. Ethical Assurances Ethical considerations are a top priority when proposing a curriculum for the pediatric cath lab. All suggested content needs to be of the highest standard with a strong emphasis on patient 39 safety. This curriculum includes proper citation of all reviewed studies, following AMA 11 formatting. No data has been selectively presented to support any preconceived conclusions. Since this curriculum is based solely on a comprehensive literature review and does not involve original research or patient interaction, IRB approval is not required. Summary In summary, this literature review serves as a guideline to support cath lab technologists trained in the adult cath labs to transition to Pediatric Cath Labs. The review focuses on the most common procedures in the Pediatric Cath Lab, comparing them with the techniques already familiar to adult-trained technologists. With the absence of standard curriculums, this will offer guidance to cath lab technologists that want to transition into the pediatric setting. The decision to develop a curriculum stems as a way to address the lack of cohesion in training for pediatric cath labs. The differences in pediatric cath labs from adult cath labs present significant challenges for the transitioning cath lab technologists. This review addresses key assumptions, limitations, and delimitations necessary for presenting a clear and useful curriculum. These include the assumption that current literature is valid, the limitation of procedure variability across institutions, the deliberate exclusion of neonatal and adult congenital cases, and the ethical responsibility of working with a vulnerable pediatric population. Chapter 4: Findings This study explores the challenges faced by cardiovascular invasive specialists transitioning from adult to pediatric settings, focused on the lack of structured training. This chapter discusses key competencies needed, unfamiliar pediatric procedures and invasive specialists experiences adapting to new environments. The findings address training gaps, potential impacts on patient safety, and strategies for developing an effective educational framework to improve efficiency 40 and outcomes in pediatric cardiac catheterization labs. The current training paradigm for cardiac catheterization laboratory technologists focuses predominantly on adult procedures, leaving a critical knowledge gap for technologists transitioning to pediatric settings. This research aims to address this gap by developing a comprehensive curriculum that systematically compares adult and pediatric cardiac catheterization procedures and equipment, with specific focus on the more common interventions according to multiple hospital websites, which includes patent ductus arteriosus (PDA) closure, atrial septal defect (ASD) closure, balloon valvuloplasty, (VSD) closures, and balloon septostomy/stenting procedures.17,18,23,65 Synthesis of Findings The included studies were analyzed based on the primary themes emerging from the literature. The findings are presented in relation to the research question(s) and grouped according to the following categories: Current approaches to pediatric cath lab training, procedural differences, equipment and technical adaptations, curriculum development, and general pediatric cath lab examination. Procedural Adaptations for Pediatric Catheterization Analysis of the common procedures in the pediatric cath lab showed significant differences in procedures in adult and pediatric settings. Most procedures in the pediatric cath lab are performed due to congenital heart defects in ASD/PDA closures, congenital valve defects in balloon valvuloplasty, and congenital vessel stenosis or post surgical vessel narrowing.3 With these unique considerations, modified anesthesia protocols, age specific preperation, consideration of vessel growth potential, and many more procedural adaptations were found when comparing with adult cath lab procedures. 41 Equipment and Technical Considerations Analysis of equipment and technical considerations revealed differences in nearly all equipment used in pediatric catheterization. This includes, imaging equipment with biplane configurations, lower frame rates, tight collimation, reduced magnification, and specialized pediatric radiation dose protocols. Catheterization equipment in pediatric laboratories require a wider range of catheter sizes from neonatal to adult sized for adolescents. Specialized heart disease catheters are shaped for navigating complex anatomy, and miniaturized closer devices, balloons, and stents are needed for smaller cardiac structures.66 Educational Framework With analysis of education needed for adult cath lab technologists transferring over to pediatric, it was found that there are several core knowledge fundamentals essential for transitioning. Congenital heart disease must be studied with understanding the most common defects, hemodynamic assessments, and natural history. Adaptations are common, and a cath lab technologist needs to understand any adaptation that occurs during the procedure. As outlined by the American Heart Association, “you must know procedural techniques for catheterization and specific interventions”.9 Specialized knowledge also is needed for equipment operation and selection, radiation safety reduction strategies, and emergency preparedness for specific complications. The findings indicate procedural adaptations, equipment technical considerations, and educational framework are key trends needed for a comprehensive educational training for adult cath lab technologists transferring to pediatrics. While some studies demonstrated coherent procedures step by step and equipment based on pediatric procedures of the common procedures 42 written in this paper, others showed variations, likely due to differences in study design, sample characteristics, or intervention methodologies. Results This data of case studies involved more common pediatric procedures done in the Cath Lab to support a transfer of cath lab technologists from adult to pediatric. These procedures included: Atrial Septal Defects, Ventricular Septal Defects, Patent Ductus Arteriosus Closures, Valve Stenosis Treatments, Septostomy/Stenting.17, 18, 23, 65 We analyzed key factors in these case studies which included age range, equipment used, procedural steps, pre diagnosis, outcomes, management strategies, and trends in Pediatric Cath Labs geographically. Average patients in pediatrics were 0-18 years old, and had pre diagnosis complications.27 The most common symptoms include shortness of breath, infections, poor weight gain, chest pain, fainting, and cyanosis.27 Atrial septal defect (ASD), is a common congenital heart malfunction and compromises 5.9% 10% of all congenital heart disease (CHD).67 Studies on transcatheter ASD closure in pediatric patients using the Amplatzer Septal Occluder reported success rates exceeding 95%, with complete defect closure in over 99% of cases at follow-up. Utilizing echocardiography including intracardiac echocardiography and fluoroscopy for procedural guidance, the catheter-based procedure, performed under general anesthesia, showed significant improvements in exercise capacity and cardiac function. Complications were minimal, with transient arrhythmias occurring in only 2.2% of patients. These findings confirm transcatheter ASD closure as a safe and effective alternative to surgery, highlighting the critical role of specialized pediatric cath labs.68, 69 43 Patent ductus arteriosus (PDA) is among the most common congenital heart defects, representing 5% - 10% of all congenital heart disease (CHD) cases in term infants.70 Transcatheter PDA closure, particularly in premature infants, is typically performed in pediatric cardiac catheterization laboratories by specialized teams trained in neonatal interventions. Studies used focus on the use of the Amplatzer Piccolo™ Occluder, a device specifically designed for PDA closure in small infants. This highlights the direct relevance of these studies to pediatric cath lab procedures, emphasizing the specialized skills required for such interventions.71, 72 A reference tool for Patent Ductus Arteriosus Closure can be found in Appendix C.25,27,34,35 Valve stenosis treatments focus on two valves of the heart; pulmonary valve stenosis accounts for 6-9%75 and aortic valve stenosis accounts for 3-6%.73 Although there is also some interest in treating mitral regurgitation in pediatrics with valvuloplasty as well it has not become the established procedure as of yet.26,74 The equipment for this procedure includes each of the following available in a variety of sizes in order to properly assess and correct pediatric anatomy: balloon, catheter, sheaths and guidewires.26 The guidelines for the radiology aspect of the procedure are that biplane fluoroscopy/cineangiography should be available in a pediatric or congenital treatment catheterization lab.26 A reference tool for Pulmonary Valve Stenosis can be found in Appendix B. 25,27,34,35A reference tool for Aortic Valve Stenosis can be found in Appendix E.25,27,34,35 Angioplasty/Stenting is one of the most common procedures performed in the Pediatric Cath lab, with various congenital heart defects contributing to this procedure. In a study of 24 pediatric CHD patients, 43 procedures were performed in the pediatric cath lab, and 20 involved angioplasty, 10 stent placements, and 13 combined both.76 Equipment used during these procedures depend on the severity of the case. They appear similar to adult cath lab procedures 44 but are done with smaller catheter, balloon caths, stents, sheaths, and guidewires. This equipment sizing is based on Cath lab to Cath lab, but technologists should ensure what the most common specialized equipment is in the pediatric cath lab. This includes the Tracker 18 catheter, Palmaz balloon-expandable stent, Minima growing stents, etc. Evaluation of Findings This study has aimed to define the conceptual framework of a curriculum for a cardiovascular invasive specialist transitioning from adult to pediatric cath labs. Pediatric cases require a solid understanding of congenital heart defects, unique equipment, hybrid procedures, and advanced radiation safety. Each of those subjects are critical for any cath lab technologists transitioning to be in the pediatric cath lab and should be a core part of any training or curriculum that is developed. Data has shown that atrial septal defects (ASD), patent ductus arteriosus (PDA) closures, valve stenosis (valvuloplasty), and balloon angioplasty with stenting are the more common congenital heart diseases (CHD) in pediatrics.17, 18, 23, 65 A strong grasp of these CHDs along with the unique equipment and radiation concerns are all essential to a pediatric cath lab curriculum. Summary This review has highlighted several common CHDs with ASD and VSD cases accounting for 46.8% of the cases performed in the pediatric cath lab.32 Other key curriculum topics include the equipment sizing and the unique pediatric anatomy that accounts for radiography differences from the adult cath lab. While most patients in the pediatric cath lab experience successful outcomes, the efficiency and safety of pediatric procedures could be improved by a more comprehensive training program for the pediatric invasive specialist. This review brings attention 45 to an often overlooked and undervalued part of an invasive specialist training, and gives a comprehensive curriculum to be utilized as training for the pediatric cath lab in the future. Chapter 5: Implications, Recommendations, and Conclusions Introduction This study addressed the critical gap in structured training pathways for cath lab technologists transitioning from adult to pediatric settings. Despite growing demand for qualified personnel in pediatric cardiac catheterization laboratories, most cardiovascular technology education programs focus primarily on adult populations, leaving technologists inadequately prepared for the unique challenges of pediatric practice. Through a literature review examining existing training programs, procedural documentation, and expert perspectives, this research aimed to identify the essential components of a comprehensive transition curriculum addressing procedural and equipment differences, educational frameworks, and procedural steps for common procedures such as: PDA closures, ASD closures, VSD closures, valvuloplasty, and balloon/stenting.17, 18, 23, 65 Several limitations should be acknowledged, including the variable quality of available documentation across institutions, the evolving nature of catheterization technology and techniques, the limited documentation of technologist-specific training, and geographic variations in practice. Ethical considerations included ensuring confidentiality of institutional sources and expert contributors while maintaining transparent reporting of findings. This chapter discusses the implications of the study findings, provides recommendations for curriculum development and implementation, and presents conclusions regarding the transition of technologists between adult and pediatric settings. 46 Implications Research Question: What are the essential components of a comprehensive transition curriculum for cath lab technologists moving from adult to pediatric settings? The findings indicate that a comprehensive transition curriculum must address four key domains: procedural adaptations, equipment and technical considerations, educational framework requirements, and competency assessment approaches. This multifaceted approach aligns with existing literature on specialized training in pediatric cardiology, which emphasizes the need for both knowledge acquisition and practical skills development through structured experiences. The identification of specific procedural differences between adult and pediatric approaches to common interventions such as PDA closure, ASD closure, VSD closure, valvuloplasty, and balloon stenting,17, 18, 23, 65 has significant implications for curriculum development. These differences necessitate targeted educational content that builds upon existing adult catheterization knowledge while emphasizing the unique considerations of pediatric practice. As noted in the literature on training in congenital heart disease interventions, "intermediate and advanced levels of training... [are] acquired through additional year(s) of dedicated interventional training",15 suggesting that transition education should be conceptualized as an advanced training module rather than simply an orientation to a new setting. The equipment and technical considerations identified in this study underscore the need for specialized training in radiation safety and imaging optimization for pediatric patients. This has implications for both didactic content and hands-on training components of a transition curriculum. The finding that pediatric cath labs often incorporate specialized imaging systems with "a special dose tracking system to reduce radiation exposure to pediatric patients"18 47 suggests that technologists transitioning to pediatric settings must develop proficiency with different equipment interfaces and operational protocols than those used in adult laboratories. The competency assessment approaches identified in this study have implications for how transition training is evaluated and credentialed. The American Heart Association's recommendation for assessment through "direct observation, conference participation and presentation, procedure logs, and in-training examination"9 suggests a multifaceted approach to competency verification that goes beyond simple procedural checklists. This has implications for the development of assessment tools and processes within a transition curriculum. When considered in context of the existing literature on health professional education, these findings suggest that the transition curriculum should be structured as a formal educational program rather than an informal on-the-job training experience. This aligns with the broader trend toward competency-based education in healthcare, where specific knowledge, skills, and attitudes are systematically developed and assessed against established standards. Within the context of cardiovascular technology education and practice, this study's findings offer several practical applications: Curriculum Blueprint, Competency Assessment Tools, Professional Development Pathways, and Quality Improvement Initiatives. The domains identified provide a curriculum blueprint for developing institutional transition programs for technologists moving from adult to pediatric settings. The specific knowledge and skill requirements identified can inform the development of Competency Assessment Tools for evaluating technologist readiness for pediatric practice, an example of this can be found in Appendix F. The findings support the creation of specialized certification or recognition for technologists with pediatric catheterization expertise, potentially enhancing career advancement/professional development opportunities. The identification of critical differences 48 between adult and pediatric practice can inform quality improvement efforts in catheterization laboratories serving pediatric populations. The findings contribute to the profession by providing a comprehensive understanding of the specialized knowledge and skills required for pediatric catheterization practice. This addresses a significant gap in the literature, as most existing resources focus either on physician training or on general cardiovascular technology education without specific attention to the adult-topediatric transition. Recommendations Based on the study findings, the following recommendations are proposed for the development and implementation of transition curriculum for cath lab technologists: Structured Curriculum Development, Graduated Responsibility Model, Procedure-Specific Modules, Simulation-Based Training, Formal Mentorship Program, Competency Assessment Framework, Interdisciplinary Education Institutions should develop a formal transition curriculum that addresses all four thematic domains identified in this study: procedural adaptations, equipment and technical considerations, educational framework requirements, and competency assessment approaches. Transition training for cath lab technologists should follow a graduated responsibility model similar to that used in fellowship programs, with structured observation, supervised participation, and progressive independence under appropriate oversight. Curriculum should include dedicated modules for each of the five focal procedures (PDA closure, ASD closure, valvuloplasty, PFO closure, and balloon angioplasty/stenting), highlighting the specific differences from adult practice. Where available, simulation technology should be incorporated to provide safe practice opportunities for critical technical skills before application in clinical settings. 49 Institutions should establish structured mentorship relationships pairing transitioning technologists with experienced pediatric cath lab personnel. A formal assessment framework should be implemented, including both knowledge-based evaluation and skills demonstration, with clear benchmarks for achievement. Transition curriculum should include opportunities for learning alongside other members of the pediatric cardiac care team, such as nurses and doctors, fostering understanding of team dynamics and communication patterns. Transition training should be integrated with continuing education requirements, potentially offering specialized credentialing or recognition upon completion. This research supports the development of credentials for pediatric practice analogous to the RCIS. Given the specialized knowledge and skill set required, it is recommended that CCI consider establishing dedicated credentials for pediatric cath lab technologists to ensure standardized competency and elevate the quality of care. Future Directions Future research should address several areas that would enhance understanding of technologist transition between adult and pediatric settings: Outcome Evaluation, Competency Validation, Technology Integration, Cross-Institutional Standardization, Bidirectional Transition, and LongTerm Career Impact. There should be an outcome evaluation of the proposed curriculum, future studies should examine the impact of structured transition curriculum on procedural quality metrics, radiation safety, and team performance. Another possible future study should assess competency, research should be done to validate specific competency benchmarks for technologists in pediatric catheterization laboratories. Future validation efforts should be grounded in a job task analysis specific to pediatric cath lab practice. This would ensure that any assessments or certifications 50 developed are truly reflective of real-world responsibilities and skill sets. Technology is rapidly changing and has the potential to aid in many aspects of the cath lab, investigation needs to be done on how technological tools such as virtual reality simulation and AI could enhance transition training effectiveness. Development and validation of standardized transition curriculum should also take place, this curriculum could be implemented across multiple institutions, this includes both universities and hospitals. This paper explored the transition from the adult to the pediatric cath lab setting, another study should be done on the knowledge and skill requirements for technologists transitioning from pediatric to adult settings, which may involve different challenges. Lastly, a possible direction to explore is a study that examines how specialized pediatric training influences technologist career trajectories and long-term professional satisfaction. Conclusions This study identified four key domains essential for a comprehensive transition curriculum for cath lab technologists moving from adult to pediatric settings: procedural adaptations, equipment and technical considerations, educational framework requirements, and competency assessment approaches. The findings demonstrated significant differences between adult and pediatric catheterization practice, including procedural technique, equipment utilization, patient management, and team dynamics. The results support the development of structured, competency-based transition programs that address both the technical and didactic aspects of pediatric catheterization practice. Since it is important enough to be credentialed in RCIS, it is equally important that pediatric practice is credentialed, given the unique demands and specialized competencies required in this setting. The graduated responsibility model employed in fellowship training programs offers a valuable 51 framework for technologist transition, providing a balance of supervised experience and progressive independence. The study contributes to the field of cardiovascular technology education by compiling the specific knowledge and skill requirements for pediatric catheterization practice, addressing a significant gap in existing educational frameworks. The findings have practical utility for institutions seeking to develop transition programs, offering a comprehensive blueprint for curriculum structure and content. In conclusion, the transition of cath lab technologists from adult to pediatric settings represents a significant professional adaptation requiring specialized education beyond standard cardiovascular technology training. 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Pediatric Cardiology. 2021;43(4):769-775. doi:https://doi.org/10.1007/s00246021-02784-x 77. Cardiovascular Credentialing International (CCI). Registered Cardiovascular Invasive Specialist (RCIS). https://cci-online.org/credentials/registered-cardiovascular-invasive-specialist/ 59 Appendix A: Diagnostic Patient Preparation Reference Tool Diagnostic Patient Preparation ● ● ● ● ● Patient history and procedure information Physical examination findings Prepare procedure room (equipment, optimizing radiation safety, quality assurance) Anesthesia consultation, psychological preparation for children/families Imaging studies: Chest X-ray, 12-lead ECG, and echocardiography Laboratory Test ● ● ● ● ● Complete blood count (CBC) Pregnancy test for females aged 12 years and older Electrolyte levels Coagulation profile Blood type and crossmatch Patient Positioning ● ● ● ● ● ● ● ● Secure soft restraints on wrists and ankles to stabilize the patient. Apply tape or straps over the mid-thigh and lower calf if additional support is required. Use padding to protect areas prone to pressure injuries. Position arms with elbows flexed at a 90° angle, hands near the ears, and pad the elbows. Rotate elbows inward toward the midline to minimize brachial plexus injury risks. Release restraints immediately after the procedure is completed. Utilize specialized foam, gel, or eggshell mattresses as needed for comfort and safety. Employ warming devices to prevent hypothermia during the procedure. Monitoring ● ● ● ● ● Auditory and visual electrocardiogram (ECG) signals Non-invasive blood pressure measurement Oxygen saturation levels (SpO₂) Body temperature monitoring Respiratory rate assessment Emergency Equipment ● Ensure availability of a defibrillator set to the appropriate level with correctly sized paddles attached. ● Have a code cart ready with equipment such as masks, endotracheal tubes, oral and nasal airways, suction catheters, and laryngoscope blades in various sizes. Access Site Preparation ● Confirm that the patient is properly positioned, sedated, monitored, warmed, and stable. ● Cleanse access areas using an antibacterial surgical preparation solution. For infants younger than two months, avoid chlorhexidine and use iodine-based alternatives or other suitable options. ● Drape the patient with sterile coverings while leaving the access site exposed. ● Administer local anesthesia at the catheter insertion site: typically 1% lidocaine for infants under one year old and 2% lidocaine for older children. 60 Appendix B: Diagnostic Procedure and Balloon Atrial Septostomy Reference Tool Diagnostic Procedure ● Administer heparin upon sheath placement with an initial bolus of 100 IU/kg intravenously. ● Measure activated clotting time (ACT) within 3–5 minutes post-administration and every 20–30 minutes thereafter. Adjust heparin doses to maintain ACT above 200 seconds or as per institutional guidelines. ● Optimize imaging by minimizing fluoroscopy time and limiting contrast medium usage to no more than 6–10 mL/kg depending on institutional protocols. ● Use biplane imaging systems to enhance visualization while Balloon Atrial Septostomy ● After prepping the groin, obtain venous access and place a sheath. ● If the patient is stable, a diagnostic catheterization may be performed. ● Start prostaglandin E1 as soon as the diagnosis of TGA is verified. ● The Rashkind balloon catheter is passed through the catheter, then from the right atrium through the open foramen ovale to the left atrium. ● Inflate the balloon with a diluted contrast medium. ● Draw back the inflated balloon against the atrial septal wall, then pull it with a short jerk into the right atrium, tearing the atrial septum. ● Measure the newly enlarged opening with a measuring balloon. The opening should have a diameter of at least 10 mm. Pulmonary Valve Stenosis ● Prepare and drape the access site. ● Choose the access sheath size based on the anticipated valvuloplasty balloon size. • Perform a right heart catheterization. ● Measure the pulmonary artery and right ventricle pressures. ● Perform a right ventricular angiogram to confirm the diagnosis. ● Measure the pulmonary annulus to determine the balloon size. ● Insert an end-hole catheter with a stiff guidewire within it. ● Manipulate the catheter through the PA and anchor in a stable position in a branch of the pulmonary artery. ● Remove the end-hole catheter, leaving the guidewire in place. ● Advance the balloon catheter over the guidewire into position, straddling the pulmonary valve. ● The balloon is filled with a diluted contrast medium so it is visible on fluoroscopy, allowing the operator to control the positioning. ● The balloon will be inflated until the “waist” around the middle of the balloon disappears, signaling the relief of the stenosis. ● Deflate and withdraw the balloon catheter. ● Replace the end-hole catheter, and measure any residual gradient. ● Perform a control angiogram to visualize and measure the opening area of the valve. ● Remove the catheter. ● Remove the sheath as for a right heart procedure 61 Appendix C: Patent Ductus Arteriosus Closure Reference Tool Patent Ductus Arteriosus Closure Procedure ● Bring the patient into the cardiac cath lab, anesthetized. ● Obtain access to both the femoral vein and the femoral artery. ● Place a sheath in each. ● Catheterize the right side of the heart; this is usually done with a balloon wedge catheter. ● Measure RV and PA pressures and O2 saturations. ● Using a pigtail catheter through the arterial sheath, visualize the descending aorta to measure the PDA. ● After careful measurement of the PDA, select a vascular occlusion plug. ● Place the occlusion device antegrade from the pulmonary artery side of PDA. ● Partially deploy the device in the aorta, then withdraw to the dilated portion (the aortic ampulla). The cap of the occluder may rest in the aortic ampulla. ● Deploy the remainder of the plug within the ductus, leaving a small portion protruding into the pulmonary side. ● Obtain an angiogram following deployment of either the coil or plug to evaluate position and any residual leak. Postprocedure Care ● ● ● ● ● ● Remove catheters and sheaths from the patient. Clean the access sites with saline. Remove the drapes. Assess vital signs and puncture sites regularly. Continuously record oxygen saturations to give early notice of pulmonary edema or thrombosis. The patient will be on antibiotics. 62 Appendix D: Atrial Septal Defect Closure and Ventricle Septal Defect Closure Reference Tool Atrial Septal Defect Closure/Ventricle Septal Defect Closure Procedure ● Bring the patient into the cath lab and prepare in the usual fashion. ● Administer a dose of IV antibiotics before the procedure begins. ● Transesophageal echocardiography (TEE) or Intracardiac Echocardiography (ICE) is routinely used to help determine the size of the defect, so intubation of the child is often necessary. ● Place a venous sheath and administer a bolus of 5000 IU heparin. ● Pass a diagnostic multipurpose catheter through the ASD into the left atrium. ● Using an exchange wire, replace the catheter with the transseptal sheath. ● Remove the exchange wire. ● Insert a sizing balloon over the wire and advance until it is within the atrial septum. ● Inflate the balloon with diluted contrast media and visualize the balloon waist created by the edges of the ASD itself. ● Capture a fluoroscopic image of the balloon and measure the waist to select the device size for closure. ● Feed the device into the sheath. ● Feed the device through the catheter until the distal part emerges into the left atrium under fluoroscopy. It should exhibit elastic resistance to a gentle pull, without falling through back into the right atrium. ● Slowly withdraw the sheath; the rest of the device emerges from the sheath and extends in the right atrium. ● With a bolus of contrast medium through the sheath, confirm that the device is firmly in place and patent. ● Disengage the device and withdraw the sheath. Postprocedure Care ● Return the patient to their bed. ● The patient typically experiences no pain during the procedure, so no additional analgesia is necessary in most cases. ● Observe the patient post procedure as with other cardiac catheter patients. ● Follow hospital protocol for mobilization. ● Obtain an echocardiogram prior to discharge. ● Endocarditis prophylaxis is usually prescribed, as is aspirin for life and clopidogrel for 6 months. 63 Appendix E: Aortic Valve Stenosis Reference Tool Aortic Valve Stenosis Procedure ● Prepare the patient for an interventional procedure. ● Perform the diagnostic portion of the procedure under as little conscious sedation as can be tolerated, then deeper sedation or even general anesthesia for the intervention. ● Place multifunction defibrillator pads. ● Establish femoral arterial and venous access. ● Advance the pacing catheter to the right ventricle and perform test pacing. ● Perform a complete right- and left-heart hemodynamic assessment. ● Measure the aortic valve gradient. ● Perform a ventriculogram, usually with a pigtail catheter, to visualize and measure the aortic valve. ● Pass a stiff, exchange-length guidewire through the catheter into the left ventricle and remove the pigtail catheter. ● Replace it with a guiding catheter that will guide the balloon through the aortic valve. Balloon Inflation ● ● ● ● ● ● ● ● A large volume of diluted contrast medium is required to fill the balloon. Connect a 10-mL syringe to the sidearm of the stopcock to maximize pressure. Two operators may be required to time and deliver the inflation successfully. Dedicated large-volume inflation devices can be used. Provide enough recovery time between dilatations to ensure that the vital signs can stabilize. When the balloon waist disappears, remove the balloon catheter. Measure pressures again and perform a left ventricular control angiogram. Perform an aortic angiogram to check for any resultant aortic valvular insufficiency. Postprocedure Care ● ● ● ● ● Remove catheters from the patient. Clean the access sites with saline. Remove the drapes. Assess vital signs and puncture sites regularly. These patients will be cared for in an intensive care environment. 64 Appendix F: Competency Assessment Checklist/HR Handout 65 Can the Cath Lab Technologist Explain the Importance of the Topic? Preprocedural Activities Pediatric-specific Sedation Anesthesia Planning Radiation Safety Psychological Preparation for Children and Family Diagnostic Procedures Shunt Detection Hemodynamic Assessments Congenital Defect Imaging Radiation Minimization Strategies Interventional Procedures ASD Closures VSD Closures PDA Closures Balloon Valvuloplasty Transcatheter Valve Implantation Emergency Interventions such as Balloon Atrial Septostomy Emergency Response Ability to Manage Pediatric Cardiac Crises Airway Management Pediatric Advanced Life Support (PALS) protocols Post-Procedural Activities Pediatric Hemostasis Complication Management Caregiver Education Coordinated ICU/NICU Transfers Yes No