Training Pathways in Neonatal Hemodynamics

The Structured Pathway (Neonatal Hemodynamics Subspecialty)

Program Description at McGill University

Hemodynamics & TnECHO Training Timeline

Other structured pathways include:

The Non-Structured Pathway (Neonatal Cardiovascular Care)

References

Navigating Hemodynamics Without a Hemodynamics Program

Mentoring and Development in NH-TNE

Learn more on our Neonatal Hemodynamics Fellowship program at McGill University / NeoCardioLab

Royal College Documents, AFC Training and Practice Eligibility Route

The field of neonatal cardiovascular health is categorized into neonatal cardiovascular care, the broader field encompassing the monitoring and management of blood flow and circulation, and neonatal hemodynamics, a specialized subspecialty within that broader field. Neonatologists interested in the cardiovascular health of newborns can pursue several distinct training routes categorized into advanced structured and non-structured pathways.

The Structured Pathway (Neonatal Hemodynamics Subspecialty)

The evolution of hemodynamic science has also led to the creation of a specific hemodynamics fellowship (as the one that we offer at McGill University / NeoCardioLab), which is distinct from pediatric cardiology because it emphasizes cardiovascular decision-making for infants with structurally normal hearts experiencing physiological disturbances. This training is typically conducted in two phases, starting with basic imaging and moving toward advanced integration within a neonatal intensive care unit. While formal accreditation for this pathway was initially concentrated in Australia and Europe, the Royal College of Physician and Surgeons of Canada recognized it as an area of focused competence in 2020. The modern training in this field is shifting toward a competency-based model rather than relying on a fixed number of procedures or a set duration of time. This approach focuses on the hemodynamic consultation model, which requires the neonatologist to perform a comprehensive integrated assessment that combines medical history, bedside imaging, and physiological interpretation. For those pursuing hemodynamic expertise, training must include a thorough understanding of ultrasound physics, neonatal physiology and pathophysiology, and the pharmacology of cardiovascular drugs. A critical component of this training involves rotations in pediatric echocardiography laboratories to learn how to recognize normal cardiac anatomy and identify deviations that may indicate congenital heart disease. To maintain high standards, these programs require close collaboration between neonatology and pediatric cardiology departments, ensuring that trainees receive feedback on their imaging acquisition and cognitive interpretation skills. At McGill, our trainees spend time as a consultant role in both Pediatric Cardiology and in Neonatal Hemodynamics, as our program is run in collaboration with our Pediatric Cardiology division. Effective training environments are supported by the use of standardized imaging protocols for common conditions, such as evaluating the significance of a patent ductus arteriosus or managing pulmonary hypertension. For example, a trainee must demonstrate specific milestones, such as the ability to accurately calculate left ventricular output and distinguish between pathological shunts and supportive physiology. At NeoCardioLab, we firmly believe that a strong and successful neonatal hemodynamics program must be developed in close partnership with pediatric cardiology. Optimal clinical care for our shared vulnerable patients depends on true interdisciplinary collaboration, with care delivered as an integrated team to achieve the best possible outcomes. To be recognized as a neonatal hemodynamics specialist, a neonatologist must undergo rigorous, formal training that goes beyond the standard neonatal fellowship. In Canada, this training must follow the AFC regulations by the Royal College of Canada.

Formal Fellowship: The traditional pathway involves usually a one-year intensive immersion program following a neonatal-perinatal fellowship. This training focuses heavily on acquired heart disease in preterm and critically ill neonates, providing deep expertise in the cardiovascular care of newborns with a structurally normal heart. Some programs offer extended training pathways to achieve these competencies over 2–4 years, combining short on-site training blocks with ongoing remote mentorship and learning support.
Curriculum Requirements: Training include the study of ultrasound physics, pulmonary physiology, cardiac physiology, vascular physiology, therapeutics and more. It requires mastering comprehensive Targeted Neonatal Echocardiography (TnEcho), which involves advanced image acquisition, measurement analysis, and—most importantly—hemodynamic integration (the ability to combine imaging findings with clinical physiology to guide management).
• The External Pathway: For faculty members already established at institutions without a formal program, an external fellowship exists. This is not an "easier" or "fast" route; it often involves prolonged training periods (for example, training in Toronto while working in another city) to ensure the practitioner achieves the same level of proficiency as those in immersion programs.
Beyond our training program, other fellowship opportunities can be found here.

Program Description at McGill University

Hemodynamics & TnECHO Training Timeline

Months 0–3
- Focus on image acquisition and basic measurements. Trainees develop technical proficiency in obtaining standard views, Doppler interrogation, and reproducible quantitative measurements, while building core knowledge elements in neonatal cardiovascular physiology.
Months 3–6
- Transition toward cardiovascular care and hemodynamic assessment. Emphasis shifts to integrating echocardiographic findings with clinical data, understanding loading conditions, shunt physiology, ventricular performance, and cardiopulmonary interactions. Measurement skills continue to mature alongside interpretation.
Months 6–9
- Primary focus on hemodynamic management. Echocardiography is used to guide clinical decision-making, formulate physiology-based recommendations, and reassess responses to interventions. Trainees begin functioning in a consultative role within the care team.
Months 9–12
- Development of consultant-level practice. Trainees refine synthesis, communication, prioritization, and leadership skills, progressing toward independent performance of TNE, integrated assessment, and management recommendations.
Throughout the timeline
- Professionalism, wellness, academic productivity, research, teaching skills and service development run continuously across all stages, alongside progressive involvement in teaching, research, and program building.
Flexible completion model
- This timeline may be completed as a continuous 12-month program or longitudinally over 2–4 years using repeated short training blocks combined with remote mentorship.

Other structured pathways include:

A dual-board certified specialist by completing both a neonatology fellowship and a pediatric cardiology fellowship. This extensive route provides a comprehensive understanding of cardiac physiology and anatomy from the neonatal period through adulthood and allows for hospital privileges in both disciplines.
Another structured option is a year in cardiac intensive care unit fellowship, where neonatologists undergo one to two years of specialized training alongside pediatric critical care or cardiology fellows to manage infants with congenital heart disease. This pathway focuses on enhancing skillsets in cardiac physiology and inpatient management, though primary attending roles in units that treat older children may remain limited without further subspecialty training.

The Non-Structured Pathway (Neonatal Cardiovascular Care)

This pathway is typically followed by neonatologists who have completed a standard neonatal-perinatal medicine fellowship and wish to focus their clinical and academic careers on cardiovascular health without pursuing a formal subspecialty designation.

In contrast to the formal training programs in neonatal hemodynamics, pediatric cardiology or pediatric CVICU, non-structured pathways allow neonatologists to build expertise through clinical exposure and mentorship without additional board certifications. These roles include prenatal cardiac consulting, where neonatologists advise families on delivery and postnatal transition, and delivery room management focusing on the transitional physiology of infants with congenital heart defects. Other non-structured routes involve acting as a neonatal consultant within a cardiac intensive care unit to manage non-cardiac comorbidities like nutrition and respiratory support or focusing strictly on cardiovascular research to develop an academic niche.
Other non-structured official pathways include the development of skills and knowledge through exposure in research, clinical practice, lifelong mentorship and collaborations.
Clinical Focus: These practitioners often manage congenital heart disease (CHD) through fetal consulting and delivery room management, or focus on acquired heart diseases, such as managing patent ductus arteriosus (PDA) consultation services and pulmonary hypertension in infants with severe bronchopulmonary dysplasia (BPD).
Engagement and Education: Development in this pathway involves individual and institutional investment. The sources suggest engaging with physiology through institutional lectures, attending national conferences (such as those hosted by the American Society of Echocardiography), and participating in virtual series like the Dr. Reagan Gisinger clinical cardiopulmonary physiology course.
Collaboration with Cardiology: A key component is building trust with the cardiology department by attending catheterization and echo labs, participating in joint research, and integrating the real-time reading of echocardiograms into daily NICU practice to better understand shifting physiology. The collaboration with Cardiology is crucial to both structured and non-structured pathway.

Distinguishing Roles and Programs

While many neonatologists may use Point of Care Ultrasound (POCUS), there is a significant difference between Cardiac POCUS (used for basic assessments like fluid responsiveness, sevel cardiac hypokinesia or line placement) and Consultative Hemodynamic care provided by a NH-TNE specialist. Currently, formal programs are limited but growing. As of 2025, there are established programs in Canada and the United States.