Telemedicine in Congenital Heart Disease
Periclis Davlouros, MD, Ignatios Ikonomidis, MD, Nicolaos Beratis, MD,
Vassilis Thanopoulos, MD, Antonis S. Manolis, MD
BACKGROUND: The primary rationale for the development of telemedicine has been
to serve populations that have limited access to traditional, high quality medical ser-
vices. These include those living in rural areas or other underserved areas, like is-
lands, or even urban areas when a rare medical subspecialty, such as pediatric cardiol-
ogy is not available.
OBJECTIVE: The aim of the present study was to present our results with use of tele-
medicine during the European project TELEREMEDY over a period of 26 months
when adult cardiologists and pediatricians of our hospital communicated with pedi-
atric cardiologists at the tertiary Children’s Hospital “Agia Sofia” in Athens and at
the Royal Brompton Hospital in London, as well as with physicians at the “Venizelio”
Hospital in Crete.
METHODS AND RESULTS: Over 26 months, 31 teleconference sessions were organized.
During this period, 155 children with suspected congenital heart disease (CHD) un-
derwent echocardiographic examination, which confirmed CHD in 83 (54%), ac-
quired heart disease in 13 (8%) and normal anatomy in 59 (38%). Ventricular septal
defect was diagnosed in 26/83 (31%), complex CHD in 20 (24%), atrial septal defect
in 12 (14%) and patent ductus arteriosus in 8 (10%) children. Our hospital with the
adult electrophysiology team was the expertise center for diagnosis and treatment of
30 children with arrhythmia.
During 23 sessions with the tertiary Children’s Hospital “Agia Sofia” in Athens, an
immediate transfer to the pediatric intensive care unit of the tertiary center was de-
cided for 27 cases (17%). During 3 sessions with one participating hospital we pro-
vided consultation for 10 cases with arrhythmias. During 6 sessions with the Royal
Brompton Hospital in London, rare cases of CHD, both adult and pediatric, were
discussed. Two multilane conferences were organized among all participants and the
systems capabilities in each hospital were discussed.
CONCLUSION: Telemedicine systems, like the one used herein in the context of the
TELEREMEDY program, facilitate a timely diagnosis and management of children
with CHD in hospitals lacking pediatric cardiology service. In the present series, use
of this program obviated unnecessary and costly transfers in 83% of cases Thus, im-
mediate access to specialists can guide patient management and thus may alter the
morbidity and mortality in this patient population.
Cardiology Department, Patras
University Hospital, Patras, Greece
HOSPITAL CHRONICLES 2009, 4(3): 119–122
Periclis Davlouros, MD
Department of Cardiology
Patras University Hospital
KEY WORDS: pediatric cardiology;
telemedicine; congenital heart disease;
CHD = congenital heart disease
Presented in part at the American College of Cardiology (ACC) Annual Scientific Session, Anaheim, CA, USA, March 12-15, 2000 and at the
“Cardiology Update 2000”, International Cardiology Symposium of Patras University, Patras, Greece, April 20-23, 2000
HOSPITAL CHRONICLES 4(3), 2009
Telemedicine involves the use of telecommunication tech-
nologies as a medium for providing medical information and
services to consumers located at sites that are at a distance
from the provider.
The concept encompasses everything
from plain old telephone systems, to high speed, wide band-
width transmission using fiber optics, satellites or a combina-
tion of terrestrial and satellite communication technologies.
The peripheral software could be as simple as a typewriter
used to type a letter seeking for an opinion, to high capacity
parallel processing computers and imaging devices. Although
the definition includes telephone, facsimile and distance learn-
ing, telemedicine is being used in a generic format for remote
diagnosis and consultation at this time.
Pediatric Cardiology is a subspecialty that is lacking from
many peripheral hospitals, and certainly from rural areas.
Congenital heart diseases (CHD) are the most frequent con-
genital diseases. It is estimated that about 1% of live births
have some form of congenital heart disease. Correct diagnosis
is of critical value for proper management especially when it
comes to critically ill neonates. Most of the regional hospitals
in Greece lack pediatric cardiology teams and the pediatrician
(sometimes with the aid of the adult cardiologist), is the first
who deals with the neonate that is suspected to have or has
congenital heart disease. Quick diagnosis and transportation
of the critically ill neonate could be life saving, and avoiding
unnecessary transportations could save a lot of money for the
health care system on the other hand.
Echocardiography is one of the imaging modalities that
can quickly and safely diagnose all forms of congenital heart
disease, when conducted by experienced in the field physicians.
Telemedicine has the ability to transmit echocardiographic
images from one location to another either as video, digitized
images, or digital data, even in real time with acceptable
resolution. It is an invaluable tool for the inexperienced adult
cardiologist and the pediatricians of the peripheral hospital
who are caring for a neonate or a child with possible CHD
and can communicate through the link with the experts in a
This was the idea of the project called TELEREMEDY
(TELEmedicine for REmote diagnosis Management and
EDucation in CHD) funded by the European Community
(EC) and 6 regional hospitals in Europe. Our hospital par-
ticipated in this project and we are herein presenting our data.
PATIENTS AND METHODS
For the duration of 26 months, adult cardiologists and
pediatricians of our hospital, as part of the TELEREMEDY
project, communicated with pediatric cardiologists at the
tertiary Children’s Hospital “Agia Sofia” in Athens and at
the Royal Brompton Hospital in London, as well as with
physicians at the “Venizelio” Hospital in Crete, using the
TELEREMEDY program. Six hospitals (Santa Cruz and Red
Cross in Spain in addition to the above mentioned) in Europe
communicated through Euro-ISDN (Integrated System Digi-
tal Network) lines. The high speed of data transmission (64
Kbps per channel) permits on-line, real-time teleconference,
transmission of ECG, x-rays and echocardiograms between
the connected hospitals.
Our equipment included a) two personal computers, b) a
video camera for transmission of picture and sound, c) two
television sets for projection of picture and sound transmis-
sion among connected sites with the capability to transmit
echocardiograms in real time as well as echocardiographic
studies recorded on a video player, d) a document camera, for
transmission of ECGs, x-rays and other printed material, e)
two monitors and a sound transmission set for communication
with the echocardiography and catheterization laboratories.
We connected the videoconference room with our echocar-
diography laboratory, the neonatal intensive care unit and
the catheterization laboratory through Hospitals Local Area
Network. We also connected the hospital amphitheatre with
these sites. Through these connections we were able to trans-
mit moving and still images to the referral hospitals.
Over 26 months, 155 children with suspected congenital
heart disease (CHD) were examined. The echocardiogram
confirmed congenital heart disease in 83 (54%) children,
acquired heart disease in 13 (8%) and normal anatomy in
59 (38%). Ventricular septal defect was diagnosed in 26/83
(31%), complex congenital heart disease in 20 (24%), atrial
septal defect in 12 (14%) and patent ductus arteriosus in 8
(10%) of the children (Table 1). Our hospital with the adult
electrophysiology team was the expertise center for diagno-
sis and treatment of 30 children with arrhythmia. Totally 31
teleconference sessions were organized.
During 23 sessions with the tertiary Children’s Hospital
“Agia Sofia” in Athens, decisions were taken about the optimal
treatment plan of children with newly diagnosed congenital
heart disease, whereas an immediate transfer to the pediatric
intensive care unit of the tertiary center was decided for 27
cases (17%). During 3 sessions with one of the participating
hospitals we provided consultation for 10 cases with arrhyth-
mias. During 6 sessions with the Royal Brompton Hospital in
London, rare cases of congenital heart disease, both adult and
paediatric were discussed. Two multilane conferences were
organized among all participants and the systems capabilities
in each hospital were discussed.
We continued using the system beyond the 18-month pe-
riod and had an additional 5 sessions of teleconference with the
other hospitals of our network. One of the project’s aims was
the development of a European registry of patients with CHD
for facilitating management as well as for research reasons.
Our experience using the TELEREMEDY system was
very favorable. We found that the medical community accepted
this novel mode of communication with great interest because
of the obvious advantages it had in facilitating diagnosis and
treatment. Physicians in our hospital very soon became ac-
quainted and fully accustomed with it. It was a great relief for
pediatricians of our hospital to have access to expert pediatric
cardiology consultation and service through collaboration
with a team of adult cardiologists. Pediatric patients’ parents
were also very pleased to have a way to communicate with
the experts “locally”. They were also relieved to know that
their critically ill neonate was managed in collaboration with
a specialist through the telemedicine link getting stabilized
and transferred under controlled conditions to the referral
center, which is 240 km away from the city of Patras. It is also
significant to mention that apart from the physicians who
were using the system, technical support was always needed,
and was provided by a specialized technician in our hospital.
Telemedicine is not a medical subspecialty, but a facilitator
of all medical and surgical specialties. Although telemedicine
dates back to1950s, it is a phenomenon that is currently being
embraced enthusiastically by telecommunication providers,
hardware and software manufacturers, medical care providers,
policy makers and politicians alike.
The main purpose of
such systems is to provide rapid access to the experts when a
remote medical advice could be life saving. The proponents of
distance health believe that in addition to providing specialty
care for isolated communities, distance health can provide uni-
versal access to high quality medical care at an affordable cost.
Existing distance health applications can be grouped into
three categories: 1) Remote diagnosis and consultation, pri-
marily between a specialist and another health provider such
as primary care physician, nurse practitioner or other allied
health care provider, but can also occur between the health
care provider and the patient, 2) Distance learning for continu-
ing education, and 3) Research purposes, when a physician
can have access to remote medical records, or exchange data
with colleagues in a remote location.
The primary rationale for the development of telemedi-
cine has been to serve those populations that, for one reason
or another, have limited access to traditional, high quality
These include those living in rural areas
or other underserved areas, like islands, or even urban areas
when a rare medical subspecialty (i.e. pediatric cardiology) is
not available. The geographic distribution of health care pro-
viders, driven largely by economic and cultural factors further
compounds the problems faced by the rural and underserved
residents. It is the combination of all of these factors that
makes telemedicine an attractive alternative to complement
whatever health care services may be available in these areas.
The question is whether telemedicine is safe and medically
effective and what legal and economic implications will arise
as the field is expanding. As it is expected several studies have
appeared in the literature and guidelines are being formed
about these issues.
Future applications would include administering therapeu-
tics remotely such as telesurgery. Extensive use of powerful
computers, virtual reality and high speed, reliable communi-
cations network using protocols such as ATM (asynchronous
transfer mode), would make this a reality!
Telemedicine systems like the one we have used in the
context of the TELEREMEDY program facilitate a timely
diagnosis and management of children with congenital heart
disease in hospitals lacking pediatric cardiology service. The
immediate access to specialists can guide patient management
and thus may alter the morbidity and mortality in this patient
population. Furthermore, in the present series use of this
program obviated unnecessary and costly transfers in 83%
of cases (Table 1). Potential problems to be solved, will be
TABLE 1. Results of the TELEREMEDY Program.
Duration (months) 26
Congenital heart disease (%) 83 (54%)
Acquired heart disease (%) 13 (8%)
Normal cardiac anatomy (%) 59 (38%)
Congenital heart disease 83
VSD (%) 26 (31%)
Complex CHD (%) 20 (24%)
ASD (%) 12 (14%)
PDA (%) 8 (10%)
Immediate transfer (%) 27 (17%)
Consultations rendered (cardiac arrhyth-
ASD = atrial septal defect; CHD = congenital heart disease; PDA =
patent ductus arteriosus; VSD = ventricular septal defect
HOSPITAL CHRONICLES 4(3), 2009
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defining the population needs in certain rural communities,
constructing an electronic environment (patient records, etc.)
for rapid communication, defining legal and economical issues
of remote consultation, and defining standards for telecom-
munication, data transmission and computing in medicine,
just to mention a few. It should be made perfectly clear that
telemedicine should not replace existing health services but
supplement or complement what is already available. On the
other hand, the critical success of telemedicine will depend
ultimately, not on legal, ethical or economical issues, but on
the acceptance of this modality by health care providers and
patients and demonstration of improved patient outcomes and
cost savings by the use of this mode of health care delivery.
1. Ikonomidis I, Davlouros P, Thanopoulos V, et al. TELEREM-
EDY: 18 months experience with a telemedicine system for re-
mote diagnosis, management and education in congenital heart