Telemedicine in Pediatric Cardiology: Current Applications, Clinical Impact, and Future Perspectives

1. Introduction

Over the past decade, pediatric cardiology has undergone a substantial transformation, driven by rapid technological advances and by the need to overcome geographical barriers to highly specialized care, which remains largely concentrated in a limited number of tertiary referral centers. In this context, telemedicine has progressively evolved from an emergency or contingency solution into an increasingly integrated component of contemporary digital healthcare. This is particularly relevant in pediatric cardiology, a highly specialized field in which timely access to expert evaluation can significantly influence diagnosis, management, and outcomes. For children with congenital or acquired heart disease, telemedicine is mainly developing along three interconnected axes: decentralized early diagnosis, remote home monitoring of clinically complex patients, and optimization of long-term follow-up, including transition pathways from pediatric to adult care.

The methodological validity and clinical utility of telemedicine in pediatric cardiology have been supported by leading international scientific societies. The American Heart Association (AHA), in a dedicated Scientific Statement, provided guidance and operational standards for fetal and pediatric tele-echocardiography, reporting that remote transmission and interpretation of diagnostic imaging can achieve accuracy rates comparable to those of in-person assessment when appropriate technical and clinical standards are applied [1]. In Italy, telemedicine has been framed within a model that strongly emphasizes territorial and community-based care. A recent multi-society Consensus Document highlighted that the systematic use of telehealth for children with chronic conditions may strengthen the connection between tertiary referral centers, local healthcare services, and family pediatricians, thereby improving continuity of care, reducing avoidable hospitalizations, and supporting the quality of life of patients and caregivers [2].

The practical feasibility of these models has been increasingly documented across different healthcare settings. Beyond diagnostic imaging, recent literature has focused on active home monitoring and virtual outpatient care. One of the most relevant applications concerns infants with complex congenital heart disease, including those with single-ventricle physiology, during the interstage period between initial palliation and subsequent surgical repair. In this high-risk phase, dedicated smartphone applications, wearable ECG devices, digital stethoscopes, and structured remote monitoring programs may facilitate early identification of hemodynamic instability, arrhythmias, or clinical deterioration, contributing to timely intervention and potentially reducing morbidity and mortality [3]. At the same time, telemedicine may improve outpatient triage by helping clinicians identify which patients require urgent in-person assessment, instrumental testing, or specialist referral, while supporting more efficient use of healthcare resources and waiting lists. Table 1 summarizes the main clinical applications of telemedicine in pediatric cardiology.

This narrative review aims to summarize current evidence on the applications of telemedicine in pediatric cardiology, with particular attention to tele-echocardiography, remote monitoring of children with congenital heart disease, home blood pressure monitoring, and digital tools for arrhythmia detection, while also discussing current limitations, implementation challenges, and future perspectives.

2. Methods

A literature search was conducted in the main biomedical databases, including PubMed, Scopus, and the Cochrane Library, to identify relevant studies on telemedicine applications in pediatric cardiology. The search covered articles published between 2010 and 2025, reflecting the rapid expansion of digital health and telemedicine in clinical practice over recent years.

Search terms included combinations of keywords and Medical Subject Headings (MeSH) related to telemedicine and pediatric cardiology, such as “telemedicine,” “telehealth,” “digital health,” “remote monitoring,” “pediatric cardiology,” “congenital heart disease,” “acquired heart disease,” “tele-echocardiography,” “home monitoring,” “wearable devices,” and “arrhythmia detection.” Boolean operators were used to combine search terms and broaden or refine the search strategy as appropriate.

Studies were considered eligible if they met the following criteria: (1) inclusion of a pediatric population, defined as patients younger than 18 years of age; (2) focus on congenital or acquired cardiovascular disease; and (3) evaluation or discussion of telemedicine-based interventions in pediatric cardiology, including teleconsultation, tele-echocardiography, remote monitoring, home blood pressure monitoring, mobile health applications, and wearable technologies. Observational studies, randomized and non-randomized clinical trials, systematic reviews, narrative reviews, consensus documents, and relevant guidelines were considered.

Articles were excluded if they focused exclusively on adult populations, did not address cardiovascular conditions, or described telemedicine interventions unrelated to pediatric cardiology. Additional relevant references were identified through manual screening of the reference lists of selected articles. Given the narrative nature of this review, the literature was synthesized qualitatively, with emphasis on clinical applications, feasibility, reported benefits, limitations, and future perspectives of telemedicine in pediatric cardiology.

3. Telehealth Solutions for Patients with Congenital Heart Disease

Congenital heart disease (CHD) represents one of the main areas in which telemedicine has been integrated into pediatric cardiology practice. Digital health tools are increasingly used across different stages of care, from fetal and neonatal diagnosis to postoperative surveillance and long-term follow-up. In children with CHD, telehealth solutions may be particularly valuable because clinical expertise is often concentrated in tertiary referral centers, whereas patients and families may live far from specialized services. In this setting, telemedicine can support early diagnosis, improve referral appropriateness, enhance continuity of care, and reduce unnecessary transfers or hospital visits.

The main applications of telemedicine in CHD include neonatal and fetal triage through tele-echocardiography, high-risk infant home monitoring programs during the surgical interstage period, and remote follow-up of children and adolescents with complex cardiac conditions [3,4,5]. Available evidence suggests that these approaches may improve clinical outcomes and optimize healthcare resource use, particularly when embedded within structured hub-and-spoke networks. However, broader implementation still requires the resolution of several barriers, including fragmentation of data collection and retrieval, limited validation of pediatric-specific digital tools, heterogeneous protocols, and socioeconomic disparities in access to technology [6].

Advances in surgical, interventional, and intensive care management have markedly improved survival in patients with CHD, with most affected infants now reaching adolescence and adulthood. As survival improves, the burden of long-term cardiovascular morbidity also increases, requiring lifelong surveillance for residual lesions, ventricular dysfunction, hemodynamic deterioration, and arrhythmias. Telemedicine may help tertiary pediatric cardiology centers extend their clinical reach into local communities and patients’ homes, supporting early triage, proactive intervention, and longitudinal multidisciplinary care [7].

3.1. Tele-Echocardiography

Tele-echocardiography is one of the most established applications of telemedicine in pediatric cardiology. It allows echocardiographic images to be acquired in peripheral or spoke centers and interpreted remotely by expert pediatric cardiologists located in tertiary hub centers. This model is particularly relevant in neonatal and pediatric populations, in which early recognition of CHD is essential, but access to on-site pediatric cardiology expertise may be limited [8,9].

Tele-echocardiography can also be applied during fetal life, improving access to prenatal cardiac assessment and facilitating the detection of critical CHD, especially in peripheral, rural, or resource-limited settings. Early prenatal diagnosis enables appropriate planning of delivery in specialized centers, timely postnatal management, and, when needed, the treatment and follow-up of fetal arrhythmias. In this context, telemedicine may contribute to more coordinated perinatal care and potentially improve clinical outcomes [10].

In neonatal and pediatric practice, tele-echocardiography is mainly used for screening, initial evaluation of suspected CHD, and clinical decision support in Level I–II Neonatal Intensive Care Units (NICUs) without on-site pediatric cardiology services. Two main operational models are available: asynchronous, or store-and-forward, systems, in which recorded images are transmitted for later interpretation; and synchronous systems, which allow real-time interaction between the local operator and the remote pediatric cardiologist during image acquisition. Several studies have shown that tele-echocardiography is feasible and diagnostically reliable for identifying clinically significant CHD [1]. Its implementation may improve the appropriateness of referrals to tertiary centers, reduce unnecessary neonatal transfers, and generate organizational and economic benefits.

Makkar et al. evaluated a hybrid tele-echocardiography system for CHD screening in a Level II NICU without on-site pediatric cardiology expertise. The system improved the timeliness of clinical decision-making, enabling early identification of neonates requiring transfer to tertiary care while reducing unnecessary transfers. These findings support the use of hybrid telemedicine models to optimize resource allocation and improve access to specialized expertise in peripheral or resource-limited settings [8]. Similarly, McCrossan et al. reported an eight-year experience in which tele-echocardiography enabled a definitive diagnosis in 97% of neonates, while transfer to a higher-level center was avoided in 95 patients, corresponding to 72% of cases [11].

Despite these advantages, the effectiveness of tele-echocardiography depends on several factors, including the quality of image acquisition, the training and experience of local personnel, the availability of adequate technological infrastructure, and the use of standardized acquisition and reporting protocols. Current limitations include variability among protocols, limited interoperability between systems, and the relative scarcity of prospective multicenter studies assessing long-term clinical outcomes [3,10,12].

The principal tele-echocardiography models, together with their advantages and limitations, are summarized in Table 2.

3.2. High-Risk Infant Home Monitoring Programs

High-risk infant home monitoring (IHM) programs represent another major application of digital health in pediatric cardiology. These programs are most commonly used during the surgical interstage period in infants with single-ventricle physiology, such as hypoplastic left heart syndrome or tricuspid atresia. The interstage period, between the first palliative procedure, such as the Norwood operation or a hybrid approach, and the second-stage Glenn procedure or superior cavopulmonary anastomosis, is one of the most vulnerable phases in the care of children with complex CHD [14].

During this period, infants remain at high risk of clinical deterioration because systemic and pulmonary blood flow depend on a delicate hemodynamic balance. This balance may be maintained by a surgical shunt, such as a Blalock-Taussig-Thomas shunt or a Sano shunt, or by a patent ductus arteriosus, structures that may be vulnerable to obstruction, thrombosis, or changes in vascular resistance [12,15]. For this reason, timely recognition of early warning signs is crucial.

Before hospital discharge, caregivers are usually trained to perform daily monitoring at home using structured protocols and, increasingly, digital tools. These may include dedicated mobile applications, digital scales, and Bluetooth-enabled pulse oximeters. The parameters most commonly monitored include oxygen saturation, body weight, and nutritional intake. Oxygen saturation provides information on shunt patency and the balance between pulmonary and systemic blood flow; body weight helps detect poor growth, dehydration, or fluid retention; and caloric and fluid intake allow assessment of feeding tolerance and energy balance [13,16,17].

Patient-generated health data can be transmitted in real time, or at predefined intervals, to tertiary pediatric cardiology teams, allowing early triage and proactive clinical intervention when concerning trends emerge. Evidence suggests that structured IHM programs may reduce interstage mortality, support earlier recognition of clinical deterioration, decrease inappropriate emergency transfers, and improve healthcare resource utilization [18]. However, universal implementation remains challenging because of data fragmentation, differences in monitoring protocols, limited interoperability between platforms, and socioeconomic or geographic disparities in access to digital technologies.

With technological progress, traditional paper-based or telephone-based monitoring strategies have increasingly evolved toward application-based remote monitoring systems. These platforms allow caregivers to enter key physiological parameters through smartphones or tablets, often with automated alerts and longitudinal visualization of clinical trends. Observational studies indicate that application-based systems are feasible, well accepted by families, and associated with high adherence to daily data entry and improved communication between caregivers and healthcare providers [19]. Such tools may also standardize care pathways and reduce caregiver burden compared with less integrated monitoring approaches [20].

Nevertheless, most available studies remain limited by single-center design, retrospective methodology, small sample sizes, and heterogeneity in the technologies and protocols used. Therefore, application-based IHM should currently be considered a valuable adjunct to structured clinical programs rather than a replacement for in-person evaluation and specialist follow-up. Future multicenter prospective studies are needed to define standardized protocols, validate pediatric-specific digital tools, assess cost-effectiveness, and ensure equitable access for all families affected by complex CHD.

4. Telehealth Solutions for Patients with Non-Congenital Heart Disease

Although telemedicine has been widely applied in congenital heart disease, its role is increasingly expanding to children and adolescents with non-congenital cardiovascular conditions. In this setting, digital health tools may support diagnosis, follow-up, and long-term risk stratification, particularly for conditions characterized by intermittent findings, variable clinical expression, or the need for repeated measurements over time. Among these, pediatric hypertension and arrhythmias represent two major areas in which telehealth-based approaches have shown growing clinical relevance.

4.1. Home Blood Pressure Monitoring in Children and Adolescents

In recent years, increasing attention has been directed toward pediatric arterial hypertension, whose prevalence is rising worldwide, largely in parallel with the growing burden of childhood overweight and obesity. Accurate diagnosis remains challenging because blood pressure values in children are influenced by age, sex, height, emotional state, measurement technique, and environmental factors. In this context, telemedicine and digital health may help overcome one of the main limitations of pediatric blood pressure assessment: the unreliability of isolated office or hospital measurements [21].

Home blood pressure monitoring allows repeated measurements to be obtained in a familiar environment, reducing the influence of anxiety and improving the assessment of true blood pressure patterns over time. Current recommendations emphasize the importance of correct measurement technique, validated devices, appropriate cuff size, and repeated readings when evaluating blood pressure in children and adolescents [22,24]. Compared with single in-clinic measurements, home monitoring may improve diagnostic accuracy, support the identification of white-coat hypertension or masked hypertension, and facilitate safer follow-up after lifestyle or pharmacological interventions.

The usefulness of remote home blood pressure monitoring is supported by recent evidence. Studies evaluating telemedicine-based home monitoring have shown that repeated digital measurements may reduce diagnostic error and improve adherence to follow-up. In particular, home-based strategies may help identify or exclude the white-coat effect, which can lead to overestimation of cardiovascular risk and unnecessary treatment when blood pressure is assessed only in clinical settings [22]. Moreover, caregiver-performed measurements using automatic oscillometric devices and dedicated applications have shown good feasibility and concordance with measurements obtained by trained healthcare professionals, supporting the reliability of remote blood pressure monitoring in children and adolescents aged 3–17 years [23].

Digital platforms may further improve pediatric blood pressure assessment by integrating automated algorithms that calculate percentiles according to age, sex, and height. This is particularly relevant because interpretation of pediatric blood pressure values is more complex than in adults and requires comparison with normative percentile tables. Applications capable of rapidly classifying blood pressure values may support both primary care pediatricians and families, facilitating early identification of children who require further evaluation or specialist referral [24,25].

The clinical importance of early recognition of pediatric hypertension is underscored by evidence linking elevated blood pressure in childhood with increased risk of cardiovascular and renal complications later in life. Children with undiagnosed or untreated hypertension may be at higher risk of adverse cardiovascular outcomes in young adulthood, including myocardial infarction, stroke, and chronic kidney disease. Therefore, telemedicine-supported home blood pressure monitoring should be regarded as a valuable tool for early detection, longitudinal surveillance, and prevention, particularly when embedded within structured clinical pathways and combined with appropriate medical interpretation.

4.2. Arrhythmias

Cardiac arrhythmias are an important cause of morbidity in children and adolescents. Their diagnosis may be challenging because many rhythm disturbances are paroxysmal, intermittent, and difficult to capture during conventional clinical evaluation. Traditional diagnostic tools include 24-hour Holter monitoring, external event recorders, and implantable loop recorders; however, these approaches may be inconclusive when symptoms are infrequent and may require repeated use or prolonged observation.

Telemedicine and remote monitoring have introduced new opportunities for arrhythmia detection and management. In children and young adults with congenital or acquired heart disease who carry pacemakers or implantable cardioverter defibrillators, home monitoring systems can automatically transmit device data to the clinical team. This allows earlier identification of device malfunction, arrhythmic events, or clinically relevant changes, without requiring active intervention by the patient or caregiver [27]. Such systems may improve surveillance, reduce unnecessary hospital visits, and support timely therapeutic adjustments.

Smartphone-enabled ECG devices have also shown promising results in pediatric outpatient arrhythmia management. Gropler et al. evaluated the comparability of electrocardiographic intervals recorded with the AliveCor Kardia Mobile device and those obtained using a standard 12-lead ECG in pediatric patients. Their findings suggested that heart rate, rhythm, and ECG intervals can be accurately assessed using this wireless device in children with and without congenital heart disease or arrhythmias [28]. Similarly, Nguyen et al. demonstrated that smartphone-enabled ECG recordings can provide diagnostic-quality tracings in children with atrial fibrillation and supraventricular tachycardia, including at heart rates exceeding 200 beats per minute, thereby supporting remote clinical assessment and management [26].

These tools may also be useful in community and low-resource settings. Shepherd et al. described the successful use of a Kardia monitor to assess a pediatric patient with suspected arrhythmia in a remote coronavirus assessment center. In that case, the device was delivered to the patient’s mother, who was able to record an ECG tracing and transmit it to both the assessment center and the pediatric specialist, minimizing the need for direct physical contact and facilitating timely evaluation [29,30]. Overall, smartphone-based ECG devices may help reduce emergency department visits, improve symptom-rhythm correlation, and support earlier diagnosis of intermittent arrhythmias.

The rapid spread of wearable devices has further changed the diagnostic paradigm in arrhythmia care. Increasingly, patients and families are able to detect rhythm abnormalities and share recordings with healthcare professionals, rather than relying exclusively on physician-initiated monitoring [31]. Smartwatches are among the most widely used devices in this field. Most use photoplethysmography to detect pulse irregularities and may prompt users to record a single-lead ECG when an arrhythmia is suspected. Devices such as the Apple Watch and Samsung Galaxy Watch can generate ECG tracings that may provide clinically useful information and support more timely decision-making [34,35].

In pediatric populations, Kobel et al. evaluated the use of Apple Watch iECG and reported good comparability between lead I of the standard 12-lead ECG and the smartwatch-derived tracing, both in terms of amplitude and interval measurements. The recordings were also considered suitable for rhythm classification, including in children with congenital heart disease, a population at increased risk of arrhythmias [33]. These findings suggest that smartwatch-based ECG may represent a useful adjunct in selected pediatric patients, particularly for documenting intermittent symptoms.

Other wearable technologies are also being investigated. Smart rings, for example, use photoplethysmography to measure physiological parameters from a highly vascularized anatomical site; however, most commercially available smart rings do not currently provide ECG tracings. Patch monitors and textile-based systems, such as smart shirts equipped with ECG sensors, may represent alternatives to conventional Holter monitoring. Patch ECG devices can provide prolonged monitoring and have shown higher arrhythmia detection rates than standard 24-hour Holter recordings in selected settings. Smart shirts may offer signal quality comparable to traditional Holter devices, with the additional advantage of improved comfort, which may increase adherence in children and adolescents [35].

Despite their potential, consumer and wearable technologies also raise important concerns. Many devices become widely available before undergoing rigorous validation in pediatric populations, and even approved devices are often developed for adults or for general wellness rather than disease-specific management. Therefore, their use in children requires careful clinical interpretation, attention to false positives and false negatives, and integration into defined care pathways. Further challenges include data overload, interoperability with hospital systems, privacy and security issues, unequal access to technology, and the need for clinician training [32,33].

Overall, telemedicine-based arrhythmia tools should be considered complementary to conventional diagnostic strategies rather than replacements for specialist evaluation. When appropriately validated and integrated into clinical workflows, smartphone ECG devices, remote monitoring platforms, and wearables may improve arrhythmia detection, strengthen outpatient management, reduce unnecessary emergency visits, and promote more personalized care for children and adolescents with rhythm disorders.

Table 3 summarizes the main digital tools currently used or under investigation for home monitoring and arrhythmia detection in pediatric populations.

5. Conclusions

Pediatric cardiology is progressively moving from a predominantly hospital-centered model toward a more decentralized, patient-centered, and digitally supported approach. As discussed in this review, telemedicine is no longer limited to a supportive or emergency-based role, but is increasingly becoming an integral component of pediatric cardiovascular care. Its applications in tele-echocardiography, remote monitoring of high-risk children, home blood pressure assessment, smartphone-enabled ECG recording, and wearable technologies may improve diagnostic accuracy, enhance continuity of care, optimize the use of healthcare resources, and support earlier clinical intervention.

The benefits of telemedicine are particularly relevant in a highly specialized field such as pediatric cardiology, where expertise is often concentrated in tertiary referral centers and timely access to specialist evaluation can influence outcomes. By connecting hospitals, local healthcare providers, patients, and families, digital health tools may strengthen hub-and-spoke models of care, reduce unnecessary transfers and hospital visits, and facilitate longitudinal follow-up for children with both congenital and acquired cardiovascular conditions.

However, several challenges must be addressed before telemedicine can be implemented as a sustainable and universal standard of care. First, data fragmentation and limited interoperability between digital platforms remain major barriers and should be overcome through integrated, user-friendly systems that allow secure sharing of clinically relevant information. Second, the rapid diffusion of direct-to-consumer devices and wearable technologies requires rigorous validation in pediatric populations, since tools designed for adults or for general wellness may not provide reliable or actionable data in children. Third, socioeconomic and geographic disparities in access to technology must be reduced to avoid widening existing inequalities in healthcare delivery. Additional priorities include standardized protocols, clinician training, protection of data privacy, and prospective multicenter studies assessing clinical effectiveness, cost-effectiveness, and long-term outcomes.

The future of pediatric cardiology will depend on the thoughtful integration of digital health into routine clinical practice. When appropriately validated and embedded within structured care pathways, telemedicine has the potential to support families in the management of congenital and acquired cardiovascular diseases, improve communication with healthcare teams, and promote more timely, equitable, and personalized care for children and adolescents with heart disease.