Author + information
- Hugh Calkins, MD∗ ()
- ↵∗Address for correspondence:
Dr. Hugh Calkins, Johns Hopkins Hospital, Sheikh Zayed Tower 7125R, 1800 Orleans Street, Baltimore, Maryland 21287-6568.
The field of interventional electrophysiology (EP) has grown tremendously since its birth 4 decades ago. This exponential growth is a result of both the growing number of patients with cardiac arrhythmias as well as advances in the techniques and outcomes of catheter ablation. It is remarkable that in 2018, catheter ablation efficacy exceeds 90%, and complications are <1% for most types of cardiac arrhythmias. The notable exceptions to this rule are catheter ablation of atrial fibrillation and nonidiopathic ventricular tachycardia, for which single procedure efficacy remains <80% and complication rates exceed 1%. To advance the field of interventional EP further, training guidelines and EP center standards have been developed by organizations on both sides of the Atlantic (1–6)
In this issue of JACC: Clinical Electrophysiology, Eckhardt et al. (1) report the results of a comprehensive survey of the field of interventional EP in Germany focused on defining the current state of interventional EP, including infrastructure, procedures, and training requirements. The results of this survey are compared with a similar survey conducted 5 years earlier (2). This was a comprehensive survey resulting in an interesting paper. Let me focus first on reviewing the components of this paper, which I found to be of greatest importance.
Let us start with procedural volumes. The median number of ablation procedures per hospital was 297. A total of 11% of hospitals performed <100 ablation procedures/year. A total of 80% of centers performed 50 or more atrial fibrillation (AF) ablation procedures/year, 14% of hospitals performed <50 AF ablation procedures/year, and 6% did not perform AF ablation. The overall distribution of ablation procedures was as follows: supraventricular tachycardia (22%), atrial flutter (20%), ventricular tachycardia (11%), and atrial fibrillation (47%). Epicardial ventricular tachycardia ablation was offered by 29% of EP centers. The most common technique for AF ablation was radiofrequency (72%), followed by cryoballoon (41%), circular multipolar ablation tools (17%), and 6% other. Pulmonary vein isolation alone was first-line therapy for persistent AF in 82% of centers. Imaging before AF ablation was performed by 50% of centers, and general anesthesia with intubation by 2%. H-2 blockers were prescribed before AF ablation by 69% of centers, and esophageal temperature probes were used by 42% of centers. In-house cardiac surgery back-up was available in 45% of hospitals performing AF ablation. Surgical AF ablation was performed by 28% of centers, and 8% of centers perform stand-alone AF ablation.
Next, let us examine how centers adhered to the center recommendations for interventional EP established by both the European Heart Rhythm Association (EHRA) as well as the German Society (1,3,4). These requirements and the adherence to these requirements are shown in Table 4 of the document (1). Both the EHRA and the German Society advise that ablation centers should perform at least 250 procedures/year. A total of 71% of centers met this volume requirement. The EHRA has no specific AF ablation volume requirement, but the German Society recommends 75 procedures/year/center. The 2015 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) Advanced Training Statement on Clinical Cardiac Electrophysiology advises that fellows perform 50 AF ablation procedures and 50 ablation procedures for atrial flutter during their 2-year fellowship. No institutional volume requirements are specified in the ACC/AHA/HRS document (7). A total of 70% of German centers met the AF ablation procedural requirement. The EHRA document recommends that cardiac surgery be available onsite. Only 42% of centers met this requirement.
Let me now make a few comments concerning this document. I would like to start by congratulating the authors for an excellent paper. I believe this paper provides important insights into the current status and trends in interventricular EP in Germany. I suspect these trends also reflect the situation in the United States and other countries in Europe. The amount of time and effort invested into obtaining these data and preparing this paper cannot be underestimated. The main limitation in the design of this survey was that centers performing <30 ablation procedures/year were excluded from analysis. The authors state that this cutoff was used because a low number of coded ablation procedures “increased the likelihood that the procedure itself was performed in a different hospital or by an external electrophysiologist (employed at another hospital).” Data from 97 of 327 centers that were identified as performing ablation procedures were eliminated from analysis. This is concerning to me and represents an important limitation of this paper, because prior studies have revealed that procedural outcomes are significantly worse at low-volume centers. In my mind, an opportunity was missed by excluding them from analysis. This reflects the fact that the outcomes of ablation procedures reflect, not only the skill of the primary operator, but also the experience and skill of the EP laboratory staff and the overall infrastructure of the EP program. I suspect that procedural outcomes were significantly worse at these centers.
Finally, it is worth commenting on some of the differences between the recommendations for EP training and for EP centers in the United States versus Germany and Europe. The requirements for EP training in the United States are defined by the 2015 ACC/AHA/HRS Advanced Training Statement on Clinical Cardiac Electrophysiology (5). This document identifies the core competencies required for EP training and also provides specific procedural requirements that should be met during the course of a 2-year dedicated EP fellowship. It is notable that once this initial EP training has been obtained, no specific volume requirements for ongoing competency exist. The 2017 HRS/EHRA/European Cardiac Arrhythmia Society/Asia Pacific Heart Rhythm Society/Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología Consensus Document on AF Ablation recommends that fellows perform 50 AF ablation procedures during their fellowship, but the only procedural requirement post-training is a statement that electrophysiologists should perform “several per month” to maintain competency (7). No other firm individual or hospital-based procedural requirements following training are provided. The recently published 2017 ACC/HRS Lifelong Learning Statement for Clinical Cardiac Electrophysiology Specialists does not contain any procedural volume requirements, but rather defines lifelong learning competencies and distinguishes competencies that are required of all EP specialists and those required by selected EP specialists based on their practice focus. In taking this approach, this document recognizes that electrophysiologists often specialize or focus on various subareas of electrophysiology during their career. In Europe, the requirements for EP training are defined by the Core Curriculum for the Heart Rhythm Specialist by Merino et al. (3). This document is similar in scope to the 2015 ACC/AHA/HRS Advanced Training Statement on Clinical Cardiac Electrophysiology, defines a 2-year training period for EP, and also recommends specific procedural requirements (5). The EHRA document differs from the U.S. version in that is also makes recommendations concerning hospital procedural volumes. This is valuable because the experience of the training centers is also of great importance.
At the end of the day, please join me in congratulating Eckhardt et al. (1) for an excellent paper that has provided us a chance to examine interventional EP trends in Germany and also review important similarities and differences in EP training guidelines on both sides of the Atlantic.
↵∗ Editorials published in JACC: Clinical Electrophysiology reflect the views of the authors and do not necessarily represent the views of JACC: Clinical Electrophysiology or the American College of Cardiology.
Dr. Calkins has served as a consultant to Medtronic, Boehringer Ingelheim, and Abbott Medical; and has received lecture honoraria from Medtronic, Boston Scientific, Boehringer Ingelheim, and Abbott Medical.
The author attests he is in compliance with human studies committees and animal welfare regulations of the author’s institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
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