Staying on Your Toes in the EP Lab

Dear Readers,

The field of cardiac electrophysiology has evolved rapidly over the past 10 to 15 years as implantable devices and ablation procedures have become more complex, and as interventional electrophysiologists have had to continuously learn new techniques and adopt new technology. Therefore, it is critical that electrophysiologists maintain their skills.

The ACC/AHA 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion1 states that “As is true for many other procedures, a minimum number of cases is necessary to ensure continued proficiency in quality of care. The individual should participate in greater than or equal to 100 diagnostic EPS per year to maintain skills ... These cases can include the diagnostic portions of ablation procedures.” It is also stated that “it is recommended that physicians who perform ablations maintain a volume of 20–50 ablations per year. The CCEP Training Program Directors' Survey respondents indicate that, to maintain competency in catheter ablation, a mean of 38 (median, 50) cases/year are required.” Beyond these statements, one could argue that the expectation at most hospitals should be more than just maintenance of competence, but should be maintenance of expertise.

Although performance of a minimum number of procedures is a useful way to try and keep up one’s skills, on a practical level, it would be helpful when making schedules to establish the minimum amount of time a person should spend in the EP lab. This is a particularly important issue at an academic medical center where cardiologists are involved in federally funded research that limits their percent clinical effort.

In May 2011, an informal email survey was sent to 33 clinically active electrophysiologists in the United States and Canada, asking the following question: “In your judgment, how many days per month should an interventional electrophysiologist perform EP procedures to maintain expertise in 2011?” Among the 33 EPs, 25 worked in an academic setting and 8 were in private practice. The response rate was 24/33 (73%). Several electrophysiologists commented that the actual number of procedures performed is more important than the number of days in the lab, that more experienced electrophysiologists would need less time in the EP lab, and that the amount of time depends on what types of cases the person is doing. A typical statement was: “This isn’t something that should be captured in days. Depends on prior experience, number of cases done, type of case being considered, etc. One day a week may be fine for me ... It wouldn’t be for a new fellow coming out.” Nevertheless, 22 of the 24 responders provided a minimum number of days in the EP lab. The mean number of days was 8.0 ± 2.7 days (median 8, range 4–12 days). There was no difference in the responses among those in academia or private practice (8.1 vs. 7.6 days).

Several new technologies have been introduced in the EP lab over the past few years, including the newest versions of three-dimensional mapping systems, the cryoballoon for pulmonary vein isolation, and new coronary sinus pacing leads. These numerous new technologies do not include investigational devices, such as the totally subcutaneous implantable defibrillator, left atrial appendage occlusion devices, and multielectrode duty-cycle radiofrequency ablation catheters for pulmonary vein isolation. Therefore, it is very important that electrophysiologists remain active in the EP lab. In addition to satisfying the minimum procedural requirements published by our professional societies to maintain competency, the results of this survey of peers suggest that electrophysiologists who are performing the full range of interventional EP procedures should be spending at least 8 days per month in the EP lab.

Reference

1. Tracy CM, Akhtar M, DiMarco JP, et al. American College of Cardiology/American Heart Association 2006 update of the clinical competence statement on invasive electrophysiology studies, catheter ablation, and cardioversion: a report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training developed in collaboration with the Heart Rhythm Society. J Am Coll Cardiol 2006;48:1503-1517.