Updated Training Guidelines in Pacing and EP

What was the purpose of Task Force 6? The purpose of the EP Task Force 6 was to update the 2002 COCATS training in specialized electrophysiology, cardiac pacing and arrhythmia management document for the American College of Cardiology. The update was to include changes in the arrhythmia field over the last four years. Beside myself, writers of this document included two previous authors, John DiMarco, MD, Professor of Medicine and Director of Cardiac Electrophysiology at the University of Virginia in Charlottesville, and Jamie Conti, MD, Director of Cardiac Electrophysiology at the University of Florida in Gainesville. In addition, there was one new writer representing the Heart Rhythm Society: Cindy Tracy, MD, Professor of Medicine and Director of Clinical Electrophysiology at the George Washington University in Washington, D.C.  What changes in particular have been made from the previous recommendations in the 2002 ACC Revised Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training II (COCATS 2)? Along with updating the original, there was an attempt by the writing committee to be consistent with other documents and recommendations made in the past by the American College of Cardiology and the Heart Rhythm Society. What are the differences between each level of training (Levels 1, 2, and 3)? Are certain levels more appropriate for certain positions in the EP lab? Level 1 training is basic training required of all trainees in cardiology in order for them to be competent consulting cardiologists and meet requirements for sitting for their ABIM boards in Cardiovascular Diseases. Level 2 training provides cardiologists training in one or more specialized areas. This enables the cardiologist to perform or interpret specific procedures at an intermediate skill level or engage in rendering cardiovascular care in specialized areas. Level 3 is advanced training in a specialized area that enables a cardiologist to perform, interpret, and train others to perform and interpret specific procedures at a high skill level. Thus, Level 3 in arrhythmias is required for cardiologists that sit for their boards in Clinical Cardiac Electrophysiology. Describe the requirements needed to complete each level (please also include the number of procedures required to complete each level). Level 1 cardiologists in training would only spend two months on cardiac arrhythmia service. This is designed so that the cardiology trainees can acquire knowledge and experience in the diagnosis and management of bradyarrhythmias and tachyarrhythmias. It is hoped that the trainee would learn indications for and limitations of electrophysiological studies, appropriate indications for pharmacologic and nonpharmacologic therapies, and proper use of antiarrhythmics agents. The Level 1 trainees exposed to non-invasive and invasive techniques related to arrhythmias would concentrate on non-invasive techniques such as Holter monitoring, event recorders, exercise testing, tilt table testing and cardiac consultation. It is hoped that the Level 1 trainee will get an introduction to cardiac pacing, including basic indications and interrogation of devices. From a numbers standpoint, Level 1 training suggests that a minimum of 10 temporary pacemakers and 10 elective cardioversions are required.  Level 2 trainees would require an additional four months of training; this level is appropriate for those individuals wishing to have careers in a heart station or a pacemaker/ICD follow-up clinic, or as an electrocardiography laboratory director. In addition to the Level 1 training requirements, the six months of training is in-depth at the non-invasive level of arrhythmia management. The trainee is expected to function as the primary programming operator who interrogates, interprets, prescribes and reprograms devices in at least 100 patients. The Level 2 training, by itself, does not qualify the trainee to perform invasive procedures.  Level 3 trainees will have a minimum of 12 and up to 24 months of training in order to meet all of the criteria to sit for the cardiac electrophysiology board examination. In addition to the Level 1 and Level 2 requirements, trainees at this level should perform at least 150 electrophysiology studies as the primary operator; of these, at least 50 - 70 procedures should be in patients with supraventricular tachycardia. They should be a primary operator in 25 or more electrophysiological evaluations of implantable devices. Experience in transseptal cardiac catheterization, and a minimum of 75 catheter ablation procedures is required. In addition to the above, in order to be trained in the implantation of cardiac implantable electrical devices such as pacemakers and implantable cardioverter-defibrillators (ICDs), such training requires the implantation of 75 or more pacemakers or ICDs. To be proficient in the implantation of biventricular systems, an additional 15 implants are required, and to be trained in lead extractions, a minimum of 20 lead extractions as primary operator is required. Approximately how long does it take to complete each (or all three) levels? Level 1 usually takes two months, and Level 2 is a total of six months. Level 3 is a minimum of 12 months in cardiac electrophysiology and usually an additional 12 months in order to meet all the requirements for insertion and follow-up of implantable devices, as required. How is training for atrial fibrillation ablation covered in Level 3? The field of atrial fibrillation ablation is growing. No numeric guidelines have been established for training and such. It is anticipated that Level 3 trainees should participate in 30 - 50 mentored atrial fibrillation ablations in order to achieve competence in this area.  Describe the optional training objectives in device implantation for Levels 2 and 3. The objectives of Level 2 training in devices are for the trainee to function at the level of interrogating, prescribing and reprogramming devices it does not qualify the trainee to implant devices. Level 3 training is at the level for implantation of pacemakers and ICDs. How does this document differ from Heart Rhythm Society's 2004 Clinical Competency Statement: Training Pathways for Implantation of Cardioverter Defibrillators and Cardiac Resynchronization Devices and 2005 Addendum?   As you know, an alternative pathway for training in ICD implantation has been suggested. This Heart Rhythm Society competency statement related to training for a special group of physicians not in the cardiology fellowship situation. The Heart Rhythm Society addendum was specific to physicians in training who were already putting in more than 30 pacemakers per year for the last three years, and offered a fast track solution to training in ICDs. COCATS training is the classic recommended training to achieve Level 3 competency; it is required of all fellows to be signed off by their training director in order to perform such procedures. Is there anything else you'd like to add? The only other information that I have to add is that the current Task Force 6 was written a year in advance of a rewrite of the entire COCATS document. Besides cardiac electrophysiology, there were updates in the training of nuclear cardiology (Task Force 5), training in advanced cardiac imaging, including cardiovascular magnetic resonance imaging (Task Force 12), and training in advanced computed tomography (Task Force 12). It was felt that these areas needed to be updated in advance of the planned update next year. The COCATS committee is starting to meet this spring to update the entire document for all areas of cardiovascular disease. It is my guess that, given the recent revisions of our task force and the cardiac imaging task forces, the changes in these areas in the final document will be minor in the next year's document.