Updated Survey on Interventional Electrophysiology

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ª 2018 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER

Updated Survey on Interventional Electrophysiology 5-Year Follow-Up of Infrastructure, Procedures, and Training Positions in Germany Lars Eckardt, MD,a Gerrit Frommeyer, MD,a Philipp Sommer, MD,b Daniel Steven, MD,c Thomas Deneke, MD,d Heidi L. Estner, MD,e Charalampos Kriatselis, MD,f Malte Kuniss, MD,g Sonia Busch, MD,h Roland R. Tilz, MD,i Hendrik Bonnemeier, MD,j Christian von Bary, MD,k Frederik Voss, MD,l Christian Meyer, MD,m Dierk Thomas, MD,n,o Hans-Ruprecht Neuberger, MDp

ABSTRACT OBJECTIVES This study provides an update and comparison to a 2010 nationwide survey on cardiac electrophysiology (EP), types and numbers of interventional electrophysiological procedures, and training opportunities in 2015. BACKGROUND In 2010, German cardiology centers performing interventional EP were identified and contacted to provide a survey on cardiac EP. METHODS German cardiology centers performing interventional EP in 2015 were identified from quality reports and contacted to repeat the 2010 questionnaire. RESULTS A majority of 131 centers (57%) responded. EP (ablation procedures and device therapy) was mainly part of a cardiology department (89%) and only independent (with its own budget) in 11%. The proportion of female physicians in EP training increased from 26% in 2010 to 38% in 2015. In total, 49,356 catheter ablations (i.e., 81% of reported ablations in 2015) were performed by the responding centers, resulting in a 44% increase compared with 2010 (the median number increased from 180 to 297 per center). Atrial fibrillation (AF) was the most common arrhythmia interventionally treated (47%). At 66% of the centers, (at least) 2 physicians were present during most catheter ablations. A minimum of 50 (75) AF ablations were performed at 80% (70%) of the centers. Pulmonary vein isolation with radiofrequency point-by-point ablation (62%) and cryoablation (33%) were the preferred ablation strategies. About one-third of centers reported surgical AF ablations, with 11 centers (8%) performing stand-alone surgical AF ablations. Only one-third of the responding 131 centers fulfilled all requirements for training center accreditation. CONCLUSIONS Comparing 2010 with 2015, an increasing number of EP centers and procedures in Germany are registered. In 2015, almost every second ablation was for therapy for AF. Thus, an increasing demand for catheter ablation is likely, but training opportunities are still limited, and most centers do not fulfil recommended requirements for ablation centers. (J Am Coll Cardiol EP 2018;-:-–-) © 2018 by the American College of Cardiology Foundation.

From aAbteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster, Münster, Germany; b

Abteilung für Rhythmologie, Herzzentrum der Universität Leipzig, Leipzig, Germany; cAbteilung für Elektrophysiologie, Herzzen-

trum der Uniklinik Köln, Köln, Germany; dKlinik für Kardiologie, Herz- und Gefäß-Klinik GmbH, Bad Neustadt an der Saale, Germany; e

Medizinische Klinik und Poliklinik, Interventionelle Elektrophysiologie, Klinikum der Universität München, Campus Großhadern,

München, Germany; fKlinik für Innere Medizin – Kardiologie, Deutsches Herzzentrum Berlin, Berlin, Germany;

g

Abteilung

Kardiologie, Kerckhoff Klinik GmbH, Bad Nauheim, Germany; hII Medizinische Klinik für Kardiologie, Pneumologie und Angiologie, Krankenhaus Coburg, Coburg, Germany; iMedizinische Klinik II (Kardiologie, Angiologie, Intensivmedizin), Universitäres Herzzentrum Lübeck, Lübeck, Germany; jKlinik für Innere Medizin III, Schwerpunkt Kardiologie und Angiologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany; kMedizinische Klinik I, Rotkreuzklinikum München, LKH der TU München, München, Germany; lInnere Medizin III, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany; mKlinik für Kardiologie mit Schwerpunkt Elektrophysiologie, Universitäres Herzzentrum, Universitätsklinikum Hamburg-Eppendorf, DZHK Standort Hamburg/ Lübeck/Kiel, Kiel, Germany; nKlinik für Kardiologie, Universitätsklinik Heidelberg, Heidelberg, Germany; oHCR (Heidelberg Center for Heart Rhythm Disorders), University Hospital Heidelberg, Heidelberg, Germany; and pInnere Medizin, Kardiologie/Rhythmologie, Klinikum Traunstein, Traunstein, Germany. The authors received an unrestricted travel grant from Johnson & Johnson Medical. Manuscript received October 3, 2017; revised manuscript received January 5, 2018, accepted January 5, 2018.

ISSN 2405-500X/$36.00

https://doi.org/10.1016/j.jacep.2018.01.001

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ABBREVIATIONS

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Survey on Interventional Electrophysiology

ver the past 2 decades, clinical

number of coded ablation procedures increased the

electrophysiology (EP), including

likelihood that the procedure itself was performed at

device therapy and catheter abla-

a different hospital or by an external electrophysi-

tion of arrhythmias, has rapidly developed

ologist (e.g., employed at another hospital). The

as a subspecialty in cardiology. Catheter abla-

head of the cardiology department or of interven-

tion is first-line therapy for regular supraven-

tional EP was contacted by e-mail and/or phone to

tricular tachycardias and at least second-line

answer a questionnaire that had already been used

therapy for most symptomatic patients with

in the previous survey (5). The following parameters

atrial fibrillation (AF). It has been estimated

were queried: type of hospital, staff numbers and

code(s)

that about 60,000 catheter ablation proced-

functions in cardiology and EP, sex, infrastructure,

PVI = pulmonary vein isolation

ures are performed per year in Germany (1).

number and types of electrophysiological proced-

The increasing number of procedures and

ures, techniques used, imaging modalities, presence

quality issues require national and interna-

of or distance to cardiac surgery (for a detailed

AND ACRONYMS AF = atrial fibrillation DGK = German Society of Cardiology

EHRA = European Heart Rhythm Association

EP = electrophysiology OPS = operation and procedure

VT = ventricular tachycardia

tional standards as well as trained specialists in the

description, see Neuberger et al. [5]).

field of cardiac EP. National and international cardiol-

In addition to previous data (5), information on

ogy societies have developed training programs for a

methods for protection of esophageal lesions during

“heart rhythm specialist,” and the Accreditation

ablation of AF was collected. Data were made anon-

Committee of the European Heart Rhythm Associa-

ymous and sent to a statistical center. Descriptive

tion (EHRA), American societies (American College

statistics were analyzed using SPSS version 24.0

of Cardiology, American Heart Association, and Heart

(SPSS, Chicago, Illinois).

Rhythm Society), and the German Society of Cardiology (DGK) have recently published curricula for clinical electrophysiologists (2–4). These curricula recommend requirements for training centers and trainees. In view of this background, we performed a survey on infrastructure, training conditions, and procedure numbers in Germany in 2010, which served as a reference for the present survey (5). The purpose of this study was to provide a 5-year follow-up of this nationwide survey on cardiac EP, including types and numbers of electrophysiological studies and ablations performed in 2015 in Germany.

RESULTS According to OPS data, 327 centers coded ablation procedures in 2015. Among them were 97 centers that coded <30 catheter ablation procedures. Of the remaining 230 centers (n ¼ 189 in 2010), which coded $30 procedures, 131 (57%) responded. The completed questionnaires of these centers were used for analysis (Tables 1 to 4). Data came from 31 university

hospitals

(24%),

84

teaching

hospitals

(nonuniversity hospitals involved in training of medical students) (64%), 13 nonteaching hospitals (6.9%), and 3 private medical practices (1.6%) per-

METHODS

forming catheter ablations at a neighboring hospital.

German cardiology centers performing interventional

THE

EP were identified from (legally mandatory) quality

(ablation procedures and device therapy) was mainly

STRUCTURE

OF

INTERVENTIONAL

EP. EP

reports of German hospitals (http://www.dimdi.de/

part of a cardiology department (n ¼ 117 of 131

static/de/klassi/ops/anwendung/zweck/qualitaetsberichte/

[89.3%]), and only 14 centers were independent (with

index.htm). Hospitals reporting the following operation

their own budgets; 10.7%). Ninety-three centers

and procedure codes (OPS) were identified: 8-835.2

(70%) were officially certified training centers for

(radiofrequency ablation), 8-835.3 (irrigated radio-

interventional EP according to the EP curriculum of

frequency ablation), 8-835.4 (ablation with other

the DGK. In 2015, overall, 109 centers were officially

energy sources), 8-835.9 (mesh ablation), 8-835.a

certified for EP by the DGK (DGK, personal commu-

(cryoablation),

with

nication); thus 85% of those participated in the sur-

3-dimensional mapping). The number of OPS is not

vey. Interventional EP was the main area of expertise

necessarily identical to the number of ablation pro-

of the head of the cardiology department at 28 centers

cedures performed, because more than 1 OPS (e.g.,

(12%). At least 1 catheter laboratory was almost

irrigated radiofrequency ablation plus ablation using

exclusively (>90%) used for EP in 88 centers (67%),

3-dimensional mapping) can be coded for a single

whereas at the remaining centers (n ¼ 43 [33%]) the

ablation

centers

EP laboratory was used for non-EP procedures as

coding <30 ablation procedures were excluded from

well. At 18 centers (14%), at least 2 dedicated EP

analysis. This cutoff was chosen because a small

laboratories were available. An electroanatomical

and

procedure.

8-835.8

As

(ablation

previously

(5),

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T A B L E 1 Comparison of 2010 and 2015 Survey Data on Structure

T A B L E 2 Comparison of 2010 and 2015 Survey Data on Number

and Training in Electrophysiology in Germany

and Technical Aspects of Catheter Ablation Procedures

Responding centers EP part of a cardiology department

2015

2010

131

122

117 (89)

2015

2010

Responding centers

131

122

100 (82)

Median number of ablations

297

180

Independent EP (own budget)

14 (11)

11 (9)

Centers with <100 ablations

19 (15)

32 (26)

>1 head of department

35 (27)

12 (10)

Centers with $200 ablations

91 (69)

59 (48)

105 (80)

65 (53)

59,033

40,735

Heads of department Women Consultants (“Oberärztin/arzt”) Women

166

149

Centers with $50 PVIs

4 (2)

3 (2)

988

764

Total number of electrophysiological procedures

201 (21)

109 (14)

Total number of ablations

49,356

33,420

Paroxysmal SVT ablations

11,221 (22)

10,726 (32)

Arial flutter ablations

9,749 (20)

8,396 (25)

5,621 (11)

2,837 (8)

Centers with only 1 electrophysiologist

8 (6)

30 (25)

Fellows in cardiology/EP

2,801

2,365

1,371 (49)

1,044 (44)

Women Fellows in EP only Women EP consultants Women

291

235

112 (38)

61 (26)

276

193

Ventricular tachycardia/VPC ablations Atrial fibrillation ablations

23,441 (47)

11,685 (35)

Centers with transseptal approach for left-sided accessory pathways

83 (63)

55 (56)

111 (85)

81 (66)

48 (17)

19 (10)

1 EP consultant

28 (22)

49 (40)

Centers performing ablation of left ventricular VT

2 or more EP consultants

88 (67)

55 (45)

Centers performing no VT ablations

18 (14)

27 (22)

Centers with EP consultants also performing PCI

83 (63)

94 (77)

Primary retrograde approach for left ventricular VT ablations

51 (46)

55 (68)

Primary transseptal approach for left ventricular VT ablations

60 (54)

26 (32)

Centers performing epicardial VT ablations

38 (29)

15 (19)

Centers with no EP fellows*

41 (33)

42 (34)

Centers with 1 EP fellow

28 (22)

29 (24)

Centers with 2 EP fellows

20 (16)

19 (16)

Centers with $3 EP fellows

37 (29)

32 (26)

403

309

Primary operators for ablation Women

Patient consent for ablation before hospital admission with ablation on day of admission

73 (18)

28 (9)

<40 yrs of age

163 (40)

122 (39)

Always

22 (17)

22 (18)

40–50 yrs of age

166 (41)

152 (48)

>50%

44 (34)

42 (34)

>50 yrs of age

74 (18)

35 (2)

<50%

31 (24)

17 (14)

Worked part time

32 (8)

7 (2)

<10%

34 (26)

41 (34)

86 (66)

71 (58)

Centers with $2 physicians during ablation procedures

Values are n or n (%). *At 5 centers, the number of EP fellows was not available.

Values are n or n (%). PVI ¼ pulmonary vein isolation; SVT ¼ supraventricular tachycardia; VPC ¼ ventricular premature complex; VT ¼ ventricular tachycardia.

EP ¼ electrophysiology; PCI ¼ percutaneous coronary intervention.

mapping system was present at 121 centers (92%) (CARTO, n ¼ 82; NAVX, n ¼ 77; Rhythmia, n ¼ 2; CARTO and NAVX, n ¼ 40). Device implantation was at least partly performed in a catheter laboratory at 90 of the centers (69%), always at 61 (47%), most often ($50%) at 12 (9%), and sometimes (<50%) at 17 (13%). At the remaining 41 centers (31%), device implantation was done in the operating room. Devices were implanted by cardiologists at 76 (69%), by surgeons at 20 (16%), and by both at 32 (24%) of the EP facilities.

and 2,801 physicians in training (1,371 women [49%]) were employed. At these centers, 1 (n ¼ 28 [22%]), 2 (n ¼ 49 [37%]), or more than 2 (n ¼ 39 [30%]) electrophysiological

consultants

(Oberarzt)

were

employed. At 83 centers, electrophysiological consultants

also

performed

coronary

interventions

(63%). No EP fellows in training were present at 41 of the centers (33%), 1 fellow at 28 (22%), 2 at 20 (16%), and 3 or more at 31 (29%) (Figure 1). In

total,

276

electrophysiological

consultants

(48 women [17%]) were accompanied by 291 training positions (112 women [38%]). The centers employed

PHYSICIANS INVOLVED IN EP. Thirty-five of the 131

403 physicians (73 women [18%]) able to perform

cardiology departments (27%) at which $30 catheter

catheter ablations as primary operators (only 1 per

ablations were performed had >1 department head

center at 8 centers [6%]). Of these, 163 (40%) were

(e.g., head of interventional cardiology, head of EP)

younger than 40 years, 166 (41%) between 40 and 50

(Table 1). In total, 166 department heads (4 women

years of age, and 74 (18%) older than 50 years; 32 (8%)

[2%]), 988 consultants (Oberarzt; 204 women [21%]),

worked part-time.

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T A B L E 3 Comparison of 2010 and 2015 Survey Data on Technical Aspects of Catheter

Ablation of Atrial Fibrillation

(>50%) at 44 (34%), often (<50%) at 31 (24%), and rarely (<10%) at 34 (26%) centers. In case of consent before admission, the electrophysiological study was

Responding centers

2015

2010

131

122

Strategy for AF ablation Centers performing AF ablations

performed on the day of admission. Target arrhythmias (>1 type of arrhythmia could be ablated in a single case) were regular supraventricular

123 (94)

99 (81)

23,441 (47)

11,685 (35)

14,728

NA

[20%]), ventricular tachycardia (VT) (n ¼ 5,621 [11%]),

7,781

NA

and AF (n ¼ 23,441 [47%]) (Figure 2). Ablation of left-

PVAC ablations

811

NA

sided accessory pathways was reported by 126 centers

Other energy sources

121

NA

(97%) (no accessory pathway ablation at 3 [2%], no

106 (86)

74 (75)

data available for 2 [2%]) using either a transseptal

102 (82)

NA

as primary access. Left-sided VT ablation was

AF ablations Radiofrequency point-by-point ablations Cryoablations

Centers performing ablations of consecutive left atrial arrhythmias after PVI

(n ¼ 83 [63%]) or a retrograde approach (n ¼ 43 [34%])

Preferred ablation strategy for persistent AF PVI only

tachycardia (n ¼ 11,221 [22%]), atrial flutter (n ¼ 9,749

PVI plus linear ablation

11 (9)

NA

reported by 111 centers (85%) (no VT ablation at 18

PVI plus defragmentation and/or substrate modification

10 (8)

NA

[15%], no data for 2 [2%]). Access to the left ventricle

In-house surgical back-up

55 (45)

44 (44)

Centers performing surgical AF ablations

37 (28)

41 (34)

11 (8)

10 (7)

61 (50)

59 (60)

EP centers).

MRI

16 (13)

14 (14)

performed AF ablation procedures. As the method for

CT

38 (30)

43 (43)

7 (6)

2 (2)

AF ablation, the majority of centers (n ¼ 89 [72%])

3 (2)

6 (6)

used a cryoballoon (Arctic Front, Medtronic, Minne-

Sedation with propofol

92 (75)

54 (55)

apolis, Minnesota), 21 (17%) a circular multielectrode

Sedation without propofol

28 (23)

35 (35)

ablation catheter (PVAC; Medtronic), and 7 (6%) other

96 (78)

NA

Energy reduction at the posterior wall

66 (54)

NA

Use of esophageal temperature probes

52 (45)

NA

ablations performed by the participating centers

Use of H2-blockers post-ablation

85 (69)

NA

covered about 80% of the distributed balloons. PVI

Surgical backup and AF surgery

Centers performing stand-alone surgical AF ablations

was primarily retrograde via the aorta at 51 (46%) and

Rotational angiography

In total, 123 of the responding 131 centers (94%)

Sedation/anesthesia for AF ablations Centers using general anesthesia during AF ablations

Protection of the esophagus during AF ablations Centers using strategies for special protection of the esophagus

Additionally, epicardial ablation was performed at 38 centers (34%) performing VT ablation (i.e., 29% of all

Imaging before AF ablation Centers routinely performing LA imaging before AF ablation

using a transseptal approach at 60 (54%) centers.

used point-by-point radiofrequency current, 50 (41%)

energy sources. In 2015, 9,644 cryoballoon ablation catheters were sold in Germany (Medtronic, personal communication). Therefore, the 7,781 cryoballoon

was the ablation strategy for paroxysmal AF at all Values are n or n (%). AF ¼ atrial fibrillation; CT ¼ computed tomography; LA ¼ left atrial; MRI ¼ magnetic resonance imaging; NA ¼ not applicable; PVAC ¼ pulmonary vein ablation catheter; PVI ¼ pulmonary vein isolation.

centers. For persistent AF, PVI was first-line therapy at 102 centers (82%), whereas a minority performed PVI plus linear ablation (n ¼ 11 [9%]) and/or PVI plus substrate modification (n ¼ 10 [8%]). Imaging before

At 86 of the centers (66%), (at least) 2 physicians were present during the majority of catheter ablations. The median number of ablations per center was 297. At 15 of the centers (11%), <100 ablations were performed; at least 200 catheter ablations were performed at 79 centers (60%). At least 50 [75] pulmonary vein isolations (PVIs) were performed at 105 (80%) [92 (70%)] of the centers; 18 centers (14%) performed <50 PVIs, and 8 centers (6%) did not ablate AF.

AF ablation was routinely performed at 61 centers (50%) (magnetic resonance imaging at 16 [13%], computed tomography at 38 [30%], rotational angiography at 7 [6%]). During AF ablation, patients were under general anesthesia (tracheal intubation, n ¼ 3 [2%]) or sedated with (n ¼ 92 [75%]) or without (n ¼ 28 [23%]) propofol. Consecutive left atrial arrhythmias following AF ablations were treated by catheter ablation at 106 of 123 centers (86%) performing AF ablation procedures. The majority of centers (n ¼ 96 [78%]) used stra-

PROCEDURAL DATA. In total, 59,033 EP procedures,

tegies

including 49,356 catheter ablations, were reported for

included administration of H2-blockers post-ablation

2015 (Table 2). Patient consent for interventional

(n ¼ 85 [69%]), use of esophageal temperature

electrophysiological procedures was obtained before

probes (n ¼ 52 [42%]), and/or energy reduction at the

hospital admission always at 22 (17%), most often

posterior left atrial wall (n ¼ 66 [54%]).

for

protection

of

the

esophagus.

These

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Fifty-five centers (45%) performing AF ablation had in-house cardiosurgical backup. For the other

T A B L E 4 Curriculum Heart Rhythm Specialists: Training Center Requirements and

Reality (Germany 2015)

centers, the distance to the next hospital performing cardiac surgery ranged from 2 to 100 km (mean 27.6  28.6 km). Surgical ablations were performed at 37 centers (28%) (surgical AF ablation, n ¼ 37 [28%]; VT ablation, n ¼ 6 [5%]). Eleven centers (8%) performed surgical AF ablations as stand-alone procedures. TRAINING CENTER REQUIREMENTS. Table 4 lists the

requirements

for

training

center

accreditation

Parameter

Physicians present during ablation

EHRA Centers Fulfilling DGK Requirements EHRA Requirements Requirements

—

2

21 (16) (always)* 86 (66) (most cases)

Number of EP procedures per year

250

93 (71)

250

93 (71)

Number of ablations per year

200

91 (69)

200

91 (69)

Number of AF ablations per year

—

—

50[75]†

105 (80) [92 (70)] 121 (92)

according to the EHRA and the DGK (2–4). Approxi-

3D mapping system

Yes

121 (92)

Yes

mately two-thirds of the centers reported a number of

Cardiosurgical unit

Yes

55 (42)

No

procedures that fulfilled these criteria. However, all

All requirements

European requirements together were fulfilled only by one-third of the centers. Besides, more recently German national recommendations for AF ablation have been published (4), which include, for example, 75 AF ablations per year. This would have been

38 (29)

— 83 (63)*

Values are n or n (%). Requirements are defined according to guidelines and curricula as published (2–4). *Under the requirement that 2 physicians are always present during an ablation, only 20 centers (15%) would have fulfilled DGK requirements. †According to a recent position paper by the DGK (4), 75 AF ablations per year are required. 3D ¼ 3-dimensional; DGK ¼ German Society of Cardiology; EHRA ¼ European Heart Rhythm Association; other abbreviations as in Tables 1 and 3.

fulfilled by only 70% of the centers performing AF ablation in 2015. about one-third of the EP centers fulfilled all

DISCUSSION

Centers Fulfilling DGK Requirements

European training center requirements. Compared with 2010, these data illustrate an increase in electro-

For the second time, this survey reports detailed data

physiological training centers but also the continuous

from the majority of German centers performing

need for collaboration of EP centers to guarantee

interventional EP. The present survey allows the

training standards and qualification. Being aware that

opportunity to report trends in EP over a period of

the recommendations of the DGK advise the presence

5 years, as it compares survey data from 2010 and

of 2 physicians during catheter ablation, it is remark-

2015. In total, almost identical to the previous survey

able that catheter ablations were performed always or

(5) about two-thirds of the identified centers respon-

in most cases by 2 physicians at only 21 (16%) and 65

ded. They carried out 49,356 catheter ablations,

(50%) centers, respectively. Furthermore, almost

which represent the majority (81%) of catheter abla-

identical to 2010, about one-third of centers did not

tions performed in Germany (60,933 diagnosis-

employ EP fellows. Thus, a realistic chance of training

related groups including a catheter ablation [F50A,

in interventional EP does not exist at a relevant pro-

F50B, F50C, and F50D]). Compared with 2010, we

portion of the participating centers, even independent

observed an almost 50% increase in the total number

of curricular requirements.

of ablations. Interventional EP was performed at a

Comparable with 2010, at the majority of centers,

relatively large number of hospitals; more than 300

clinical EP was part of a cardiology department.

hospitals were identified.

Despite a high degree of subspecialization in cardi-

For training in the subspecialty of EP, the DGK and

ology and the increasing complexity of procedures

the EHRA have published requirements for physi-

(e.g., AF, VT, device therapy), only about 20% of

cians in training and for training centers (not legally

EP centers were independent. Nevertheless, it is

binding). It seems relevant to interpret our data with

remarkable that this percentage doubled over the

regard to these curricula (2,3). On the basis of EHRA

5-year period (from 10% in 2010). It remains impor-

recommendation, an electrophysiological training

tant that almost one-third of EP consultants also

center should, for example, employ at least 2 fully

performed coronary interventions. This was 77% in

trained heart rhythm specialists and needs to be

2010 and thereby illustrates growing independence of

integrated within a cardiosurgical unit (Table 4).

clinical EP in Germany.

According to our data, only 42% of the responding

The proportion of female physicians in EP training

centers would have fulfilled this criterion. Besides,

increased from 26% to 38%. The proportion of women

31% of the centers performed <200 ablations a year,

among physicians able to perform catheter ablations

which is recommended by the EHRA and the DGK as a

as primary operator is at 17% still very low but has

minimum number for a training center. In fact, only

increased (from 10% in 2010). This proportion is still

5

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F I G U R E 1 Number of Training Positions in 2010 and 2015 per Center Performing

Interventional Electrophysiology

pathways (from 56% to 66% in 2015) and left ventricular VT ablations (from 32% to 54% in 2015) at the responding

centers.

Growing

experience

likely

further increases the safety of transseptal procedures (6). Point-by-point radiofrequency current was the method most commonly used for PVI (63%), with 33% cryoablations in 2015. A low prevalence of other less established technologies (e.g., PVAC [7] at 3.5%) was observed. Given the high prevalence of AF and its consequences, prospective AF ablation trials with mortality as an endpoint are still urgently needed. Positive results may further increase the already growing demand for the procedure. It is surprising that still a relevant proportion of 14% (25% in 2010) of centers performing PVI did not treat consecutive left atrial arrhythmias (8). Thus, there is still a mismatch lower than the proportion of female cardiology consultants (21% in 2015 vs. 14% in 2010). Duration of training and radiation exposure during child-bearing age may have contributed to this observation. The option to work part-time in this field has only slightly changed between 2010 (2%) and 2015 (8%). Of note, in 2015 almost every second catheter ablation (47% vs. 35% in 2010) was an ablation of AF (PVI). Thus, in the presence of an almost 50% increase in the total number of ablations, the proportion of ablation procedures has shifted over a relatively short period of time as well. In consequence, the relative number of SVT and atrial flutter ablations decreased from 32% and 25% in 2010 to 22% and 20% in 2015, respectively. As a likely result of the increasing numbers

and

experience,

primarily

transseptal

approaches increased for both left-sided accessory

between the need for interventional AF treatment and the availability of experienced EP specialists performing ablations for secondary “iatrogenic” atrial arrhythmias. This mismatch may further increase with growing use of the technically less demanding cryoballoon ablation. Of note, “single-shot devices” such as the PVAC catheter (9) but also the cryoballoon (10) have been reported to cause a smaller number of left atrial arrhythmias after PVI. With regard to persistent AF, it is remarkable that 82% of the responding centers performed (only) PVI during a first catheter ablation, which is in line with the STAR AF II trial (11), which was published in May 2015. Almost 80% of AF ablation centers reported strategies to protect the esophagus, including the use of H2-blockers (12) (69%), energy reduction at the posterior wall (54%), and the use of esophageal temperature probes (45%). This illustrates the widespread fear and growing awareness of the dramatic

F I G U R E 2 Targets for Catheter Ablations in Germany, 2010 (n ¼ 33,420) Versus 2015

(n ¼ 49,356)

and mostly lethal complication of an atrioesophageal fistula (13,14). No general and conclusive documentation of atrioesophageal fistula apart from case reports are available, however. In the presence of the most recent European Society of Cardiology AF guidelines (15), which strengthen the role of surgical AF ablation, it is remarkable that only 28% of the responding centers, which included almost all large ablation centers in Germany covering 81% of all ablations, performed surgical AF ablations in 2015 (less than in 2010, at 34%). Stand-alone surgical AF ablations were performed at only 8% of the responding ablation centers. This questions the practicability of AF heart teams and surgical AF ablation suggested by the recent guidelines (16).

AF ¼ atrial fibrillation; AFLU ¼ atrial flutter; SVT ¼ supraventricular tachycardia; VT ¼ ventricular tachycardia.

A comparison with the American College of Cardiology/American Heart Association/Heart Rhythm Society advanced training statement on clinical

JACC: CLINICAL ELECTROPHYSIOLOGY VOL.

-, NO. -, 2018

Eckardt et al.

- 2018:-–-

cardiac

EP

Survey on Interventional Electrophysiology

(17) to

define

potential

differences

met the requirements for ablation centers but does

between the United States and Europe reveals that

not display the corresponding figures for single op-

requirements suggested for the United States are

erators. The given data also provide an incomplete

similar to those established in Europe and in

perspective because of a lack of outcome data and in

Germany. Of note, the required numbers for ablation

particular of procedure-related complications. This is

procedures for physicians are slightly larger in

important because the safety of ablation therapy may

Europe.

depend on the volume of procedures performed at

Specific certifications for electrophysiologists may

centers and by single operators (19). However,

play an important role for outcome quality. Similar to

because this project was designed to assess nation-

the situation in the United States, specific certifica-

wide structural conditions with specific regard to

tions have therefore been established by the DGK as

training in EP, these data cannot be provided.

well as by the EHRA to ensure increasing quality in particular for AF ablation. In the recently published

CONCLUSIONS

2017 Heart Rhythm Society/EHRA/European Cardiac Arrhythmia

Society/Asia

Pacific

Heart

Rhythm

The results of this survey indicate a continuous

Society/Sociedad Latinoamericana de Estimulación

increase

Cardiaca y Electrofisiologia expert consensus state-

large number of electrophysiological centers and

ment on catheter and surgical ablation of AF (18)

procedures. In 2015, almost every second ablation

training

been

performed in Germany was a PVI. At most, one-third

addressed. Although this consensus document con-

of EP centers fulfilled suggested requirements for

cludes that exact procedure numbers are difficult to

training

specify, minimum numbers have been suggested.

clearly

These numbers are similar in the United States and in

electrophysiologists.

Europe, as the consensus document is a joint

ACKNOWLEDGMENTS The

document from American and European societies.

nucleus of the working group AG1 Rhythmologie of

However, recommended numbers may still underes-

the DGK (speakers: T. Deneke and C. Piorkowski) for

timate the experience required for a high degree of

collaboration.

requirements

for

operators

have

in

specialization

centers.

In

in

cardiology

addition,

underrepresented

women

among

and

a

remain

interventional

authors

thank

the

proficiency (18). STUDY LIMITATIONS. Comparable with 2010, not all

ADDRESS FOR CORRESPONDENCE: Dr. Lars Eckardt,

EP centers responded, and possibly not all centers

Abteilung für Rhythmologie, Universitätsklinikum

were identified. Nevertheless, the reported data cover

Münster,

the majority of EP centers and procedures performed

Münster,

in 2015 in Germany and give a unique opportunity to

ukmuenster.de.

Albert-Schweitzer Germany.

Campus

E-mail:

1,

48149

lars.eckardt@

illustrate recent trends in EP over a period of 5 years. The numbers rely on self-reporting. Thus, the results may not exactly represent the exact number of

PERSPECTIVES

procedures. Additionally, the responding two-thirds of the identified EP centers reported 81% of all DRG-coded catheter ablations. Thus, smaller centers are probably underrepresented, resulting in an overestimation of the median and mean number of procedures per center. Furthermore, as in the previous survey (5), we excluded centers coding <30 ablation procedures in 2015 to prevent an overestimation of sites at which catheter ablation is rarely performed. As a result, this survey may again even overestimate the number and percentage of possible training centers fulfilling curricular requirements, which, however, are not based on evidence-based information. In addition, the present survey only displays how many centers in Germany would have

COMPETENCY IN MEDICAL KNOWLEDGE: The present study illustrates a clear trend toward increasing numbers of catheter ablations, with almost every second ablation for therapy of AF. Future studies and trends in cryoablation versus radiofrequency ablation for PVI will be of interest. The growing need for EP centers is in contrast to a limited number of training positions. In the presence of suggested training requirements for EP centers, the majority of centers performing catheter ablation did not fulfill suggested recommendations in 2015. Future studies should investigate possible changes and whether training requirements correlate with the safety, efficacy, and therefore quality of invasive EP.

7

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Survey on Interventional Electrophysiology

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KEY WORDS catheter ablation, interventional electrophysiology, survey, training requirements