Empfehlungen zur Strukturierung der Herzschrittmacher- und Defibrillatortherapie

[Structural requirements and prerequisites for outpatient implantation of defibrillators, devices for cardiac resynchronization and event recorders]

Die Möglichkeiten der ambulanten Implantation von Defibrillatoren, Geräten zur kardialen Resynchronisation und Ereignisrekordern („cardiac implantable electronic devices“, CIEDs) gewinnen zunehmend an Bedeutung. In Deutschland existieren aktuell vereinzelte Möglichkeiten zur ambulanten Implantation. Es fehlt allerdings an einheitlichen, anerkannten und verbindlichen Qualitätskriterien sowie an Grundzügen vertraglicher Gestaltungen. Der vorliegende Artikel stellt einen Einblick in die aktuellen Vertragskonstellationen zur ambulanten Operation bereit und definiert ein erstes, holistisches Qualitätskonzept für ambulante Implantationen von CIEDs. Im Zentrum steht das Ziel, einen Diskurs in der Fachgesellschaft anzustoßen, um ein abgestimmtes, verbindliches Qualitätskonzept zu definieren. Dieses sollte als Grundlage für zukünftige Leistungen der ambulanten Implantation dienen, die Leistungen vergleichbar machen und einen Beitrag zum langfristigen Nachweis der Evidenz leisten.

[GSTCVS certificate for cardiac pacemaker, ICD and CRT therapy]

Medical qualifications to perform operations with cardiac electronic implantable devices as well as for preoperative and postoperative therapy, including follow-up in this patient population are not well defined. Based on recommendations which have been worked out and published by an interdisciplinary consensus of cardiac surgeons, cardiologists and electrophysiologists, a certificate with three modules has been developed by the Working Group for Electrophysiologic Surgery of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS, Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, DGTHG). First examinations for this certificate will be held in 2013 and transitional regulations apply until 1st April 2014. Further details are available on the homepage of the GSTCVS.

[Diagnosis of atrial fibrillation. From the standard ECG to analysis of electrograms]

The early diagnosis of asymptomatic atrial fibrillation is important because of the associated risk for arterial embolism. Routine ECG recording, however, is not effective in asymptomatic patients. The goal of this article is to show the general practitioner and internist how the search for atrial fibrillation can be made more efficacious. For example, recording an ECG in patients older than 65 years with irregularities in their pulse or repeated ECG recording in patients older than 75 years with hypertension shows improved results in this regard. It is interesting that elements of the CHA2DS2-VASc score, which was developed to predict risk for arterial embolism, are also effective for defining populations to screen for atrial fibrillation. In the subgroup of patients with a pacemaker or implantable converter-defibrillator (ICD), histograms or intracardiac electrograms can be used to identify previously undiagnosed atrial fibrillation. The general practitioner should take these results which are usually obtained by a cardiologist into consideration in the follow-up treatment of his or her patients.

[The "Recommendations for the structure of cardiac pacemaker and defibrillator therapy"--what can they achieve?: Implementation of the concept paper for HSM/ICD therapy]

Implantable devices in cardiac electrophysiology have developed from simple machines that prevent bradycardia to complex systems that treat malignant tachyarrhythmias and severe heart failure. Optimal therapeutic utilization of these systems requires profound knowledge of those who treat patients with devices. To account for that, the German Cardiac Society has published "Recommendations for the structure of cardiac pacemaker and defibrillator therapy" to achieve an expertise in 2 levels. These define topics for interdisciplinary education to ensure implantation and follow-up of high quality, as well as infrastructural requirements such as staff and operation rooms. The implementation of these guidelines offers a great opportunity for good quality in device therapy and may enhance the results of the compulsory German quality registry of the respective institution. The established courses of the German Cardiac Society to achieve competence in pacemaker and ICD therapy according to the curricula should be complemented by practical training in accredited centers. Minimum numbers for implantation and follow-up are necessary to ensure a continuously high quality.

[Continuing education through the European Heart Rhythm Association (EHRA): chance for European standardization?]

Standardization of training with an examination in cardiac electrophysiology represents a milestone in the unification and improvement in the quality of electrophysiological therapy within the member countries of the European Society of Cardiology (ESC). Since 2004 the European Heart Rhythm Association (EHRA) has established an Educational Committee with the mission of improving training in device therapy and electrophysiology in the ESC with accredited materials and educational initiatives. The Educational Committee established Europe-wide courses for continuous medical education in 1. invasive electrophysiology and catheter ablation, 2. pacemaker, ICD and cardiac resynchronization therapy and 3. case-based tutorials to prepare for the EHRA examinations for electrophysiology/ablation and device therapy. Independent from participation in EHRA examinations these courses represent a useful aid for daily practice in cardiac electrophysiology and help to bring young and advanced European cardiologists with an interest in electrophysiology together.

[Curriculum and expert courses on pacemaker and ICD therapy]

The curricula "Practice of Pacemaker Therapy" and "Practice of ICD Therapy" have been developed from practical experience with the first educational courses which are necessary to fulfill the German requirements of the medical products law which restricts the application of medical products to persons with the necessary education, knowledge and experience. The corresponding courses of competence under the auspices of the German Cardiac Society derive from this legal prerequisite. Competence refers to technical knowledge in cardiac implantable electrical devices (CIEDs) and understanding of possible dysfunctions as well as substantial knowledge on arrhythmia. The two curricula form the theoretical basis for the application of CIEDs. These courses represent an offer to cardiologists and all other physicians who wish to acquire and document competency in this field. A legal obligation to participate in these competency courses does not currently exist in Germany as long as evidence can be provided that this competency has been achieved by other means. Both curricula have proven to be comprehensive and practically highly useful and have been presented by highly committed specialists with expertise in this topic at a high level. Since 2005 some 2,000 physicians have been trained in courses on pacemaker therapy and more than 1,000 physicians in courses on ICD therapy with an ongoing high level demand to be expected in the future.