Curriculum Spezielle Rhythmologie

[Mentorship in electrophysiology : What does it take? What's the advantage?]

Mentoring has long been a fundamental part of medical education. In this article, the term mentoring is defined and the requirements, advantages, and methods of structuring are discussed. Further, the use of mentoring in the context of education in electrophysiology will be highlighted. In this setting, requirements on the personal level of mentors and mentees as well as on the institutional level are outlined, and different phases and types of mentoring are discussed.

10-year follow-up of interventional electrophysiology: updated German survey during the COVID-19 pandemic

INTRODUCTION

This study provides an update of survey-based data providing an overview of interventional electrophysiology over the last decade. Overall infrastructure, procedures, and training opportunities in Germany were assessed.

METHODS

By analyzing mandatory quality reports, German cardiology centres performing electrophysiological studies were identified to repeat a questionnaire from 2010 and 2015.

RESULTS

A complete questionnaire was returned by 192 centers performing about 75% of all ablations in Germany in 2020. In the presence of the COVID-19 pandemic, a total of 76.304 procedures including 68.407 ablations were reported representing a 38% increase compared to 2015. The median number of ablations increased from 180 in 2010 to 377 in 2020. AF was the most common arrhythmia ablated (51 vs. 35% in 2010). PVI with radiofrequency point-by-point ablation (64%) and cryo-balloon ablation (34%) were the preferred strategies. Less than 50 (75) PVI were performed by 31% (36%) of all centres. Only 25 and 24% of participating centres fulfilled EHRA and national requirements for training centre accreditation, respectively. There was a high number of EP centres with no fellows (38%). The proportion of female fellows in EP increased from 26% in 2010 to 33% in 2020.

CONCLUSION

Comparing 2020, 2010 and 2015, an increasing number of EP centres and procedures were registered. In 2020, more than every second ablation was for therapy of AF. In the presence of an increasing number of procedures, training opportunities were still limited, and most centres did not fulfill recommended EHRA or national requirements for accreditation.

[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.

[Current status of cardiac electrophysiology training in Germany]

Hintergrund

Die rhythmologische Ausbildung junger Kardiologinnen und Kardiologen bildet das Fundament für eine optimale Versorgung von Patienten mit Herzrhythmusstörungen. Die Rhythmologie zeichnet sich durch einen hohen Innovationsgrad aus und hat sich innerhalb der letzten Jahre rasant weiterentwickelt. Dies könnte zu einer Kluft zwischen der klinischen Ausbildung und neuer Technologien geführt haben und die Ausbildungsanforderungen maßgeblich verändern.

Fragestellung

Das Ziel der Umfrage war es, ein Meinungsbild junger Kardiologinnen und Kardiologen über den Stellenwert und die Zufriedenheit der rhythmologischen Ausbildung zu erheben und Verbesserungsansätze zu formulieren.

Methoden

Die Umfrage wurde im Mai 2020 durchgeführt. Mitglieder der Sektion Young-DGK der deutschen Gesellschaft für Kardiologie wurden via E‑Mail kontaktiert und gebeten einen onlinebasierten Fragebogen zu beantworten. Der Fragebogen beinhaltete Informationen über den aktuellen Stellenwert, die Zufriedenheit und die Strukturen der rhythmologischen Ausbildung in Deutschland.

Ergebnisse

Insgesamt 131 Young DGK-Mitglieder (68 % männlich) nahmen an der Umfrage teil. Das Durchschnittsalter betrug 33 ± 3,3 Jahre und der Ausbildungsstand gliederte sich wie folgt: 64 % Assistenzärzte, 20 % Fachärzte und 16 % Oberärzte. 72 Teilnehmer (53 %) berichteten, mit ihrer kardiologischen Weiterbildung sehr zufrieden zu sein. Die Hälfte der Teilnehmer wünschte sich einen höheren Umfang an rhythmologischen Inhalten in ihrer Weiterbildung. Rhythmologische Fortbildungsveranstaltungen und Fellowships wurden überwiegend positiv bewertet (70 % bzw. 93 %), jedoch waren diese jeweils für knapp die Hälfte der Teilnehmer unbekannt. Verbesserungsansätze sahen die Teilnehmer in der Einführung einer generellen rhythmologischen Rotation, einem gesteigerten Zugang zu Prozeduren um invasive Fähigkeiten zu erlernen (falls nötig auch klinikübergreifend), einer intensivierten Werbung für Fortbildungsveranstaltungen und Fellowships sowie einer Zunahme onlinebasierter Fortbildungsveranstaltungen.

Schlussfolgerung

Die Umfrage unterstreicht das Interesse junger Kardiologinnen und Kardiologen an einer strukturierten und intensivierten rhythmologischen Ausbildung innerhalb ihrer kardiologischen Weiterbildung.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00399-020-00717-4) enthalten.

[Safety and efficiency of interventional electrophysiology utilizing the German "Belegarztsystem"]

INTRODUCTION

Electrophysiology study (EPS) and catheter ablation (abl.), in particular for atrial fibrillation, are increasingly performed in Germany. Therefore, measures and steps to ensure quality assurance are indicated. Most of the procedures are performed by physicians employed by hospitals; however, some are also carried out by attending cardiologists on contract in private practice, applying the so-called Belegarztsystem. The aim of this study was to determine the safety and efficiency of an interventional electrophysiology performed in a German Belegarztsystem.

METHODS

Based on a prospective registry, we analyzed procedure-related data from 1400 consecutive EPS/abl. performed at our center between 2014 and 2018. One-year follow-up data (arrhythmia recurrences, complications, deaths) were collected for all procedures carried out during the first 2 years.

RESULTS

In the total study cohort, no periprocedural death occurred, and there was a low cumulative incidence of groin complications (0.9%). The most common procedure (n = 772) was complex ablation for atrial fibrillation/flutter (55%). In this group, the success rate was 98% (acute) and 65% (1 year), and the cumulative rate of complications was 5.0% (transient ischemic attack/stroke 0.1%, pericardial tamponade 0.4%, relevant pericarditis/pericardial effusion 1.1%, groin complication 1.5%, other 1.9%). For the other procedures, rates for success and complications were comparable, and procedure times and x‑ray doses tended to be lower in our analysis as compared to prior reports.

CONCLUSION

Interventional electrophysiology, carried out by experienced operators and qualified staff, can be performed safely and effectively by attending physicians in a Belegarztsystem.

[Certification : Pro: indispensable component of quality]

Certification is a critical component of quality assurance in medicine. From the certification of individual persons, through units and up to whole hospitals, certification stimulates testing and optimization of treatment processes, thereby improving the quality of care. Minimum case numbers needed to acquire a certificate are an important and objective attribute of quality. Advantages of certification include an improved treatment of patients, structured training of new employees and enhanced cost efficiency.

German Cardiac Society Working Group on Cellular Electrophysiology state-of-the-art paper: impact of molecular mechanisms on clinical arrhythmia management

Cardiac arrhythmias remain a common challenge and are associated with significant morbidity and mortality. Effective and safe rhythm control strategies are a primary, yet unmet need in everyday clinical practice. Despite significant pharmacological and technological advances, including catheter ablation and device-based therapies, the development of more effective alternatives is of significant interest to increase quality of life and to reduce symptom burden, hospitalizations and mortality. The mechanistic understanding of pathophysiological pathways underlying cardiac arrhythmias has advanced profoundly, opening up novel avenues for mechanism-based therapeutic approaches. Current management of arrhythmias, however, is primarily guided by clinical and demographic characteristics of patient groups as opposed to individual, patient-specific mechanisms and pheno-/genotyping. With this state-of-the-art paper, the Working Group on Cellular Electrophysiology of the German Cardiac Society aims to close the gap between advanced molecular understanding and clinical decision-making in cardiac electrophysiology. The significance of cellular electrophysiological findings for clinical arrhythmia management constitutes the main focus of this document. Clinically relevant knowledge of pathophysiological pathways of arrhythmias and cellular mechanisms of antiarrhythmic interventions are summarized. Furthermore, the specific molecular background for the initiation and perpetuation of atrial and ventricular arrhythmias and mechanism-based strategies for therapeutic interventions are highlighted. Current "hot topics" in atrial fibrillation are critically appraised. Finally, the establishment and support of cellular and translational electrophysiology programs in clinical rhythmology departments is called for to improve basic-science-guided patient management.

[Certification in cardiology : Contra: The concept should be improved]

Increasing complexity and new highly differentiated therapeutic procedures in cardiology result in a need for additional training beyond cardiology board certification. The German Cardiac Society therefore developed a variety of certifications of educational curricula and definition of specialized centers. Standardization and structuring in education and patient treatment, as defined by certifications may be helpful; however, introduction of certification can have serious consequences for hospital structure, the side effects of which may impair quality of treatment for individual patients. The current article discusses these issues against the background of the following questions: how is quality defined? How do certifications interfere with patient care on a nationwide level, how do they influence responsibilities and teamwork? Are there conflicts of interests by designing certifications and how good are the organizational structures? Finally, suggestions are made on what has to be considered when designing certifications. Certifications should acknowledge all cardiologists, irrespective of their position in the level of care. There should be a coherent unified concept synchronizing all certifications and administration needs to be transparent and well structured.

Updated Survey on Interventional Electrophysiology: 5-Year Follow-Up of Infrastructure, Procedures, and Training Positions in Germany

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.

[How to approach the patient with supraventricular tachycardia in the EP lab: A systematic overview]

The term supraventricular tachycardia (SVT) summarizes those tachycardias involving the atrial myocardium along with the atrioventricular (AV) node. The prevalence is about 2.25 per 1000 (without atrial fibrillation and atrial flutter) and, therefore, SVT represents one of the most common group of arrhythmias besides atrial fibrillation encountered in the emergency department especially since they tend to recur until definite therapy. The clinical symptoms may include palpitations, anxiety, presyncope, angina, and dyspnea. Pharmacological therapy of these arrhythmias often fails. The present article deals with the differential diagnosis of SVT and also introduces a series of manuscripts that provide detailed insight into the differential diagnosis and treatment of these arrhythmias.

Personnel, equipment, and facilities for electrophysiological and catheter ablation procedures in Europe: results of the European Heart Rhythm Association Survey

Clinical electrophysiology (EP) and catheter ablation of arrhythmias are rapidly evolving in recent years. More than 50 000 catheter ablations are performed every year in Europe. Emerging indications, an increasing number of procedures, and an expected high quality require national and international standards as well as trained specialists. The purpose of this European Heart Rhythm Association (EHRA) survey was to assess the practice of requirements for EP personnel, equipment, and facilities in Europe. Responses to the questionnaire were received from 52 members of the EHRA research network. The survey involved high-, medium-, and low-volume EP centres, performing >400, 100-399, and under 100 implants per year, respectively. The following topics were explored: (i) EP personnel issues including balance between female and male operators, responsibilities within the EP department, age profiles, role and training of fellows, and EP nurses, (ii) the equipments available in the EP laboratories, (iii) source of patient referrals, and (iv) techniques used for ablation for different procedures including sedation, and peri-procedural use of anticoagulation and antibiotics. The survey reflects the current EP personnel situation characterized by a high training requirement and specialization. Arrhythmia sections are still most often part of cardiology departments and the head of cardiology is seldom a heart rhythm specialist. Currently, the vast majority of EP physicians are men, although in the subgroup of physicians younger than 40 years, the proportion of women is increasing. Uncertainty exists regarding peri-procedural anticoagulation, antibiotic prophylaxis, and the need for sedation during specific procedures.

A survey of German centres performing invasive electrophysiology: structure, procedures, and training positions

AIMS

To provide a nationwide survey (and reference for the future) on cardiac electrophysiologists, types and numbers of invasive electrophysiological procedures, and training opportunities in 2010.

METHODS AND RESULTS

German cardiology centres performing invasive electrophysiology were identified from quality reports and contacted to fill a questionnaire. A majority of 122 centres (65%) responded. Electrophysiology (ablation procedures and device therapy) was mainly part of a cardiology department (82%), and only in 9% independent (own budget). In only 58% of the centres, (at least) two physicians were present during catheter ablations. Although in 2010, women represented 59.4% of physicians <35 years old, only 26% of physicians in electrophysiology training were female. In total, 33 420 catheter ablations were performed with a median number of 180 per centre. Atrial fibrillation (AF) was the most common arrhythmia invasively treated (35%). At least 50 AF ablations were performed in 53% of the centres. Of the centres performing AF ablations, consecutive left atrial arrhythmias were treated by catheter ablation only in 75%, and only 44% had in-house surgical backup. Only one-fourth of the 122 centres fulfilled all requirements for training centre accreditation according to the European Heart Rhythm Association and the German Cardiac Society.

CONCLUSION

The results indicate a high number of electrophysiology centres and procedures in Germany. Atrial fibrillation was the most common arrhythmia invasively treated. An increasing demand for catheter ablation is likely, but training opportunities are limited. Women are clearly underrepresented. A co-operation of higher and lower volume electrophysiology centres may be necessary for training purposes.