Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing, and Arrhythmia Management

Deaths and cardiovascular injuries due to device-assisted implantable cardioverter-defibrillator and pacemaker lead extraction

AIMS

An estimated 10,000-15,000 pacemaker and implantable cardioverter-defibrillator (ICD) leads are extracted annually worldwide using specialized tools that disrupt encapsulating fibrous tissue. Additional information is needed regarding the safety of the devices that have been approved for lead extraction. The aim of this study was to determine whether complications due to device-assisted lead extraction might be more hazardous than published data suggest, and whether procedural safety precautions are effective.

METHODS AND RESULTS

We searched the US Food and Drug Administration's (FDA) Manufacturers and User Defined Experience (MAUDE) database from 1995 to 2008 using the search terms 'lead extraction and death' and 'lead extraction and injury'. Additional product specific searches were performed for the terms 'death' and 'injury'. Between 1995 and 2008, 57 deaths and 48 serious cardiovascular injuries associated with device-assisted lead extraction were reported to the FDA. Owing to underreporting, the FDA database does not contain all adverse events that occurred during this period. Of the 105 events, 27 deaths and 13 injuries occurred in 2007-2008. During these 2 years, 23 deaths were linked with excimer laser or mechanical dilator sheath extractions. The majority of deaths and injuries involved ICD leads, and most were caused by lacerations of the right atrium, superior vena cava, or innominate vein. Overall, 62 patients underwent emergency surgical repair of myocardial perforations and venous lacerations and 35 (56%) survived.

CONCLUSION

These findings suggest that device-assisted lead extraction is a high-risk procedure and that serious complications including death may not be mitigated by emergency surgery. However, skilled standby cardiothoracic surgery is essential when performing pacemaker and ICD lead extractions. Although the incidence of these complications is unknown, the results of our study imply that device-assisted lead extractions should be performed by highly qualified physicians and their teams in specialized centres.

Reassessment of radiation risks from electrophysiology procedures compared to coronary angiography

BACKGROUND

Electrophysiology (EP) procedures have been reported to carry a significantly greater radiation risk than that of coronary angiography (CA). This is largely due to numerous reports linking severe deterministic radiation effects to long procedure and fluoroscopy times (FTs). This study documents low radiation doses achieved by strategies involving operator training and education as well as equipment and technique optimisation to reduce radiation risks.

METHODS

Records relating to 732 diagnostic EP and 1744 therapeutic EP procedures performed between January 2002 and December 2007 were analysed. Data from 1458 diagnostic only CA procedures performed in 2006 was used for comparison. For each procedure type, FT, number of digital frames acquired and estimated effective dose (E) were compared.

RESULTS

Although the FT for CA procedures is significantly less than for therapeutic EP procedures (FT for diagnostic EP being similar), EP procedures generally are associated with lower E, the exception being procedures for atrial fibrillation (AF).

CONCLUSION

Through the application of a comprehensive exposure minimisation strategy, the radiation risk to patients undergoing diagnostic and, therapeutic EP procedures (except AF ablation procedures) is significantly less than that faced by patients undergoing CA. E, however, is heavily dependent on procedure type and as such care must be taken in undertaking generalised comparisons for audit and benchmarking purposes.

Fast-track training of nonelectrophysiologists to implant defibrillators: is it needed?

Standard training pathways in cardiac electrophysiology are being short-circuited for a "fast-track" approach to train nonelectrophysiologists (not necessarily cardiologists) to implant defibrillators in patients. This approach has been undertaken by a professional society (The Heart Rhythm Society), a society that cannot police, or properly credential. They have support from the American College of Cardiology and, perhaps, even the Combined Medicare and Medicaid Services. This issue is particularly disturbing as there are no data to support the approach taken with regard to the safety and benefit for patients. This process disrupts the standard training pathways and will have long-term implications for the field of clinical cardiac electrophysiology and for the availability of highly trained individuals qualified to implant defibrillators. This issue has broad implications with regard to medical training pathways. We discuss these issues in detail and provide the results of two surveys, including a survey from members of the Heart Rhythm Society, most of whom disagree with the "fast-track" approach. A survey of cardiologist faculty members of the American College of Cardiology yielded similar results. We are particularly concerned about the disruption of training pathways in medicine and how this can affect patient care and can influence established training pathways in medicine.