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

Development of simulation combining a physical heart model and three-dimensional system for electrophysiology training

BACKGROUND

A new three-dimensional heart anatomical simulator (3D HAS) has been created combining a physical heart model with an electroanatomic mapping (EAM) system. The aim of this study is to describe the development and the validation process of this device.

METHODS

We developed the 3D HAS combining a physical heart model with an EAM system. This simulator was then validated by 10 electrophysiologists, subdivided in two groups based on their experience in electrophysiology procedures. The performance of the experts was compared to the one of the novices in achieving three different tasks: fluoroless reconstruction of the right atrium, coronary sinus cannulation, and deployment of a linear ablation lesion in the cavotricuspid isthmus. For each operator, a score was calculated based on objective parameter for each task and for the overall performance.

RESULTS

The 3D HAS was located in an environment that allowed use of the main features of the EAM system including contact force sensing. No technical issue was encountered during the validation process. The experts' performance was significantly better than the one of the novices both overall (P = 0.009) and in each task (right atrium reconstruction, P = 0.016; coronary sinus cannulation, P = 0.008; ablation lesion, P = 0.03).

CONCLUSIONS

The 3D HAS is reliable and allows use of the main features of an EAM system in the right atrium. The ability to discriminate different levels of experience suggests that this simulator is enough realistic and could be useful for electrophysiology training.

Atrial fibrillation ablation by use of electroanatomical mapping: efficacy and recurrence factors

Background

Radiofrequency catheter ablation guided by electroanatomical mapping is currently an important therapeutic option for the treatment of atrial fibrillation. The complexity of the procedure, the several techniques used and the diversity of the patients hinder the reproduction of the results and the indication for the procedure.

Objective

To evaluate the efficacy and factors associated with recurrence of atrial fibrillation.

Methods

Prospective cohort study with consecutive patients submitted to atrial fibrillation ablation treatment guided by electroanatomical mapping. The inclusion criteria were as follows: minimum age of 18 years; presence of paroxysmal, persistent or long-standing persistent AF; AF recording on an electrocardiogram, exercise testing or Holter monitoring (duration longer than 15 minutes); presence of symptoms associated with AF episodes; AF refractoriness to, at least, two antiarrhythmic drugs, one of which being amiodarone, or impossibility to use antiarrhythmic drugs.

Results

The study included 95 patients (age 55 ± 12 years, 84% men, mean CHADS2 = 0.8) who underwent 102 procedures with a median follow-up of 13.4 months. The recurrence-free rate after the procedure was 75.5% after 12 months. Atrial fibrillation recurred as follows: 26.9% of patients with paroxysmal and persistent atrial fibrillation; 45.8% of patients with long-standing persistent atrial fibrillation (p = 0.04). Of the analyzed variables, the increased size of the left atrium has proven to be an independent predictor of atrial fibrillation recurrence after the procedure (HR = 2.58; 95% CI: 1.26-4.89). Complications occurred in 4.9% of the procedures.

Conclusion

Atrial fibrillation ablation guided by electroanatomical mapping has shown good efficacy. The increase in left atrium size was associated with atrial fibrillation recurrence.

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.

Simulator training reduces radiation exposure and improves trainees' performance in placing electrophysiologic catheters during patient-based procedures

BACKGROUND

Currently, training in interventional electrophysiology is based on conventional methodologies, and a paucity of data on the usefulness of simulation in this field is available.

OBJECTIVE

The purpose of this study was to evaluate the impact of simulator training on trainees' performance in electrophysiologic catheter placement during the early phase of their learning curve.

METHODS

Inexperienced electrophysiology fellows were considered. A hybrid high-fidelity simulator (Procedicus VIST, version 7.0, Mentice AB Gothenburg, Sweden for Biosense Webster) was used. The following parameters were evaluated in 3 consecutive patient-based procedures before and after two training sessions of at least 1.5 hours on the simulator: (1) ability to place catheters in conventional recording/pacing sites (coronary sinus, His-bundle area, high right atrium, and right ventricular apex); (2) amount of help provided by the supervisor (scale from 1-3; 3 for maximal help); (3) fluoroscopy time; and (4) positioning time.

RESULTS

Seven fellows performed 168 catheter placements during 42 patient-based procedures with no complications. Comparing parameters before and after simulator training, there was a significant reduction in the mean amount of help and in fluoroscopy and positioning times per placement: from 1.71 ± 1.24 to 0.42 ± 0.68 (P <.001), from 121 ± 88 seconds to 76 ± 54 seconds (P <.001), and from 175 ± 138 seconds to 102 ± 74 seconds (P <.001), respectively. Overall fluoroscopy time per patient decreased from 567 ± 220 seconds to 305 ± 111 seconds (P <.0001). Improvement appeared to be related to simulator training alone and not to the previously performed patient-based procedures.

CONCLUSION

During the early phase of the trainees' learning curve, simulator training significantly improves the independent trainees' performance with reduction in radiation exposure.

How much training is required to implant and manage CRT?

PURPOSE OF REVIEW

The number of patients receiving cardiac resynchronization therapies (CRTs) is increasing at a substantial rate. The implant, however, is not always performed effectively and the complication rates are considerable. The training and accreditation to perform CRT need to be evaluated to optimize procedural and patient outcomes.

RECENT FINDINGS

The relationship between higher procedural volumes and reduced procedural complications is evident and consistent across a range of surgical specialties and procedures. Present guidelines recommend that training in CRT can be achieved with five to 25 cases. The limited studies in this area suggest that this is inadequate, with complication rates of CRT reducing significantly with procedural experience well beyond 100 cases.There is increasing evidence that the development of procedural skills is dependent not only on cognitive factors, but also on a number of intrinsic visuospatial factors and fine motor dexterity. These factors can be tested objectively and the validity of adopting these techniques for the selection and training of operators is being evaluated.

SUMMARY

Ongoing evaluation of the training requirements and accreditation is required to optimize the implantation of CRT.