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CLINICAL RESEARCH Europace (2013) 15, 1741–1746 doi:10.1093/europace/eut149 Pacing and resynchronization therapy A survey of German centres performing invasive electrophysiology: structure, procedures, and training positions Hans-Ruprecht Neuberger1*, Roland Richard Tilz 2, Hendrik Bonnemeier 3, Thomas Deneke 4, Heidi L. Estner 5, Charalampos Kriatselis 6, Malte Kuniss 7, Armin Luik 8, Philipp Sommer 9, Daniel Steven 10, Christian von Bary11, Frederik Voss 12, and Lars Eckardt 13 1 Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische. Intensivmedizin, Universitätsklinikum des Saarlandes, D-66421 Homburg/Saar, Germany; 2II. Medizinische Abteilung, Fachabteilung Kardiologie, Asklepios Klinik St Georg, D-20099 Hamburg, Germany; 3Schwerpunkt Kardiologie und Angiologie, Klinik für Innere Medizin III, Universitätsklinikum SchleswigHolstein, Campus Kiel, D-24105 Kiel, Germany; 4Klinik für Kardiologie, Herz- und Gefäß-Klinik GmbH, D-97616 Bad Neustadt a. d. Saale, Germany; 5Medizinische Klinik u. Poliklinik, Interventionelle Elektrophysiologie, Klinikum der Universität München, Campus, Großhadern, D-81377 München, Germany; 6Klinik für Innere Medizin - Kardiologie, Deutsches Herzzentrum Berlin, D-13353 Berlin, Germany; 7Abteilung Kardiologie, Kerckhoff Klinik GmbH, D-61231 Bad Nauheim, Germany; 8Medizinische Klinik IV, Kardiologie, Angiologie und Internistische Intensivmedizin, Städt. Klinikum Karlsruhe gGmbH, D-76133 Karlsruhe, Germany; 9Abteilung für Rhythmologie, Herzzentrum der Universität Leipzig, D-04289 Leipzig, Germany; 10Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie, Universitäres Herzzentrum Hamburg gGmbH, D-20246 Hamburg, Germany; 11Medizinische Klinik I, Rotkreuzklinikum München, Lehrkrankenhaus der Technischen Universität München, D-80634 München, Germany; 12Innere Medizin III, Krankenhaus der Barmherzigen Brüder Trier, D-54292 Trier, Germany; and 13Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster, D-48149 Münster, Germany Received 26 February 2013; accepted after revision 2 May 2013; online publish-ahead-of-print 4 June 2013 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 German cardiology centres performing invasive electrophysiology were identified from quality reports and contacted to and results 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. ----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords Invasive electrophysiology † Catheter ablation † Survey † Training requirements Introduction Clinical electrophysiology including device therapy and catheter ablation of arrhythmias is rapidly developing as a subspeciality in cardiology. Today, catheter ablation is the first-line therapy for the majority of regular supraventricular tachycardias (SVTs) and at least second-line therapy for most patients with atrial fibrillation (AF). It has been estimated that about 50 000 catheter ablation procedures are performed every year in Germany.1 Emerging indications, an increasing number of procedures, and the expected * Corresponding author. Tel: +49 6841 162 3387; fax: +49 6841 162 3381, Email: [email protected] Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2013. For permissions please email: [email protected]. 1742 What’s new? † Electrophysiology (ablation procedures and device therapy) is mainly part of a cardiology department. † Female invasive electrophysiologists are clearly underrepresented. † A median number of 180 catheter ablations was performed per centre. † Atrial fibrillation was the most common arrhythmia invasively treated. † Only one-fourth of the electrophysiology centres fulfilled all requirements for training centre accreditation according to the European Heart Rhythm Association and the German Cardiac Society. quality require national and international standards, comprehensive knowledge, as well as trained specialists in the field of cardiac electrophysiology. Therefore, it seems important to train young cardiologists in this field. To illustrate the importance of a structured training programme for a ‘heart rhythm specialist’, the Accreditation Committee of the European Heart Rhythm Association as well as national organizations such as the German Cardiac Society have recently published curricula for clinical electrophysiologists.2,3 These curricula define requirements for training centres and trainees. In view of this background, we thought that it would be of major interest to find out the current status quo as the basis for future national and international programmes. This knowledge could indicate how realistic training requirements are. The purpose of this study was therefore to provide a nationwide survey on cardiac electrophysiologists as well as types and numbers of electrophysiological studies and ablations performed in 2010 in Germany. Furthermore, the study serves as the reference for a planned second survey in 2015. Methods German cardiology centres performing invasive electrophysiology were identified from (legally mandatory) quality reports of German hospitals (http://www.dimdi.de/static/de/klassi/ops/anwendung/zweck/ qualitaetsberichte/index.htm). Hospitals with the following OPS (operation and procedure code) were identified: 8 –835.2 [radiofrequency (RF) ablation], 8 – 835.3 (irrigated RF ablation), 8 – 835.4 (ablation with other energy sources), 8 – 835.9 (MESH ablation), 8 – 835.a (cryoablation), and 8 –835.8 [ablation with three-dimensional (3D) mapping]. The number of OPS is not necessarily identical with the number of ablation procedures performed, because more than one OPS (e.g. irrigated RF ablation plus ablation using 3D mapping) can be coded for a single ablation procedure. Regarding our survey and further analysis, centres coding less than 30 ablation procedures were excluded. This cut-off had been predefined because such a low number of coded ablation procedures increased the likelihood that the procedure itself was performed in a different hospital or by an external electrophysiologist (employed, e.g. at another hospital). The head of the cardiology department or of invasive electrophysiology was contacted by phone and/or e-mail to fill a questionnaire. The following parameters were queried: type of hospital; staff numbers and functions in cardiology and electrophysiology; gender H.-R. Neuberger et al. aspects; number of EP laboratories; number and types of EP procedures; techniques used; imaging modalities; and presence of or distance to cardiac surgery (for a detailed description see Table 1). Data were made anonymous and send to a statistical centre. Descriptive statistics were performed with SPSS version 15.0 (SPSS Inc.). Results According to OPS data, 277 centres coded ablation procedures in 2010. Among them were 88 centres that coded ,30 catheter ablation procedures. Of the remaining 189 centres coding ≥30 procedures, 122 (65%) responded. Their questionnaires were used for analysis. Data came from 30 (25%) university hospitals, 71 (58%) teaching hospitals (non-university hospitals involved in training of medical students), 20 (16%) non-teaching hospitals, and one private medical practice performing catheter ablations in a neighbouring hospital (1%, Figure 1). The structure of invasive electrophysiology Electrophysiology (ablation procedures and device therapy) was mainly part of a cardiology department (n ¼ 100 of 122, 82%), and 11 centres were independent (own budget, 9%). Invasive EP was the main area of expertise of the head of the cardiology department in another 11 centres (9%). At least one catheter laboratory was almost exclusively (.90%) used for EP in 78 centres (64%), whereas in the remaining centres (n ¼ 44, 36%) the EP lab was used for non-EP procedures, too. In 12 centres (10%) at least two dedicated EP laboratories were available. A three-dimensional mapping system was present in 95 centres (77%). In total, at the EP centres 26 864 pacemakers and 17 791 implantable cardiovert-defibrillators (ICD) were implanted in 2010. Device implantation was at least partly performed in a catheter laboratory in 87 of the centres (71%): always in 36 (30%), most often (≥50%) in 17 (14%), and sometimes (,50%) in 34 (28%) of the centres. In the remaining 35 centres (29%) this was done in the operating room. Devices were implanted by cardiologists in 67 (55%), by surgeons in 20 (16%), and by both in 35 (29%) of the EP facilities. Physicians involved in electrophysiology Twelve (10%) of the 122 cardiology departments where ≥30 catheter ablations were performed had more than one head of department (e.g. head of invasive cardiology, head of electrophysiology, etc.). In total, 149 heads of department (female: 3; 2%), 764 consultants (‘Oberarzt’, female: 109; 14%), and 2365 physicians in training (female: 1044; 44%) were employed. In a majority of these centres one (n ¼ 49, 40%) or two (n ¼ 40, 33%) EP consultants (‘Oberarzt’) were employed. In 94 centres, EP consultants also performed coronary interventions (77%). No electrophysiology fellows in training were present in 42 (34%) of the centres, one in 29 (24%), two in 19 (16%), and three or more in 32 (26%, Figure 2). In total, 193 EP consultants (19 females; 10%) were accompanied by 235 training positions (61 females; 26%), and the centres employed 315 physicians (28 females; 9%) able to perform catheter ablations as primary operators (only 1 per centre in 30 centres; 25%). Of these, 122 (39%) were 1743 A survey of German centres performing invasive electrophysiology in 2010 Table 1 Questionnaire Parameter Options Type of hospital University, teaching, other, and private practice Staffing of cardiology Structure of Rhythmology Staffing of Rhythmology No. of heads, consultants (Oberärzte), physicians in training Male/female Independent of cardiology, mostly independent (no budget), part of cardiology dpt., head of cardiology is heart rhythm specialist No. of heads, consultants (Oberärzte), physicians in training Male/female HR specialists performing PCI Yes, partly, and no HR specialists are cardiology consultants Yes, partly, and no ............................................................................................................................................................................... Phys. performing ablations No., gender, age, and part-time EP recording systems 3D mapping system No. Yes, no Cath. labs .90% used for EP No. Device implantation in EP lab Phys. present during ablation Always, ≥50%, ,50%, and no (operation room) No. Device implantation by HR specialist, surgeon, and both Pacemaker implantations ICD implantations No. No. Diagnostic EP procedures No. Catheter ablations SVT No. No. Main access left AP Atrial flutter Atrial fibrillation Transseptal, aorta, and not done No. No. Energy source RF, Cryo, PVAC, and other Imaging (mainly) Sedation CT, rotational angiography, MRI, and none Intubation, analgo-sedation with / without propofol Card. surgery backup In-house, if not: distance in km Treatment of secondary arrhythmias VT Main access LV Yes, no No. Transseptal, aorta, and not done Epicardial ablations Pt. consent obtained ambulant Yes, no 100%, ≥50%, ,50%, and ,10% Surgical ablations AF, VT, and none No., number. less than 40 years old, 152 (48%) were between 40 and 50 years old, and 35 (11%) were older than 50 years (no data: 2%); 7 (2%) worked part-time. In only 71 (58%) of the centres, (at least) two physicians were present during the majority of catheter ablations. The median number of ablations per centre was 180 (Figure 3, upper panel). In 32 (26%) of the centres, ,100 ablations were performed, at least 200 catheter ablations were performed in 59 (48%). At least 50 AF ablations were performed in 65 of the centres (53%, Figure 3, lower panel). Procedural data In total, 40 735 EP procedures including 33 420 catheter ablations were reported for 2010. Target arrhythmias (more than one type of arrhythmia could be ablated in a single case) were regular SVT (n ¼ 10 726; 32%), atrial flutter (n ¼ 8396; 25%), ventricular tachycardia (VT, n ¼ 2837; 8%), and AF (n ¼ 11 685; 35%, Figure 4). Ablation of left-sided accessory pathways was reported by 99 (81%) of centres [no accessory pathway ablation in 10 (8%), no data available for 13 centres (11%)] using either a trans-septal (n ¼ 55, 56%) or a retrograde approach (n ¼ 44, 44%) as primary access. Left-sided VT ablation was reported by 81 (66%) of EP centres [no VT ablation in 27 (22%), no data from 14 centres, 11%]. The access to the left ventricle was primarily retrogradely via the aorta in 55 (68%) and via a transseptal approach in 26 (32%) of the centres. In addition, epicardial ablation was performed in 15 (19%) of these centres. In total, 99 centres performed AF ablation procedures. As the method for AF ablation, the majority of centres (n ¼ 89, 90%) used point-by-point RF current, 50 (51%) used a cryoballoon (Arctic 1744 H.-R. Neuberger et al. Centers performing invasive electrophysiology University hospitals (25%) Number of ablations performed in 2010 per center 2000 1800 1600 Private practice (1%) 1400 Non-teaching hospitals (16%) 1200 1000 Teaching hospitals (58%) 800 600 400 200 Figure 1 Type of centres performing invasive electrophysiology in Germany in 2010 and responding to the survey (n ¼ 122). 0 1 21 41 61 81 101 121 Number of AF ablations performed in 2010 per center 1400 1200 1000 Training positions for electrophysiologists / center 800 600 >3 (26%) None (34%) 400 200 50 0 2 (16%) 1 1 (24%) Figure 2 Number of training positions per centre performing invasive electrophysiology. Front, Medtronic Inc.), 21 (21%) a circular non-irrigated ablation catheter (PVACw, Medtronic Inc.), and 7 (7%) other energy sources. Imaging before AF ablation was routinely performed in 59 (60%) of centres [magnetic resonance imaging in 14 (14%), computed tomography in 43 (43%), rotational angiography in 2 (2%) centres]. During AF ablation, patients were under general anaesthesia (tracheal intubation, n ¼ 6, 6%), or sedated with (n ¼ 54, 55%) or without propofol (n ¼ 35, 35%). Consecutive left atrial arrhythmias following AF ablations were treated by catheter ablation only in 74 (75%) of 99 centres performing AF ablation procedures. Only 44 (44%) of EP centres performing AF ablation had in-house surgical backup. For the other centres, the distance to the next hospital performing cardiac surgery ranged from 2 to 100 km (median and mean: 20 and 31 km, respectively). Surgical ablations were performed in 41 (34%) of EP centres (surgical AF ablation: n ¼ 41, 34%; VT ablation: n ¼ 10, 7%). Patient consent for invasive EP procedures is obtained before hospital admission always in 22 (18%) of centres, most often (.50%) in 42 (34%), often (,50%) in 17 (14%), and rarely (,10%) in 41 (34%) (In case of consent before admission, the EP study was performed on the day of admission.). 21 41 61 81 101 121 Figure 3 Number of catheter ablations of any arrhythmia (upper panel) and of AF (lower panel) are given per centre. The bold lines (n ¼ 200 and 50, respectively) represent the minimal number of procedures required for a heart rhythm specialist training centre (Table 2). Targets for catheter ablation Supraventricular tachycardias (32%) Ventricular tachycardia (8%) Atrial fibrillation (35%) Atrial flutter (25%) Figure 4 Targets for catheter ablations (n ¼ 33 420). Atrial fibrillation was the most often treated arrhythmia. Training centre requirements Table 2 lists the requirements for training centre accreditation according to the European Heart Rhythm Association and the 1745 A survey of German centres performing invasive electrophysiology in 2010 Table 2 Curriculum heart rhythm specialists: Training centre requirements and reality (Germany, 2010) Parameter EHRA requirements Centres fulfilling EHRA requirements (n, %) DGK requirements Centres fulfilling DGK requirements (n, %) ............................................................................................................................................................................... Physicians present during ablation – – 2 71 (58) No. EP procedures/year 250 61 (50) 250 61 (50) No. ablations/year No. AF ablations/year 200 – 59 (48) – 200 50 59 (48) 65 (53) 3D mapping system Yes 95 (78) Yes 95 (78) Cardio surgical unit All requirements Yes 44 (36) 30 (25) No – 34 (28) Requirements are defined according to guidelines and curricula as published.2 – 4 German Cardiac Society (DGK).2 – 4 About half of the centres reported a number of procedures that fulfilled these criteria. However, all requirements together were fulfilled by only one-fourth of the centres. Discussion For the first time, this survey reports detailed data from the majority of German centres that performed invasive electrophysiology in 2010. In total, two-thirds of the identified EP centres responded. They carried out 33 420 catheter ablations that represent the majority (80%) of catheter ablations performed in Germany (41 913 diagnosis-related groups (DRGs) including a catheter ablation (F50A, F50B, F50C, and F50D) were brought to account with health insurance companies in 2010).5 The responding EP centres carried out a minority of all pacemaker implantations (88.461 according to DRG data) and about every second ICD implantation in Germany (35.329 according to DRG). Invasive electrophysiology is performed in a relatively large number of hospitals; almost 200 centres were identified. For comparison, 556 institutions performed 845 172 coronary angiographies in 2008.6 The need for electrophysiological training will be high in the future. For training in the subspecialty ‘Electrophysiology’, European and German curricula have been published defining requirements for physicians in training and for training centres (not legally binding). It seems relevant to interpret our data with regard to this aspect.2,3 Based on the EHRA recommendation, an EP training centre should, for example, employ at least two fully trained heart rhythm specialists and needs to be integrated within a cardio-surgical unit (Table 2). According to our data, only 36% of included centres would have fulfilled this criterion. Besides, 52% of the centres performed ,200 ablations a year, which is recommended by EHRA and DGK as a minimum number for an EP training centre. In fact, only about onefourth of the EP centres fulfilled all training centre requirements. These data illustrate the need for collaboration of EP centres to guarantee training standards and qualification. A highly specialized and high-volume EP centre could offer a time period of intensive EP training. On the other hand, smaller centres could offer in exchange broader training in cardiology and internal medicine for trainees from highly specialized EP centres. This could improve clinical and scientific training for both cooperation partners and could make both departments more attractive for trainees. Being aware that the recommendations of the DGK advise the presence of two physicians during catheter ablation it is remarkable that in 50 centres (41%) catheter ablations were performed only by one physician. Furthermore, 35% of the centres did not employ electrophysiology fellows. Thus, a realistic chance of training in invasive electrophysiology does not exist in a relevant proportion of the participating centres, even independent of curricular requirements. In 2010, in the majority of centres clinical electrophysiology was part of a cardiology department. Despite a high degree of subspecialization in cardiology and the increasing complexity of ablation procedures (e.g. AF, ventricular tachycardia, and device therapy) only about 10% of EP centres were independent. In this context, it is also remarkable that the majority of EP consultants also performed coronary interventions. It will be of interest to observe the development during the following years. Although in 2010, women represented 62.6% of first-year medical students,7 59.4% of physicians younger than 35 years, 50.6% of physicians 35 to less than 40 years old, and 44.1% of all physicians in Germany,8 only 26% of physicians in EP training were female. Even more accentuated was the low proportion of women among physicians able to perform catheter ablations as primary operator (9%). This proportion was even lower than the proportion of female cardiology consultants (9 vs. 14%). We can only speculate about the reasons. The extremely low proportion of female heads of departments, the duration of training, or radiation exposure during childbearing age may contribute. Furthermore, the option to work parttime in this field seemed almost not to exist. Research into this field could offer a basis for attracting more women to this subspeciality. Although in the early years of RF ablation regular SVTs and typical atrial flutter were treated predominantly, the most common procedure in our survey in 2010 was AF ablation (36%). As one consequence, transseptal puncture has become a routine procedure in most EP centres. This is probably the reason for a relatively frequent transseptal access to left-sided accessory pathways (45%).This experience probably increases the safety of other trans-septal procedures (e.g. mitral valve interventions). On the other hand, VT ablations were mainly performed retrogradely via the aorta. Point-by-point RF current was the method most commonly used for AF ablation. However, the high prevalence of other and less 1746 established technologies indicates the search (and need) for a more rapid and effective method to treat AF. Given the high frequency of the arrhythmia and its consequences, prospective AF ablation trials with mortality as an endpoint are needed (e.g. the CABANA trial; ClinicalTrials.gov identifier: NCT00911508). A positive result would further increase the already growing demand for the procedure. It is surprising that a relevant proportion of centres performing AF ablations do not treat consecutive left atrial arrhythmias (atypical left atrial flutter).9 This probably indicates some mismatch between the need for invasive AF treatment and the availability of experienced EP specialists. In-house cardiac surgery was available for only one-third of EP centres. Remarkably, even EP centres performing AF ablation had in-house surgical backup only in 44%. According to large surveys cardiac tamponade is observed in about 1.3% of AF ablation procedures while surgical treatment is necessary in only a minority of cases.10,11 However, every time delay to surgical intervention may endanger the patient. The vast majority of cardiac surgery departments associated with EP centres performed surgical ablations (mainly AF). Data on this topic are sparse, and the relative large number of centres would offer the opportunity to investigate surgical arrhythmia treatment on a large scale. Limitations Obviously, not all EP centres responded and possibly not all EP centres were identified. However, our data cover the majority of EP centres and procedures performed in 2010 in Germany. We do neither have data on acute success of treatment nor follow-up data. Our numbers rely on self-reporting. Thus, the results may not exactly represent the number of procedures. In addition, two thirds of the identified EP centres that responded reported 80% of all DRG-coded catheter ablations. In consequence, smaller EP centres are probably underrepresented. Furthermore, we excluded centres coding ,30 ablation procedures in 2010 to prevent an overestimation of sites where catheter ablation is performed. As a result, this survey may even over-estimate the number and percentage of possible EP training centres fulfilling curricular requirements of EHRA or DGK. H.-R. Neuberger et al. Summary The results of this survey indicate an increasing specialization in cardiology and a high number of EP centres and procedures. Atrial fibrillation was the most common arrhythmia invasively treated in 2010 in Germany. An increasing demand for catheter ablation is likely, but training opportunities are limited. Women are clearly underrepresented in the field of invasive EP. Only a minority of EP centres fulfilled recently suggested criteria for training centres. Training co-operation of higher and lower volume EP centres may improve the number and quality of training opportunities in both EP and cardiology. Acknowledgements We thank the nucleus of the working group ‘AG1 Rhythmologie’ of the German Cardiac Society (speakers: C. W. Israel and D. Bänsch) for collaboration. The authors received an unrestricted travel grant from Biosense Webster, Norderstedt, Germany. Conflict of interest: none declared. References 1. Auricchio A, Kuck K-H, Hatala R, Arribas F. The EHRA White Book 2012. France: European Heart Rhythm Association, 2012. 2. Merino JL, Arribas F, Botto GL, Huikuri H, Kraemer LI, Linde C et al. Core curriculum for the heart rhythm specialist. Europace 2009;11(Suppl 3):iii1 –26. 3. Breithardt G, Krämer LI, Willems S. Curriculum Spezielle Rhythmologie. Kardiologe 2012;6:219 –25. 4. Kuck KH, Ernst S, Dorwarth U, Hoffmann E, Pitschner H, Tebbenjohanns J et al. [Guidelines for catheter ablation]. Clin Res Cardiol 2007;96:833 – 49. 5. Wiesbaden, Germany: Statistisches Bundesamt; 2013. 6. van Buuren F. 25. Bericht über die Leistungszahlen der Herzkatheterlabore in der Bundesrepublik Deutschland. Kardiologe 2010;4:502 – 8. 7. Gerst T, Hibbeler B. Ärztemangel im Labor. Deutsches Ärzteblatt 2012;109:B 1466 –469. 8. http://www.gbe-bund.de. 9. 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