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ACC/AHA/ACP CLINICAL COMPETENCE STATEMENT

American College of Cardiology/American Heart Association 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion

A Report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training Developed in Collaboration With the Heart Rhythm Society

	Table of Contents

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

Introduction......1504

Clinical Competence in Invasive EPS, Catheter Ablation, and Cardioversion: Overview of the Procedure......1504

Justification for Recommendations......1505

Minimum Training Necessary for Competence......1506

Alternate Routes to Achieve Competence......1507

Maintenance of Competence......1507

Catheter Ablation: Overview of the Procedure......1507

Justification for Recommendations......1508

Minimum Training Necessary for Competence......1509

Alternate Routes to Achieve Competence......1509

Maintenance of Competence......1510

Use of Emerging Technology and New Techniques: Assessment of Clinical Competence in Invasive Cardiac Electrophysiologic Procedures......1510

Competence in the Use of Emerging Technology......1510

Specific Training Requirements......1510

Clinical Competence in Elective DCCV: Overview of the Procedure......1511

A. External Cardioversion......1511

B. Internal Cardioversion......1512

Justification for Recommendations......1512

Minimum Training Necessary for Competence......1512

Maintenance of Competence......1513

References......1514

Appendix 1......1516

Appendix 2......1517

	Preamble

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
The granting of clinical staff privileges to physicians is a primary mechanism used by institutions to uphold the quality of care. The Joint Commission on Accreditation of Health Care Organizations requires that the granting of continuing medical staff privileges be based on assessments of applicants against professional criteria specified in the medical staff bylaws. Physicians themselves are thus charged with identifying the criteria that constitute professional competence and with evaluating their peers accordingly. Yet the process of evaluating physicians’ knowledge and competence is often constrained by the evaluator’s own knowledge and ability to elicit the appropriate information, problems compounded by the growing number of highly specialized procedures for which privileges are requested.

The American College of Cardiology Foundation/American Heart Association/American College of Physicians (ACCF/AHA/ACP) Task Force on Clinical Competence and Training was formed in 1998 to develop recommendations for attaining and maintaining the cognitive and technical skills necessary for the competent performance of a specific cardiovascular service, procedure, or technology. These documents are evidence based, and where evidence is not available, expert opinion is utilized to formulate recommendations. Indications and contraindications for specific services or procedures are not included in the scope of these documents. Recommendations are intended to assist those who must judge the competence of cardiovascular health care providers entering practice for the first time and/or those who are in practice and undergo periodic review of their practice expertise. The assessment of competence is complex and multidimensional; therefore, isolated recommendations contained herein may not necessarily be sufficient or appropriate for judging overall competence. The current document addresses competence in electrophysiology, catheter ablation, and cardioversion and is authored by representatives of the ACCF, the AHA, and the Heart Rhythm Society (HRS).

The ACCF/AHA/ACP Task Force makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or a personal interest of a member of the ACCF/AHA/ACP Writing Committee. Specifically, all members of the Writing Committee are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest relevant to the document topic. These changes are reviewed by the Writing Committee and updated as changes occur. The relationships with industry information for authors and peer reviewers are published in Appendix 1 and Appendix 2, respectively.

Mark A. Creager, MD, FACC, FAHA, Chair ACCF/AHA/ACP Task Force on Clinical Competence and Training

	Introduction

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
This statement is a revision and extension of the 2000 ACP/ACC/AHA document on clinical competence in invasive cardiac electrophysiologic studies (EPS) (1), 1994 ACP/ACC/AHA competency document, and the 1993 report on elective direct current cardioversion (DCCV) (2). This statement is designed to assist in the assessment of physicians’ competence on a procedure-specific basis. The minimum education, training, experience, and cognitive and technical skills necessary for the competent performance of invasive cardiac EPS, catheter ablation, and cardioversion are specified. It is important to note that these are the minimum training and experience requirements for the assessment of competence in these disciplines (or procedures) in the broadest sense. Whenever possible, the specifications are based on published data that link these factors with competence or, in the absence of such data, on the consensus of expert opinion. The specifications are applicable to any practice setting and can accommodate a number of ways in which physicians can substantiate competence in the performance of specific procedures (3). Expertise in the performance of these procedures in patients with infrequently encountered diagnoses or of less commonly performed variations of standard procedures may require additional experience or training. It is therefore expected that even highly competent practitioners will occasionally benefit from consultation with colleagues who have even more highly specialized interests, experience, or skills. This document in large part does not deal with pacing and defibrillator therapies. Competencies regarding these devices are covered in the HRS competency statement (4).

In addition to members of ACC and AHA, the Writing Committee included a representative from the HRS. Representation by an outside organization does not necessarily imply endorsement. In addition to content peer reviewers, "official" reviewers were provided by ACC and AHA. This document was approved for publication by the governing bodies of ACC and AHA. In addition, HRS’s governing board formally endorsed this document.

	Clinical competence in invasive EPS, catheter ablation, and cardioversion: Overview of the procedure

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
Catheter techniques for the recording of the His bundle potential in humans were first reported in 1969 by Scherlag et al. (5). Initially, data from EPS were used to determine the mechanisms of spontaneously occurring arrhythmias, including atrioventricular (AV) conduction abnormalities, premature complexes, and a variety of tachycardias (6,7). Subsequently, techniques for programmed electrical stimulation were developed, which permitted the reproducible initiation of both supraventricular (7,8) and ventricular (9–11) arrhythmias in the laboratory. Pacing protocols to characterize sinus node function (12) and AV conduction (13) were also introduced. Because sustained arrhythmias are often episodic in nature or can terminate spontaneously or require intervention before full clinical evaluation, invasive EPS have become a standard means of reproducing an arrhythmia in a controlled laboratory setting.

In this report, the term "EPS" refers to a procedure that involves the recording of intracardiac electrical signals and programmed electrical stimulation. The EPS either may be performed for diagnostic purposes only or may be part of a combined diagnostic and therapeutic (e.g., ablation) procedure. Although a thorough description of EPS is beyond the scope of this document, the procedure is briefly outlined here.

An EPS requires the placement of electrode catheters for pacing and recording in multiple cardiac chambers. The designs of the catheters and the sites appropriate for their placement are determined according to the nature of the arrhythmia under investigation. Typically, each catheter will have multiple electrode poles for both recording and local stimulation. Many types of specially designed catheters have been developed to facilitate recording and stimulation, and new catheters are frequently introduced into clinical practice. The intracardiac signals are acquired, amplified, filtered, displayed, stored, and analyzed, either in real time or for subsequent offline review. A potentially important part of an EPS is the use of intracardiac recordings to determine activation sequences during arrhythmias. This process is usually called "mapping." Analysis of the responses of an arrhythmia to various pacing techniques is also a component of the mapping process.

Electrophysiologic studies provide clinically valuable diagnostic information. In patients with bradyarrhythmias, EPS are occasionally necessary to clarify electrocardiographic phenomena or to explain symptoms that are possibly due to a transient, clinical bradyarrhythmia. Electrophysiologic studies are useful to determine the mechanisms and physiological characteristics and drug responses of supraventricular tachycardias and to determine whether arrhythmias are suitable for drug, device, or ablation therapy, as described later in this document. In patients with ventricular tachycardia, EPS are useful to confirm the mechanism of the arrhythmia, to assess the effects of pharmacologic therapy, and to select patients for nonpharmacologic treatment. Acute or follow-up testing for antiarrhythmic device efficacy falls under the definition of "EPS." These studies can often be performed noninvasively through the device, but the placement of temporary catheters may be necessary.

Electrophysiologic studies have also been used to assess the future risk of serious antiarrhythmic events and to provide data on which prophylactic therapy may be based (14). In patients with undocumented symptoms that suggest an arrhythmia that was not previously documented (e.g., syncope or palpitations), EPS are frequently used to assess the patient’s predisposition for spontaneously occurring arrhythmias (15).

Physicians involved in the performance of invasive EPS should be cognizant of the indications, contraindications, and potential complications of the procedure in a given patient (15,16). Absolute contraindications to EPS are few but include unstable angina, bacteremia or septicemia, acute decompensated congestive heart failure not caused by the arrhythmia, major bleeding diathesis, and acute lower extremity venous thrombosis, if femoral vein cannulation is desired. The appropriate use of invasive EPS, therefore, requires a careful nonprocedural assessment to ensure that the patient is stable and able to tolerate the procedure. In the vast majority of situations, an EPS is performed on an elective basis. However, an EPS is justifiable in such situations if an arrhythmia is the main or major cause of the emergency, as occurs in patients with incessant ventricular or supraventricular tachycardia. General indications for invasive EPS were described by the ACC/AHA Task Force on Practice Guidelines, in conjunction with the HRS (17).

	Justification for recommendations

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
The recommendations for minimum education, training, experience, and skills necessary to perform EPS are based on a review of statements by the ACP, the ACC, and the AHA (1,18); the Canadian Cardiovascular Society (19); and the British Cardiac Society and Royal College of Physicians (20); a report from a Core Cardiology Training Symposium (COCATS) (21); and policies of the Accreditation Council of Graduate Medical Education (ACGME) (22) and the American Board of Internal Medicine (ABIM) (23) (Table 1). The American groups (Table 1) recommend training after the completion of 3 years of a general cardiology fellowship. The British statement discusses specialized training in the last year (year 6) of a cardiology fellowship. The Canadian Cardiovascular Society describes 2 levels of specialized training: Level 2 may be achieved during 3 years of a general cardiology fellowship program, whereas Level 3 requires additional years of training. In preparation of this document, 63 program directors were surveyed regarding training and competency issues; 33 directors (52.4%) responded. Where results pertaining to this document are available, they will be indicated as Clinical Cardiac Electrophysiology (CCEP) Training Program Directors’ Survey results.

	Minimum training necessary for competence

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

	Alternate routes to achieve competence

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
In the absence of completion of the formal 1-year training program, competence in CCEP is difficult to achieve. The current requirement for residency education in CCEP as stated by the ACGME is 1 year of training in an ACGME electrophysiology program after the completion of an accredited cardiovascular disease residency program (22). This requirement must be met to sit for the ABIM subspecialty examination in CCEP (23). For those who choose to gain competency in the performance of EPS but not within an accredited U.S. program, training should still be completed in a structured environment. The operator should perform the same number of the above-listed procedures as currently recommended for U.S. trainees. He or she should also participate in courses designed to provide specific instruction in CCEP. Prior competency statements have suggested a minimum of 30 h of continuing medical education (CME) every 2 years; this recommendation is endorsed in the present document. Any such training should be performed under the supervision and mentorship of a recognized expert in the field of cardiac electrophysiology who has achieved board certification by the ABIM in CCEP or an equivalent degree of training in countries outside the U.S. The trainee who completes this latter program in a training program that is not approved by the ACGME will not be eligible to take the ABIM examination.

	Maintenance of competence

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
As is true for many other procedures, a minimum number of cases is necessary to ensure continued proficiency in quality of care. The individual should participate in greater than or equal to 100 diagnostic EPS per year to maintain skills and should attend greater than or equal to 30 h of formal CME (Level 1 category) every 2 years to remain abreast of changes in knowledge and in technology. These cases can include the diagnostic portions of ablation procedures.

	Catheter ablation: Overview of the procedure

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
Catheter ablation has revolutionized the field of electrophysiology. The performance of catheter ablation was initially accomplished through the delivery of high-energy, direct current (DC) shocks (24,25). These early procedures had limitations in usefulness and safety because of barotrauma. They also carried the potential for significant complications, such as cardiac tamponade and the early or late occurrence of sudden death (26,27). Technological advancements in the late 1980s led to the ability to apply continuous-wave unmodulated radiofrequency energy through catheters to heat myocardium at the catheter-tissue interface, creating ablative lesions (28). Although initial success rates were modest (28,29), further development in technology resulted in a technique that has replaced DC energy delivery (30,31). Radiofrequency ablation has also quickly supplanted open-heart surgery for several arrhythmias and is an acceptable alternative to long-term drug treatment.

The lesions created by radiofrequency are well demarcated. This characteristic, along with improved catheter technology, allows very specific and focal energy delivery, which permits the cure or modification of many arrhythmias. Through targeting of the specific site of origin of the arrhythmia, as with atrial tachycardia, or through interruption of a critical pathway needed for the maintenance of a re-entrant arrhythmia, such as an accessory pathway, many arrhythmias of various mechanisms can be eliminated. Since its inception, catheter ablation has grown tremendously in its application. The number of reported ablation procedures performed annually in the U.S. has increased from 450 in 1989 to 15 000 annually in the most recent U.S. survey (32). The success rates reported in the 1995 Scheinman (32) survey of 157 laboratories in the U.S. were 97% for AV node ablations, 90% for accessory pathways in all locations, 94% for AV node modifications in the treatment of AV nodal re-entry, 72% for the treatment of atrial flutter, and 71% for the treatment of atrial tachycardia. Complication rates derived from the Scheinman (32) survey and the 1993 Multicentre European Radiofrequency Survey (MERFS) from 86 institutions (33) were reported in just under 4% of AV node interruptions, 2.6% of accessory pathway ablations, 1.7% of AV node modifications, and 1.6% of flutter and atrial tachycardia ablations.

Although the incidence of complications is low, serious complications can occur and include valvular disruption, coronary occlusion, cerebrovascular accident, and death. In U.S. centers, procedural deaths occur in 0.2% of patients who undergo AV node ablation and 0.1% of patients with accessory pathways (32). The most common complication in AV node modification has been the development of heart block through the inadvertent ablation of both the fast and slow AV nodal pathways. In the 1996 study from the MERFS (Multicenter European Radiofrequency Survey) (34), 4.7% of patients developed heart block during AV node modification. Heart block was significantly higher in patients in whom the fast pathway was targeted (5.3%) rather than the slow pathway (2%). This is higher than the overall rate of inadvertent heart block reported by Calkins et al. (35) from the Akhtar Multicenter Ablation Investigators Group, in which the incidence of inadvertent heart block in patients who underwent AV node modification was 1.3%. Importantly, a slow pathway ablation approach was used in this study. This study also reported serious complications in 3% of patients and minor complications in 8%.

Despite these complications, studies have clearly shown that symptomatic patients are afforded important improvements in the quality of life with catheter ablation (36–39). The benefit gained through arrhythmia treatment with catheter ablation is superior to that achieved through medical therapy. The cost of catheter ablation, although not trivial, is less over time than the cost of alternatives such as medical therapy or surgical interventions (36,40).

Catheter ablation provides a safe and highly effective treatment for symptomatic patients with supraventricular tachycardia. Ablation should not be reserved as a last resort treatment but is appropriate to consider, in some cases, as first-line therapy (e.g., a symptomatic patient with Wolff-Parkinson-White syndrome) (41–46). However, for patients with rhythm disturbances that are likely to spontaneously resolve (e.g., atrial tachycardia) or unlikely to recur (e.g., a first episode of atrial flutter), ablation would not be appropriate first-line therapy (47). Its role would be limited to patients in whom medical therapy is intolerable or in whom there is evidence for adverse consequences of the arrhythmia. The complete list of indications is detailed in the ACC/AHA guidelines for CCEP and catheter ablation procedures (17).

Atrioventricular node re-entry in a structurally normal heart typically is a benign arrhythmia, and there is a reasonable chance that no therapy is required (48). However, if patients have other compounding heart disease, such as coronary artery disease, or if the arrhythmia produces hemodynamic compromise or intolerable side effects, ablation can be considered as first-line treatment because of the high likelihood of recurrence or of serious consequences to the arrhythmia (48).

The area of atrial fibrillation (AF) ablation has undergone rapid evolution over the last 3 to 5 years. Initial attempts at catheter ablation attempting to recreate the maze procedure were only marginally successful and carried relatively high complication rates. However, the transition to focal ablation and to now substrate modification with wide area circumferential ablation has led to greater application of this technique.

In a recent survey of electrophysiologists, 30% (n = 92 of 304 respondents) reported that they performed AF ablations. In this self reporting study, the number of reported AF ablations from 2000 to 2003 was 5 592 AF ablations of 72 575 total ablation procedures during the same time period. The self reported 1-month, 1-year, and 2-year success rates were: 71 ± 4%, 66 ± 5%, 63 ± 6%, respectively. Respondents reported procedure times of 4.5 ± 0.4 h (49). Other published series of ablation for paroxysmal AF ablation report success rates of approximately 85%, which may require more than 1 ablation procedure to achieve (50,51). Large series report complications in the 2% to 11% range including perforation, tamponade, stroke, pulmonary vein stenosis, and, with certain lesion sets, atrioesophageal fistula, which is often fatal (52).

It is not anticipated that all trainees would want to pursue training in AF ablation nor should it be a mandatory part of training. Atrial fibrillation ablation is of higher risk than ablation of other arrhythmia substrates, and the trainee must be aware of the special risks such as pulmonary vein stenosis; atrioesoghageal fistula; and the higher risk of stroke, perforation, and tamponade. They must also be proficient in acute management of potential complications.

While the exact lesion set required to treat AF remains debatable, there are several common elements to the ablation procedures that are currently being performed (53,54). Access to the left atrium is achieved via transseptal puncture. It is anticipated that the operator will have already acquired experience at performance of transseptal punctures before performing AF ablation. There are no established norms for achieving competency in transseptal puncture, but, for a reasonably experienced operator, it would be expected that performance of 20 supervised transseptal punctures would display a reasonable amount of competence (55). The operator should have ready access to transthoracic echocardiography and be proficient in performing pericardiocentesis.

Often visualization with intracardiac echocardiography is utilized to improve safety and to monitor therapy during energy delivery during AF ablation (56–58). As such, the electrophysiologist should be familiar with the placement of the intracardiac echocardiography catheter and the use of and interpretation of data acquired. Frequently, AF ablation is facilitated by using imported 3-dimensional images of the left atrium acquired either through cardiac magnetic resonance imaging or computed tomography scan (59,60). These imported data are used in conjunction with real-time 3-dimensional images created with 1 of several electroanotomic mapping systems during the ablation procedure. The electrophysiologist must be familiar with the utility of and interpretation of these data.

Radiofrequency ablation has been applied in the treatment of ventricular tachycardia in ischemic disease, bundle-branch re-entry, and idiopathic tachycardia (61–64). A decision to perform an ablation in a patient with ventricular tachycardia must take into account the risks and benefits of doing so as well as subsequent risks of arrhythmia occurrence in abnormal but unablated tissue. Techniques such as ablation of ventricular fibrillation are not within the realm of standard training in CCEP.

	Justification for recommendations

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
The performance of catheter ablation requires skills detailed previously as necessary for the performance of diagnostic electrophysiologic testing. The indications, contraindications, and complications for catheter ablation are largely derived from the ACC/AHA Guidelines for Clinical Intracardiac Electrophysiologic and Catheter Ablation Procedures (17). The performance of catheter ablation requires the ability and dexterity to successfully manipulate catheters in all locations of the heart to achieve adequate contact between the catheter and the myocardium to create curative lesions. This requires detailed knowledge of cardiac anatomy. Left-sided arrhythmia substrates such as left atrial foci usually require the ability to perform transseptal catheterization (65). In some laboratories, this approach is routinely used for left-sided accessory pathways as well. For these pathways, knowledge of trans-septal catheterization and the retrograde aortic technique is needed (65,66). A thorough knowledge of arrhythmia mechanisms and the treatment of complex arrhythmias, including pharmacologic effects, is a prerequisite to catheter ablation. The ability to interpret complex mapping with multiple intracardiac electrograms is required.

Because the possibility of creating AV heart block through the application of radiofrequency energy exists either as a desired end point or as an inadvertent result of energy application, physicians who perform ablations should be capable of managing the bradyarrhythmia and AV heart block.

	Minimum training necessary for competence

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
Program requirements for residency education in CCEP are outlined by the ACGME and are effective as of July 1999 (22). Training in an accredited program is required for admission to the ABIM examination for certification in CCEP. Programs accredited for training in CCEP must function as a part of an accredited subspecialty fellowship in cardiovascular disease. These programs should also meet the training in specialized electrophysiology, cardiac pacing, and arrhythmia management guidelines outlined by the COCATS Task Force (21).

The performance of catheter ablation procedures requires skills that are developed over time. Several studies have shown that success rates improve and fluoroscopy times decrease with experience (67–70). Although there are many determinants of arrhythmia recurrences, recurrence rates drop with operator experience (71). Each of these studies involved operators with extensive prior experience in electrophysiology, and it would be expected that the number of procedures required for a new trainee to gain expertise in ablation would be higher than that for an experienced electrophysiologist. The risks of ablation similarly have been reported by experienced operators. The MERFS volunteer registry reported an overall complication rate of 4.6% at high-volume centers (100 ablations/year) compared with 5.6% at low-volume centers (50 ablations/year) (33). Similar data were reported in the 1994 North American Society of Pacing and Electrophysiology survey, with a 1.5% complication rate at high-volume centers (50 cases/year) and a 3.2% rate at low-volume centers (20 ablations/year) (64).

It is strongly recommended that all physicians who perform ablations in the U.S. meet the minimum ACGME training requirements for education in CCEP. Although credentialing at most institutions does not require board certification in CCEP, applicants should have met board requirements. As stated by the ACGME, the current program requirements for training in electrophysiology are for 12 months of specialty training after the completion of training in cardiovascular disease. This should provide adequate training for the performance of routine electrophysiologic procedures. Training in electrophysiology and ablation techniques can occur simultaneously with incremental responsibility for the trainee during the entire period. However, most training program directors agree that to gain proficiency in interventional electrophysiology and catheter ablation, additional training is required. Adequate training in all aspects of electrophysiology, including ablation, is expected to take up to 2 years depending on the skills of the trainee. The certified year in EP must occur after the completion of a 3-year training program in cardiovascular disease (19,38,40,41,72,73). Much discussion is underway to recognize the sentiment that 2 years of training in CCEP is optimal but may require adjustment in the overall training of the cardiovascular specialist, but this is beyond the purview of this paper.

It is anticipated that the more experienced the electrophysiologist, the quicker she or he will learn new techniques. As such, it is difficult to set requirements for a number of procedures to gain proficiency. The HRS Ad Hoc Committee on Catheter Ablation has recommended that a physician who performs catheter ablation procedures should have been the primary operator on 30 ablations (74); this should include 15 accessory pathway ablations. The Canadian Cardiovascular Society Committee (19) recommends a training experience that includes the performance of 50 transvenous catheter ablations. The ACGME recommends a minimum of 75 catheter ablative procedures, including a mix of AV nodal re-entrant tachycardia, atrial flutter, AV junction ablation, and ventricular tachycardia (22). For left-sided mapping procedures, the COCATS guidelines (21) recommend 15 cases with the retrograde aortic approach. For transseptal catheterization experience, greater than 10 procedures are recommended. The COCATS guidelines also recommend participation in 75 catheter ablation procedures. It is the consensus of this task force that, for new trainees, the physician should be involved in 75 ablation procedures. It is notable that, for candidates who take the first cardiac electrophysiology examination given by the ABIM, the pass rates were significantly higher for those who performed a greater number of ablations compared with those who performed a lesser number of procedures (75). The CCEP Training Program Directors’ Survey indicated that a minimum of 90 (mean; median, 100) cases were required to acquire clinical competence in catheter ablation.

No numeric guidelines have been established for training in AF ablation, but it is anticipated that the trainee should participate in 30 to 50 mentored AF ablations. These are in addition to the 75 procedures required to achieve competency for other ablation procedures.

	Alternate routes to achieve competence

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
At this time, it is anticipated that physicians who perform ablations will have either received instruction during their training or been among those who developed the technique. In the rare instance of a board-eligible or -certified electrophysiologist who desires to learn the techniques required for ablation, mentoring by an electrophysiologist who is trained in ablation should be pursued. Documentation of satisfactory completion of such training should be kept in a log book. It is anticipated that, depending on the level of skill, a minimum of 75 procedures will be required. In addition, such an individual should participate in courses designed to provide specific instruction in the cognitive and technical skills required for catheter ablation as listed earlier.

	Maintenance of competence

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
The field of interventional electrophysiology is evolving rapidly. Although it is anticipated that most physicians who perform ablations will have received instructions during their training, newer techniques will arise that require new skills or adaptations of old skills. The maintenance of skills needed to perform ablations successfully with acceptably low complication rates requires continued clinical activity. It is recommended that physicians who perform ablations maintain a volume of 20 to 50 ablations/year. The CCEP Training Program Directors’ Survey respondents indicate that, to maintain competency in catheter ablation, a mean of 38 (median, 50) cases/year are required.

With the future development of new techniques, it is likely that some form of retraining will be required. Every 2 years, physicians who are involved in ablation therapy should attend CME activities that pertain to interventional electrophysiology. For novel treatments, some form of monitoring should be considered. The CCEP Training Program Directors’ Survey results indicated that, to maintain competency in the performance of diagnostic EPS, a mean of 49 (median, 50) cases/year was required and that a mean of 49 (median, 50) could be in association with the performance of ablation procedures.

	Use of emerging technology and new techniques: Assessment of clinical competence in invasive cardiac electrophysiologic procedures

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
During the past 10 years, the technology of cardiac electrophysiology has evolved rapidly. The rather straightforward electrophysiologic procedures from the diagnostic era have given way to the multicatheter techniques and accompanying technologies that are necessary for interventional practice. The 8- to 16-channel analog recording systems are being replaced in routine procedures with 16- to 48-channel, computer-based digital recording platforms. Furthermore, 48- to 128-channel mapping capabilities are being developed and increasingly applied in cardiac ablation procedures. These systems not only simultaneously record and display activation from multiple regions of the heart but also format both activation and voltage information in 3- and 4-dimensional renderings.

Electroanatomic magnetic mapping capabilities, for example, are being applied to aid in the diagnosis and nonpharmacologic treatment of arrhythmias (76,77). These systems involve the interaction of a sensing unit in the catheter tip positioned within a triangulating magnetic field to display temporal activation in a 3-dimensional pseudoanatomic context. Noncontact mapping probes are also being used to record actual and virtual electrograms from the endocardial surface of each heart chamber. With this technology, cardiac activation can be displayed in terms of 3-dimensional isochronal and full cardiac cycle isopotential maps (78,79). Several other systems that use active signaling between multiple exclusively intracardiac catheter electrodes or the body surface and catheter electrodes are being developed to provide a 3-dimensional framework for cardiac arrhythmias (80). In each case, these new technologies increase the amount and complexity of data generated during a mapping procedure.

Use of cryoablation is gaining popularity in certain patient populations although its use has not become widespread (81,82). Those in training or who have completed training must be aware of ongoing developments in energy delivery systems including new energy sources and other components of energy delivery systems (e.g., catheter modifications, manipulable sheaths, and so on).

Two-dimensional fluoroscopic imaging is also being supplemented with intracardiac echocardiography. This approach has capabilities of visualizing cardiac structures, endocardial surfaces, and the interaction between interventional catheters and targeted structures that are superior to those available with fluoroscopy (83–85). Although not yet established as requisite or "core" equipment for the electrophysiology laboratory, these and other emerging technologies have had, and will continue to have, a major impact on the practice of cardiac arrhythmia management. It is also anticipated that additional new technologies will be developed at ever faster rates in the future.

	Competence in the use of emerging technology

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
This evolution of new means of diagnosing and treating arrhythmias is accompanied by an ever-increasing challenge to the practicing electrophysiologist. Specifically, the use of additional techniques and technologies will require the acquisition of sufficient cognitive and technical expertise to ensure safe and effective application. Although cardiac electrophysiology trainees may encounter these approaches and systems during their fellowships, by default, the majority of clinical electrophysiologists will first be exposed to, and begin using, emerging techniques and technologies outside of their training experience. As such, the skills required to record, compile, synthesize, integrate, render, interpret, and apply the resulting data will be acquired through alternative educational pathways.

	Specific training requirements

Top Table of Contents Preamble Introduction Clinical competence in invasive... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Catheter ablation: Overview of... Justification for... Minimum training necessary for... Alternate routes to achieve... Maintenance of competence Use of emerging technology... Competence in the use... Specific training requirements Clinical competence in elective... Justification for... Minimum training necessary for... Maintenance of competence References

 
The training required for proficiency in the application of new technologies and techniques will depend on the technology and procedures under consideration. When emerging techniques and technology represent straightforward incremental progress, their use may rely on already resident cognitive and technical skills. For example, many new intracardiac mapping technologies involve the same venous and arterial access skills, arrhythmia induction protocols, catheter positioning and mapping techniques, electrogram pattern recognition, and arrhythmia mechanism deduction previously acquired though years of training and clinical practice. In these cases, training should be focused on the appropriate operation of the system and interpretation and application of data displays.

In other cases, however, application of the emerging techniques and technology will undoubtedly represent a major paradigm shift in interventional approaches thus requiring the accumulation of very different technical and cognitive skills than those required to use the current procedures or technology. In such cases, sufficient education and experience are imperative for both understanding the general operational principles behind that technology and ensuring sufficient technical abilities for the safe and efficient application of the technology. This exposure may come from national and local CME seminars; emerging scientific information from reputable, established scientific journals; local or regional training sessions; or on-site teaching by certified industry engineers. In any event, sufficient experience should be acquired such at the actual application of the technology and performance of the procedure are conducted safely under the direction of the practicing physician, without relegation of this responsibility to an industry representative. This obviously requires that a practitioner have a sufficient understanding of appropriate indications, contraindications, and risks for the application of that technology.

The duration of training or number of procedures required to establish competence will be dependent on the new techniques or technology used. This should be based on definable measures of individual competence and should include appropriate documentation of the specific cases undert