2015 ACC/AHA/HRS Advanced Training Statement on Clinical Cardiac Electrophysiology

36 Pages·2017·0.52 MB·English

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 66, NO. 24, 2015
ª2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION, ISSN 0735-1097/$36.00
AMERICAN HEART ASSOCIATION, INC., AND THE HEART RHYTHM SOCIETY http://dx.doi.org/10.1016/j.jacc.2015.08.040
PUBLISHED BY ELSEVIER INC.
TRAINING STATEMENT
2015 ACC/AHA/HRS Advanced
Training Statement on Clinical Cardiac
Electrophysiology (A Revision of the
ACC/AHA 2006 Update of the
Clinical Competence Statement on
Invasive Electrophysiology Studies,
Catheter Ablation, and Cardioversion)
Writing DouglasP.Zipes,MD,FAHA,FHRS,MACC,Chair LaxmiS.Mehta,MD,FACC,FAHA
Committee HughCalkins,MD,FACC,FAHA,FHRS,ViceChair* LisaA.Mendes,MD,FACC
Members JohnM.Miller,MD,FACC,FHRS
JamesP.Daubert,MD,FACC,FHRS* ThomasM.Munger,MD,FACC
KennethA.Ellenbogen,MD,FACC,FAHA,FHRS WilliamH.Sauer,MD,FACC,FHRS
MichaelE.Field,MD,FACC,FHRS Win-KuangShen,MD,FACC,FAHA,FHRS
JohnD.Fisher,MD,FACC,FHRS WilliamG.Stevenson,MD,FACC,FAHA,FHRS
RichardIraFogel,MD,FACC,FHRS WilberW.Su,MD,FHRSy
DavidS.Frankel,MD,FACC,FHRS* CynthiaM.Tracy,MD,FACC
AnuragGupta,MD,FACCy AngelaTsiperfal,NP-Cy
JuliaH.Indik,MD,PHD,FACC,FAHA,FHRS
FredM.Kusumoto,MD,FACC,FHRS
BruceD.Lindsay,MD,FACC,FAHA,FHRS *OfficialHeartRhythmSocietyrepresentative.
yOfficialAmericanHeartAssociationrepresentative.
JosephE.Marine,MD,FACC,FHRS
ThedocumentwasapprovedbytheAmericanCollegeofCardiologyBoardofTrusteesinAugust2015andExecutiveCommitteeinSeptember2015,
theAmericanHeartAssociationScienceAdvisoryandCoordinatingCommitteeinAugust2015andExecutiveCommitteeinSeptember2015,andbythe
HeartRhythmSocietyBoardofTrusteesinAugust2015.Forthepurposeoftransparency,disclosureinformationfortheACCBoardofTrustees,the
boardoftheconveningorganizationofthisdocument,isavailableat:http://www.acc.org/about-acc/leadership/officers-and-trustees.
TheAmericanCollegeofCardiologyrequeststhatthisdocumentbecitedasfollows:ZipesDP,CalkinsH,DaubertJP,EllenbogenKA,FieldME,Fisher
JD,FogelRI,FrankelDS,GuptaA,IndikJH,KusumotoFM,LindsayBD,MarineJE,MehtaLS,MendesLA,MillerJM,MungerTM,SauerWH,ShenW-K,
Listentothismanuscript’s StevensonWG,SuWW,TracyCM,TsiperfalA.2015ACC/AHA/HRSadvancedtrainingstatementonclinicalcardiacelectrophysiology(arevisionofthe
ACC/AHA2006UpdateoftheClinicalCompetenceStatementonInvasiveElectrophysiologyStudies,CatheterAblation,andCardioversion).JAmColl
audiosummaryby
Cardiol2015;66:2767–802.
JACCEditor-in-Chief
Dr.ValentinFuster. ThisarticlehasbeencopublishedinCirculation:ArrhythmiaandElectrophysiologyandHeartRhythm.
Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmericanCollegeofCardiology(www.acc.org),AmericanHeartAssociation
(http://myamericanheart.org), and HeartRhythmSociety (www.hrsonline.org). Forcopies of thisdocument, pleasecontactElsevierInc. Reprint
Department,fax(212)[email protected].
Permissions:Multiplecopies,modification,alteration,enhancement,and/ordistributionofthisdocumentarenotpermittedwithouttheexpress
permissionoftheAmericanCollegeofCardiologyFoundation.RequestsmaybecompletedonlineviatheElseviersite(http://www.elsevier.com/about/
policies/author-agreement/obtaining-permission).
2768 Zipesetal. JACC VOL. 66, NO. 24, 2015
2015ACC/AHA/HRSCCEPAdvancedTrainingStatement DECEMBER 22, 2015:2767–802
ACC EricS.Williams,MD,MACC,Chair NkechinyereIjioma,MDz
Competency JonathanL.Halperin,MD,FACC,Co-Chair SadiyaS.Khan,MD
Management JeffreyT.Kuvin,MD,FACC
Committee JamesA.Arrighi,MD,FACC JosephE.Marine,MD,FACC
EricH.Awtry,MD,FACC JohnA.McPherson,MD,FACC
EricR.Bates,MD,FACC LisaA.Mendes,MD,FACC
JohnE.Brush,JR,MD,FACC ChitturA.Sivaram,MBBS,FACC
SalvatoreCosta,MD,FACC RobertL.Spicer,MD,FACC
LoriDaniels,MD,MAS,FACC AndrewWang,MD,FACC,FAHA
AkshayDesai,MD,FACCz HowardH.Weitz,MD,FACP,FACC
DouglasE.Drachman,MD,FACCz
SusanFernandes,LPD,PA-C zFormerCompetencyManagementCommitteemember;
RosarioFreeman,MD,MS,FACC currentmemberduringthiswritingeffort.
TABLE OF CONTENTS
PREAMBLE.................................... 2769 4.2. NumberofProceduresandDurationofTraining ..2782
4.3. DiagnosticTesting ........................2785
1.INTRODUCTION ............................. 2770
4.3.1.NoninvasiveDiagnosticTests ..........2785
1.1. DocumentDevelopmentProcess .............2770
4.3.2.InvasiveElectrophysiologicalEvaluation ..2786
1.1.1.WritingCommitteeOrganization........ 2770
1.1.2.DocumentDevelopmentandApproval... 2770 4.4. ArrhythmiaTypesandSyndromes ...........2786
4.4.1.PathophysiologicalBasisofCardiac
1.2. BackgroundandScope .....................2770 Arrhythmias/BasicElectrophysiology ...2786
1.2.1.EvolutionofCCEP ....................2771 4.4.2.InheritedArrhythmiaSyndromesand
1.2.2.LevelsofTraining.....................2771 GeneticTesting .....................2786
1.2.3.MethodsforDetermining 4.4.3.Bradyarrhythmias ...................2786
ProceduralNumbers...................2771 4.4.4.PalpitationsandParoxysmalSVDs...... 2787
2.GENERALSTANDARDS....................... 2772 4.4.5.SupraventricularTachycardias ......... 2787
4.4.6.AFandAtrialFlutter................. 2787
2.1. Faculty.................................. 2772
4.4.7.VAsandSuddenCardiacDeath ........2788
2.2. Facilities ................................ 2772 4.4.8.Syncope ...........................2788
2.3. Equipment .............................. 2772
4.5. NondeviceTherapies ......................2789
2.4. AncillarySupport ......................... 2772 4.5.1.AntiarrhythmicMedications ...........2789
3.TRAININGCOMPONENTS..................... 2772 4.5.2.CatheterAblation....................2789
4.5.3.SurgicalAblation ....................2789
3.1. DidacticProgram ......................... 2772
4.6. ImplantableDevices.......................2789
3.2. ClinicalExperience........................ 2773
4.6.1.Pacemakers ........................2790
3.3. Hands-OnProceduralExperience ............ 2773 4.6.2.ImplantableCardioverter-Defibrillators ..2790
3.4. DiagnosisandManagementofEmergencies 4.6.3.ResynchronizationTherapy ...........2790
andComplications ........................2774
4.6.4.ImplantableLoopRecorders........... 2791
3.5. DiagnosisandManagementofRareClinical 4.6.5.LeftAtrialAppendageOcclusion/Ligation.. 2791
ConditionsandSyndromes .................2774
4.6.6.LeadManagement................... 2791
3.6. ResearchandScholarlyActivity .............2774
4.TRAININGREQUIREMENTS ................... 2774 5.EVALUATIONOFPROFICIENCY ............... 2791
4.1. DevelopmentandEvaluationof
CoreCompetencies .......................2774 6.MAINTENANCEOFCOMPETENCY ............. 2792
JACC VOL. 66, NO. 24, 2015 Zipesetal. 2769
DECEMBER 22, 2015:2767–802 2015ACC/AHA/HRSCCEPAdvancedTrainingStatement
REFERENCES ................................. 2792 procedures or duration of training time to ensure
adequate exposure to the range of clinical disorders and
APPENDIX1 to effectively evaluate the trainee, it is the objective
assessment of proficiency and outcomes that demon-
AuthorRelationshipswithIndustryandOtherEntities
(Relevant) ................................... 2795 strates the trainee’s achievement of competency. Such
evaluation tools may include in-training examinations,
APPENDIX2 direct observation, procedure logbooks, simulation,
conferencepresentations,andmultisource(360(cid:2))evalua-
ReviewerRelationshipswithIndustryand
tions,amongothers.Forpracticingphysicians,thesetools
OtherEntities(Relevant)....................... 2797
mayalsoincludeprofessionalsocietyregistryorhospital
qualitydata,peer-reviewprocesses,andpatientsatisfac-
APPENDIX3
tion surveys. A second feature of a competency-based
Abbreviations ................................2802 trainingprogramistherecognitionthatlearnersdevelop
some competency components at different rates. For
multiyear training programs, assessment of selected
PREAMBLE representative curricular milestones during training can
identifylearnersor areasthat requireadditionalfocused
Since the 1995 publication of its Core Cardiovascular attention.
Training Statement (COCATS), the American College of The recommendations in the ACC cardiovascular
Cardiology (ACC) has played a central role in defining training statements are based on available evidence,
the knowledge, experiences, skills, and behaviors ex- and where evidence is lacking, reflect expert opinion.
pected of all clinical cardiologists upon completion of The writing committees are broad-based, and typically
training. Subsequent updates have incorporated major include content experts, general cardiology and sub-
advances and revisions—both in content and structure— subspecialty training directors, practicing cardiologists,
including, most recently, a further move toward com- and early-career representatives. All documents go
petency (outcomes)-based training, and the use of the through a rigorous peer-review process. Recommenda-
6-domain competency structure promulgated by the tions are intended to guide the assessment of compe-
Accreditation Council for Graduate Medical Education tence of cardiovascular care providers beginning
(ACGME)andtheAmericanBoardofMedicalSpecialties, independent practice as well as those undergoing pe-
and endorsed by the American Board of Internal Medi- riodic review to help ensure that competence is
cine(ABIM).AsimilarstructurehasbeenusedbyACCto maintained.
describe the aligned general cardiovascular lifelong This Advanced Training Statement addresses the added
learning competencies that all practicing cardiologists competencies required of sub-subspecialists in CCEP for
are expected to maintain. Many hospital systems also diagnosisandmanagementofpatientswithcardiacarrhyth-
now use the 6-domain structure as part of medical staff miasandconductiondisturbancesatahighlevelofskill.Itis
privileging and peer-review professional competence intendedtocomplementthebasictrainingincardiacelectro-
assessments. physiology(EP)requiredofalltraineesduringthestandard3-
Whereas COCATS has focused on general clinical car- yearcardiovascularfellowship.Thetrainingrequirementsand
diology, ACC Advanced Training Statements define designatedclinicalcompetenciesinthisreportfocusonthe
selected competencies that go beyond those expected of corecompetenciesreasonablyexpectedofallclinicalcardiac
all cardiologists and require training beyond a standard electrophysiologists.ItalsoidentifiessomeaspectsofCCEP
3-year cardiovascular disease fellowship. This includes thatgobeyondthecoreexpectationsandmaybeachievedby
sub-subspecialties for which there is an ABIM added- some clinical cardiac electrophysiologists, based on career
qualification designation, such as clinical cardiac elec- focus, either during formal CCEP fellowship training or
trophysiology (CCEP). The Advanced Training State- subsequently.
ments also describe key experiences and outcomes The work of the writing committee was supported
necessary to maintain or expand competencies during exclusively by the ACC without commercial support.
practice. Writing committee members volunteered their time to
The ACC Competency Management Committee over- this effort. Conference calls of the writing committee
sees the development and periodic revision of the car- were confidential and attended only by committee
diovascular training and competency statements. A key members. To avoid actual, potential, or perceived con-
feature of competency-based training and performance flict of interest arising as a result of relationships with
is an outcome-based evaluation system. Although spe- industry or other entities (RWI) of writing committee
cificareasoftrainingmayrequireaminimumnumberof members or peer reviewers of the document, each
2770 Zipesetal. JACC VOL. 66, NO. 24, 2015
2015ACC/AHA/HRSCCEPAdvancedTrainingStatement DECEMBER 22, 2015:2767–802
individual is required to disclose all current healthcare- 1.1.2. DocumentDevelopmentandApproval
related relationships, including those existing 12 The writing committee convened by conference call and
months before initiation of the writing effort. The ACC e-mail to finalize the document outline, develop the
Competency Management Committee reviewed these initial draft, revise the draft based on committee feed-
disclosures to identify products (marketed or under back, and ultimately approve the document for external
development) pertinent to the document topic. On the peer review. In addition, the committee conducted a
basis of this information, the writing committee was survey of EP training program directors to obtain addi-
constituted to ensure that the Chair and a majority of tional insight into procedural numbers to consider in
members have no relevant RWI. Authors with relevant writingcommitteedeliberations.
RWI were not permitted to draft initial text or vote on The document was reviewed by 9 official representa-
recommendations or curricular requirements to which tives from the ACC, AHA, and HRS, as well as by 26
their RWI might apply. RWI was reviewed at the start of additional content reviewers, including CCEP training
all meetings and conference calls and updated as program directors, resulting in 417 peer review com-
changes occurred. The RWI of authors and peer re- ments. The list of peer reviewers, affiliations for the re-
viewers relevant to this document are disclosed in view process, and corresponding RWI is included in
Appendixes 1 and 2, respectively. To ensure trans- Appendix2.Commentswerereviewedandaddressedby
parency, comprehensive healthcare-related disclosure thewritingcommittee.AmemberoftheACCCompetency
information, including RWI not pertinent to this docu- Management Committee served as lead reviewer to
ment, is posted online. Disclosure information for the ensureafairandbalancedpeerreviewresolutionprocess.
ACC Competency Management Committee is also avail- Both the writing committee and the ACC Competency
ableonline,asistheACCdisclosurepolicyfordocument ManagementCommitteeapprovedthefinaldocumentto
development. besentfororganizationalapproval.Thegoverningbodies
EricS.Williams,MD,MACC of the ACC, AHA, and HRS approved the document for
Chair,ACCCompetencyManagementCommittee publication. This document is considered current until
JonathanL.Halperin,MD,FACC the ACC Competency Management Committee revises or
Co-Chair,ACCCompetencyManagementCommittee withdrawsitfrompublication.
1. INTRODUCTION
1.2. BackgroundandScope
The original 1995 ACC recommendations for training
1.1. DocumentDevelopmentProcess
in adult cardiology evolved from a Core Cardiology
1.1.1. WritingCommitteeOrganization TrainingSymposium(1).Afterseveraliterations,COCATS
The writing committee consisted of a broad range of 4(2)focusesontraineeoutcomesthatrequiredelineation
members representing ACC, the American Heart Asso- of specific components of competency within the sub-
ciation (AHA), and the Heart Rhythm Society (HRS), specialty, definition of the tools necessary to assess
identified because they perform $1 of the following training, and establishment of milestones documenting
roles: cardiovascular training program directors; EP the trainee’s progression toward independent compe-
training program directors; early-career experts; general tency.Ultimately,thegoalisforthetraineetodevelopthe
cardiologists; EP specialists representing both the aca- professionalskillsettobeabletoevaluate,diagnose,and
demic and community-based practice settings as well as treat patients with acute and chronic cardiovascular
small, medium, and large institutions; specialists in all disturbances.
aspects of CCEP, including catheter ablation, device The COCATS 4 document includes individual task
management, antiarrhythmic drug therapy, lead extrac- force reports that address subspecialty areas in cardiol-
tion, and left atrial appendage occlusion/ligation; phy- ogy, each of which is an important component in
sicians experienced in training and working with the trainingafellow incardiovascular disease.TaskForce11
ACGME/Residency Review Committee as well as the of that document addresses training in arrhythmia
ABIM examination writing committee; physicians expe- diagnosis and management, cardiac pacing, and EP (3)
rienced in defining and applying training standards and updated previous standards for general cardiovas-
according to the 6 general competency domains cular training for fellows enrolled in cardiovascular
promulgated by the ACGME and the American Board of fellowship programs. It addresses faculty, facilities,
Medical Specialties and endorsed by the ABIM; and equipment, and ancillary support. It also addresses
nurses. This writing committee met the College’s training components, including didactic, clinical, and
disclosure requirements for relationships with industry hands-onexperience,andthenumberofproceduresand
as described in the Preamble. duration of training. Importantly, the COCATS 4 Task
JACC VOL. 66, NO. 24, 2015 Zipesetal. 2771
DECEMBER 22, 2015:2767–802 2015ACC/AHA/HRSCCEPAdvancedTrainingStatement
Force 11 report did not provide specific guidelines for selected areas may be achieved by some trainees dur-
advanced CCEP training. ing the standard 3-year cardiovascular fellowship,
This document focuses on training requirements for depending on their career goals and use of elective
advanced training in adult CCEP. For training standards rotations. Level II EP training during the general
related to pediatric EP, readers should refer to the fellowship can provide the knowledge and skills
SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric neededforthefellowtoprovidespecializedarrhythmia
Cardiology Fellowship Programs Task Force 4: Pediatric and CIED management, including implantation, inter-
Cardiology Fellowship Training in Electrophysiology (4) rogation and programming of pacemakers and
and to Recommendations for Advanced Fellowship implantable loop recorders (ILRs), and interrogation
Training in Clinical Pediatric and Congenital Elec- andprogrammingofotherCIEDs.
trophysiology: a Report From the Training and Cre- (cid:3) LevelIIItraining,theprimaryfocusofthisdocument,
dentialing Committee of the Pediatric and Congenital requires additional training and experience beyond
ElectrophysiologySociety(5). the cardiovascular fellowship for the acquisition of
specialized knowledge and experience in performing,
1.2.1. EvolutionofCCEP interpreting, and training others to perform specific
TraininginCCEPhasbecomemorecomplexastheclinical procedures or render advanced, specialized care for
specialty has matured. The use of cardioactive drugs, specific procedures at a high level of skill. Level III
implantation and use of cardiac implantable electronic trainingisrequiredofindividualsseekingsubspecialty
devices (CIEDs) and left atrial appendage occlusion de- board certification in CCEP. Trainees in CCEP are
vices, and performance of invasive catheter ablation expectedtohavecompletedLevelItraininginallareas
procedures for arrhythmia management have reached a of general cardiovascular medicine before beginning
levelofsophisticationthatnecessitatesare-evaluationof theirCCEPfellowship.
thetrainingcurriculum.
The ABIM requires 3 years of cardiology fellowship
1.2.3. MethodsforDeterminingProceduralNumbers
training before fellows may sit for the certification ex-
As noted in the COCATS 4 Task Force 11 report (3), the
amination in cardiovascular medicine. Previously, it had
recommended number of procedures performed and
required an additional year of training in CCEP for eligi-
bilitytotakethecertificationexaminationinEP.Itisnow interpreted by trainees under faculty supervision has
been developed on the basis of published studies and
clearthatCCEPdemandsaskillleveltodiagnoseandtreat
guidelines, competency statements, and the experience
patients with cardiac arrhythmias and conduction disor-
and opinions of the members of the writing group. In
ders that can no longer be attained in a single year of
addition, the writing committee surveyed CCEP training
training.Twoyearsofadvancedtrainingarenowrequired
program directors to gain additional insight into proce-
toachievetheexperiencenecessarytobecomeacompe-
dural volumes. Of 100 directors of ABIM–recognized
tent,independentexpertinCCEP.
trainingprograms,33responded.Theproceduralvolumes
suggested in this document were determined to be the
1.2.2. LevelsofTraining
minimum numbers sufficient to provide trainees with
COCATS 4 Task Force 11 was charged with updating
exposure to a variety and spectrum of complexity of
previously published standards for training fellows in
clinical case material and to give supervising faculty
cardiovascular medicine and establishing consistent
sufficient opportunity to evaluate the competency
trainingcriteriaacrossallaspectsofcardiologyincluding
developed by each trainee. The numbers of procedures
advanced training in CCEP (3). For the cardiovascular
thatshouldbeperformedand/orinterpretedsuccessfully
fellowship, the following 3 levels of training have been
to achieve competence (see Section 4.2) are intended as
delineated for training in arrhythmia diagnosis and
general guidance, based on the educational needs and
management,cardiacpacing,andEP:
progress of typical CCEP trainees in typical programs.
(cid:3) LevelItraining,thebasictrainingrequiredoftrainees Those considering these volume figures should bear in
to become competent consultant cardiologists, is mindthefundamentalnatureofeducationalmilestones—
required of all fellows in cardiology, and can be that proficiency and outcomes, rather than length of
accomplished as part of a standard 3-year training exposure or the exact number of procedures performed,
programingeneralcardiology. arethedominantrequirements.Flexibilityisinherentto
(cid:3) LevelIItraining,referstoadditionaltrainingin$1area thisconcept,andtheACGMEmandatesthatallprograms
thatenablessomecardiologiststoperformorinterpret establish milestones for the acquisition of various com-
specificproceduresorrendermorespecializedcarefor petencies by trainees during the course of fellowship
patients with certain conditions. Level II training in training.
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2015ACC/AHA/HRSCCEPAdvancedTrainingStatement DECEMBER 22, 2015:2767–802
2. GENERAL STANDARDS equipment, including alternative imaging methods (e.g.,
intracardiac echocardiography), advanced 3-dimensional
2.1. Faculty mapping systems, ablation energy sources, CIED pro-
EngagedfacultywhoarecommittedtoteachingEParethe grammers, and extraction tools, is often necessary for
most important resource for a successful CCEP training safeandmaximally-effectivecareofpatientswithintheEP
program. Faculty must include specialists who are laboratory. Appropriate resuscitation equipment must
knowledgeable about basic and clinical aspects of EP, beimmediatelyavailable.Inadditiontofacilitiesrecom-
including anatomy, physiology, and pathophysiology of mendations, the HRS Expert Consensus Statement on
arrhythmias; both noninvasive and invasive diagnostic Electrophysiology Laboratory Standards: Process, Pro-
strategies and tests; and therapeutic options, including tocols, Equipment, Personnel, and Safety provides
device-based therapies, medical management, and detailed recommendations on equipment necessary for
catheter ablation. The most recent ACGME Program performing invasive EP studies and placing CIEDs (7).
Requirements for Graduate Medical Education in CCEP Equipment and technology in the EP laboratory will
require a single designated program director and at continue to evolve rapidly, and a mechanism must be
least 1 additional key clinical faculty member (6). Each presentthatallowsassessmentandintegrationofimpor-
of the key clinical faculty members should be currently tantnewtechnologies.Inadditiontoequipmentphysically
certified in CCEP by the ABIM. Furthermore, it is rec- located within the EP suite, access to equipment and
ommendedthatthenumberofABIM-certifiedEPfaculty technologies outside of the EP suite, such as trans-
equal or exceed the number of trainees enrolled in the esophagealechocardiographyandadvancedimaging(e.g.,
training program. In addition to subject knowledge, computed tomography [CT] scanning, cardiovascular
faculty shouldbe active bothclinically andacademically magnetic resonance [CMR]), is essential for successful
in the field of EP; should have experience and/or un- traininginEP.
dergo professional training in teaching and mentoring;
and must have sufficient time to fulfill the teaching, 2.4. AncillarySupport
mentoring, and administrative responsibilities required Adequate EP training requires interaction among many
for participation as active faculty in the CCEP training different specialties within the healthcare environment.
program. Communication with, and access to, cardiologists who
have advanced training in interventional cardiology,
echocardiography and advanced imaging, and heart
2.2. Facilities
failure are critical. In addition, interaction with and
Facilities must include dedicated areas for both outpa-
availability of anesthesiologists and cardiothoracic sur-
tient care and hospital-based treatment. An outpatient
geons are important for safe performance of some
areathatallowsforlongitudinalmanagementofpatients
advanced EP procedures. Physicians from other fields
with arrhythmia problems is essential for complete
of medical and surgical practice should be available
training. In the hospital environment, a dedicated
for consultation, and access to other healthcare pro-
area that provides a safe and sterile environment for
fessionals, including genetic counselors, pharmacists,
performing invasive electrophysiological procedures is
dieticians, occupational therapists, physical therapists,
necessary.The“HeartRhythmSocietyExpertConsensus
socialworkers,andbiomedicalengineers,isrequired.
Statement on Electrophysiology Laboratory Standards:
Process, Protocols, Equipment, Personnel, and Safety” 3. TRAINING COMPONENTS
provides general recommendations for the EP laboratory
(7). In addition to physical space and facilities, the 3.1. DidacticProgram
teaching environment must include a systems-based
Didactic instruction may take place in a variety of for-
practice that allows for effective communication be-
mats,includinglectures,conferences,journalclub,grand
tween the outpatient and inpatient environments and
rounds, clinical case presentations, electrocardiogram
among different specialists. Facilities must also have
(ECG) and electrogram review conferences, and patient
systems or mechanisms in place that continuously eval-
safety or quality improvement conferences. Topics for
uatequalityandclinicaloutcomes.
discussionincludegenetics;anatomy;neuralinnervation;
pathology; molecular,cellular,whole-animalandhuman
2.3. Equipment EP; radiation safety; imaging; specific arrhythmia mech-
EP laboratories that provide a safe environment for anisms; and patient-centered care. Didactic sessions and
invasive EP studies require imaging capabilities such case reviews are important mechanisms for training in
as fluoroscopy and equipment for recording electrical the interpretation of complex surface and intracardiac
and hemodynamic signals. In addition, specialized electrograms and in the evaluation and management of
JACC VOL. 66, NO. 24, 2015 Zipesetal. 2773
DECEMBER 22, 2015:2767–802 2015ACC/AHA/HRSCCEPAdvancedTrainingStatement
hospitalized patients and outpatients with cardiac ar- duringthe24 monthsofCCEPtrainingissummarizedin
rhythmias. The latter includes the interpretation of Section4.2.
ambulatorymonitoringandCIEDdatacriticalforpatient Level III trainees require experience in performing
management.Hands-onuseofsimulatorsisanemerging diagnostic EP studies and standard ablation procedures
platform to assist in the training of electrophysiologists, including ablation of atrioventricular (AV) nodal re-
particularly in areas such as lead extraction, lead entrant tachycardia, atrial flutter, atrial tachycardia,
placement, trans-septal puncture, catheter ablation pro- accessory pathways (APs), the AV node, and ventricular
cedures,andpreparationforinfrequentemergenciessuch arrhythmias (VAs). They also require experience in
as cardiac perforation and tamponade (8,9). The same endocardial mapping including exposure to left heart
requirements for frequency of didactic instruction in mapping by the retrograde aortic and trans-septal ap-
generalcardiologytrainingarerecommendedforLevelIII proaches. Performance of procedures such as atrial
training in CCEP (3). Moreover, it is expected that the fibrillation (AF) ablation, ablation of left-sided APs, and
CCEPtraineesembarkonalifelongjourney ofeducation placement of left atrial appendage occlusion devices/
and learning that does not end with the completion of ligation requires training in trans-septal catheterization.
the fellowship, especially as new technologies and pro- Ablation of AF, atrial tachycardia, premature ventricular
ceduresaredeveloped. complexes, and ventricular tachycardia (VT) requires
additionalexpertiseincathetermanipulation,deliveryof
3.2. ClinicalExperience ablative energy, and integration of knowledge related to
3-dimensional mapping systems and supporting modal-
Level III trainees are required to have completed Level I
ities, such as intracardiac echocardiograms, CMR, and
training. Level II training can be completed before or in
CTscans.
conjunction with Level III training. In either situation,
To gain skills in CIED implantation, the trainees
Level III training cannot start until 3 years of cardiovas-
should have adequate supervised experience perform-
culartraininghavebeencompleted.LevelIIItrainingre-
ing this procedure (see Section 4.2). CIED lead extrac-
quires robust clinical experiences in the outpatient and
tion is a specialized procedure that requires special
inpatient consultation settings and in the EP laboratory.
training but is not required to qualify for CCEP exam-
Ineachoftheseclinicalarenas,traineesassist inpatient
ination eligibility. Level III training in ICD implantation
care in a supervised setting that provides for patient-
requires an extensive knowledge of ICD indications and
centered education in all aspects of arrhythmia manage-
contraindications, and of management of complications;
ment. During a portion of clinical training, the Level III
an ability to assess patients for their risk of elevated
trainee is expected to act as a first-line consultant in
defibrillation thresholds (DFTs), determine DFTs when
arrhythmia management with appropriate on-site
appropriate, and manage high DFTs; an understanding
attending backup. In this capacity, the Level III trainee
of drug- and pacemaker-ICD interactions; and a thor-
isexpectedtogatheraccurate,essentialinformationfrom
ough knowledge of ICD programming, management of
all sources, including medical interviews, physical ex-
ICD malfunction, and postoperative complications.
amination,records,deviceinterrogation,anddiagnostic/
Level III trainees must have an extensive knowledge
therapeutic procedures; make informed recommenda-
of left ventricular lead indications and contrain-
tions about preventive, diagnostic, and therapeutic op-
dications, management of biventricular pacemaker
tions and interventions that on the basis of clinical
malfunctions and interactions, and postoperative com-
judgment, scientific evidence, and patient preferences;
plications (10).
develop, negotiate, and implement patient management
CardiacEPisarapidlyevolvingfield,andtheongoing
plans;andperformcompetentlythediagnosticandther-
introduction of new technology can be expected. These
apeuticproceduresconsideredessentialtothepracticeof
new technologies include leadless pacing systems, left
CCEP.
atrial appendage exclusion devices, renal denervation
procedures, implantable hemodynamic and pressure
3.3. Hands-OnProceduralExperience monitors, and novel methods for arrhythmia mapping.
Hands-on experience is essential for training in Therefore, although specific requirements for trainees in
arrhythmia and CIED management. Level III training in these new technologies cannot be stipulated, Level III
CCEP requires a robust experience in the EP laboratory trainees will be expected to attain the same minimum
performingdiagnosticandtherapeuticEPproceduresand number of supervised procedures recommended for
device implantation and programming (permanent pace- practicingelectrophysiologistsinthefuture.Inaddition,
makers, implantable cardioverter-defibrillators [ICDs], the increase in the number of left ventricular assist de-
and cardiac resynchronization therapy [CRT] devices). vices and the growth of the adult with congenital heart
The number of procedures that need to be completed disease population introduce specific, unquantifiable
2774 Zipesetal. JACC VOL. 66, NO. 24, 2015
2015ACC/AHA/HRSCCEPAdvancedTrainingStatement DECEMBER 22, 2015:2767–802
patient-based complexities. Performance of procedures be able to use information technology or other available
in these special populations may be limited to certain methodologies, including consultation with genetic
centers that expose trainees to a larger number of these counselors,clinicalgeneticists,andexpertsinthesecon-
patients. ditions,todiagnoseandmanageaffectedpatients.
3.4. DiagnosisandManagementofEmergenciesand 3.6. ResearchandScholarlyActivity
Complications
All trainees are expected to carry out scholarly activities
The nature of procedures performed in the practice of and/or research during Level III training in CCEP. Level
CCEPraisestherealpossibilityofpotentialcomplications III training in CCEP may include structured activities
that range from minor tomajor, including those that are designed to support careers in cardiovascular investiga-
immediateandlifethreatening.ItiscriticalthattheLevel tion(11).However,notallLevelIIICCEPtraineesareex-
III trainee be proficient at recognizing potential compli- pectedtofollowthisroute.DuringLevelIIItraining,the
cations for each type of procedure being performed and trainee is expected to work with a mentor(s) to develop
understandsafeguardsthatmustbeinplacetominimize areas of scholarly achievement. Scholarly activity may
risk. In addition, the Level III trainee must become pro- include original clinical, basic science, or translational
ficient at managing acute intraprocedural complications research;qualityimprovementactivities;presentationat
as well as postprocedural complications. Potential com- institutional, local, regional, or national meetings; and
plications include death, vascular disruption (e.g., at an publicationoforiginalarticles,reviews,chapters,orcase
accesssiteorduringleadextractions),pulmonaryemboli, reports. In addition, a scholarly approach to answering
respiratory compromise, stroke, infection (either device- clinical questions and enhancing patient care through
related or not device-related), cardiac perforation with conducting literature reviews should be promoted
effusionand/ortamponade,hemothorax,pneumothorax, throughout the fellowship years. Trainees should be en-
venous thromboses (both those related to CIED implan- couragedtodevelopandmaintainhabitsofself-learning,
tationandthosethatarenotdevicerelated),phrenicnerve particularly through regular reading of cardiology and
paralysis,atrialesophagealfistula(followingAFablation), CCEPjournalsandattendingappropriatescholarlymeet-
andairembolism.TheLevelIIItraineemustbeproficient ings. Progress in research and scholarly training is
atmanagingthosecomplicationsthatcanbetreatedbythe assessedbytheprogramdirectorandinstructorsthrough
electrophysiologist,aswellasunderstandingwhenaddi- evaluation tools such as direct observation, reviewing
tional support is needed from cardiothoracic surgery, presentations and manuscripts, and overseeing research
interventionalcardiology,oranesthesiology.TheLevelIII activities.
trainee is expected to follow institutional requirements
4. TRAINING REQUIREMENTS
for reporting complications, present and discuss them
at patient safety or quality improvement conferences,
andlearnfromsuchexperiences. 4.1. DevelopmentandEvaluationofCoreCompetencies
TrainingandrequirementsinCCEPaddressthe6general
3.5. DiagnosisandManagementofRareClinicalConditions competencies promulgated by the ACGME and American
andSyndromes Board of Medical Specialties and endorsed by the ABIM.
Alargenumberofhereditaryconditionscanbeassociated These competency domains are: medical knowledge, pa-
withcardiacarrhythmias,andtheLevelIIItraineemustbe tient care and procedural skills, practice-based learning
familiarwithinheritedionchanneldisorderssuchaslong and improvement, systems-based practice, interpersonal
QT syndrome, Brugada syndrome, short QT syndrome, andcommunicationskills,andprofessionalism.TheACC
and catecholaminergic polymorphic VT as well as with has used this structure to define and depict the compo-
inherited cardiomyopathies that have arrhythmic mani- nents of the clinical competencies for cardiology. The
festations including hypertrophic cardiomyopathy, curricular milestones for each competency and domain
arrhythmogenicrightventriculardysplasia/cardiomyopa- alsoprovideadevelopmentalroadmapforfellowsasthey
thy,myotonicdystrophy,othermusculardystrophies,and progressthroughvariouslevelsoftrainingandserveasan
other types of cardiomyopathies. In addition, numerous underpinning for the ACGME reporting milestones. The
autoimmune and inflammatory disorders have potential ACC has adopted this format for its competency and
electrophysiologicalmanifestations.TheLevelIIItrainee training statements, career milestones, lifelong learning,
shalldevelopclinicallyapplicableknowledgeofthebasic andeducationalprograms.
and clinical sciences that underlie these disorders and Table 1 delineates each of the 6 competency domains,
applythisknowledgeinpatientcare.TheLevelIIItrainee as well as their associated curricular milestones for
isnotexpectedtobeexpertinthecompletemanagement training in CCEP. Included in the table are examples of
ofpatientswiththeseconditionsandsyndromesbutmust evaluation tools suitable for assessing competence in
JACC VOL. 66, NO. 24, 2015 Zipesetal. 2775
DECEMBER 22, 2015:2767–802 2015ACC/AHA/HRSCCEPAdvancedTrainingStatement
TABLE 1 CompetencyComponentsandCurricularMilestonesforLevelIIITraininginClinicalCardiacElectrophysiology
CompetencyComponent Milestones(Months)
MEDICALKNOWLEDGE 12 24 Add
PathophysiologicalBasisofCardiacArrhythmias/BasicElectrophysiology
1. Knownormalcardiacanatomy,includingtheanatomyoftheconductionsystem. III
2. Knowbasiccardiacelectrophysiology. III
3. Knowthemechanismsofcardiacarrhythmias,includingtherelationshipbetweencardiacarrhythmiasand III
structuralheartdisease(includingcongenitalheartdisease),sympatheticaswellasparasympathetictone,
myocardialischemia/infarction,anddrugs.
4. Knowthephysiologyandpathophysiologyoftheatrioventricularconductionsystemandthetypesand III
associatedclinicalmanifestationsofaccessorypathways.
5. Knowthegeneticbasisofarrhythmias,includinggenetically-basedionchannelabnormalitiesandinherited III
cardiomyopathies.
6. Knowtheepidemiologyofarrhythmias. III
7. Knowtheinfluenceofacquiredstructuralorcongenitalheartdiseaseincausingcardiacarrhythmiasanditseffecton III
clinicaldecision-makingaboutarrhythmiariskandmanagement.
8. Knowthesystemicdisordersandmetabolicabnormalitiesassociatedwitharrhythmiasandconductionabnormalities. III
DiagnosticTests
NoninvasiveDiagnosticTests
9. KnowtheroleandmethodofinterpretingECGsobtainedduringsinusrhythm,exercise,andcardiacarrhythmias III
intheevaluationofpatientswithknownorsuspectedcardiacarrhythmias.
10. KnowthemethodstointerpretsurfaceECGforthedifferentialdiagnosisofcardiacarrhythmias. III
11. Knowtheindicationsforeventmonitors/recordersandHoltermonitors/recordersandthemethodstointerprettheresults. III
12. Knowtheindicationsfortilttabletests,themethodstoperformatilttabletest,andthemethodstointerprettheresults. III
13. Knowtheroleofexercisestresstesting,withorwithoutimaging,intheevaluationandmanagementofpatientswith III
cardiacarrhythmias.
14. Knowtheroleoftransthoracicandtransesophagealechocardiographyinthemanagementofpatientswithcardiac III
arrhythmias.
15. Knowtheroleoftransesophagealechocardiographyandintracardiacechocardiographyinguidingtrans-septal III
punctureandablationnearkeyanatomicstructuresandmonitoringforthedevelopmentofapericardialeffusion.
16. Knowtheroleofadvancedimaging(computedtomography,magneticresonanceimaging,andpositronemission III
tomography)intheevaluationandmanagementofpatientswithcardiacarrhythmias.
17. Knowtheelectrophysiologicalbasisofvariouselectrocardiographicparameterssuchassignal-averaged III
electrocardiography.
18. Knowthemethodstointerprettracingsandotherinformationdownloadedfrompacemakers,defibrillators,and III
implantedloopmonitorswithrespecttobotharrhythmiasandheartfailuremanagement.
19. Knowtheindicationsforreferringpatientsforsleepapneaevaluation. III
InvasiveElectrophysiologicalTesting
20. Knowthetechniquesof,indicationsfor,contraindications,andpotentialcomplicationsofinvasiveelectrophysiological III
studies.
21. Knowtheprinciplesofobtainingvascularaccess,multielectrodecatheterplacement,electrogramrecording,and III
stimulation.
22. Knowtheinvasivelaboratoryrecordingtechniques,includingtheprinciplesofamplifiers,filters,andsignalprocessors. III
23. Knowtheprinciplesofadvanced3-dimensionalmappingsystems,includinganatomicalchamberreconstruction,image III
integration,andcreationandinterpretationofelectroanatomicalactivationandvoltagemaps.
24. Knowtheprinciplesofradiationsafetyandofelectricalsafety(relatedtofluoroscopyandotherequipmentused III
inthelaboratory)intheperformanceofelectrophysiologystudies,ablation,ordevicetherapy.
25. Knowthecharacteristicsofunipolarandbipolarintracardiacelectrocardiographicsignals. III
26. Knowthemethodsofprogrammedelectricalstimulation,theroleofprovocativedrugtesting/stimulation,andthe III
characteristicfindingsinpatientswithandwithoutarrhythmiasorconductiondisturbances.
2776 Zipesetal. JACC VOL. 66, NO. 24, 2015
2015ACC/AHA/HRSCCEPAdvancedTrainingStatement DECEMBER 22, 2015:2767–802
TABLE1 Continued
CompetencyComponent Milestones(Months)
MEDICALKNOWLEDGE 12 24 Add
27. Knowthepacingprotocolstoevaluatesinusnodeandatrioventricularnodefunctionandtoinducesupraventricular III
andventriculararrhythmias,includinguseofentrainment.
28. Knowthepredictivevalueandlimitationsofinvasiveelectrophysiologicalstudiesinpatientswithvariousarrhythmias III
andclinicalsyndromes.
NondeviceTherapies
AntiarrhythmicMedications
29. Knowtheindications,contraindications,andclinicalpharmacologyofantiarrhythmicdrugsandsympatheticand III
parasympatheticagonistsandantagonists.
30. Knowtheclinicalpharmacokineticsandpharmacodynamicsofantiarrhythmicmedications. III
31. Knowtheadverseeffectsofantiarrhythmicdrugs,includingdrug–druganddrug–deviceinteractionsand III
proarrhythmiapotential.
CatheterAblation
32. Knowthebiophysicsofradiofrequency,cryoablation,andotherablationenergysourcesthatbecomeavailable. III
33. Knowtheindicationsandcontraindicationsforcatheterablationofalltypesofcardiacarrhythmias. III
34. Knowthecomplicationsassociatedwithcatheterablationofalltypesofcardiacarrhythmias. III
35. Knowthemethodstominimizetherisksofcomplicationsofcatheterablation. III
36. Knowthemethodstomanagecomplicationsthatoccurduringcatheterablation. III
37. Knowtherelativebenefitsandrisksassociatedwithradiofrequencyablation,cryoablation,andotherablation III
technologiesthatbecomeavailable.
SurgicalAblation
38. Knowthepathophysiologicalbasisofarrhythmiasurgery. III
39. Knowthetechniques,indicationsfor,andcomplicationsassociatedwithsurgicaltreatmentofcardiacarrhythmias, III
includingsurgicalatrialfibrillationablation.
ImplantableDevices
Pacemakers
40. Knowtheindicationsforimplantationofacardiacpacemakerandthemethodstoselecttheappropriatepacemaker III
typeforaparticularpatient.
41. Knowthecomplicationsassociatedwithplacementofacardiacpacemakerandthemethodstomanagethose III
complications.
42. Knowthemethodstointerrogate,program,andtroubleshootcardiacpacemakers,includingtheuseofremote III
monitoringandinterrogation.
ImplantableDefibrillators
43. Knowtheindicationsforimplantationofanimplantablecardioverter-defibrillatorforprimaryandsecondary III
preventionofsuddencardiacdeath.
44. Knowthemethodsforselectingtheappropriateimplantablecardioverter-defibrillatortype(includingsubcutaneous III
implantablecardioverter-defibrillators)foraparticularpatient.
45. Knowthecomplicationsassociatedwithimplantationofanimplantablecardioverter-defibrillatorandthemethodsto III
managethem.
46. Knowthemethodstointerrogate,program,andtroubleshootimplantablecardioverter-defibrillatorsincludingthe III
useofremoteinterrogation.
ResynchronizationTherapy
47. Knowtheindicationsforcardiacresynchronizationtherapy. III
48. Knowthecomplicationsassociatedwithplacementofacardiacresynchronizationtherapydeviceandthemethodsto III
managethosecomplications.
49. Knowthetheoriesandmethodologyofoptimizationofcardiacresynchronizationtherapyaswellasthemethodsto III
interrogate,program,andtroubleshootcardiacresynchronizationtherapy.