Task Force 4: Pediatric Cardiology Fellowship Training in Electrophysiology
- AHA Scientific Statements
- cardiac arrhythmias
- clinical competence
- fellowship training
- implantable defibrillators
- pediatric cardiology
1.1. Document Development Process
The Society of Pediatric Cardiology Training Program Directors (SPCTPD) board assembled a Steering Committee that nominated 2 chairs, 1 SPCTPD Steering Committee member, and 5 additional experts from a wide range of program sizes, geographic regions, and subspecialty focuses. Representatives from the American College of Cardiology (ACC), American Academy of Pediatrics (AAP), American Heart Association (AHA), and Pediatric and Congenital Electrophysiology Society (PACES) participated. The Steering Committee member was added to provide perspective to each Task Force as a “nonexpert” in that field. Relationships with industry and other entities were not deemed relevant to the creation of a general cardiology training statement; however, employment and affiliation information for authors and peer reviewers are provided in Appendixes 1 and 2, respectively, along with disclosure reporting categories. Comprehensive disclosure information for all authors, including relationships with industry and other entities, is available as an online supplement to this document.
The writing committee developed the document, approved it for review by individuals selected by the participating organizations (Appendix 2), and addressed their comments. The final document was approved by the SPCTPD, AAP, and AHA in February 2015 and approved by the ACC and endorsed by PACES in March 2015. This document is considered current until the SPCTPD revises or withdraws it.
1.2. Background and Scope
Pediatric electrophysiology is a rapidly evolving field. New technology for implantable devices and ablations, and advances in the genetic diagnosis of channelopathies challenge the pediatric electrophysiologist. The need for formal guidelines to train the pediatric cardiologist in electrophysiology is readily apparent, with a formal statement from the AHA, ACC, and Heart Rhythm Society (HRS) published in 2005.1 This initial set of guidelines was derived in part from training guidelines in adult clinical cardiac electrophysiology but recognizes the important difference between the pediatric and adult arrhythmia patient.2
Pediatric patients differ in important ways from adult patients, as recognized by the separate training programs and board certifications for adult and pediatric cardiologists. The pediatric cardiologist should be able to manage the child with a structurally normal heart and supraventricular tachycardia and the child with a perioperative arrhythmia following congenital heart disease (CHD) repair, as well as be knowledgeable about the fetus with an in utero arrhythmia and where and when to refer. The adult CHD patient offers further challenges. These new guidelines have been modified to reflect the changing practice of pediatric electrophysiology, and stress the need for a working understanding of genetic channelopathies, as well as the importance of a deeper understanding of the indications for––and management of––the present generation of pacemakers, defibrillators, resynchronization devices, and implantable loop recorders.
Our revised training recommendations describe the program resources and environment that are required for training pediatric cardiology fellows, together with a competency-based system promulgated by the American College of Graduate Medical Education (ACGME), to implement specific goals and objectives for training pediatric cardiology fellows. This system categorizes competencies into 6 core competency domains: Medical Knowledge, Patient Care and Procedural Skills, Systems-Based Practice, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills, along with identification of suggested evaluation tools for each domain. Core competencies unique to pediatric cardiac electrophysiology are listed in Section 3 (see the “2015 SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric Cardiology Fellowship Programs [Revision of the 2005 Training Guidelines for Pediatric Cardiology Fellowship Programs]: Introduction” for additional competencies that apply to all Task Force reports).
1.3. Levels of Expertise—Core and Advanced
Core training must be available at all centers with a fellowship program in pediatric cardiology. The core curriculum described in Section 3 is intended to be sufficient for fellows who do not plan a formal career in electrophysiology. Core training is required for all trainees and is intended to ensure that each fellow acquires the knowledge base and skills necessary to become a pediatric cardiologist referring his/her patient for more detailed and invasive rhythm investigation. Advanced training guidelines are designed for fellows who wish to embark on a career that will include invasive electrophysiology procedures. Advanced electrophysiology training should only take place at select centers with a procedural volume that can satisfy the minimum recommended procedural experience (Section 4).
2. Program Resources and Environment
For training in pediatric electrophysiology, training should be obtained in a center where there is a pediatric cardiology training program accredited by the ACGME. Pediatric catheterization laboratory facilities should be available with the appropriate equipment to perform electrophysiology studies and catheter ablation. Such facilities should include the capability for 3-dimensional electroanatomic mapping and be equipped for both radiofrequency ablation and catheter cryoablation. The program must also have facilities for the implantation of arrhythmia control devices (ie, pacemakers and implantable cardioverter-defibrillators [ICDs]). In some settings, this will be the pediatric cardiac catheterization laboratory or electrophysiology laboratory, and in others, it may be the operating room. The center’s clinical procedural volume must be sufficient to allow for exposure of each trainee to clinical cases in numbers that satisfy trainee procedure volume expectations. Some centers may have inadequate volume in every clinical area to ensure that trainees get adequate exposure in the allotted core training period, particularly when considering exposure to pacemaker and ICD implantation. In such cases, it may be feasible for a trainee to gain this experience at a partner adult institution. At least 1 board-certified pediatric cardiologist with advanced electrophysiology skills should be identified as the director of the pediatric electrophysiology core training program, and at least 1 staff cardiologist and/or cardiac surgeon should be skilled in the implantation of pacemakers and ICDs.
Although third-tier board certification is not available through the American Board of Pediatrics for the subspecialty of pediatric electrophysiology, the International Board of Heart Rhythm Examiners (IBHRE) now offers certification examinations for competency in both pediatric cardiac electrophysiology and cardiac rhythm device therapy. For any center offering advanced fellowship training, at least 1 electrophysiology staff member should hold current certification in either (or both) of the IBHRE examinations.
3. Core Training: Goals and Methods
By the completion of the core training period, the trainee should achieve high-level competency in clinical aspects of noninvasive electrophysiology. Table 1 lists the core curricular competencies for pediatric electrophysiology, along with corresponding evaluation tools. Specifically, they should be able to independently evaluate, treat, and know when to refer young patients with syncope, palpitations, supraventricular arrhythmias, ventricular arrhythmias, atrioventricular conduction disturbances, and all forms of early postoperative arrhythmias. They will have developed skills in risk assessment for sudden death in young patients having heritable disorders and in those having worrisome, but nonspecific, symptoms or laboratory findings. They should understand the indications for and be competent in the interpretation of electrocardiograms, ambulatory rhythm monitoring (Holter), and event monitoring. There should be adequate diversity in clinical material, such that patients having pre- and postoperative congenital heart disease are adequately represented.
Basic science knowledge in the core curriculum includes pharmacology, cellular and anatomic electrophysiology, molecular and clinical genetics, and rudimentary physics. This knowledge should be acquired in the context of clinical care, didactic lectures, bedside teaching, and independent reading. This knowledge will be applied to the use of pharmacological agents to treat arrhythmias in the fetus, child, and adolescent and those having CHD, including specific understanding of electrophysiological pharmacodynamics, pharmacokinetics, drug–drug interactions, drug–electrolyte interactions, and side effects; expert knowledge of the anatomy of the conduction system in congenital heart disease; working knowledge of the genetics of channelopathies and cardiomyopathies, the indications to order genetic testing, and general interpretation of the results of genetic testing for such conditions; and basic knowledge of the physics of pacing, cardioversion, defibrillation, and therapeutic ablation of arrhythmia substrates.
The trainee should acquire basic knowledge regarding nonpharmacological electrophysiology, heretofore defined as invasive electrophysiology. Table 2 delineates the recommended minimal procedural experience required to assess competency in pediatric cardiac electrophysiology for both core and advanced training. By the completion of core training, the individual should be capable of managing acute pacing strategies including the use of temporary transvenous pacing catheters, esophageal electrode catheters, and percutaneous surgical wires. This includes skills in interpretation of acute postoperative arrhythmias; management and follow-up of temporary pacing systems; termination of supraventricular tachycardia and/or VT with pacing maneuvers; and indications, techniques, and associated risks (including stroke) of elective and emergent direct current cardioversion. This also includes the ability to determine pacing and sensing thresholds. It is expected that the trainee will have contemporary knowledge of indications, risks, benefits, and limitations of electrophysiological testing and catheter ablation of tachyarrhythmias. They will have general understanding of the diagnostic methods for discriminating arrhythmia types using intracardiac testing, the use of pharmacological agents during testing, principles of substrate mapping, and fundamental risks and methodologies of catheter ablation. They will be capable of interpreting common and straightforward intracardiac electrograms, including electrical interval measurements. These skills will be accomplished by a combination of clinical exposure, conferences, didactic lectures, and supplemental reading.
All trainees should understand the indications for pacemaker and ICD placement, know the differences in pacing modes, be capable of performing basic pacemaker interrogation, be able to perform fundamental reprogramming and troubleshooting, and recognize basic device and lead malfunction. This includes recognition of sensing abnormalities, failure to capture, and battery end-of-service characteristics. The trainee will be able to evaluate the radiographic studies and perform basic device evaluation in young patients presenting with symptoms that could be attributable to device malfunction.
4. Advanced Training: Goals and Methods
Advanced training guidelines for pediatric electrophysiology were recently reviewed and updated by the Pediatric and Congenital Electrophysiology Society (PACES) and the HRS.3 That publication should be referred to for a comprehensive training syllabus and detailed description of procedural instruction. Included here is a brief synopsis of advanced pediatric electrophysiology training.
The goal of advanced electrophysiology training is to equip new practitioners with the knowledge and technical skills necessary to manage all manner of rhythm disorders in the fetus, infant, child, and adolescent, as well as in adults with CHD. This must involve extensive instruction in invasive procedures, including intracardiac electrophysiological studies, catheter ablation, and implantable devices. The new guidelines for advanced training3 recognize that learning curves for complex technical skills do not reach a plateau at the moment of graduation from formal instruction but will continue to rise throughout a trainee’s early career. Additional mentoring may be required to achieve full competency in certain demanding procedures such as lead extraction and ablation in the setting of complex anatomy.
Trainees entering an advanced fellowship in pediatric electrophysiology must have successfully completed a core fellowship and be eligible for certification by the Cardiology Subboard of the American Board of Pediatrics (or its equivalent). Attaining advanced skills requires 12 months or more of focused training at an accredited high-volume academic center. The program must include instruction in all important bench science and clinical science that underlies the field, with particular emphasis on CHD, developmental influences on rhythm status, and hereditary arrhythmias. This information should be conveyed through a combination of bedside teaching, directed readings, and an organized series of didactic lectures. See Table 2 for a brief summary of the minimal procedural experience required to assess competency for advanced trainees.
5. Evaluation and Documentation of Competence
All training programs should include written goals and objectives for each cardiac electrophysiology rotation, with performance goals set according to the fellow’s level of training. These will serve as the basis for formative feedback. A copy of these goals and objectives should be supplied and explained to the trainee at the onset of fellowship training and reviewed at the beginning of each rotation. Evaluation of fellows should be performed midway through, and at the completion of, each rotation; evaluations should be directed toward whether the fellow met those prespecified aims. The fellow evaluation should be performed by the cardiac electrophysiology laboratory director and/or senior cardiac electrophysiology physician chosen as director of electrophysiology training. The fellow evaluation should assess the fellow’s performance in each of the 6 areas of core competencies, as appropriate for the level of training, and should be based on direct observation of the fellow. Evaluation of competency in preparation, performance, and interpretation of the results of a procedure should be given more consideration than a focus on the number of procedures performed. Evaluation of competency should be done in person with the trainee and documented in his or her fellowship record. If the trainee is not progressing as expected, remedial actions should be arranged and documented in accordance with institutional procedures. All fellows should maintain a log (preferably electronic) of all procedures performed.
Endorsed by the Pediatric & Congenital Electrophysiology Society
The cover page, introduction, and other task force reports for these Training Guidelines for Pediatric Cardiology Fellowship Programs are available online at http://circ.ahajournals.org (Circulation. 2015;132:e41–e42; e43–e47; e48–e56; e57–e67; e68–e74; e81–e90; e91–e98; e99–e106; and e107–e113).
The American Heart Association requests that this document be cited as follows: Dubin AM, Walsh EP, Franklin W, Kanter RJ, Saul JP, Shah MJ, Van Hare GF, Vincent JA. Task force 4: pediatric cardiology fellowship training in electrophysiology. Circulation. 2015;132:e75–e80.
This article is copublished in Journal of the American College of Cardiology.
The online-only Comprehensive RWI Data Supplement table is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0000000000000195/-/DC1.
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- © 2015 American Heart Association, Inc.
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