CURRICULUM for Clinical Cardiac
Electrophysiology Training: Part I
I. General objectives and length of training.
The trainee in Clinical Cardiac
Electrophysiology should acquire broad knowledge in all aspects of arrhythmology, including but not limited to bradyarrhythmias, tachyarrhythmias,
syncope, non-invasive and invasive diagnostic electrophysiology, and
interventional electrophysiology including catheter ablation and device
implantation. The trainee should have
sufficient knowledge of basic electrophysiology to understand current theories
of the mechanisms of cardiac dysrhythmias
and the rationale for both pharmacologic and non-pharmacologic therapy.
Candidates are eligible for training in
Clinical Cardiac Electrophysiology if they have completed two to three years of
training in Cardiovascular Disease and are or will be Board-Eligible in Cardiovascular
Disease. The length of the Clinical
Cardiac Electrophysiology training program is 1-2 years, with two years
recommended for those desiring additional training in research and complex
catheter ablation.
II. Basic electrophysiology.
A. Objective. In order to be a superior practitioner of
Clinical Cardiac Electrophysiology, an understanding of basic cellular
mechanisms as they relate to clinical practice is important.
B. Teaching
method. Tutorial (direct discussion
between the faculty and trainee; for example, during the portion of the
electrophysiology study where atrial pacing is
performed to assess sinus node automaticity, the
basic cellular mechanisms of overdrive suppression of automaticity
will be discussed); self-study; conferences.
C. Content.
1. Determinants
of the normal cardiac rhythm (genesis of the resting potential and action
potentials, ion channels, ionic currents).
2. Determinants
of normal conduction (for example passive membrane properties, maximal upstroke
velocity, cell to cell interaction).
3. Genesis
of tachyarrhythmias (automaticity,
triggered activity, re-entry, anisotropy, influence of various modulators such
as autonomic tone and electrolyte disturbances).
4. Antiarrhythmic drug actions (modulated receptor hypothesis,
antiarrhythmic drug classifications, cellular electrophysiologic
effects of various classes of antiarrhythmic drugs).
D. Education materials.
1. Textbook: Zipes and Jalife, Editors, Cardiac Electrophysiology.
2. Fellow's
Teaching Notebook (reprints of seminal journal articles, which fellows will
retain for personal reference).
E. Evaluation.
The resident's core knowledge of basic
electrophysiology will be assessed in the tutorial process, by the Socratic method. A strength of this program is the high faculty to resident
ratio, namely 5:2. The resident will
evaluate the training program in writing every six months, and will be specifically
asked to comment on whether each portion of the curriculum is achieving it's objectives.
Although this training program does not have an electrophysiologist
who performs basic electrophysiologic research, there
are medical school faculty in the physiology section
who have basic electrophysiology skills (for example patch clamp technique); if
the trainee is specifically interested in basic electrophysiology, these
faculty based at
III. Basic
pharmacokinetics and pharmacodynamics.
A. Objective.
A trainee in Clinical Cardiac
Electrophysiology will be prescribing complex drug regimens with the potential
for substantial toxicity, and should have an understanding of both basic and
clinical pharmacokinetics.
B. Teaching method: Tutorial,
self-study, conferences.
C. Content.
1. Basic
pharmacokinetics (absorption, distribution, metabolism, elimination).
2. Clinical
pharmacokinetics.
A. Clearance,
half-life, compartmental analysis, loading
doses.
B. Principles
of drug level monitoring.
C. Drug
interactions.
3. Pharmacodynamics (receptor theory, agonists/antagonists,
therapeutic index).
4. Practical
aspects of antiarrhythmic drug therapy (indications,
contra-indications, dosing considerations).
5. Drug-device
interactions (the effects of drugs on pacing and defibrillation thresholds).
D. Educational materials.
1. Textbooks: Zipes and Jalife, Editors, Cardiac Electrophysiology; Podrid and Kowey, Editors,
Cardiac Arrhythmia.
2. Fellows
Teaching Notebook.
3. Clinical
material: The trainee will have the
opportunity to initiate antiarrhythmic drug therapy
on a frequent basis for inpatients on the electrophysiology service or for
inpatients seen in consultation. On
average, the daily census of inpatients on antiarrhythmic
drugs numbers 3 (including
CCU patients on intravenous therapy and patients on the telemetry unit
receiving oral antiarrhythmic drug therapy). In addition, during the resident's 1/2 day
per week of Clinical Cardiac Electrophysiology clinic, there will be an
opportunity for longitudinal follow-up of the patient on antiarrhythmic
drug therapy, as well as the opportunity to initiate therapy for outpatients
(for example AV nodal active drugs for supraventricular
tachyarrhythmias).
E. Evaluation:
The resident will be
evaluated during the tutorial process, utilizing the Socratic method. The resident
will evaluate the curriculum in writing every six months. A strength of this
training program is a broad spectrum of clinical material, ranging from
patients with new onset atrial fibrillation or
symptomatic VPB's to patients with drug-resistant
sustained ventricular tachyarrhythmias.
IV. Electrocardiography.
A. Objective.
The Clinical Cardiac Electrophysiologist should be fully familiar with the
indications and interpretation of the following electrocardiographic
(ECG) tests: standard surface ECG's, ambulatory ECG's (Holter monitors as well as transtelephonic
ECG transmissions from event recorders and transtelephonic
ECG transmissions to evaluate pacemaker performance), continuous on-line ECG
monitoring in-hospital (telemetry), exercise treadmill testing, analysis of
signal-averaged ECG's, and analysis of
microvolt-level T-wave alternans studies.
B. Teaching method. Since
our trainees in Clinical Cardiac Electrophysiology are Board Eligible in
Cardiovascular Disease, it is assumed that the trainee has acquired minimal
competency for the interpretation of standard surface ECG's
and exercise stress tests. A tutorial
teaching method is utilized for electrocardiography; the trainee is asked to
interpret for the faculty electrophysiologist
multiple ECG's daily, during supervised experiences
in the outpatient and inpatient arenas, including the electrophysiology
laboratory. Other teaching methods
include self-study and conferences.
C. Content.
1. Bradyarrhythmias (sinus node dysfunction, AV nodal and His
Purkinje system dysfunction, bundle branch and fascicular blocks).
2. Supraventricular tachyarrhythmias
(presence and location of accessory atrioventricular
connections by surface electrocardiography, differential diagnosis of supraventricular tachyarrhythmias
based on P wave characteristics, aberrancy).
3. Ventricular
tachyarrhythmias (VT).
A. Types
(non-sustained vs. sustained, polymorphic
vs. monomorphic).
B. Etiology
(coronary disease, cardiomyopathy, valvular heart
disease, congenital heart disease,
idiopathic VT, long QT syndromes).
C. Distinction
between supraventricular tachycardia (SVT) and VT (AV dissociation, fusion or capture beats, morphology guidelines).
4. Ambulatory
ECG recordings.
1. Holter monitoring.
2. Transient
arrhythmia monitoring.
3. Transtelephonic
evaluation of pacemaker function.
4. In-patient telemetry monitoring.
5. Signal-averaged
electrocardiography (time domain vs. frequency domain).
6. Microvolt-level T-wave alternans studies (derived by pacing in the
Electrophysiology Lab or exercise-treadmill testing).
D. Educational materials:
1. Textbooks
are Kowey and Podrid,
Editors, Cardiac Arrhythmia; Chou's Electrocardiography in Clinical Practice; Fisch's Electrocardiography of Arrhythmias; Pick and Langendorf, Interpretation of Complex Arrhythmias.
2. Fellow's
Teaching Notebook.
3. Clinical
material: The trainee will interpret
multiple standard surface ECG's
daily during both inpatient and outpatient encounters, as well as in patients
coming to the electrophysiology laboratory.
In our pacemaker clinic, 2200 patients are followed transtelephonically,
resulting in daily ECG's. About 25% of these ECG's
will be evaluated by the fellow, with supervision. The fellow will review Holter
monitors, transient arrhythmia monitors, and exercise tests as they are ordered
on outpatients and inpatients on the electrophysiology service, and will also
have multiple opportunities to review telemetry strips on inpatients (the
step-down cardiology unit has 47 telemetry beds). Signal-averaged electrocardiograms and T-wave
alternans studies are ordered on a selected basis,
about 25 times yearly. All of these will
be reviewed by the trainee, under supervision.
E. Evaluation
The resident will be evaluated during
the tutorial process, and will evaluate this portion of the curriculum every
six months in writing. A strength of this training program is the scope and volume
of surface electrocardiographic tracings.
V. Invasive
Electrophysiologic (EP) Studies.
A. Objective.
A clinical cardiac electrophysiologist
is expected to acquire expert knowledge of the indications for invasive electrophysiologic testing, and the diagnostic, prognostic,
and therapeutic implications of this data.
The trainee should have a good understanding of the equipment utilized (xray equipment, a programmable stimulator, a multichannel physiologic recorder, non-fluoroscopic 3-D
mapping, intracardiac echo) as well as proper filter
settings and the use of unipolar vs. bipolar
recordings. The trainee will acquire the
technical skills to cannulate peripheral veins and
arteries, as well as placing catheters in all cardiac chambers. The resident should also understand the risks
of diagnostic electrophysiologic studies and be able
to manage complications (for example cardiac tamponade,
refractory ventricular fibrillation).
B. Teaching method.
A faculty electrophysiologist
is assigned to the electrophysiology laboratory for the week, and is
responsible for carrying out all invasive electrophysiologic
studies. The trainee is primary operator
on all of these studies, and is closely supervised throughout the whole study
by the faculty electrophysiologist. Both the cognitive and technical aspects of
invasive electrophysiologic studies are discussed in
a tutorial fashion on a daily basis.
Other teaching methods include self-study and conferences.
C. Content.
1. Gross
anatomy and fluoroscopic anatomy.
2. Evaluation
of sinus node function.
3. His
bundle recordings and the evaluation of the AV node and His Purkinje system.
A. Natural history of various conduction
disorders; significance of HV interval prolongation and atrial
pacing-induced infra-Hisian block.
B. Indications for permanent pacing in various
conduction disorders.
4. Supraventricular tachyarrhythmias.
A. Mechanisms, and electrophysiologic techniques
distinguishing between types of SVT
(for example ventricular extrastimulus technique
during SVT).
1. Atrial arrhythmias
(for example sinus node re-entry,
inappropriate sinus tachycardia, unifocal atrial tachycardia).
2. Junctional
arrhythmias (for example AV nodal
re-entry, junctional
ectopic
tachycardia).
3. SVT utilizing accessory atrioventricular
connections (for example WPW, and tachycardias utilizing a Mahaim
fiber).
B. The use of various pharmacologic agents in the
course of evaluating patients with SVT (for example adenosine, atropine, isoproterenol).
C. Serial electropharmacologic
testing.
5. Ventricular
tachycardia and ventricular fibrillation.
A. Electrophysiologic
techniques for determining the mechanism of wide complex tachycardias.
B. The sensitivity and specificity of various
programmed stimulation protocols for VT/VF induction in various types of heart
disease.
C. Serial electropharmacologic
testing.
D. Stimulation protocols for tachycardia
termination.
D. Educational materials.
1. Textbooks:
Josephson, Clinical Cardiac
Electrophysiology: Prystowski
and Klein, Cardiac Arrhythmias
2. Fellow's Teaching Notebook.
3. Clinical material: A steady volume of patients at our training
center requires diagnostic electrophysiologic testing
for ventricular and supraventricular tachyarrhythmias, wide complex tachycardias
of undetermined etiology, and syncope of undetermined etiology. In 1995, 121 patients had primary electrophysiologic studies and 63 had follow-up electrophysiologic studies for a variety of
indications. These totals do not include
patients undergoing radiofrequency catheter ablation (see below).
E. Evaluation.
The trainee spends a large percentage of his/her
time in the electrophysiology laboratory, namely 1/2 day or more four days
weekly. A faculty electrophysiologist
is present on these occasions, and directly evaluates the fellow's cognitive
and technical skills. The trainee will
have the opportunity to evaluate each portion of the curriculum in writing,
every six months.
VI. Endocardial mapping/catheter ablation.
A. Objective.
The trainee should acquire the
knowledge for endocardial mapping of all monomorphic supraventricular and
ventricular tachyarrrhythmias, in all cardiac
chambers. Furthermore, the trainee
should be familiar with the indications, technical aspects, and complications
of catheter ablation for these tachyarrhythmias.
B. Teaching method.
The trainee is first operator on 1-2
catheter ablations per week, supervised by one or more faculty electrophysiologists.
Other teaching methods include self-study, and conferences.
C. Content.
1. General
interpretation of local electrograms (activation
times, late potentials, fractionated electrograms,
continuous electrical activity, effects of filtering).
2. Pacing
techniques that assist in mapping (entrainment, resetting).
3. The
biophysics of tissue damage with various ablative techniques (radiofrequency
energy, cryoablation).
4. The
indications for catheter ablation and complications specific to the type of
ablation.
A. Unifocal atrial tachycardias, atrial flutter, AV nodal re-entry, tachycardias
utilizing accessory atrioventricular connections, monomorphic ventricular tachycardia, atrial fibrillation.
D. Educational materials.
1. Textbooks: Josephson, Clinical
Cardiac Electrophysiology; Kowey and Podrid, Editors Cardiac Arrhythmia; Zipes,
Editor, Cardiac Ablation of Arrhythmias.
2. Fellow's
Teaching Notebook.
3. Clinical
material: 4-5 endocardial
mapping/radiofrequency catheter ablation procedures are performed at our center
each week.
E. Evaluation.
The resident is evaluated during the
process of performing the mapping/ablative procedure (closely supervised by the
faculty clinical electrophysiologist). The trainee
evaluates each portion of the curriculum in writing, every six months. It is recommended to the fellows that they
consider two years of training if they want more experience in mapping and
ablating some of the rare cardiac dysrhythmias that
they may only encounter on a few occasions in one year of training.
VII. Implantable
devices.
A. Objective.
Trainees in Clinical Cardiac
Electrophysiology should be capable of selecting patients for permanent
pacemakers and implantable cardioverter-defibrillators
(ICD's), and should be able to implant these devices
independently. Furthermore, they should
be aware of all aspects of post-operative patient care and long-term follow-up
in patients with implantable devices.
B. Teaching method.
In our institution, all pacemakers and
ICD's are implanted skin to skin by the electrophysiologists in the electrophysiology
laboratory. Cardiothoracic surgery
back-up is readily available but rarely required. The trainee is prime operator on every
implant, and scrubs with a faculty electrophysiologist. Other teaching methods include self-study,
and conferences.
C. Content.
1. Sterile
operating room technique.
2. Surgical
skills for vascular access, creating subcutaneous and submuscular
pockets, and tunneling electrodes.
3. Engineering
aspects of electrical sensing and stimulation, and pulse generator design.
4. Indications
for the use of implanted devices for the management of bradyarrhythmias
and tachyarrhythmias.
A. Types of pacemakers and defibrillators
(Inter-Society Commission for Heart Disease Resources coding system).
5. Measurement
of sensing thresholds, pacing thresholds, and defibrillation thresholds.
6. Methods
for pacemaker and ICD follow-up.
A. Differential diagnosis of failure to sense or pace, or "inappropriate" ICD shocks.
B. Use of external programmers.
C. Indicators of cell depletion.
D. Management of complications of device therapy
(including surgical complications such as infection).
D. Educational materials.
1. Core
textbooks. Ellenbogen, Kay, and Wilkoff, Editors, Clinical Cardiac Pacing.
2. Fellow's
Teaching Notebook.
3. Clinical
material: Our center implants 300
devices (pacemakers and defibrillators combined) annually. We follow about 1700 patients in our
pacemaker and ICD clinic (> 25% are ICD patients; April 2004). These patients rotate through the fellow's
Clinical Cardiac Electrophysiology clinic (1/2 day per week), providing the
opportunity for the longitudinal care of patients with implantable
devices. In addition, the trainee
performs a pre-operative assessment of both outpatients and inpatients
requiring devices, supervised by a faculty electrophysiologist.
E. Evaluation.
The resident in Clinical Cardiac
Electrophysiology is continuously evaluated as part of the tutorial
process. The resident has the
opportunity every six months to evaluate the curriculum in writing. A strength of this
program is that device implants are totally under the aegis of Clinical Cardiac
Electrophysiology.
VIII. Autonomic
testing.
A. Objective.
Clinical Cardiac Electrophysiologists
are expected to be capable of performing head-up tilt testing as part of the
evaluation of patients with syncope of undetermined etiology. In addition, the electrophysiologist
should be familiar with other forms of autonomic testing which may prove useful
in evaluating a patient's risk for sudden death (for example heart rate
variability and T wave alternans assessment).
B. Teaching method.
The
fellow will perform about 50 tilt tests yearly, under the supervision of a
faculty electrophysiologist. Patients undergoing tilt testing for syncope
of undetermined etiology also receive a formal consultation from a Clinical
Cardiac Electrophysiologist, prior to performing the tilt
test. The primary teaching method is
tutorial, but self-study and conferences are also utilized.
C. Content.
1. Indications
and limitations of head-up tilt testing in the evaluation of syncope.
A. The
sensitivity and specificity of various tilt protocols; normal and abnormal
blood pressure and pulse responses to head-up tilting.
B. Pharmacologic
and non-pharmacologic therapies for autonomically-mediated
syncope.
2. Autonomic
testing to assess patients at risk for sudden cardiac death: heart rate
variability and baro- receptor sensitivity.
D. Educational material.
1. Textbook: Podrid and Kowey, Editors, Cardiac Arrhythmia.
2. Fellow's
Teaching Notebook.
3. Clinical
material: Our center performs 2-3 tilt
tests weekly for syncope of undetermined etiology.
E. Evaluation.
The trainee is evaluated during the
tutorial process, in part utilizing the Socratic method. The trainee has the opportunity every six
months to evaluate all aspects of the curriculum in writing.
IX. Research.
A. Objective.
Trainees in Clinical Cardiac
Electrophysiology should understand the design and interpretation of research
studies, and the responsible use of informed consent. They should be able to critically assess the
medical literature with regard to new therapies and techniques. A meaningful research experience, tailored to
the needs of the individual trainee, is required.
B. Teaching method.
All electrophysiology faculty participate
in clinical research, with one (Dr. Steiner) designated as the Director of Electrophysiologic Research. At a minimum, the trainee will be exposed to
some of this research, including participation in multi-center studies as well
as original research. Self-study and
conferences represent other teaching methods.
C. Content.
1. The
design of various types of research studies.
2. Interpretation
of research studies, including basic statistics (confidence intervals, tests of
statistical significance, linear correlation, multi-variate
analysis, meta-analysis, and decision analysis).
3. FDA
requirements for informed consent and protection of human subjects.
D. Educational materials.
1. Fellow's
Teaching Notebook.
2. Clinical
material: Clinical Cardiac
Electrophysiology is a new and rapidly changing field. Clinical research can be incorporated into
the daily routine.
E. Evaluation.
Even for trainees headed for a career
in private practice, we require research exposure since we feel this is a
scholarly activity that will make the clinical practitioner of Cardiac
Electrophysiology critically aware of how the scientific basis of the field is
advanced. The trainee is evaluated as
part of the tutorial process, which is tailored in part to the research
interests of the trainee. It is expected that each trainee will have completed
a manuscript suitable for publication, prior to the end of training. The
resident has the opportunity to evaluate this part of the curriculum every six
months in writing.
The principle faculty in Clinical
Cardiac Electrophysiology are heavily invested in patient care, but still
committed to performing some clinical research.
The faculty and trainees have from 1/2 to 1 day weekly of protected time
for research. There are other potential
research mentors in our medical center, especially
those in