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Who should implant Permanent Pacemakers Current guidelines and outcomes data on pacemaker and ICD implantation James L

. . . . Faculty Disclosure The presenter has advised that the following presentation will NOT include discussion on any commercial products or services and that there are NO financial interest or relationships with any of the Commercial Supporters of this years ASM.Warning! I am a cardiologist. The source of the problem?.

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Who should implant Permanent Pacemakers Current guidelines and outcomes data on pacemaker and ICD implantation James L

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    3. The source of the problem? John England (card soc 03) 60% reoperation rate 81% atrial lead repositioning Substantial infection rate Marked operator and institution variation The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man. George Bernard Shaw Irish dramatist & socialist (1856 - 1950)

    4. Centre of Clinical Excellence Study 18 hospitals in NSW 13 months 2005-2006 2596 patients admitted for PPM insertion identified from discharge diagnosis File review conducted in 51% - 1317 patients Complication defined as “any untoward event that required or might have required surgical intervention” during the index admission or any readmission during 13 month study period. Complications detected at outpatient visits excluded. Individual implanters not identified

    5. Patient details

    6. Major Findings Pacemaker complication rates in NSW were similar “compared favourably” to those reported internationally No significant differences in complications among the 18 hospitals No difference between Cardiologists and Cardiothoracic surgeons No relationship between hospital volume and complication rate Delineation of clinical privileges was rudimentary Most hospitals did not have systematic performance review either of the institution or individual operators (informal - ad hoc – close knit team)

    8. CEC Report Findings

    9. CEC Report Findings

    10. %Complications CEC report

    11. Comparison to other major studies

    12. PPM complications in the MOST Study Ellenbogen Am J Cardiol 2003;92:740

    13. Reoperation rate in the CEC report does not compare favourably to the literature

    14. Operator volume predicts complications

    15. Pacemaker Implantation at JHH Effect of Operator experience

    16. Operator volume and complications from AICD implants (Sana M. Al-Khatib, JACC 2005 46, 1536-1540)

    17. Relation of operator volume to complications from PTCA Ellis, S. G. et al. Circulation 1997;95:2479-2484

    18. Credentials For PPM and AICD Cardiac Society (2005) Pacemaker Completed Cardiology or Cardiothoracic surgery programs Trained in PPM implantation in an institution with 2 device specialists and >50implants/yr 75 new implants and 20 revisions as primary operator under supervision Competency maintained by 12 new implants and 5 revisions a year AICD Completed Cardiac EP training Or all of the following: 35 PPM implants /yr and 100 in 3 yrs 10 Proctored ICD implants Competition of a didactic course Monitoring of outcomes Established patient follow-up Competency maintained by 10 implants/yr

    19. Demarcation dispute? Competition between craft groups (EP vs non EP vs CT surgeon) Claims that one craft group is better than another do not have much scientific support (at least for PPM implants) Different credentialing requirements are a problem

    21. Early complications following AICD Implants in USA (Curtis JAMA 2009;301:1661)

    22. Who should implant Permanent Pacemakers? Someone who does it well! Someone who has been though an appropriate training program who has an interest in the procedure – maintains follow-up, CME Implants a lot (>50 year)

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