When Implanting and Extracting Implantable Defibrillators, Experience Matters!

Dear Readers, If there is one constant in the medical literature related to the quality of patient care, it is that physician experience and training matter. Better procedural outcomes have been linked repeatedly to higher operator volume. Two recent publications have further reinforced the value of formal subspecialty training as it relates to patient outcomes in the areas of both device implantation and extraction. Significant pressure mounted a few years ago for professional societies to support the notion that cardiologists who are not board certified in electrophysiology should implant defibrillators. The arguments were that the growing indications for defibrillator therapy would overwhelm electrophysiologists, and that cardiologists who were high-volume pacemaker implanters but who had not completed a clinical cardiac electrophysiology fellowship could safely and effectively implant a defibrillator with limited additional training. The endorsement of the Heart Rhythm Society of an alternative training pathway was highly contentious, and this policy was allowed to expire. However, about one-third of implantable defibrillators are still implanted by cardiologists who are not board certified in electrophysiology, because hospital privileging is a local matter and is vulnerable to politics and potential conflicts of interest. Although implantation of defibrillators by nonelectrophysiologist cardiologists remains controversial, there has been little data to argue against it — until now. A recent paper by Curtis et al entitled the “Association of Physician Certification and Outcomes Among Patients Receiving an Implantable Cardioverter-Defibrillator” addresses this issue.1 The authors used information from the ACC-NCDR® National ICD Registry database that was collected between January 2006 and June 2007 to determine if there was a difference in patient outcomes between implanting physicians based on board certification. They found that compared with patients whose defibrillator was implanted by an electrophysiologist, patients whose device was implanted by either a nonelectrophysiologist cardiologist or a thoracic surgeon had a higher complication rate (electrophysiologists, 3.5%; nonelectrophysiologist cardiologists, 4.0%; and thoracic surgeons, 5.8%; P