Curriculum „Praxis der ICD-Therapie“

[History of the implantable cardioverter-defibrillator in Germany]

The implantable cardioverter-defibrillator (ICD) was a breakthrough in the prevention of sudden cardiac death. After years of technical development in the USA, Michel Mirowski succeeded in proving reliable automatic defibrillation of ventricular tachyarrhythmias through initial human implantations in 1980, despite many obstacles. Nearly 4 years later, the first patients received ICDs at multiple centers in Germany. Subsequently, outside the USA, Germany became the country with highest implantation rates. The absolute number of implantations remained small as long as implantations required epicardial defibrillation electrodes and therefore thoracotomy by cardiac surgeons. Pacemaker-like implantation using a transvenous defibrillation electrode with a pectoral ICD became feasible in the early 1990s pushing implantation rates to the next level. Technical advancements were accompanied by clinical research in Germany, and often, the first-in-human studies were conducted in Germany. In 1991, the first guidelines for indications were established in the USA and Germany. Several randomized studies on indications were published between 1996 and 2009, mostly led by American teams with German participation, but also under German leadership (CASH, CAT, DINAMIT, IRIS). The DANISH study in 2016 questioned the results of these long-standing studies. Instead of providing ICDs to patients using a broad indication, future efforts aim to identify patients who, despite optimal medical therapy, cardiac resynchronization therapy (CRT), and/or catheter ablation, need protection against sudden cardiac death. Risk scores incorporating myocardial scars in magnetic resonance imaging (MRI) and genetic information are expected to contribute to more individualized and effective indications.

[The "Recommendations for the structure of cardiac pacemaker and defibrillator therapy"--what can they achieve?: Implementation of the concept paper for HSM/ICD therapy]

Implantable devices in cardiac electrophysiology have developed from simple machines that prevent bradycardia to complex systems that treat malignant tachyarrhythmias and severe heart failure. Optimal therapeutic utilization of these systems requires profound knowledge of those who treat patients with devices. To account for that, the German Cardiac Society has published "Recommendations for the structure of cardiac pacemaker and defibrillator therapy" to achieve an expertise in 2 levels. These define topics for interdisciplinary education to ensure implantation and follow-up of high quality, as well as infrastructural requirements such as staff and operation rooms. The implementation of these guidelines offers a great opportunity for good quality in device therapy and may enhance the results of the compulsory German quality registry of the respective institution. The established courses of the German Cardiac Society to achieve competence in pacemaker and ICD therapy according to the curricula should be complemented by practical training in accredited centers. Minimum numbers for implantation and follow-up are necessary to ensure a continuously high quality.

[Continuing education through the European Heart Rhythm Association (EHRA): chance for European standardization?]

Standardization of training with an examination in cardiac electrophysiology represents a milestone in the unification and improvement in the quality of electrophysiological therapy within the member countries of the European Society of Cardiology (ESC). Since 2004 the European Heart Rhythm Association (EHRA) has established an Educational Committee with the mission of improving training in device therapy and electrophysiology in the ESC with accredited materials and educational initiatives. The Educational Committee established Europe-wide courses for continuous medical education in 1. invasive electrophysiology and catheter ablation, 2. pacemaker, ICD and cardiac resynchronization therapy and 3. case-based tutorials to prepare for the EHRA examinations for electrophysiology/ablation and device therapy. Independent from participation in EHRA examinations these courses represent a useful aid for daily practice in cardiac electrophysiology and help to bring young and advanced European cardiologists with an interest in electrophysiology together.

[Curriculum and expert courses on pacemaker and ICD therapy]

The curricula "Practice of Pacemaker Therapy" and "Practice of ICD Therapy" have been developed from practical experience with the first educational courses which are necessary to fulfill the German requirements of the medical products law which restricts the application of medical products to persons with the necessary education, knowledge and experience. The corresponding courses of competence under the auspices of the German Cardiac Society derive from this legal prerequisite. Competence refers to technical knowledge in cardiac implantable electrical devices (CIEDs) and understanding of possible dysfunctions as well as substantial knowledge on arrhythmia. The two curricula form the theoretical basis for the application of CIEDs. These courses represent an offer to cardiologists and all other physicians who wish to acquire and document competency in this field. A legal obligation to participate in these competency courses does not currently exist in Germany as long as evidence can be provided that this competency has been achieved by other means. Both curricula have proven to be comprehensive and practically highly useful and have been presented by highly committed specialists with expertise in this topic at a high level. Since 2005 some 2,000 physicians have been trained in courses on pacemaker therapy and more than 1,000 physicians in courses on ICD therapy with an ongoing high level demand to be expected in the future.