ICD implant risks highlight increasing sub-specialisation

Should cardiologists who are not electrophysiologists be inserting implantable cardioverter-defibrillators (ICDs)? Curtis et al. performed a retrospective cohort study of patients who had an ICD fitted between January 2006 and June 2007. Patients were grouped according to whom had implanted their device: electrophysiologists, nonelectrophysiologist cardiologists, thoracic surgeons, and other specialists. The main outcome measures examined were the proportion of patients meeting the criteria for a defibrillator with cardiac resynchronization therapy (CRT-D) who received that device, and the in-hospital procedural complication rates.

111293 ICD implantations were included in the analysis. Overall, 70.9% were performed by electrophysiologists, 21.9% by nonelectrophysiologist cardiologists, 1.7% by thoracic surgeons, and 5.5% by other specialists. Patients who had an ICD inserted by anyone other than an electrophysiologist were found to be at an increased risk for complications both in unadjusted (p<0.001) and adjusted analyses (relative risk for nonelectrophysiologist cardiologists, 1.11; relative risk for thoracic surgeons, 1.44). Although 35841 patients met criteria for CRT-D, when a nonelectrophysiologist cardiologist or thoracic surgeon performed the procedure, patients were significantly less likely to receive the correct device (relative risk for nonelectrophysiologist cardiologists, 0.93; relative risk for thoracic surgeons, 0.81). The study also demonstrated that electrophysiologists were available in the majority of hospitals where thoracic surgeons and general cardiologist were performing their ICD insertions.

This study only looked at in-hospital outcomes, and it may be that long-term complications are equally as skewed; the same group is planning longer-term follow-up.Currently, no criteria exist for determining what procedures a physician may or may not perform; this paper demonstrates that this problem will become increasingly important as sub-specialisation in cardiology continues.

Curtis JP, Luebbert JJ, Wang Y, et al. Association of physician certification and outcomes among patients receiving an implantable cardioverter defibrillator. JAMA 2009; 301:1661-1670.

Coromilas J. Physician credentials and ICD implantation. JAMA 2009; 301:1713-1174.

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