To minimise the risk of complications, implantable cardioverter defibrillators (ICDs) should be implanted by board-certified electrophysiologists, according to Dr James Coromilas, chief of and professor in the division of cardiovascular diseases and hypertension at the UMDNJ-Robert Wood Johnson Medical School, USA. His views on physician credentials and ICD implantation appear in The Journal of the American Medical Association (JAMA).
Coromilas’ editorial comments on a new study which found that overall complication rates from registered ICD implantations were lowest for electrophysiologists and highest for thoracic surgeons. The study, which also appears in the new edition of JAMA, used data reported to the National ICD Registry to evaluate four groups of physicians who performed ICD implantations. The four physician groups were: electrophysiologists with board certification; nonelectrophysiologists with cardiovascular board certification; board-certified thoracic surgeons; and other specialists who have never been certified or allowed their board certification to lapse.
The results of the study led by Dr Jeptha P Curtis, University of Yale, New Haven, USA, showed that, of 111,293 ICD implantations included in the analysis, 78,857 (70.9%) were performed by electrophysiologists, 24,399 (21.9%) by nonelectrophysiologist cardiologists, 1,862 (1.7%) by thoracic surgeons, and 6,175 (5.5%) by other specialists. Compared with patients whose ICD was implanted by electrophysiologists, patients whose ICD was implanted by either nonelectrophysiologist cardiologists or thoracic surgeons were at increased risk of complications in both unadjusted (electrophysiologists, 3.5% [2,743/78,857]; nonelectrophysiologist cardiologists, 4.0% [970/24,399]; thoracic surgeons, 5.8% [108/1,862]; p<.001) and adjusted analyses (relative risk [RR] for nonelectrophysiologist cardiologists, 1.11 [95% confidence interval, 1.01-1.21]; RR for thoracic surgeons, 1.44 [95% CI, 1.15-1.79]).
Among 35,841 patients who met criteria for CRT-D, those whose ICD was implanted by physicians other than electrophysiologists were significantly less likely to receive a CRT-D device compared with patients whose ICD was implanted by an electrophysiologist in both unadjusted (electrophysiologists, 83.1% [21,303/25,635]; nonelectrophysiologist cardiologists, 75.8% [5,950/7,849]; thoracic surgeons, 57.8% [269/465]; other specialists, 74.8% [1,416/1,892]; p<.001) and adjusted analyses (RR for nonelectrophysiologist cardiologists, .93 [95% CI, .91-.95]; RR for thoracic surgeons, .81 [95% CI, .74-.88]; RR for other specialists, .97 [95% CI, .94-.99]).
Based on the researchers’ analysis, “a compelling argument can be made based on the outcome measure of procedural complications [that], whenever possible, a board-certified electrophysiologist should be implanting ICDs,” wrote Coromilas.