Cardiac Electrophysiology (EP) Procedure Elective

The purpose of the elective rotation is to gain an understanding of the anatomy, physiology, pharmacology and technology central to the field of cardiac electrophysiology, to acquire a deeper knowledge of patient presentations and diagnostic testing, and to develop the technical, cognitive and motor skills required to gain the venous and arterial access needed to perform device implantations and catheter studies, to place intracardiac catheters, and to understand intracardiac electrograms.  It is important to emphasize that the rotation is not designed to develop full clinical competence in device implantation and EP study/ablation, but rather to develop skills and knowledge in this field that will serve as a foundation for further training in an EP fellowship program, or to support future practice in cardiology that will intersect with EP. 

The rotation will generally consist of

1. Performance of procedures 1:1 with an EP faculty in the laboratory at the Iowa City Veterans Affairs (VA) Health System.
2. Performance of procedures 1:1 with an EP faculty at the University of Iowa Hospitals and Clinics (UIHC) facilities (Adult EP lab, Pediatric EP lab, OR, minor procedure) on days/cases when the subspecialty EP fellow(s) are in clinic or otherwise not available
3. Performance of procedures in the UIHC facilities as the second assistant when the subspecialty EP fellow is present
4. Opportunities to train 1:1 with device company representatives and our nurse specialists on pacemaker/ICD interrogations and reprogramming
5. Participation in Advanced EP conference

In the EP lab, the trainee will develop and be expected to demonstrate expertise in the following aspects related to EP procedures, including:

1. Understand the indications for the procedure, its appropriateness, and alternatives. The trainee should understand the indications for various modes of pacing, transvenous vs. subcutaneous ICD implantation, and various types of electrophysiology studies and ablations. The trainee should be able to estimate the risk and benefit of the various procedures being performed and comorbid factors that may increase the risk of the procedure or require special approaches.
2. Obtaining informed consent. The trainees should be able to communicate the general details of the procedures, their risks and benefits, in a way that is understood by the patient and be able to address questions raised by the patient. In situations where the patient cannot give informed consent, the trainee should obtain consent from appropriate sources.
3. Administering anesthesia. The trainee should demonstrate knowledge of the pharmacology of medications used for conscious and deep sedation, contraindications for their use, side effects and appropriate treatment for side effects. The trainee should develop the skills to make the patient comfortable during the procedures, follow the degree of sedation, and recognize and treat complications.
4. Device implantation. The trainee should develop skills in establishing and maintaining a high level of sterility, performing venograms, skin incisions, obtaining axillary, subclavian or cephalic vein access, obtaining hemostasis with electrocautery, inserting sheaths, inserting electrodes into appropriate intracardiac locations, attaching pacing devices, suturing/closing incisions, and performing/interpreting pacemaker/ICD implant testing.
5. Electrophysiology studies/ablations: The trainee should develop skills in obtaining vascular access to the femoral veins and femoral arteries, placing electrodes in appropriate intracardiac locations, use and interpretation of intracardiac echocardiography, and performing transseptal punctures. Trainees should also develop skills in pacing maneuvers, interpreting intracardiac electrograms, development and interpretation of 3D mapping, and performance of ablation.
6. Safety. Trainees should gain skill in the proper use of fluoroscopy and methods to limit its use. Trainees should have full knowledge of the potential safety issues relevant to both the patient and to the staff, and how to recognize and treat/avoid such complications.
7. Drug studies. Trainees should understand the pharmacology of provocative drug studies and the channelopathies or arrhythmia disorders they are designed to uncover.
8. Understand indications for tilt table testing, how the test is performed, its interpretation and limitations.

1. The fellow will attend Advanced EP conference on Thursday mornings.
2. The fellow will be in the EP facilities at the Iowa City Veterans Affairs Health System or University of Iowa Hospitals and Clinics where they will take part in the work up and performance of procedures scheduled for the day, as well as last-minute add-ons. Specific duties for procedures include:
   1. Evaluate inpatients and outpatients referred for procedures and complete the H&P and consent paperwork and pre-procedure orders.
   2. Evaluate each patient prior to performing any invasive procedure. This includes reviewing history, labs, studies and talking to the patient and family to answer questions.
   3. Discuss each patient and their procedure with the attending performing the procedure.
   4. Assist in the performance of the procedure under the supervision of the attending. The trainee will have progressive increase in the extent of maneuvers they may perform during the procedure depending on the progress of their skills.
   5. Complete post-procedure paperwork including procedure note, and orders. For inpatients, the trainee will contact the team to update them on the procedural outcome and plans.
   6. The trainee will assist with the evaluation and discharge of patients after their procedures.
   7. The trainee will keep a log of their procedures in MedHub.

The fellow will review all cases with the EP attending prior to performing any procedure. All invasive procedures will be performed under the direct supervision of an EP attending. Procedures may not start until the attending is physically present in the EP lab or control room.

1. Learn the indications and contraindications of EP lab procedures.
2. Learn to recognize and treat immediate complications.
3. Become proficient in the technical aspects of vascular access, device implantation and EP studies.
4. Learn the indications for and gain exposure to ablation and 3D mapping.
5. Learn and understand the protocols for correct performance and interpretation of pacing maneuvers.
6. Learn proper radiation safety.
7. Develop an academic approach to the proper utilization of invasive electrophysiology testing.
8. Understand the roles and responsibilities of various cath lab staff members including radiation technologists, nurses and device company representatives and technical support.

The trainee will review each patient’s history and planned procedure with the attending. The attending will supervise the fellow during the procedure, and the fellow will assume progressive levels of responsibility as his or her skill level improves. The attending will review all procedure data with the fellow after the procedure is completed. Fellows are expected to attend weekly Advanced EP conference.

The goals and objectives for the rotation will be communicated at the beginning of the rotation. A standard fellow evaluation form will be completed by the attending(s) at the end of the rotation. The final evaluation by the supervising physician will be based on fulfillment of the rotation objectives as determined by: personal observation during interaction with the fellow while performing procedures, evidence of literature reviews appropriate for the individual patient and topic, evidence of progress in skill development commensurate with the fellow’s level of training, correct interpretation of procedure data, ability to provide appropriate post-procedure care, feedback from EP lab staff members, other healthcare providers and patients.