Reviewing: S-CS-S2-1

Electrophysiology Procedures & Cardiac Rhythm Management

Information:

Module information

Details

Title
Electrophysiology Procedures & Cardiac Rhythm Management
Type
Specialist
Module code
S-CS-S2-1
Credits
30
Requirement
Optional

Aim of this module

This module will provide the trainee with a specialist body of knowledge that will underpin the practice of advanced cardiac rhythm management (CRM) and electrophysiology procedures. The module will enable trainees to provide high level technical and scientific support to a range of interventional procedures within CRM, including support with equipment, measurement and patient management.

In addition, it will enable trainees to perform and interpret complex cardiac implantable electronic device (CIED) follow up through in person evaluations and using remote monitoring technologies following best and evidence-based practice to assess CIED system integrity, monitor patient symptoms, disease states and manage new and progressively challenging conditions.

They will be expected to interact with patients and demonstrate safe, patient centered practice. Trainees will build practical skills in setting up and maintaining the equipment used, develop technical skills, produce reports, interpret results and make decisions on best management of patient conditions.

Work-based content

Competencies

# Learning outcome Competency Action
# 1 Learning outcome 1,6 Competency

Participate in the WHO surgical safety checklist as part of the multidisciplinary team in the CRM cath lab

 Action View
# 2 Learning outcome 1 Competency

Maintain sterile field during CRM cath lab procedures

 Action View
# 3 Learning outcome 1 Competency

Support a pacemaker implant, minimising personal radiation exposure

 Action View
# 4 Learning outcome 1 Competency

Support a complex device implant:

  • CRT
  • ICD
 Action View
# 5 Learning outcome 2 Competency

Perform a routine pacemaker follow-up and interpret device detected clinical diagnostic data

 Action View
# 6 Learning outcome 2 Competency

Perform a routine complex device follow-up and interpret device detected clinical diagnostic data:

  • CRT
  • ICD
 Action View
# 7 Learning outcome 2,7 Competency

Make prescriptive recommendations and/or programming changes based on device follow up and patient presentation:

  • Pacemaker
  • ICD
  • CRT
 Action View
# 8 Learning outcome 2 Competency

Produce a clear, accurate and concise report of device follow-up

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# 9 Learning outcome 3 Competency

Perform basic clinical and technical optimisation of CIEDs

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# 10 Learning outcome 2 Competency

Perform appropriate manoeuvres to assess lead integrity

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# 11 Learning outcome 2 Competency

Provide advice to healthcare professionals regarding pre-procedure temporary reprogramming of CIEDs for patients undergoing the following procedures:

  • Radiotherapy
  • Surgery
  • MRI
  • Endoscopy
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# 12 Learning outcome 2 Competency

Perform a pre and post procedure device reprogramming checks for the following:

  • MRI
  • Surgery
  • Endoscopy
  • Radiotherapy
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# 13 Learning outcome 2 Competency

Analyse and interpret data from a routine remote monitoring transmission and prepare a clinical report

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# 14 Learning outcome 4,5 Competency

Obtain a clinical history from a patient with a CIED and make recommendations for further investigations/interventions

 Action View
# 15 Learning outcome 2,4 Competency

Check and assess device site and escalate any abnormal findings

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# 16 Learning outcome 4 Competency

Identify, respond and escalate the following significant clinical findings during a device check

  • Device lead malfunction
  • Recurrent syncope
  • New atrial fibrillation
  • Worsening heart failure /symptoms
  • Ventricular arrythmias
 Action View
# 17 Learning outcome 5 Competency

Discuss end of life care implications of ICD deactivation to a patient and/carers

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# 18 Learning outcome 1,4 Competency

Manage device interactions for a patient undergoing a permanent CIED implant whose rhythm is supported by one of the following:

  • Temporary wire/pacing box
  • Transcutaneous pacing by external pads
 Action View
# 19 Learning outcome 2,3,4,5,7 Competency

Review and present a clinical finding requiring multidisciplinary team decision making for CIED patient management

 Action View
# 20 Learning outcome 6 Competency

Prepare the patient and select equipment for one of the following EP procedures:

  • AV node ablation
  • Typical atrial flutter
  • SVT ablation
 Action View
# 21 Learning outcome 6 Competency

Record and measure baseline measurements in an EP study

 Action View
# 22 Learning outcome 6 Competency

Perform programmed stimulation under direct supervision in an SVT study

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# 23 Learning outcome 6 Competency

Analyse and interpret EP traces recorded during the following diagnostic manoeuvres:

  • His Sync extra stimulus
  • Tachycardia entrainment
  • Anterograde and retrograde curves
  • Sense extra stimulus
  • VT Stim
 Action View
# 24 Learning outcome 6 Competency

Perform the following manoeuvres:

  • Anterograde and retrograde curves
  • Entrainment and measuring a post pacing interval
  • Sense extra stimulus
  • Assessing for a line of block
 Action View
# 25 Learning outcome 6,7 Competency

Review pros and cons of existing AF treatment strategies and present to peers

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# 26 Learning outcome 6 Competency

Select equipment for and prepare a patient for a complex mapping EP procedure

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# 27 Learning outcome 6 Competency

Perform a cardioversion

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# 28 Learning outcome 1 Competency

Recognise and assist with the management of the following significant complications in the CRM lab:

  • Tamponade
  • Pneumothorax
  • Cardiac arrest
  • Severe bradycardia
 Action View
# 29 Learning outcome 2,3,4 Competency

Assess a patient for a generator change

 Action View
# 30 Learning outcome 1,2,3 Competency

Programme ICD therapies and discriminators for a patient with an ICD

 Action View

Assessments

Complete 6 Case-Based Discussions

Complete 6 DOPS or OCEs

Direct Observation of Practical Skills Titles

  • Support a CRT generator change in a patient with no underlying rhythm.
  • Review a remote alert transmission where an ICD therapy has been delivered and instigate appropriate action with the patient.
  • Prepare a patient and equipment for an EP procedure.
  • Obtain measurements for the LV lead during CIED implant to confirm correct positioning.
  • Perform lead measurements and optimise settings on a CRT/ICD device.
  • Interrogate and reprogram a CIED prior to an MRI scan.

Observed Clinical Event Titles

  • Contact a patient to verify heart failure symptoms based on remote monitoring data.
  • Explain the importance of regular wound site assessment and care to a patient.
  • Gain informed consent to deactivate an ICD prior to a procedure e.g., MRI or surgical procedure.
  • Explain an EP procedure to a patient.
  • Support and reassure a patient during an EP procedure.

Learning outcomes

# Learning outcome
1

Demonstrate effective physiological and scientific support for complex CIED implant, providing technical expertise, ensuring patient safety and appropriate procedural documentation.
2

Perform and interpret complex CIED follow up and effectively communicate results to patients and clinical staff as appropriate.
3

Apply specialist knowledge to programme and optimise CIEDs using evidence-based practice to ensure safe patient outcomes and enhance the quality of patient care.
4

Identify changes in patient conditions requiring escalation of findings to the relevant responsible person(s) and with reference to the patient pathways.
5

Communicate complex and potentially sensitive clinical information to patients and colleagues.
6

Perform cardiac physiological role for simple electrophysiology procedures for diagnostic investigations and delivery of therapies to help terminate arrhythmias.
7

Critically appraise current literature/research studies that address the issues of the diagnosis and management of cardiac rhythm disorders, incorporating evidence-based practice.

Academic content (MSc in Clinical Science)

Important information

The academic parts of this module will be detailed and communicated to you by your university. Please contact them if you have questions regarding this module and its assessments. The module titles in your MSc may not be exactly identical to the work-based modules shown in the e-portfolio. Your modules will be aligned, however, to ensure that your academic and work-based learning are complimentary.

Learning outcomes

On successful completion of this module the trainee will be able to:

  1. Critically appraise on the basis of current evidence-based practice the use of cardiovascular implantable electronic devices in patients with cardiac rhythm abnormalities.
  2. Select and provide a rationale for the equipment required and the procedures performed in both cardiovascular implantable electronic device implantation and cardiac electrophysiology studies.
  3. Formulate appropriate programming strategies to optimise the therapy delivered through cardiovascular implantable electronic devices for patients with cardiac rhythm disorders.
  4. Analyse cardiac electrophysiology traces used to investigate cardiac rhythm disorders.

Indicative content

  • Indications for pacing, ICDs, CRT and implantable cardiac monitors implant and follow up
    • National and international guidelines
    • British Heart Rhythm Society (BHRS)
    • Heart Rhythm Society (HRS)
    • European Society of Cardiology (EHRA/ESC)
    • DVLA guidelines
    • Selection of appropriate pacing models and modes
  • CRT
    • Indications
    • Measures of response
    • Responders and non-responders
    • Evidence base
    • Long term management
    • CRT optimisation
  • Lead technology
  • Stimulation and basic electronic concepts
  • Anodal/cathodal stimulation
  • Battery technology
  • Function and connection of circuitry components
  • Timing cycles
  • Rate modulation
  • Sensing
  • CIED implant technique
  • ICD management
    • ICD therapy zone programming
    • Shock and ATP therapies
  • SVT discriminators
  • Algorithms
    • Programming possibilities for atrial arrhythmia suppression
  • Rate stabilisation
  • Automatic atrial rate increase algorithms
  • Overdrive
    • Product-specific algorithms for atrial anti-tachycardia pacing
    • Individual company/product-specific algorithms
    • Principles behind tachycardia detection and redetection
    • Individual company/product-specific algorithms
    • Definitions and terminology of tachycardia discriminator software
  • Acceptable measurements at implant
  • Normal parameter changes over time
  • Lead hardware problems
  • Device hardware problems
  • Recalls and the MHRA
  • Assessment of implanted system to ascertain potential problems
  • Radiation associated with X-rays and fluoroscopy
  • Recognition of devices using X-ray
  • Normal positions of leads on X-ray and fluoroscopy
  • Abnormal lead positions and complications
  • Remote monitoring
    • Inductive, RF and App based transmitters/technologies
    • Benefits and limitations of remote follow-up
    • Consent, patient education and support
    • Remote alert management
    • System management (non-compliance/disconnected)
    • Disease management
      • Sub clinical AF
      • HF multiparameter diagnostics
      • Ventricular arrhythmias
  • New and emerging technologies
    • Subcutaneous-ICD
    • Leadless pacing
    • Physiological pacing, His bundle and LBB pacing
    • Wireless CRT
  • Lead extraction
  • MRI and CIEDs
    • Conditionality
    • Programming considerations
    • Manufacture specific differences
  • Communication with patients and carers
    • Careful listening and proactive verbal investigation of symptoms
    • Careful listening to description of symptoms
    • Difficult conversations (Driving restrictions, end of life care and ICD therapy deactivation)
  • Inherited cardiac disorders
  • Anticoagulation
  • Basic electrophysiology
    • Indications for electrophysiological studies and the use of radiofrequency ablation
    • National and international guidelines
    • The anatomy of the conduction system
    • Impulse formation and conduction within the heart – sinus node function, atrial conduction and refractoriness, atrioventricular nodal and His Purkinje physiology, ventricular conduction and refractoriness
    • Normal and abnormal cardiac electrophysiology, including:
    • Cellular electrophysiology: action potential and ion channels
    • Refractory periods (effective, relative and functional)
    • Mechanisms of rhythm disorders: automaticity, triggered activity, re-entry;
    • Autonomic nervous system influences
    • Autonomic, pharmacological and electrical manoeuvres and techniques for terminating arrhythmias (Valsalva, carotid sinus massage, cardioversion, defibrillation and overdrive pacing) and the significance of recordings obtained for diagnosis of the arrythmias
    • Electrophysiology of abnormal conduction, to include slow and fast pathways
    • Baseline measurements of electrograms (AV, AH, VA, CL)
    • Ablation procedures
  • Mechanisms of arrhythmia and diagnostic manoeuvres
  • AF
    • Indications for ablation
    • AF ablation techniques and evidence base
  • Pharmacology
  • Types of drugs commonly used in CRM
  • ECG-pharmacological tests for unmasking arrhythmogenic syndromes (including Type I drugs for unmasking Brugada ECG and adrenaline for unmasking congenital long QT syndrome)
  • Anatomical landmarks from fluoroscopy
  • EP catheter positions from fluoroscopy

Clinical experiences

Important information

Clinical experiential learning is the range of activities trainees may undertake in order to gain the experience and evidence to demonstrate their achievement of module competencies and assessments. The list is not definitive or mandatory, but training officers should ensure, as best training practice, that trainees gain as many of these clinical experiences as possible. They should be included in training plans, and once undertaken they should support the completion of module assessments and competencies within the e-portfolio.

Activities

  1. Shadow an EP consultant in an outpatient clinic.
  2. Observe a lead extraction procedure.
  3. Observe procedures using advanced technology e.g.. S-ICD implant, leadless pacemaker implant and physiological pacing procedure (His Bundle, LBB pacing).
  4. Shadow a nurse specialist or clinical scientist led clinic.
  5. Observe a pre-assessment clinic for CRM procedures.
  6. Observe a doctor taking informed consent pre-procedure.
  7. Shadow a heart failure specialist e.g., hospital consultant, nurse specialist or community HF services.
  8. Observe complex atrial or ventricular tachyablation.

Module assigned to

Specialties

Specialty code Specialty title View
Specialty code SPS1-1-22 Specialty title Cardiac Science [2022] Action View
Specialty code SPS1-1-23 Specialty title Cardiac Science [2023] Action View
Specialty code SPS1-1-24 Specialty title Cardiac Science [2024] Action View
Specialty code SPS1-1-25 Specialty title Cardiac Science [2025] Action View
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