Career building in countries with electrophysiology underdevelopment: roadblocks and solutions—an EHRA Young EP Report

Interventional electrophysiology (EP) has become the standard of care for arrhythmia management according to current guidelines.1,2 Becoming a heart rhythm specialist can be very challenging in light of a difficult EP curriculum and even more so in the absence of a structured training programme (Table 1).3 The 2017 European Heart Rhythm Association (EHRA) report on the use of EP procedures has shown that in the non-European and Eastern European ESC member countries, procedure rates are still quite low.4 This editorial provides a review of EP training in countries with EP underdevelopment with a focus on finding solutions for young cardiologists interested in EP careers. Minimum recommended procedural numbers and levels of competence in invasive EP techniques to be achieved by the heart rhythm specialist during training (adapted from the EHRA core curriculum) EHRA, European Heart Rhythm Association; EP, electrophysiology. Level of competence III: is able to independently perform the technique or procedure unaided. Minimum recommended procedural numbers and levels of competence in invasive EP techniques to be achieved by the heart rhythm specialist during training (adapted from the EHRA core curriculum) EHRA, European Heart Rhythm Association; EP, electrophysiology. Level of competence III: is able to independently perform the technique or procedure unaided. A country with EP underdevelopment is defined as having a significant increase >50% in the number of catheter ablations per million inhabitants in the 2007–2016 period, and having ≤76 catheter ablations per million inhabitants in 2016. According to data from the 2017 EHRA White Book, the following countries were considered: Algeria, Egypt, Lebanon (based on data provided by National Young EP Ambassador), Romania, Tunisia, and Ukraine. EHRA Young EP representatives from these countries were invited to participate with country-specific information regarding local EP certification and training programme, number of EP centres and procedures in 2016, and number of centres capable of providing adequate EP training over a period of 2 years (Table 2). Extensive data obtained for Lebanon, Romania, and Ukraine, is presented below. Further data for Algeria, Egypt, and Tunisia are presented in Table 2. Current state of EP activities in countries with EP underdevelopment EHRA, European Heart Rhythm Association; EP, electrophysiology; UK, unknown. According to World Bank data for 2016. Current state of EP activities in countries with EP underdevelopment EHRA, European Heart Rhythm Association; EP, electrophysiology; UK, unknown. According to World Bank data for 2016. The Lebanese Society of Cardiology (LSC) Arrhythmia and Pacing working group includes 20 cardiac electrophysiologists with the Lebanese Young Electrophysiologists (YEP) accounting for around 50% of the EP specialists in the country. Currently, there are five EP laboratories in Beirut, and one is located approximately 40 km outside the capital. Cardiac EP in Lebanon has already reached the international standard levels of clinical practice with many EPs having pursued fellowship training in EHRA Training Centers or in the United States. Electrophysiology procedures are exclusively performed by electrophysiologists, whereas nearly one-third of device implantations are performed by general cardiologists or surgeons.5 There has been a significant increase in the number of catheter ablations per million inhabitants in the 2007–2016 period, 50–60 ablation procedures were performed annually in 2016. This increased to around 100 per year in 2017. The main limitations to cardiac EP development in Lebanon are reimbursement, referral, and patient acceptance.6 An important public health burden that Lebanon faces is that it hosts by far the highest number of refugees in the world per 1000 of its inhabitants; they are currently representing almost half of the Lebanese population including 2 million Syrian refugees, 450 thousand Palestinians, and around 50 thousand Iraqi refugees. Foreign aid is far lower than what is needed to respond effectively to this humanitarian crisis.6 Many of the refugees need EP procedures [for supraventricular tachycardia, premature ventricular contractions or atrial fibrillation (AF) ablation], which are not done due to financial limitations of the refugees and lack of support by humanitarian agencies. Despite steady increase in interventional EP activity during the last 15 years, Romania has the smallest number of catheter ablation centres per million inhabitants in the European Union (0.6), as reported in 2016.4 Reimbursement for both simple and complex procedures by the public health insurance was a significant step towards making progress, leading to dedicated EP National Programs that allowed a sustained increase in the number of procedures throughout the last decade. Still, most EP centres are limited in their activity because of insufficient funding. Romania only performs half of the procedures compared with Ukraine and the number of high-volume centres (defined as ≥200 EP procedures per year) is rather small. The Romanian Arrhythmia Working Group has undertaken steps for creating the legal environment for an EP certification and official training programme, which are expected to boost EP activities. Although there is no official EP training programme yet, candidates can get accepted as EP fellows in Romanian high-volume centres on an individual basis. Basic EP training, in respect to current EHRA core curriculum, can be successfully achieved in Romania. Access to advanced EP training, especially when considering AF or ventricular tachycardia (VT) ablation in structural heart disease, is rather limited and still requires training fellowships abroad. Following the important cut down in EHRA/ESC EP training fellowships, solutions are scarce and include a fellowship offered by the Romanian Society of Cardiology. EHRA plays an important role in EP education. Romanian EP fellows are encouraged to attend EHRA meetings and courses and to prepare for the EHRA certification exams, as well as to become part of the Young EP community. Through its networking, the EHRA Young EP community can provide support and answers for general and individual EP training-related issues and this might become a key resource for those planning an EP career in Romania. Ukraine has 11 EP centres overall, but only four perform ≥200 EP procedures per year. There is no national educational programme for EP fellows. Most EP procedures are performed by cardio-surgeons because invasive arrhythmia management is not included in the cardiology training curriculum. This is one of the most important issues that needs to be addressed. Other obstacles for developing invasive EP are lack of reimbursement (no public health insurance system), limited referral, and lack of trained personnel (both medical and paramedical). Despite these challenges, Ukrainian EP centres are still able to perform a reasonable amount of catheter ablation procedures. However, to further develop EP in Ukraine, there is a clear need for opportunities for EP training as well as improving the awareness among general cardiologists regarding invasive EP procedures. To improve this situation EHRA has actively collaborated with the Ukrainian Association of Arrhythmology and the Ukrainian Cardiac Society by helping organize several educational activities in EP. During the last couple of years, EHRA has organized joint sessions during the national congresses in Ukraine (both of cardiology and cardio-surgery) and has endorsed EP training courses as well as several conferences targeting general cardiologists and general practitioners, in order to better familiarize the local medical community with current European guidelines regarding invasive arrhythmia management. These were partly responsible for the increase in AF/VT ablation procedures in Ukraine in 2016 in comparison to 2015.5 Further information on Algeria, Egypt, and Tunisia with regard to the presence of a local EP certification, an official EP training programme, and number of EP procedures are listed in Table 2. Our report outlines several important common obstacles to EP career building in countries with EP underdevelopment: reduced number of high-volume EP centres, limited number of procedures due to poor referral systems and/or underfunding, and the absence of an official EP certification programme/training programme. Lack of manpower due to difficult EP curriculum is one of the key factors in slow progress of arrhythmia programmes in all countries. This is further aggravated in countries with EP underdevelopment by the ‘brain drain’ phenomenon, namely young EPs training abroad and not returning to their countries. On all points, EHRA can play an active role, as it has already done throughout the years. EHRA educational programmes, in collaboration with local academic societies, targeting guideline implementation for general cardiologists and practitioners can increase the referrals of arrhythmia patients for invasive EP procedures, like it has been shown in Ukraine. In addition, lobbying, in close collaboration with local societies, can at times positively influence reimbursement and funding for EP invasive procedures. Such an example for success is the ‘ICD-for-life’ programme during which in 2013, thanks to a close collaboration of the former EHRA President Angelo Auricchio and the Romanian Society of Cardiology, the Romanian Government funded a new national programme for sudden cardiac death prevention. It resulted in an exponential increase of ICD implantation in Romania during the last 4 years. EHRA EP training fellowships and proctor programmes have been crucial for EP development during the last 10 years in Eastern European countries. While basic EP training could be successfully performed locally, it is hampered by the absence of a legal setting and most countries with EP underdevelopment are unable to provide adequate training for advanced EP. Efforts should be made to continue the EHRA advanced EP training fellowship programme, at least for countries with EP underdevelopment. Also, the development of few high-volume centres, associated with better funding and highly competent staff, probably represents a much more viable and sustainable way to improve availability of interventional EP therapies and training in these countries. Currently, EHRA offers an observational fellowship programme at recognized training centres programme and EHRA and ESC provide online training webinars and courses via the ESC eLearning platform. A difficult EP curriculum, the absence of official electrophysiology training programme and the limited number of high-volume centres are the most important obstacles to local career building in countries with EP underdevelopment. EHRA and the Young EP community could play an important role in overcoming these obstacles. Activities related to EP training, raising awareness of advanced arrhythmia treatments, lobbying for reimbursement, networking within the Young EP community and beyond, have contributed to the improvement of EP training and invasive EP standards in countries with EP underdevelopment. Nevertheless, continuous engagement from EHRA and the EHRA Young EP community remains the key for the future success of EP in countries with EP underdevelopment. Conflict of interest: none declared.