Sudden Liberalization at F.A.A. and Concerns for Aviation Safety: Active Implantable‐Defibrillators in the Cockpit? Really?

BACKGROUND: The health of pilots is essential for aviation safety and the well-being of passengers. Cardiovascular disease poses the greatest medical threat to flight safety and is the leading cause of lost certification for pilots. METHODS: Public notification of a recent Federal Aviation Administration (FAA) decision granting licensure to pilots with cardiovascular disease and implanted defibrillators is notable. RESULTS: A Delta Airlines first officer received a Class A pilot license despite experiencing a full cardiac arrest (with ventricular fibrillation) in the cockpit 6 h into a transatlantic flight at 40 000 feet, resulting in incapacitation and requiring (successful) cardiopulmonary resuscitation by the captain with an on-board emergency automatic external defibrillator. The pilot soon thereafter received an implantable cardioverter-defibrillator for secondary prevention of sudden death. Electrophysiologic study demonstrated active LV arrhythmogenic foci leading to attempted myocardial ablation. After extensive litigation, the pilot was ultimately issued an unrestricted special issuance medical certificate, the first such FAA decision for a civilian pilot with an active implanted defibrillator and representing a major reversal of long-standing aeromedical policy and standards. CONCLUSIONS: This novel liberalized practice of the FAA and NTSB as regulatory agencies, certifying at-risk pilots with active defibrillators that could deliver powerful appropriate therapy or inappropriate shocks in the cockpit, raises legitimate concerns regarding the impact of such decisions on aviation safety and the confidence of the flying public.