No Cardiac EP 'July Effect' Seen for Complications

September 18, 2013

SAN FRANCISCO, CA — The risk of important in-hospital complications from cardiac electronic device implantations wasn't any higher in the first month of cardiac electrophysiology fellows' training compared with later on, at least in the experience of a single major teaching hospital[1].

On the other hand, procedure times went down as the fellowships progressed; fluoroscopy times for biventricular pacemaker implantation also declined with longer experience, report Dr Ata Soleimani Rahbar (University of California, San Francisco, School of Medicine) and colleagues online September 9, 2013 in Heart Rhythm.

The analysis based on record review included 488 patients receiving first dual-chamber pacemakers or cardiac resynchronization therapy (CRT) device implantation from February 2004 through November 2011.

After adjustment for baseline demographics, obesity, and comorbidities, procedure times went down an average of 19 minutes per year of fellowship experience for standard pacemakers and 15 minutes per year for CRT devices (p<0.001 for both decreases). Fluoroscopy time lowered by 19% per year (p=0.009) for CRT devices, but no significant decrease was seen for standard pacemakers. All times improved by the second fellowship year compared with the first year.

Change in pacemaker implantation procedure and fluoroscopy mean times (minutes) for fellows from first to second year

Parameter 1 y 2 y
Dual-chamber pacemakers    
Implantation procedure 120.9 101.7
Fluoroscopy 17 14.9
Biventricular (CRT) pacemakers    
Implantation procedure 222.1 184.4
Fluoroscopy 45.6 37.4

Neither fellow nor attending experience was associated with increased complication rates; fellows, in particular, showed no such issue in July of their first fellowship year—traditionally their first month—compared with later months. The overall in-hospital complication rate was 5%, nearly three-quarters of which were lead dislodgments or significant bleeding.

A relationship between fellow experience and complication rates, sometimes called the July effect or phenomenon, has been reported in other medical specialties, the authors observe. But they point out that EP fellows may have an edge over some others in that they usually begin training after both their internal-medicine residency and cardiology fellowship and therefore "already have considerable procedure experience and often some device implant experience by the time they start EP fellowship."

The report did not include disclosures.

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