Choosing a career in cardiac electrophysiology means entering a constantly evolving field. As newer technologies become available, it's up to the electrophysiologist to decide what to implement into their own practice. Some procedural skills and techniques that I learned during my fellowship training greatly differed from skills taught to my predecessors as well as to my successors. Open-mindedness, flexibility, and a willingness to learn will ensure that you remain on the cutting-edge of the field of electrophysiology.

The best example of this ever-changing field is the evolution of conduction system pacing. Toward the end of my fellowship, His bundle pacing had gained popularity as a promising technique in producing physiologic ventricular activation. Unfortunately, successful implantation of a right ventricular lead at the His bundle was not consistently reproducible and was also associated with increased need for lead revisions due to rising pacing thresholds and loss of conduction system capture over time. Subsequently, left bundle branch area pacing (LBBAP) became the preferred technique of conduction system pacing with more reproducible results and stable thresholds over time while maintaining near-physiologic ventricular activation.¹ LBBAP has also successfully corrected left bundle branch block with early studies showing superiority over biventricular pacing in patients with reduced ejection fraction.² I learned the technique by attending conferences and reading journal articles before attempting it on my own.

While there has been a recent renaissance in cardiac pacing, the realm of ablation has also seen recent procedural and technological advances. Radiofrequency ablation had previously been the default ablation option for atrial fibrillation until cryoballoon ablation was popularized within the last decade, producing shorter procedural times with similar efficacy.³ Subsequently, radiofrequency ablation utilizing a higher power and shorter duration approach was popularized, which also resulted in shorter procedural times that were comparable to cryoballoon ablation while maintaining similar efficacy.⁴ Recently, pulsed field ablation has shown early promise in being able to improve the safety and potentially efficacy of atrial fibrillation ablation and is currently being investigated in clinical trials.⁵ Many companies are racing to develop catheters and generators that will be utilizing this technology. It is possible that pulsed field ablation may overtake radiofrequency ablation and cryoballoon ablation in the atrial fibrillation ablation arena within the next few years. The superiority of ablation over antiarrhythmic drugs demonstrated in many recent studies shows it is only a matter of time before societal guidelines recommend atrial fibrillation ablation as first line therapy instead of having to fail at least one antiarrhythmic drug. Once this change occurs, the demand for ablations will continue to increase.

As ablation techniques and technologies have improved, Medicare has recently introduced physician reimbursement cuts for ablations in 2022 and 2023. Certain ablation components that were previously reimbursed separately are now bundled together with the ablation. In addition, reimbursement for certain types of ablations has also been reduced. Both cuts have resulted in up to a 40% reduction in physician reimbursement for certain ablation procedures. This is an important consideration for physicians who are planning to pursue a career in cardiac electrophysiology, especially regarding institutional pay models. While reimbursement at a salaried position would not be affected by these cuts, reimbursement at a position that was purely production-based would no longer be as lucrative as it would have been prior to 2022. Therefore, electrophysiologists planning on signing a work contract that is production-based should make sure they can be busy seeing patients or consider performing other types of procedures such as transesophageal echocardiograms to help decrease the financial impact of these cuts.

There is a growing demand for electrophysiologists due to an aging population, an increasing prevalence of atrial fibrillation and advances in techniques and technology. Advances in physiologic pacing and the development of pulsed field ablation illustrate the continued advancement of the cutting-edge field of electrophysiology. Recent reductions in reimbursement for ablations should not discourage prospective electrophysiologists from entering this exciting and rewarding field, though they should be considered when signing a job contract that utilizes a production model.

This article was authored by Victor Abrich, MD, a cardiac electrophysiologist at MercyOne Waterloo Medical Center in Waterloo, IA.

References

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