Statistics on the use of cardiac electronic devices and electrophysiological procedures in the European Society of Cardiology countries: 2014 report from the European Heart Rhythm Association.

Europace (2015) 17, i1–i75 doi:10.1093/europace/euu300

ORIGINAL ARTICLE

Statistics on the use of cardiac electronic devices and electrophysiological procedures in the European Society of Cardiology countries: 2014 report from the European Heart Rhythm Association M.J. Pekka Raatikainen 1*, David O. Arnar 2, Katja Zeppenfeld 3, Jose Luis Merino 4, Francisco Levya5, Gerhardt Hindriks 6, and Karl-Heinz Kuck 7 1 Department of Medicine Division of Cardiology, Central Finland Health Care District, Jyva¨skyla¨ and University of Eastern Finland, Building 1 D/9, FI-40620 Jyva¨skyla¨, Finland; 2The Heart Centre, Department of Medicine, Landspitali – The National University Hospital, Reykjavik, Iceland; 3Department of Cardiology, Leiden University Medical Centre, Leiden, Netherlands; 4 Unidad Electrofisiologia Cardiaca Robotizada-Hospital Universitario La Paz, Madrid, Spain; 5Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK; 6Department of Electrophysiology, Heart Centre, University of Leipzig, Leipzig, Germany; and 7Deparment of Cardiology, Ak St. Georg, Hamburg, Germany

Received 30 September 2014; accepted after revision 2 October 2014

There has been large variations in the use of invasive electrophysiological therapies in the member countries of the European Society of Cardiology (ESC). The aim of this analysis was to provide comprehensive information on cardiac implantable electronic device (CIED) and catheter ablation therapy trends in the ESC countries over the last five years. ..................................................................................................................................................................................... Methods The European Heart Rhythm Association (EHRA) has collected data on CIED and catheter ablation therapy since 2008. Last year 49 of the 56 ESC member countries provided data for the EHRA White Book. This analysis is based on the current and previous editions of the EHRA White Book. Data on procedure rates together with information on economic aspects, local reimbursement systems and training activities are presented for each ESC country and the five geographical ESC regions. ..................................................................................................................................................................................... Results In 2013, the electrophysiological procedure rates per million population were highest in Western Europe followed by the Southern and Northern European countries. The CIED implantation and catheter ablation rate was lowest in the Eastern European and in the non-European ESC countries, respectively. However, in some Eastern European countries with relative low gross domestic product procedure rates exceeded those of some wealthier Western countries, suggesting that economic resources are not the only driver for utilization of arrhythmia therapies. ..................................................................................................................................................................................... Conclusion These statistics indicate that despite significant improvements, there still is considerable heterogeneity in the availability of arrhythmia therapies across the ESC area. Hopefully, these data will help identify areas for improvement and guide future activities in cardiac arrhythmia management.

----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords

Pacemaker † Implantable cardioverter defibrillator (ICD) † Cardiac resynchronization pacemaker (CRT-P) † Cardiac resynchronization therapy defibrillator (CRT-D) † Catheter ablation † Atrial fibrillation ablation

Introduction This is the third year that the EHRA White Book data on the status of cardiac implantable electronic device (CIED) therapy and catheter ablation are published as a full EP Europace supplement. As in past editions, the objective is to provide comprehensive information on the

trends in the use of invasive treatment for cardiac rhythm disorders in the member countries of the European Society of Cardiology (ESC). In addition to statistics on the various invasive electrophysiological procedures, we have provided information on the social, financial, and economic aspects in the constituent ESC countries. We hope that, together with information on local reimbursement systems, these

* Corresponding author. Tel: +358 14 2691811; Fax: +358 14 2692719, E-mail address: [email protected] Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].

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Aims

i2

M.J.P. Raatikainen et al.

ESC regions Northern Europe

Western Europe Southern Europe Eastern Europe Non-European ESC countries Non-ESC countries

Figure 1 Geographic representation of the 56 European Society of Cardiology (ESC) countries according to the United Nations Statistics Division (http://unstats.un.org/unsd/methods/m49/m49regin.htm).

Northern and Western Europe. In most non-European ESC countries, the number of catheter ablations was markedly lower than in the other ESC regions. Whether this is due to economic restrictions or to more precise patient selection is unknown. Ablation therapies may be more susceptible to financial restrictions, training, and education resources than device therapies, which are frequently used for immediate and often life-saving indications. European Heart Rhythm Association Certification and Training Fellowship Programs have been very successful and have provided a platform for EHRA’s goal to promote unified standards for the training of cardiac rhythm management specialists and to assure high-quality in arrhythmia care all over the ESC area. Last year 260 physicians and 69 allied professionals participated in the EHRA Certification Examination. European Heart Rhythm Association fellowship grants have allowed many young physicians from emerging economies to be trained in high volume centres outside of their home country. The White Book has played a key role in the ICD for life programme2 and many other strategic initiatives and awareness activities of the EHRA. Over the years, several improvements have been made, but the current data indicate that there is still room for further development. We hope that these statistics will guide future activities in the field of cardiac arrhythmia management and promote EHRA’s mission, namely “to improve the quality of life of the European population by reducing the impact of cardiac arrhythmias and reduce sudden cardiac death”.

Societal, financial, and economic aspects General information In this section, an overview of the demographic and financial profile of the 56 ESC countries is provided. Population and vital statistics and GDP in the 56 ESC countries are presented in Tables 1 and 2. It is


data will contribute to the understanding of the economic aspects of electrophysiological procedures in countries affiliated to the European Heart Rhythm Association (EHRA). We also report on electrophysiology (EP) training requirements and new training initiatives. The methodology of the EHRA White Book data collection and analysis has been described elsewhere.1 In order to facilitate comparisons among various ESC countries, we presented regional data for the last five years separately for the Eastern, Northern, Southern, and Western Europe, and for the non-European ESC countries. The European regions were composed according to the United Nations (UN) Statistics Division (http://unstats.un.org/unsd/methods/m49/ m49regin.htm) without taking into account any economic, political, or historical aspects (Figure 1). Distribution of population within these regions over the last five years is shown in Table 1. Our analysis revealed considerable differences in the pacemaker (PM), implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy (CRT) device implantation rates between the ESC member countries. As in previous years, the mean CIED implantation rates per million population were higher in the Western Europe than in the other regions. The mean numbers were lowest in the Eastern Europe and in the non-European ESC countries. However, in some Eastern European countries, implantation rates for PM and ICDs per million inhabitants exceeded those of some Western European countries, suggesting that gross domestic product (GDP) is not the only driver for utilization of device therapies. During the last decade, the use of catheter ablation in the ESC area has increased substantially mainly due to the development of invasive therapies for atrial fibrillation. It was interesting to note that in many Eastern European countries where access to ablation therapy until 5 –10 years ago was extremely limited due to financial and training restrictions, the numbers of catheter ablation were still growing rapidly. In contrast, the number of catheter ablations per million population remained stable or even decreased slightly in the

ISO code

Population

............................................................................................................................................................... 2009

2010

2011

2012

2013

............................................................................................................................................................................................................................................. Northern Europe Denmark Estonia

DK EE

5 519 441 1 340 271

5 550 000 1 341 000

5 529 888 1 282 963

5 543 453 1 274 709

5 556 452 1 266 375

Finland

FI

5 338 871

5 365 000

5 259 250

5 262 930

5 266 114

Iceland Ireland

IS IE

319 246 4 459 305

320 000 4 470 000

311 058 4 670 976

313 183 4 722 028

315 281 4 775 982

Latvia

LV

2 254 834

2 252 000

2 204 708

2 191 580

2 178 443

Lithuania

LT

3 339 455

3 324 000

3 535 547

3 525 761

3 515 858

Norway Sweden

NO SE

4 828 726 9 298 515

4 883 000 9 380 000

4 691 849 9 088 728

5 000 000 9 103 788

5 085 582 9 647 386

United Kingdom

GB

Total Western Europe

61 791 956

62 036 000

62 698 362

63 047 162

63 395 574

98 490 619

98 921 000

99 273 329

99 984 594

101 003 047

Austria

AT

8 363 040

8 394 000

8 217 280

8 219 743

8 221 646

Belgium France

BE FR

10 646 804 62 342 668

10 712 000 62 787 000

10 431 477 65 102 719

11 082 744 65 630 692

10 444 268 65 951 611

Germany

DE

81 874 768

82 302 000

81 471 834

81 305 856

81 147 265

Luxembourg Netherlands

LU NL

486 181 16 445 593

507 000 16 613 000

503 302 16 653 734

509 074 16 730 632

514 862 16 805 037

Switzerland

CH

Total Eastern Europe

7 567 659

7 664 000

7 639 961

7 925 517

7 996 026

187 726 713

188 979 000

190 020 307

191 404 258

191 080 715

Belarus

BY

9 665 120

9 595 000

9 577 552

9 643 566

9 625 888

Bulgaria Czech Republic

BG CZ

7 585 131 10 491 492

7 494 000 10 493 000

7 093 635 10 190 213

7 037 935 10 177 300

6 981 642 10 609 762

Hungary

HU

10 022 650

9 984 000

9 976 062

9 958 453

9 939 470

Moldova Poland

MD PL

3 770 698 38 153 388

3 731 799 38 277 000

3 694 121 38 441 588

3 656 843 38 415 284

3 619 925 38 383 809

Romania

RO

21 469 960

21 431 298

21 904 551

21 848 504

21 790 479

Russian Federation Slovakia

RU SK

141 909 248 5 418 374

142 958 000 5 462 000

138 739 892 5 477 038

142 517 670 5 483 088

142 500 482 5 488 339

Ukraine

UA

Total Southern Europe

45 872 976

45 448 000

45 134 707

45 416 589

44 573 205

294 359 037

294 874 097

290 229 359

294 155 232

293 513 001

Albania*

AL

3 194 417

3 204 000

2 994 667

3 002 859

3 011 405

Bosnia and Herzegovina

BA

3 838 161

3 760 000

4 622 163

3 879 296

3 875 723

i3

Continued

Comparative analysis of EHRA White Book data 2009– 2013

Table 1 Populations in the five geographical European Society of Cardiology regions in 2009 –2013


i4

Table 1 Continued ISO code

Population

............................................................................................................................................................... 2009

2010

2011

2012

2013

............................................................................................................................................................................................................................................. Croatia

HR

4 429 078

4 403 000

4 483 804

4 480 043

4 475 611

Greece

GR

11 282 751

11 359 000

10 760 136

10 767 827

10 772 967

Italy Kosovo*

IT XK

60 192 696 1 804 838

60 551 000 1 815 048

61 016 804 1 825 632

61 261 254 1 836 529

61 482 297 1 847 708

FYR Macedonia

MK

2 042 485

2 061 000

2 077 328

2 082 370

2 087 171

Malta Montenegro

MT ME

413 290 631 536

417 000 631 000

408 333 661 807

409 836 657 394

411 277 653 474

Portugal

PT

10 632 482

10 676 000

10 760 305

10 781 459

10 799 270

San Marino Serbia

SM RS

28 976 7 320 807

32 000 7 291 436

31 817 7 310 555

32 140 7 276 604

32 448 7 243 007

Slovenia

SI

2 042 335

2 030 000

2 000 092

1 996 617

1 992 690

ES

45 929 476 153 783 328

46 077 000 154 307 484

46 754 784 155 708 227

47 042 984 155 507 212

47 370 542 156 055 590

Spain Total Non-European ESC countries

DZ AM

35 268 128 3 243 729

35 949 869 3 092 000

34 994 937 2 967 975

37 367 226 2 970 495

38 087 812 3 064 267

Azerbaijan

AZ

9 206 777

9 301 673

9 397 279

9 493 600

9 590 159

Cyprus Egypt

CY EG

803 147 78 866 635

1 104 000 80 471 869

1 120 489 82 079 636

1 138 071 83 688 164

1 155 403 85 294 388

Georgia

GE

4 410 900

4 352 000

4 585 874

4 570 934

4 942 157

Israel Kazakhstan

IL KZ

7 485 600 16 863 280

7 418 000 17 084 817

7 473 052 17 304 513

7 590 758 17 522 010

7 707 042 17 736 896

Kyrgyzstan*

KGZ

5 358 180

5 410 468

5 450 776

5 496 737

5 548 042

Lebanon

LB

4 099 315

4 125 247

4 143 101

4 140 289

4 131 583

Libya* Morocco

LY MA

6 002 252 31 285 174

6 110 364 31 627 428

6 597 960 31 968 361

5 613 380 32 309 239

6 002 347 32 649 130

Syria*

SY

21 762 978

22 198 110

22 517 750

22 530 746

22 457 336

Tunisia* Turkey*

TN TR

10 420 551 72 561 312

10 525 041 72 752 000

10 629 186 78 785 548

10 732 900 79 749 461

10 835 873 80 694 485

307 637 958

311 522 886

320 016 437

324 914 010

329 896 920

56

1 041 997 655

1 048 604 467

1 055 247 659

1 065 965 306

1 071 549 273

Total ESC countries


Total


Algeria Armenia

Country

Population

Population growth rate (%)

Life expectancy at birth (years)

Death rate (%) per 1000 population

GDP (x 1000 billion USD)

GDP per capita (USD)

Total health expenditure as % of GDP

............................................................................................................................................................................................................................................. Albania*

3 011 405

0.28

77.80

5.68

13.16

4039

6.32

Algeria Armenia

38 087 812 3 064 267

1.91 20.09

76.20 74.00

N/A 8.56

215.72 10.44

5668 3176

N/A 4.34

Austria

8 221 646

0.02

80.00

9.08

417.90

49 256

10.64

Azerbaijan Belarus

9 590 159 9 625 888

1.01 20.18

71.60 71.80

5.88 13.97

76.01 69.24

8165 7414

5.24 5.32

Belgium Bosnia & Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Egypt Estonia

10 444 268

0.06

79.80

9.62

507.42

45 537

10.60

3 875 723 6 981 642

20.09 20.80

76.10 74.10

9.12 14.73

18.87 53.70

4866 7411

10.22 7.28

4 475 611

20.10

76.20

11.59

58.60

13 312

7.82

1 155 403 10 609 762

1.51 0.17

78.20 78.10

6.27 10.18

21.78 198.63

24 706 18 848

7.42 7.38

5 556 452

0.23

78.90

9.37

324.29

57 999

11.16

85 294 388 1 266 375

1.90 20.66

73.20 73.80

N/A 11.35

262.03 24.28

3114 18 127

N/A 5.96

Finland

5 266 114

0.06

79.60

9.38

259.63

47 625

8.86

France Georgia

65 951 611 4 942 157

0.49 20.16

81.60 75.50

8.58 10.71

2738.68 15.95

42 991 3558

11.64 9.44

Germany

81 147 265

20.20

80.30

10.42

3593.24

43 952

11.60

Greece Hungary

10 772 967 9 939 470

0.05 20.19

80.20 75.20

9.83 12.92

243.33 130.56

21 617 13 172

9.04 7.76

Iceland

315 281

0.67

81.10

6.27

14.59

45 315

9.08

Ireland Israel

4 775 982 7 707 042

1.14 1.52

80.40 81.20

6.08 5.17

220.89 272.74

47 882 34 651

9.38 7.74

Italy

61 482 297

0.36

82.00

9.67

2068.37

33 909

9.50

Kazakhstan Kosovo*

17 736 896 1 847 708

1.22 0.61

69.90 70.80

8.94 N/A

224.86 6.99

13 048 N/A

3.92 N/A

Kyrgyzstan*

5 548 042

0.93

69.80

6.64

7.23

1282

6.50

Latvia Lebanon

2 178 443 4 131 583

20.60 20.21

73.20 75.50

13.43 N/A

30.38 43.49

14 924 10 708

6.18 N/A N/A

Libya*

6 002 347

6.70

75.80

N/A

70.92

10 864

Lithuania Luxembourg

3 515 858 514 862

20.28 1.13

75.80 79.90

12.81 7.18

46.71 60.54

15 633 110 573

6.60 7.70

FYR Macedonia

2 087 171

0.23

75.60

9.30

10.51

5073

6.58

i5

Continued


Table 2 Population and vital statistics and and gross domestic product in the 56 ESC countries. *These seven countries did not submit data for the EHRA White Book 2014.


i6

Table 2 Continued Country

Population

Population growth rate (%)

Life expectancy at birth (years)

Death rate (%) per 1000 population

GDP (x 1000 billion USD)

GDP per capita (USD)

Total health expenditure as % of GDP

............................................................................................................................................................................................................................................. Malta

411 277

0.35

80.00

7.86

9.32

22 323

8.74

3 619 925

21.01

69.80

11.11

7.88

2214

11.38

Montenegro Morocco

653 474 32 649 130

20.60 1.05

78.10 76.30

9.29 N/A

4.52 104.80

7252 3190

9.32 N/A

Netherlands

16 805 037

0.44

81.00

8.13

800.54

47 651

11.96

Norway Poland

5 085 582 38 383 809

1.28 20.08

81.50 76.50

8.34 9.75

515.83 513.93

101 271 13 334

9.08 6.74

Moldova

Portugal Romania Russian Federation San Marino

10 799 270

0.17

78.90

9.78

219.29

20 663

10.36

21 790 479 142 500 482

20.27 20.01

74.50 69.90

12.12 14.20

183.79 2117.83

8630 14 973

5.84 6.20

32 448

0.95

83.10

7.34

1.87

7 243 007 5 488 339

20.46 0.10

74.80 76.20

14.18 9.84

43.68 96.96

6017 17 929

10.44 8.70

Slovenia

1 992 690

20.20

77.70

9.08

46.82

22 719

9.06

Spain Sweden

47 370 542 9 647 386

0.69 0.77

81.40 81.80

8.41 9.65

1355.66 552.04

29 409 57 297

9.44 9.36

Serbia Slovakia

7 996 026

0.89

82.30

Syria* Tunisia*

Switzerland

22 457 336 10 835 873

20.33 0.95

75.10 75.50

Turkey*

80 694 485

1.18

73.00

Ukraine United Kingdom

44 573 205 63 395 574

20.63 0.55

68.90 80.30

8.01

N/A

7.18

646.20

80 276

10.86

N/A 48.38

N/A 4431

N/A N/A

5.10

821.80

10 745

6.66

14.60 9.02

175.53 2489.67

3862 39 049

7.26 9.32

N/A N/A


EHRA White Book 2014, http://www.census.gov/ipc/www/idb/informationGateway.php, http://data.euro.who.int/hfadb/, http://www.imf.org/external/ns/cs.aspx?id=28 (2013¼IMF est.), World Health Organization National Health Account database. *These seven countries did not submit data for the EHRA White Book 2014.


Country

Basic insurance availability

Uninsured citizens (% of population)

Distribution of insurance modality (%)

................................................................................ Public insurance

Private insurance

Private co-payment

Possibility to subscribe private health insurance plans

Co-payment necessary for EP therapies

................................

ICD

PM

Ablation

............................................................................................................................................................................................................................................. Albaniaa Algeria

Yes

30

100

0

0

Yes

No

No

No

Armenia

No

65

0

70

30

N/A

Yes

Yes

Yes

Austria Azerbaijan

Yes Yes

1.8 0

85 70

N/A 10

15 20

Yes Yes

No Yes

No Yes

No Yes

Belarus

Yes

0

100

N/A

N/A

Yes

No

No

No

Belgium Bosnia & Herzegovina

Yes No

1 25

N/A 75

N/A 0

N/A 0

Yes No

No N/A

No N/A

No N/A

Bulgaria

Yes

20

75

1

24

Yes

Yes

No

Yes

Croatia Cyprus

Yes No

10 15

90 85

5 15

5 0

Yes No

No No

No No

No No

Czech Republic

Yes

0.1

99.9

0.1

N/A

Yes

No

No

No

Denmark Egypt

Yes No

0 35

100 64

0 1

0 35

Yes Yes

No Yes

No Yes

No Yes

Estonia

Yes

N/A

N/A

N/A

N/A

Yes

No

No

No

Finland France

Yes Yes

0 0

75 55

3 0

22 45

Yes No

No No

No No

No No

Georgia

Yes

N/A

N/A

N/A

N/A

Yes

Yes

Yes

Yes

Germany Greece

No Yes

2 15

75 89

10 10

15 1

Yes Yes

No No

No No

No No

Hungary

Yes

2

99

1

0

Yes

No

No

No

Iceland Ireland

Yes Yes

0 52

100 52

0 48

0 0

No Yes

No No

No No

No No

Israel

Yes

0

100

0

0

Yes

No

No

No

Italy Kazakhstan

Yes No

0 N/A

100 N/A

0 N/A

0 N/A

Yes Yes

No No

No No

No No

Kyrgyzstana Latvia

Yes

0

88

12

0

Yes

Yes

Yes

No

Lebanon

No

40

25

25

10

N/A

Yes

Yes

Yes

Libyaa Lithuania

Yes

0

98

2

0

Yes

No

Yes

No

Luxembourg

Yes

0

100

N/A

N/A

Yes

No

No

No

FYR Macedonia

Yes

10

80

10

10

Yes

No

No

No


Table 3 Healthcare service and insurance systems in the 56 ESC countries

Kosovoa

i7

Continued


i8


Basic insurance availability

Uninsured citizens (% of population)

Distribution of insurance modality (%)

................................................................................ Public insurance

Private insurance

Private co-payment

Possibility to subscribe private health insurance plans

Co-payment necessary for EP therapies

................................

ICD

PM

Ablation

No No

No N/A

............................................................................................................................................................................................................................................. Malta Moldova

Yes Yes

0 20

100 100

0 0

0 0

Yes Yes

No N/A

Montenegro

Yes

N/A

100

0

0

No

No

No

No

Morocco Netherlands

No Yes

35 0

70 0

25 100

5 0

Yes No

Yes No

Yes No

Yes No

Norway

Yes

0

97

N/A

3

Yes

No

No

No

Poland Portugal

Yes N/A

5 0

90 100

5 0

5 0

Yes Yes

No No

No No

No No

Romania

Yes

N/A

98

0

2

Yes

Yes

No

Yes

Russian Federation San Marino

Yes No

N/A 0

85 100

10 N/A

5 0

Yes Yes

No No

Yes No

No No

Serbia

Yes

5

90

5

5

Yes

No

No

No

Slovakia Slovenia

Yes No

0 1

72 4

28 0

0 96

Yes N/A

No No

No No

No No

Spain

No

5

75

10

15

Yes

No

No

No

Sweden Switzerland

Yes Yes

0 0

N/A 70

N/A 0

N/A 30

Yes Yes

No No

No No

No No

Ukraine

No

N/A

N/A

N/A

N/A

Yes

No

No

No

United Kingdom

No

90

90

10

0

Yes

No

No

No

Syriaa Tunisiaa Turkeya

a

These 7 countries did not submit data for the EHRA White Book 2014.



i9


Netherlands France Germany Moldova Denmark Switzerland Austria Belgium Serbia Portugal Bosnia & Herzegovina Italy Georgia Spain Ireland Sweden Montenegro United Kingdom Iceland Norway Slovenia Greece Finland Malta Slovakia Croatia Hungary Israel Luxembourg Cyprus Czech Republic Bulgaria Ukraine San Marino Poland Lithuania FYR Macedonia Russian Federation Latvia Estonia Romania Belarus Azerbaijan Armenia Kazakhstan

12.0 11.6 11.6 11.4 11.2 10.9 10.6 10.6 10.4 10.4 10.2 9.5 9.4 9.4 9.4 9.4 9.3 9.3 9.1 9.1 9.1 9.0 8.9 8.7 8.7 7.8 7.8 7.7 7.7 7.4 7.4 7.3 7.3 7.2 6.7 6.6 6.6 6.2 6.2 6.0 5.8 5.3 5.2 4.3 3.9

Mean health care expenditure as % of GDP = Ø 8.4

Luxembourg Switzerland Norway Denmark Netherlands Sweden Austria Germany France Ireland Belgium Finland Iceland United Kingdom Italy Spain Greece Israel Portugal Slovenia Cyprus Malta Slovakia Czech Republic Hungary Croatia Estonia Poland Lithuania Russian Federation Latvia Serbia Montenegro Bulgaria Romania Bosnia & Herzegovina Azerbaijan FYR Macedonia Belarus Ukraine Georgia Armenia

9.415 9.229 8.770 7.031 6.149 5.719 5.374 5.168 5.168 4.551 4.519 4.438 3.925 3.691 3.519 3.143 2.520 2.500 2.352 2.350 2.332 1.928 1.556 1.544 1.149 1.136 1.006 941 871 821 756 654 621 527 506 482 394 330 325 260 198 132

Mean Health care expenditures as % of GDP = Ø 2 818 USD

Figure 3 Healthcare expenditure per capita in the European Socitety of Cardiology countries in 2011. Mean number of expenditure is weighted by population.


Figure 2 Healthcare expenditure as percentage of national gross domestic product (GDP) in the European Society of Cardiology countries in 2011. Mean number of % of expenditure is weighted by population.

i10


1.200 1.125

1.100

Hospitals

16

Beds

15 14

1.000

966

13

899

900

12 822

800

765 719 717 700 684

700

11 655

600

650 645 638 623 611 598 588 579

10 9 537 552 531

500

8 501 485 466 479 468 463 450

400 300

7 394 397 383 347 338 345 343 335 332 320 309 295 271 264

6 5 4 3

200

2 100

1

0

0 Georgia

Ireland

Sweden

Spain

Norway

Iceland

Israel

Italy

Portugal

Cyprus

Yes, it´s required for practice = 15 countries Yes, but it´s not required for practice = 12 countries No = 20 countries No answer = 2 countries

Figure 5 Certification for cardiac implantable electronic device (CIED) therapy in the European Society of Cardiology countries in 2013.



San Marino

Montenegro

Armenia

Slovenia

FYR Macedonia

Azerbaijan

Netherlands

Malta

Switzerland

Greece

Estonia

Luxembourg

Croatia

Finland

Latvia

Slovakia

Romania

Moldova

France

Bulgaria

Poland

Belgium

Czech Republic

Kazakhstan

Lithuania

Austria

Hungary

Germany

Ukraine

Russian Federation

Belarus

Figure 4 Hospitals and hospital beds per 100.000 inhabitants in the European Society of Cardiology countries.

i11




Figure 7 Certification for allied professionals in the European Society of Cardiology countries in 2013.


Figure 6 Certification for invasive electrophysiology in the European Society of Cardiology countries in 2013.

i12

financial disparities, it was not surprising at all that there were large variations in device implantation rates and use of catheter ablation therapies across the ESC regions and between countries.

Healthcare resources Health expenditure per country is shown as percentage of the national GDP in Figure 2 and as expenditure per capita in Figure 3. In the ESC countries, the mean healthcare expenditure was 8.4% of the GDP. It was highest in the Netherlands (12.0%) and lowest in Kazakhstan (3.9%). Given the trend towards a progressive ageing of populations, it is likely that the healthcare expenditure will continue to increase. The mean heath expenditure per capita in the ESC area was 2818 USD, ranging from132 USD in Armenia to 9.415 USD in Luxembourg. Hence, there was more than 70-fold difference between the lowest and the highest health expenditure per capita. The number of hospitals and hospital beds available for healthcare are shown in Figure 4. The number of hospitals and beds were not directly related to the financial profile of the countries or to healthcare expenditure. Rather, these data indicate that some countries have directed more resources towards hospital care than ambulatory and home care. For example, the number of beds per 100 000 inhabitants was 822 in Germany and only 271 in Sweden, despite the relatively high GDP and healthcare expenditure in both countries. In most ESC countries, patients provide minimum-to-no co-payment for invasive EP procedures (Table 3). In countries in which a co-payment exists, it may be one of the factors limiting access to CIED and catheter ablation therapies. However, as both the financial profile and the organization of healthcare in the ESC


Figure 8 Certification for training centres in the European Society of Cardiology countries in 2013.


hoped that these data will help clarify whether financial restrictions influence the delivery of arrhythmia care. European Society of Cardiology countries are a heterogeneous group of nations with varying political, financial, and demographic characteristics. In addition, there are large variations in the organizational aspects of healthcare across the ESC member countries. Some countries provide national healthcare services with full coverage to the whole population while in others healthcare services are primarily delivered by commercial health insurance companies and coverage depends on private co-payments (Table 3). In 2013 the economic situation in the ESC area was characterized by ongoing financial difficulties following the recent economic crisis and substantial budget cuts for healthcare.3,4 At the same time the number of elderly people, who require vast medical and social assistance, is growing rapidly. In this context, socioeconomic disparities pose major threats to healthcare systems. These aspects have an important negative impact on the use of expensive innovative technology such as CIED therapy for primary prevention of sudden cardiac death and catheter ablation therapies.5 – 8 Medium-to-high-quality data on cause of death are available in most ESC countries, although they are lacking in many other parts of the world.9 Demographic and GDP data reveal some important differences between the ESC countries. As an example, the life expectancy varied from 68.9 years (Ukraine) to 83.1 years (San Marino). It is noteworthy that in most countries with life expectancy over 80 years, the GDP per capita is also relatively high (Table 2). Total GDP ranged from 2 (San Marino) to 3.593 (Germany) trillion US dollars (USD). The GDP per capita was almost 100 times higher in Luxembourg (110.573 USD) than in Kyrgyzstan (1.282 USD). Given these huge


i13


A

therapy and invasive EP for the EHRA White Book 2014.10 A national certification programme for device therapy for physicians was in use in 27 countries and certification was mandatory in 15 countries (Figure 5). A national certification programme for invasive EP was available in 24 countries, and certification was an obligatory practice requirement in 13 countries (Figure 6). As shown in Figure 7 a national certification for allied professionals was available in 20 countries and was required for practice in 9 countries. Training centres were accredited in only 14 (25%) countries, and certification of training centres was mandatory in order to train fellows in eight countries (Figure 8). Many centres in various regions have been available as training centres for the EHRA fellows and allowed many young physicians from emerging economies to be trained in high volume centres abroad.

B

EHRA certification

Figure 9 Number of participants in the European Heart Rhythm Association examination during last five years. (A) Invasive cardiac electrophysiology. (B) Cardiac pacing and ICDs. (C) Allied professionals.

countries are heterogeneous, the impact of co-payment to implementation of interventional electrophysiological procedures in clinical practice is difficult to estimate.

Certification of professional excellence General information In 2013, 47 countries (85% of the ESC member countries) provided data on certification of physicians and allied professionals in device


C

The EHRA certification programme is the first European certification of professional excellence in the field of CIED therapies and invasive EP. The programme is designed to test theoretical knowledge and practical experience of professionals in cardiac device therapy and EP. Since 2006 a total of 1629 physicians (972 in cardiac pacing and ICDs and 657 in invasive cardiac electrophysiology) from 34 countries have participated in the EHRA examination. In 2013, the majority of them (75%) were male and most of them were 31 – 40 years of age. However, over the years, the proportion of female candidates has increased from about 10% to 25% (Figure 9). The highest number of candidates participating in the cardiac device therapy examination was from the Netherlands, followed by Spain and Germany. For EP, the highest numbers of participants were from Spain, Italy, Germany, United Kingdom, and the Netherlands. The pass rate for physicians participating in the invasive EP examination was 62% and 71% for the cardiac device therapy examination. These numbers are similar to the pass rates from previous years. Since the introduction of the EHRA examination, 887 physicians (582 in cardiac device therapy and 305 in invasive EP) have passed the examination and have reached first level certification. More than two-thirds of them have submitted the case logbook within the required time period and subsequently achieved full (level 2) certification. Since the introduction in 2011 of the EHRA certification programme for allied professionals in cardiac device therapy, 103 candidates from eight countries have participated in the EHRA examination and 84 have achieved full certification. Last year the pass rate in the allied professional examination was 61%, which is similar to the previous years. Every year, most participants have been from the Netherlands followed by Greece, Spain, and United Kingdom. For allied professionals the examination was available in six languages (English, Spanish, French, German, Italian, and Greek). In summary, the EHRA White Book data indicate that there are still significant differences in training and certification requirements between the ESC countries. In 2013, the EHRA certification programme was acknowledged by 34 ESC countries, but it was an obligatory requirement for practice in only two countries. Accordingly, there is an urgent need to involve more physicians and allied professionals in the EHRA certification system to assure uniform and high

i14

Table 4 Pacemaker implantation facilities and implantation rates in the ESC countries in 2013 and comparison to four previous years Country

ISO code

National Registry for PM implants

Number of PM implanting centres 2013

PM implantations 2013

Development potential—target number of PM implantations . . .

PM implantations per mil inhabitants

Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

To attain mean ESC area level

To attain mean EU-28 level

2009

....................................... ....................................... ............................................ ............................................ 2010

2011

2012

2013

............................................................................................................................................................................................................................................. Albaniaa

AL

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Algeria

DZ

No

19

0.50

2480

65

20 251

31 875

N/A

N/A

N/A

N/A

65

Armenia Austria

AM AT

No Yes

2 57

0.65 6.93

94 7950

31 967

1629 –

2564 –

65 948

124 919

133 950

74 957

31 967

Azerbaijan

AZ

No

6

0.63

131

14

5099

8026

N/A

N/A

15

N/A

14

Belarus Belgium

BY BE

Yes Yes

10 105

1.04 10.05

2813 12 725

292 1218

5118 –

8056 –

196 869

238 838

258 N/A

275 1156

292 1218

N/A

Bosnia & Herzegovina

BA

No

6

1.55

868

224

2061

3244

N/A

205

138

234

224

Bulgaria Croatia

BG HR

Yes N/A

17 18

2.43 4.02

3511 2418

503 540

3712 –

5843 3746

360 513

329 531

385 565

448 561

503 540

Cyprus

CY

No

5

4.33

250

216

614

967

249

208

223

211

216

Czech Republic Denmark

CZ DK

Yes Yes

37 11

3.49 1.98

9416 4725

887 850

– –

– –

859 713

849 744

881 795

899 841

887 850

Egypt

EG

No

28

0.33

2850

33

45 351

71 382

29

19

N/A

30

33

Estonia Finland

EE FI

No No

5 20

3.95 3.80

1155 5369

912 1020

– –

– –

770 796

745 917

766 923

748 990

912 1020

France

FR

No

500

7.58

60 000

910

–

–

1029

1022

969

958

910

Georgia Germany

GE DE

No No

9 1010

1.82 12.45

620 93 520

125 1152

2628 –

4136 –

60 1248

71 1257

84 1313

102 1311

125 1152

GR

No

56

5.20

7800

724

–

9016

611

713

701

691

724

HU IS

Yes No

17 2

1.71 6.34

6143 314

618 996

– –

8318 –

532 836

539 828

584 1006

607 967

618 996

Ireland

IE

Yes

17

3.56

2288

479

2539

3997

457

418

507

451

479

Israel Italy

IL IT

No Yes

20 420

2.60 6.83

3966 62 198

515 1012

4098 –

6450 –

567 1047

N/A 1047

500 1034

558 1001

515 1012

Kazakhstan

KZ

No

27

1.52

1489

84

9431

14 844

N/A

N/A

N/A

70

84

Kosovoa Kyrgyzstana

XK KGZ

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A


Greece Hungary Iceland


LV

Yes

3

1.38

1288

591

–

1823

450

490

550

548

591

Lebanon

LB

No

15

3.63

900

218

2197

3458

N/A

N/A

N/A

N/A

218

Libyaa Lithuania

LY LT

N/A No

N/A 4

N/A 1.14

N/A 2716

N/A 772

N/A –

N/A 2942

N/A 662

N/A 716

N/A 714

N/A 756

N/A 772

Luxembourg

LU

No

5

9.71

188

365

274

431

200

179

336

621

365

FYR Macedonia Malta

MK MT

Yes Yes

2 2

0.96 4.86

322 227

154 552

1110 –

1747 344

119 675

150 686

174 740

166 644

154 552

Moldova

MD

No

1

0.28

287

79

1925

3029

N/A

N/A

N/A

N/A

79

Montenegro Morocco

ME MA

No Yes

1 11

1.53 0.34

204 1109

312 34

347 17 360

547 27 324

253 N/A

257 35

264 39

218 38

312 34

Netherlands

NL

Yes

90

5.36

10 174

605

–

14 064

N/A

600

585

560

605

Norway Poland

NO PL

Yes No

23 145

4.52 3.78

3459 27 500

680 716

– –

4256 32 123

630 713

678 719

675 710

691 716

680 716

Portugal

PT

Yes

40

3.70

8790

814

–

9038

686

764

595

825

814

Romania Russian Federation

RO RU

Yes Yes

22 140

1.01 0.98

2400 34 758

110 244

11 586 75 768

18 236 119 257

140 186

117 188

139 216

144 212

110 244

San Marino

SM

Yes

1

30.82

14

431

17

27

380

688

503

809

431

Serbia Slovakia

RS SK

Yes Yes

18 14

2.49 2.55

3958 3456

546 630

– –

6062 4593

446 513

437 548

448 617

431 567

546 630

Slovenia

SI

Yes

8

4.01

1287

646

–

1668

458

568

647

668

646

Spain Sweden

ES SE

Yes Yes

230 42

4.86 4.35

35 500 9602

749 995

– –

39 644 –

747 983

762 973

734 N/A

738 1041

749 995

Switzerland

CH

Yes

76

9.50

6097

763

–

6692

713

741

791

753

763

Syriaa Tunisiaa

SY TN

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A 146

N/A 143

N/A 155

N/A 233

N/A N/A

Turkeya

TR

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A


UA GB

No Yes

36 227

0.81 3.58

6579 44 503

148 702

23 700 –

37 303 53 055

85 645

103 600

112 610

121 615

148 702

Total ESC countries

56

3580


Latvia

500 411

a

These seven countries did not submit data on PM implantation for the EHRA White Book 2014.

i15


i16

Table 5 Specialty of the physicians performing device implantations and lead extractions in the 56 ESC countries Country

ISO code

Specialist performing PM implantations (%)

Specialist performing ICD implantations (%)

Specialist performing CRT implantations (%)

Specialist performing loop recorder implantations (%)

Specialist performing lead extractions (%)

..................................... ..................................... ..................................... ..................................... .....................................

Cardiologists Surgeons Other Cardiologists Surgeons Other Cardiologists Surgeons Other Cardiologists Surgeons Other Cardiologists Surgeons Other

............................................................................................................................................................................................................................................. Albaniaa

AL

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Algeria

DZ

99

1

0

100

0

0

100

0

0

100

0

0

N/A

N/A

N/A

Armenia

AM

100

0

0

100

0

0

100

0

0

100

0

0

100

0

0

Austria

AT

50

50

0

10

90

0

50

50

0

80

20

0

10

90

0

Azerbaijan

AZ

52

48

0

100

0

0

100

0

0

100

0

0

90

10

0

Belarus

BY

0

100

0

0

100

0

0

100

0

0

100

0

0

100

0

Belgium

BE

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A


BA

50

35

15

95

5

0

100

0

0

100

0

0

0

0

0

Bulgaria

BG

99.0

1.0

0

100

0

0

100

0

0

100

0

0

100

0

0

Croatia

HR

88

12

0

65

35

0

100

0

0

100

0

0

N/A

N/A

N/A

Cyprus

CY

100

0

0

100

0

0

100

0

0

100

0

0

100

0

0

Czech Republic

CZ

90

10

0

95

5

0

95

5

0

100

0

0

80

20

0

Denmark

DK

100

0

0

100

0

0

100

0

0

100

0

0

85

15

0

Egypt

EG

60

10

30

65

0

35

65

0

35

90

0

10

80

0

20

Estonia

EE

100

0

0

100

0

0

100

0

0

100

0

0

N/A

N/A

N/A

Finland

FI

95

5

0

100

0

0

100

0

0

100

0

0

N/A

N/A

N/A

France

FR

95

5

0

100

0

0

95

5

0

100

0

0

80

20

0

Georgia

GE

90

10

0

100

0

0

100

0

0

100

0

0

N/A

N/A

N/A

Germany

DE

70

20

10

70

20

10

100

0

0

80

20

0

50

50

0

Greece

GR

97

3

0

98

2

0

98

2

0

100

0

0

90

10

0

Hungary

HU

90

5

5

90

5

5

95

2

3

100

0

0

100

0

0

IS

100

0

0

100

0

0

100

0

0

100

0

0

0

0

0

Ireland

IE

100

0

0

100

0

0

100

0

0

100

0

0

50

50

0

Israel

IL

98

2

0

100

0

0

98

2

0

100

0

0

80

20

0

Italy

IT

100

0

0

100

0

0

100

0

0

100

0

0

100

0

0

Kazakhstan

KZ

53

47

0

55

45

0

53

47

0

47

53

0

43

57

0

Kosovoa

XK

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Kyrgyzstana

KGZ

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Latvia

LV

70

30

0

70

30

0

70

30

0

70

30

0

20

80

0


Iceland


LB

75

20

5

75

20

5

90

5

5

50

50

0

100

0

0

Libyaa

LY

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A 0

Lithuania

LT

99

1

0

100

0

0

100

0

0

100

0

0

100

0

Luxembourg

LU

95

5

0

100

0

0

90

10

0

100

0

0

0

100

0

FYR Macedonia

MK

100

0

0

100

0

0

100

0

0

100

0

0

33

67

0 0

Malta

MT

100

0

0

100

0

0

100

0

0

100

0

0

0

0

Moldova

MD

100

0

0

0

0

0

0

0

0

0

0

0

100

0

0

Montenegro

ME

50

50

0

50

50

0

100

0

0

50

50

0

50

50

0

Morocco

MA

99

1

0

99

1

0

100

0

0

N/A

N/A

N/A

90

10

0

Netherlands

NL

90

5

5

90

5

5

95

0

5

80

0

20

90

10

0

Norway

NO

100

0

0

100

0

0

100

0

0

100

0

0

100

0

0

Poland

PL

99

1

0

100

0

0

100

0

0

100

0

0

80

20

0 0

Portugal

PT

99

1

0

100

0

0

100

0

0

100

0

0

50

50

Romania

RO

99

1

0

99

1

0

100

0

0

100

0

0

90

10

0

Russian Federation

RU

70

30

0

60

40

0

50

50

0

N/A

N/A

N/A

50

50

0

San Marino

SM

100

0

0

100

0

0

100

0

0

100

0

0

0

0

0

Serbia

RS

100

0

0

100

0

0

100

0

0

100

0

0

80

20

0 0

Slovakia

SK

65

35

0

100

0

0

100

0

0

100

0

0

98

2

Slovenia

SI

10

90

0

5

95

0

100

0

0

50

50

0

0

100

0

Spain

ES

70

25

5

81

14

5

90

10

0

N/A

N/A

N/A

15

85

0

Sweden

SE

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Switzerland

CH

90

10

0

98

2

0

95

5

0

N/A

N/A

N/A

40

60

0

Syriaa

SY

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Tunisiaa

TN

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Turkeya

TR

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Ukraine

UA

10

90

0

18

82

0

18

82

0

50

50

0

0

100

0

United Kingdom

GB

98

2

0

98

2

0

98

2

0

100

0

0

N/A

N/A

N/A


Lebanon

a

These seven countries did not submit data for the EHRA White Book 2014.

i17


i18


San Marino Germany Belgium Luxembourg Switzerland France Austria Italy Iceland Netherlands Greece Malta Spain Norway Sweden Cyprus Croatia Slovenia Estonia Finland Poland Portugal Lebanon United Kingdom Ireland Czech Republic Israel Slovakia Serbia Bulgaria Denmark Georgia Hungary Bosnia & Herzegovina Montenegro Kazakhstan Latvia Lithuania Belarus Romania Russian Federation FYR Macedonia Ukraine Armenia Azerbaijan Algeria Morocco Egypt Moldova

30.8 12.4 10.1

1.1 1.0 1.0 1.0 1.0 0.8 0.7 0.6 0.5 0.3 0.3 0.3

2.0 1.8 1.7 1.5 1.5 1.5 1.4

4.0 4.0 3.9 3.8 3.8 3.7 3.6 3.6 3.6 3.5

2.6 2.6 2.5 2.4

4.5 4.4 4.3

4.9 4.9

6.3

5.4 5.2

9.7 9.5

7.6

6.9 6.8

Figure 10 Number of pacemaker (PM) implanting centres per mil inhabitants in the European Society of Cardiology countries in 2013. Mean number of implantation centres is weighted by population.

Median PM implantations = 552

Belgium Germany Finland Italy Iceland Sweden Austria Estonia France Czech Republic Denmark Portugal Lithuania Switzerland Spain Greece Poland United Kingdom Norway Slovenia Slovakia Hungary Netherlands Latvia Malta Serbia Croatia Israel Bulgaria Ireland San Marino Luxembourg Montenegro Belarus Russian Federation Bosnia & Herzegovina Lebanon Cyprus FYR Macedonia Ukraine Georgia Romania Kazakhstan Moldova Algeria Morocco Egypt Armenia Azerbaijan

552 546 540 515 503 479

34 33 31 14

84 79 65

154 148 125 110

244 224 218 216

312 292

365

646 630 618 605 591

772 763 749 724 716 702 680

431

Mean number of PM implantations = Ø 532

Figure 11 Pacemaker (PM) implantations per million inhabitants 2013.

814

850

912 910 887

1.020 1.012 996 995 967

1.152

1.218

532 = Ø PM implantations per million inhabitants (weighted by population) 4th quartile > 772 ≤ 1218 3rd quartile > 552 ≤ 772 2nd quartile > 218 ≤552 1st quartile ≥ 14 ≤ 218


Mean PM implanting centres = Ø 3.80

i19


532 = Ø PM implantations per million inhabitants (weighted by population) 4th quartile > 772 ≤ 1218 3rd quartile > 552 ≤ 772 2nd quartile > 218 ≤552 1st quartile ≥ 14 ≤ 218 Not available


Figure 12 Pacemaker implantations in the European Society of Cardiology countries in 2013.

Northern Europe

1119 1120 1130 1122 646

627

644

653

European ESC countries

Western Europe

EU28

1024 845

720

640

644

656

656

847

849

852

833

654

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Southern Europe

Eastern Europe

Non-European ESC countries

ESC

819

840 816

818

833 633 283

2009 2010 2011 2012 2013

287

310

311

333

2009 2010 2011 2012 2013

357

420

422

440

638 650

649

647

439

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Figure 13 Pacemaker implantations per million inhabitants 2009 – 2013 in the five geographical regions of the European Society of Cardiology (ESC) and comparison to the total ESC area and the 28 member countries of the European Union (EU28).

i20

TOP 3

Iceland

Finland

917

923

990

1020

1006 836

796

Sweden 967

996

983

973

1041

995

2012

2013

828

* 2009

Lowest 3

2010

2011

2012

2013

2009 2010 2011 2012 2013

418

2009

2010

2010

507

451

479

2011

2012

2013

591

630

2009 2010 2011 2012 2013

2009

450

490

2011

Norway

Latvia

Ireland

457

2009

550

548

678

675

691

680

2010

2011

2012

2013

Figure 14 Pacemaker implantations per million inhabitants 2009 – 2013 in Northern Europe. *No data available.



i21


Germany

Belgium TOP 3

1156 1218 869

Austria

1248 1257 1313 1311

1152 948

838

919

957

950

967

* 2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Netherlands

Luxembourg

Lowest 3

621 200

600

585

Switzerland

560

605

741

713

791

753

763

365

336

179

2009 2010 2011* 2012 2013

* 2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013 Downloaded from by guest on October 14, 2015

Figure 15 Pacemaker implantations per million inhabitants 2009– 2013 in Western Europe. *No data available.

Poland

Czech Republic

TOP 3 859

849

881

899

Slovakia

887 713

719

710

716

716 513

2009 2010 2011 2012 2013 Lowest 3

2009 2010 2011 2012 2013

Romania

117

139

144

110

2009

2010

2011

2012

2013

85

103

617

567

630

2009 2010 2011 2012 2013

Ukraine

140

548

Russian Federation

112

121

148

2009 2010 2011 2012 2013

Figure 16 Pacemaker implantations per million inhabitants 2009– 2013 in Eastern Europe.

186

188

216

212

244

2009

2010

2011

2012

2013

i22


Italy

TOP 3

Spain

Portugal

1047 1047 1034 1001 1012 825

764

686

814

747

762

734

738

749

595

2009 2010 2011 2012 2013

Lowest 3

119

174

2009 2010 2011 2012 2013


FYR Macedonia

150

2009 2010 2011 2012 2013

166

205

154

234

Montenegro

224

253

264

257

138

312 218

* 2009 2010 2011 2012 2013

2009 2010 2011 2012 2013


Figure 17 Pacemaker implantations per million inhabitants 2009 – 2013 in Southern Europe. *No data available.

Israel

TOP 3

567

Georgia

Cyprus

500

558

515

249

208

223

211

216 102

125

2009 2010 2011 2012 2013

2009 2010 2011 2012

2013

Armenia

Egypt

60

71

84

* 2009 Lowest 3

2010

2011

2012

2013

Azerbaijan

124 65 15 *

*

2009

2010

14

133 74

31

* 2011

2012

29

30

19

33

* 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012

2013

Figure 18 Pacemaker implantations per million inhabitants 2009– 2013 in the non-European European Society of Cardiolgy (ESC) countries. *No data available.

i23


Table 6 Changes in pacemaker implantation centres in year 2012 vs. 2013 Country

ISO code



Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

....................................................

....................................................

Change %

............................................................................................................................................................................... Albaniaa

AL

N/A

N/A

N/A

N/A

N/A

Algeria

DZ

N/A

N/A

19

0.50

N/A

Armenia Austria

AM AT

3 57

1.01 6.93

2 57

0.65 6.93

235% 0%

Azerbaijan

AZ

N/A

N/A

6

0.63

N/A

Belarus

BY

10

1.04

10

1.04

0.2%


BE BA

103 6

9.29 1.55

105 6

10.05 1.55

8.2% 0.1%

Bulgaria

BG

17

2.42

17

2.43

1%

Croatia Cyprus

HR CY

17 5

3.79 4.39

18 5

4.02 4.33

6% 22%

Czech Republic

CZ

37

3.64

37

3.49

24.1%

Denmark Egypt

DK EG

9 28

1.62 0.33

11 28

1.98 0.33

22% 21.9%

Estonia

EE

5

3.92

5

3.95

1%

Finland France

FI FR

20 474

3.80 7.22

20 500

3.80 7.58

0% 5%

GE

9

1.97

9

1.82

28%

DE GR

1048 56

12.89 5.20

1010 56

12.45 5.20

23% 0.0%

Hungary

HU

16

1.61

17

1.71

6.5%

Iceland Ireland

IS IE

1 17

3.19 3.60

2 17

6.34 3.56

99% 21%

Israel

IL

18

2.37

20

2.60

9%

Italy Kazakhstan

IT KZ

400 22

6.53 1.26

420 27

6.83 1.52

4.6% 21%

Kosovoa

XK

N/A

N/A

N/A

N/A

N/A

Kyrgyzstana Latvia

KGZ LV

3

0 1.37

N/A 3

N/A 1.38

N/A 0.6%

Lebanon

LB

N/A

N/A

15

3.63

N/A

Libyaa Lithuania

LY LT

N/A 4

N/A 1.13

N/A 4

N/A 1.14

N/A 0.3%

Luxembourg

LU

5

9.82

5

9.71

21.1%

FYR Macedonia Malta

MK MT

3 2

1.44 4.88

2 2

0.96 4.86

233.5% 20.4%

Moldova

MD

N/A

N/A

1

0.28

N/A

Montenegro Morocco

ME MA

1 11

1.52 0.34

1 11

1.53 0.34

0.6% 21.0%

Netherlands

NL

90

5.38

90

5.36

20.4%

Norway Poland

NO PL

23 132

4.60 3.44

23 145

4.52 3.78

21.7% 9.9%

Portugal

PT

42

4

40

3.70

24.9%


RO RU

21 140

0.96 0.98

22 140

1.01 0.98

5% 0%

San Marino

SM

1

31.11

1

30.82

21%

Serbia Slovakia

RS SK

17 13

2.34 2.37

18 14

2.49 2.55

6.4% 8%

Slovenia

SI

6

3.01

8

4.01

34%

Spain Sweden

ES SE

220 43

4.68 4.72

230 42

4.86 4.35

3.8% 28%

Continued


Georgia Germany Greece

i24



ISO code



Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

....................................................

Change %

....................................................

...............................................................................................................................................................................

a

Switzerland Syriaa

CH SY

74 N/A

9.34 N/A

76 N/A

9.50 N/A

2% N/A

Tunisiaa

TN

10

1

N/A

N/A

N/A

Turkeya Ukraine

TR UA

N/A 36

N/A 0.79

N/A 36

N/A 0.81

N/A 2%

United Kingdom

GB

205

3.25

227

3.58

10%

Total ESC countries

56

These seven countries did not submit data for the EHRA White Book 2014.

2012 3.2 3.0

33.6 21.9 21.2 10.1 9.9 9.4 8.2 7.6 6.5 6.4 6.0 5.0 5.0 4.6 3.8 1.9 1.8 0.8 0.7 0.6 0.6 0.3 0.2 0.1 0.0

1.6 1.3 3.3 3.4 2.4

9.3

2.4 1.6 2.3 3.8

1.0

4.7

7.2 6.5

0.8 9.3

2.4 1.4 1.5 1.1 1.0 1.5 1.0

3.9

6.9 5.2 3.8 4.9 5.4 0.3

9.8 3.6 4.4 4.6

0.3

2.0

3.6 3.9

12.9

4.7

1.4 1.0

98.7

6.3

4.0 2.0 1.5 3.6 3.8 2.6

10.1

2.6 1.7 2.5 4.0

1.0

4.9

7.6 6.8

0.8 9.5

2.4 1.4 1.5 1.1 1.0 1.5 1.0

3.9

6.9

0.0 0.0 –0.1 –0.4 –0.4 –0.9 –1.0 –1.1 –1.1 –1.5 –1.7 –1.9 –3.4 –4.1 –4.9 –7.5 –7.8

31.1

2013


Iceland Slovenia Denmark Kazakhstan United Kingdom Poland Israel Belgium Slovakia Hungary Serbia Croatia Romania France Italy Spain Ukraine Switzerland Bulgaria Estonia Latvia Montenegro Lithuania Belarus Bosnia & Herzegovina Russian Federation Austria Greece Finland Malta Netherlands San Marino Morocco Luxembourg Ireland Cyprus Norway Egypt Germany Czech Republic Portugal Georgia Sweden FYR Macedonia Armenia

2013 vs. 2012 in %

3.8

5.2 4.9 5.4

0.3

30.8 9.7

3.6 4.3 4.5 0.3

1.8

–33.5 –35.4

3.5 3.7

12.4

4.4

1.0 0.7

Figure 19 Change in the number of pacemaker implanting centres per million inhabitants 2012 to 2013.

standards for theoretical and practical training for all healthcare professionals, regardless of their country of origin.

Pacemakers General information The 49 countries (88% of all ESC member countries) that submitted the requested data on PM implantation for the EHRA White Book

are listed in Table 4. According to the EHRA White Book, 808 667 710 people lived in these countries. A national registry for PM implantations existed in 26 countries (Table 4). The vast majority of implants were performed by cardiologists (82%), and the remaining implantations were performed by physicians with various training backgrounds, including surgeons, anaesthesiologists, paediatricians, and internists. In some countries (Austria, Belarus, Bosnia and Herzegovina, Montenegro, Russian Federation, Slovenia, and Ukraine), the proportion of implanting cardiologists was 50% or less (Table 5).

i25


Table 7 Changes in pacemaker implantations in year 2012 vs. 2013 Country

ISO code



Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

N/A

N/A

N/A

N/A

N/A N/A

......................................................

......................................................

Change %

............................................................................................................................................................................... Albaniaa

AL

Algeria

DZ

N/A

N/A

2480

65.11

Armenia

AM

221

74.40

94

30.68

259%

Austria

AT

7870

957.45

7950

966.96

1%

Azerbaijan

AZ

N/A

N/A

131

13.66

N/A

Belarus

BY

2651

274.90

2813

292.23

6.3%

Belgium

BE

12 817

1156.48

12 725

1218.37

5.4%


BA

909

234.32

868

223.96

24.4%

Bulgaria

BG

3153

448.00

3511

502.89

12%

Croatia

HR

2515

561.38

2418

540.26

24%

Cyprus

CY

240

210.88

250

216.37

3%

Czech Republic

CZ

9150

899.06

9416

887.48

21.3%

Denmark

DK

4663

841.17

4725

850.36

1% 11.9%

EG

2500

29.87

2850

33.41

EE

954

748.41

1155

912.05

22%

Finland

FI

5208

990

5369

1019.54

3%

France

FR

62 846

957.57

60 000

909.76

25% 23%

Georgia

GE

467

102.17

620

125.45

Germany

DE

106 567

1310.69

93 520

1152.47

212%

Greece

GR

7440

690.95

7800

724.03

4.8%

Hungary

HU

6046

607.12

6143

618.04

1.8%

Iceland

IS

303

967.49

314

995.94

3%

Ireland

IE

2129

450.87

2288

479.06

6%

Israel

IL

4236

558.05

3966

514.59

28%

Italy

IT

61 300

1000.63

62 198

1011.64

1.1%

Kazakhstan

KZ

1227

70.03

1489

83.95

20%

Kosovoa

XK

N/A

N/A

N/A

N/A

N/A

Kyrgyzstana

KGZ

N/A

N/A

N/A

N/A

N/A

Latvia

LV

1201

548.01

1288

591.25

7.9%

Lebanon

LB

N/A

N/A

900

217.83

N/A

Libyaa

LY

N/A

N/A

N/A

N/A

N/A

Lithuania

LT

2666

756.15

2716

772.50

2.2%

Luxembourg

LU

316

620.73

188

365.15

241.2%

FYR Macedonia

MK

345

165.68

322

154.28

26.9%

Malta

MT

264

644.16

227

551.94

214.3%

Moldova

MD

N/A

N/A

287

79.28

N/A

Montenegro

ME

143

217.53

204

312.18

43.5%

Morocco

MA

1231

38.10

1109

33.97

210.8%

Netherlands

NL

9370

560.05

10 174

605.41

8.1%

Norway

NO

3456

691.20

3459

680.16

21.6%

Poland

PL

27 498

715.81

27 500

716.45

0.1%

Portugal

PT

8890

825

8790

813.94

21.3%

Romania

RO

3150

144.17

2400

110.14

224%

Russian Federation

RU

30 218

212.03

34 758

243.91

15%

San Marino

SM

26

808.96

14

431.46

247%

Continued


Egypt Estonia

i26



ISO code



Absolute number

Absolute number

...................................................... Per mil inhabitants

......................................................

Change %

Per mil inhabitants

...............................................................................................................................................................................

a

Serbia

RS

3139

431.38

3958

546.46

26.7%

Slovakia

SK

3111

567.38

3456

629.70

11%

Slovenia

SI

1333

667.63

1287

645.86

23%

Spain

ES

34 710

737.84

35 500

749.41

1.6%

Sweden

SE

9476

1040.89

9602

995.30

24%

Switzerland

CH

5965

752.63

6097

762.50

1%

Syriaa

SY

N/A

N/A

N/A

N/A

N/A

Tunisiaa

TN

2500

233

N/A

N/A

N/A

a

Turkey

TR

N/A

N/A

N/A

N/A

N/A

Ukraine

UA

5491

120.90

6579

147.60

22%

United Kingdom

GB

38 770

614.94

44 503

701.99

14%

These seven countries did not submit data on PM implantations for the EHRA White Book 2014.

2013 vs. 2012 in %

217.5 431.4 102.2 120.9

2013 312.2

43.5

748.4 70.0 212.0 614.9 448.0 29.9 567.4 560.1 548.0 274.9 450.9 1.156.5 690.9 989.6 967.5 210.9 756.1 607.1 737.8 752.6 1.000.6 841.2 957.5 715.8 899.1 824.6 691.2 667.6 561.4 1.040.9

26.7 22.8 22.1 21.9 19.9 15.0 14.2 12.3 11.9 11.0 8.1 7.9 6.3 6.3 5.4 4.8 3.0 2.9 2.6 2.2 1.8 1.6 1.3 1.1 1.1 1.0 0.1

–1.3 –1.3 –1.6 –3.3 –3.8 –4.4 234.3 –4.4 –5.0 957.6 –6.9 165.7 –7.8 558.0 38.1 –10.8 1.310.7 –12.1 644.2 –14.3 144.2 –23.6 –41.2 620.7 809.0 –46.7 74.4 –58.8

Figure 20 Change in the number of pacemaker implantations per million inhabitants 2012 to 2013.


2012 Montenegro Serbia Georgia Ukraine Estonia Kazakhstan Russian Federation United Kingdom Bulgaria Egypt Slovakia Netherlands Latvia Belarus Ireland Belgium Greece Finland Iceland Cyprus Lithuania Hungary Spain Switzerland Italy Denmark Austria Poland Czech Republic Portugal Norway Slovenia Croatia Sweden Bosnia & Herzegovina France FYR Macedonia Israel Morocco Germany Malta Romania Luxembourg San Marino Armenia

546.5 125.5 147.6 912.1 83.9 243.9 702.0 502.9 33.4 629.7 605.4 591.2 292.2 479.1 1.218.4 724.0 1.019.5 995.9 216.4 772.5 618.0 749.4 762.5 1.011.6 850.4 967.0 716.4 887.5 813.9 680.2 645.9 540.3 995.3 224.0 909.8 154.3 514.6 34.0 1.152.5 551.9 110.1 365.1 431.5 30.7

i27


2013 vs. 2012

2012

64.0 59.8 25.8 23.8 21.5 18.0 17.5 13.3 9.9 7.4 5.9 5.8 5.7 5.7 4.7 4.5 4.4 3.5 2.8 1.8 0.8 0.5 0.2 0.0

181.0 514.1 402.1 348.3 101.9 670.0 67.0 179.1 470.4 797.6 515.9 432.1 751.7 420.2 630.0 241.5 511.2 557.3 636.7 694.5 509.5 634.3 572.1 476.2 629.8 766.1 734.5 535.6 489.1 234.3 37.1 132.5 729.7 517.3 141.9 428.2 466.7 64.6

–1.0 –1.0 –3.3 –4.2 –5.2 –9.0 –11.8 –13.2 –22.4 –32.8 –35.3 –43.3 –47.2

296.9 821.5 505.9 431.3 123.9 790.4 78.7 203.0 516.9 856.5 546.5 457.2

794.5 444.1 659.7 252.4 533.7 577.0 654.7 707.2 513.7 637.6 573.2 476.2 623.5 758.1 710.5 513.2 463.6 213.1 32.7 115.0 566.5 347.7 91.8 242.8 246.5 19.3

–70.2


Montenegro Iceland Serbia Bulgaria Ukraine Estonia Kazakhstan Russian Federation Slovakia Belgium Slovenia Latvia Finland Netherlands Portugal Belarus Greece Switzerland Lithuania Austria United Kingdom Denmark Poland Hungary Czech Republic France Sweden Norway Croatia Bosnia & Herzegovina Morocco FYR Macedonia Italy Malta Romania Luxembourg San Marino Armenia

2013

Figure 21 Change in the number of new pacemaker implantations per million inhabitants 2012 to 2013.

2012 United Kingdom Estonia Italy Malta Serbia Iceland Morocco Ukraine Russian Federation Belarus FYR Macedonia Armenia Slovakia Latvia Netherlands Belgium Hungary Norway Croatia Greece Denmark Poland Austria Lithuania Czech Republic Switzerland Finland Sweden Kazakhstan Romania Portugal France Bulgaria Slovenia Luxembourg San Marino Montenegro

2013 vs. 2012

271.0 126.9 29.3 134.1 1.0 19.0 32.9 33.4 33.1 9.8 97.0 115.9 139.8 332.2 130.9 155.6 72.3 179.6 208.7 143.7 262.9 119.4 269.2 195.3 237.9 306.4 6.4 22.9 194.6 191.5 99.7 151.8 192.5 342.3 36.5

2013

78.5 70.3 64.3 61.0

105.5 71.4 38.7 30.1 27.7 25.0 24.2 19.2 18.6 17.0 16.2 15.7 15.4 8.9 8.3 7.3 6.0 5.9 1.9 –0.3 –1.2 –1.4 –1.9 –5.0 –5.4 –7.0 –18.7 –19.8 –20.7 –20.8 –28.2 –34.5 –36.4 –46.0 –58.1

Figure 22 Change in the number of pacemaker replacements per million inhabitants 2012 to 2013.

188.3 121.6 445.1 204.2 40.6 174.4 1.2 23.7 40.9 39.8 39.3 11.4 112.8 134.0 161.3 361.9 141.9 166.9 76.6 190.3 212.7 143.3 259.8 117.8 264.0 185.5 225.0 284.8 5.2 18.4 154.3 151.6 71.6 99.4 122.4 184.9 15.3

i28


The change in the number of implanting centres from 2102 to 2103 is shown in Table 6 and Figure 19 and the change in the number of PM implantations per million inhabitants during the same period is presented in Table 7 and Figure 20. The increase in the number of PM implantations was highest in the Southern European countries Montenegro (44%) and Serbia (27%). Increase in PM implantation exceeded 20% also in Georgia, Ukraine, and Estonia. On the other hand, there was a .20% drop in the number of devices implanted in Armenia (59%), San Marino (47%), Luxembourg (41%), and Romania (24%). The changes in the de novo implantation rate are shown in Figure 21 and for PM generator replacements in Figure 22. The relationship between the mean annual PM implantation rate per million inhabitants and the number of PM implanting centres per million inhabitants in the 28 member countries of the European Union (EU28) is shown in Figure 23.

Pacemaker facilities and procedure rate It was reported that in 3580 centres, a total of 500 411 PMs were implanted in 2013 (Table 4). The mean number of centres implanting PMs per million inhabitants was (3.8) same as in the preceding year (Figure 10). Excluding San Marino, the country with the highest density of implanting facilities was Germany (12.4 per million in habitants) and those with the lowest density were Egypt, Moldova, and Morocco with only 0.3 implantations per million inhabitants (Figure 10) (0.3), which is consistent with EHRA White Book data from previous years. In 2013, the mean PM implantation rate in the participating ESC countries was 532 PM units per million inhabitants. The implantation rate was highest in Belgium (1218) and Germany (1152), and lowest in Azerbaijan (14) and Egypt (30). An overview of the PM implantation rate per million inhabitants for each nation that reported to the EHRA White Book is shown in Figures 11 and 12. Across the 49 countries, marked heterogeneity was observed in the geographic distribution of PM implantation rate per million inhabitants. The number of PM implantations according to the five ESC regions and the trend in implantation rate with comparison to the 28 European Union member countries (EU-28) and the whole ESC area from 2009 to 2013 are shown in Figure 13. Countries with the highest and lowest activities in each region as well as yearly trends are shown in Figures 14, 15, 16, 17 and 18. The number of PM implantations per million inhabitants was highest in the Western Europe, and lowest in the Eastern Europe and in the non-European ESC countries. The most active countries in each region were Belgium (1.218 per million inhabitants), Finland (1.020), Italy (1.012), Czech Republic (887), and Israel (515). The PM implantation rate in Israel (515) was more than double compared with the second most active non-European ESC country.

Implantable cardioverter defibrillators General information

PM implantations per million inhabitants

ESC 56 EU28

1.400

1.400

1.200

1.200

1.000

1.000

BE DE FI

CZ DK

800

800

LT

600

PT

MK

MD AZ EG

RU

IE HR

DZ

0

CY

200

LB

KZ AM

1

SM

LU

GE

RO

MA

MT

400

BA

UA

0

CH GR

ME

BY

200

FR

NL

IL BG

AT

NO ES

600

RS

400

IS

PL GB SI

SK

HU

LV

IT

SE EE

0 2

3

3

4

5

6

7

8

9

10

11

12 31

PM implanting centres per mil inhabitants

Figure 23 Pacemaker (PM) implantation centres and rates in the European Society of Cardiology (ESC) and European Union (EU28) member countries in 2013. Bubble size is related to population in the country.


The 46 countries which submitted data for the EHRA White Book on ICDs in 2013 are listed in Table 8. Albania, Belarus, France, Kosovo, Kyrgyzstan, Libya, Portugal, Syria, Tunisia, and Turkey did not report data related to ICD implantations. In 28 countries, a national registry for ICD implantations was in use, surprisingly slightly down from 30 in 2012. France, a country with a moderately high implantation rate in previous years, did not provide data on the use of ICDs for 2013. The vast majority of implants were performed by cardiologists (83%), and the remaining implantations were performed by physicians having various other training backgrounds, mainly surgical.

Country

ISO code

National Registry for ICD implants

Number of ICD implanting centres 2013

ICD implantations 2013

Development potential— target number of ICD implantations . . .

ICD implantations per mil inhabitants


2009

.....................................

..................................... ......................................... ............................................

Absolute number

Absolute number

Per mil inhabitants

Per mil inhabitants


2010

2011

2012

2013

............................................................................................................................................................................................................................................. Albaniaa

AL

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Algeria Armenia

DZ AM

No No

8 2

0.21 0.65

38 28

1 9

3800 306

6839 550

N/A 10

N/A 11

N/A 12

N/A N/A

1 9

Austria

AT

Yes

21

2.55

1296

158

–

1476

154

151

220

145

158

Azerbaijan Belarusa

AZ BY

No Yes

2 N/A

0.21 N/A

13 N/A

1 N/A

957 N/A

1722 N/A

N/A 5

2 6

2 14

N/A 12

1 N/A

Belgium

BE

Yes

23

2.20

1704

163

–

1875

169

188

197

198

163

Bosnia & Herzegovina Bulgaria

BA BG

No Yes

5 8

1.29 1.15

65 32

17 5

387 697

696 1254

N/A 1

8 1

13 8

14 7

17 5

Croatia

HR

N/A

12

2.68

156

35

447

804

24

18

19

26

35

Cyprus Czech Republic

CY CZ

No Yes

3 17

2.60 1.60

60 3196

52 301

115 –

207 –

45 117

43 251

58 270

46 277

52 301

Denmark

DK

Yes

6

1.08

1285

231

–

–

181

194

198

218

231

Egypt Estonia

EG EE

No No

13 2

0.15 1.58

178 104

2 82

8511 126

15 316 227

0 15

1 39

N/A 45

2 79

2 82

Finland

FI

No

19

3.61

1020

194

–

–

120

150

134

166

194

Francea Georgia

FR GE

No No

148 7

2.24 1.42

N/A 59

N/A 12

N/A 493

N/A 887

88 2

94 3

102 5

106 12

N/A 12

Germany

DE

No

654

8.06

27 241

336

–

–

288

305

326

326

336

Greece Hungary

GR HU

No Yes

24 14

2.23 1.41

1050 940

97 95

1075 992

1934 1785

102 61

86 72

83 80

87 85

97 95

Iceland

IS

No

1

3.17

54

171

–

57

88

78

113

134

171

Ireland Israel

IE IL

Yes Yes

17 20

3.56 2.60

732 1277

153 166

– –

858 1384

144 109

134 178

140 156

144 137

153 166

Italy

IT

Yes

365

5.94

12 556

204

–

–

174

183

196

196

204

Kazakhstan Kosovoa

KZ XK

No N/A

12 N/A

0.68 N/A

221 N/A

12 N/A

1770 N/A

3185 N/A

N/A N/A

N/A N/A

N/A N/A

7 N/A

12 N/A

Kyrgyzstana

KGZ

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Latvia Lebanon

LV LB

Yes No

2 10

0.92 2.42

88 300

40 73

217 412

391 742

16 N/A

19 N/A

29 N/A

32 N/A

40 73

Libyaa

LY

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Lithuania

LT

No

3

0.85

124

35

351

631

19

26

33

42

35

i29

Continued


Table 8 Implantable cardioverter defibrillator implantation facilities and rates in the ESC countries in 2013 and comparison to four previous years


i30


ISO code

National Registry for ICD implants



Development potential— target number of ICD implantations . . .

ICD implantations per mil inhabitants



2009

– 208

92 375

86 2

.....................................

..................................... ......................................... ............................................

Absolute number

Absolute number

Per mil inhabitants

Per mil inhabitants

2010

2011

2012

2013

............................................................................................................................................................................................................................................. Luxembourg FYR Macedonia

LU MK

Yes Yes

1 2

1.94 0.96

71 12

138 6

73 7

99 13

149 7

138 6

Malta

MT

Yes

1

2.43

67

163

–

74

82

72

71

132

163

Moldova Montenegro

MD ME

N/A No

0 1

0.00 1.53

0 38

0 58

361 65

650 117

N/A 29

N/A 29

N/A 47

N/A 44

0 58

Morocco

MA

Yes

5

0.15

34

1

3258

5863

N/A

1

1

1

1

Netherlands Norway

NL NO

Yes Yes

31 11

1.84 2.16

4096 1089

244 214

– –

– –

N/A 110

171 125

155 184

160 199

244 214

Poland

PL

No

115

3.00

9500

248

–

–

138

183

157

182

248

Portugala Romania

PT RO

Yes Yes

27 17

2.50 0.78

N/A 200

N/A 9

N/A 2174

N/A 3913

69 6

75 8

95 8

92 8

N/A 9

Russian Federation

RU

Yes

57

0.40

1870

13

14 219

25 588

4

4

10

11

13

San Marino Serbia

SM RS

Yes Yes

1 8

30.82 1.10

20 448

616 62

– 723

– 1301

656 52

625 39

597 44

404 38

616 62

Slovakia

SK

Yes

4

0.73

591

108

–

985

82

91

100

105

108

Slovenia Spain

SI ES

Yes Yes

2 153

1.00 3.23

142 3885

71 82

199 4727

358 8506

54 84

50 71

72 74

61 73

71 82

SE

Yes

29

3.01

1911

198

–

–

71

114

N/A

193

198

CH SY

Yes N/A

46 N/A

5.75 N/A

1604 N/A

201 N/A

– N/A

– N/A

176 N/A

203 N/A

142 N/A

195 N/A

201 N/A

Tunisiaa

TN

N/A

N/A

N/A

N/A

N/A

N/A

N/A

5

8

8

9

N/A

Turkeya Ukraine

TR UA

N/A No

N/A 17

N/A 0.38

N/A 85

N/A 2

N/A 4447

N/A 8004

N/A 0

N/A 1

N/A 1

N/A 1

N/A 2

United Kingdom

GB

Yes

106

1.67

5809

92

6326

11 383

82

83

86

91

92

Total

56

2052

85 289

a

These 10 countries did not submit data on ICD implantations in 2013 for the EHRA White Book.


Sweden Switzerland Syriaa


i31


ICD implanting centres per mil inhabitants San Marino Germany Italy Switzerland Finland Ireland Spain Iceland Sweden Poland Croatia Cyprus Israel Austria Portugal Malta Lebanon France Greece Belgium Norway Luxembourg Netherlands United Kingdom Czech Republic Estonia Montenegro Georgia Hungary Bosnia & Herzegovina Bulgaria Serbia Denmark Belarus Slovenia FYR Macedonia Latvia Lithuania Romania Slovakia Kazakhstan Armenia Russian Federation Ukraine Algeria Azerbaijan Morocco Egypt Moldova

30.8 8.1

2.2 2.2 2.2 2.2

0.2 0.2 0.2 0.2 0.0

0.4 0.4

1.7 1.6 1.6 1.5 1.4 1.3 1.4 1.1 1.1 1.1 1.0 1.0 1.0 0.9 0.9 0.8 0.7 0.7 0.7

2.7 2.6 2.6 2.6 2.5 2.4 2.4

3.2 3.2 3.0 3.0

5.9 5.8

3.6 3.6

1.9 1.8

Mean ICD implanting centres = Ø 2.20

Median ICD implantations = 82

San Marino Germany Czech Republic Poland Netherlands Denmark Norway Italy Switzerland Sweden Finland Iceland Israel Belgium Malta Austria Ireland Luxembourg Slovakia Greece Hungary United Kingdom Estonia Spain Lebanon Slovenia Serbia Montenegro Cyprus Latvia Lithuania Croatia Bosnia & Herzegovina 17 Russian Federation 13 12 Kazakhstan Georgia 12 9 Romania 9 Armenia FYR Macedonia 6 5 Bulgaria Egypt 2 Ukraine 2 Azerbaijan 1 Morocco 1 Algeria 1 Moldova 0

616 336 301 231 204 201 198 194

138

52

62 58

73 71

82 82

97 95 92

171 166 163 163 158 153

108

248 244

214

100 = Ø ICD implantations per mil inhabitants (weighted by population) 4th quartile > 170 ≤ 616 3rd quartile > 82 ≤ 170 2nd quartile > 13 ≤82 1st quartile ≥ 0 ≤ 13

40 35 35

Mean number of ICD implantations = Ø 100

Figure 25 Implantable cardioverter defibrillator (ICD) implantations per million inhabitants in 2013.


Figure 24 Implantable cardioverter defibrillator (ICD) implanting centres per million inhabitants in 2013. Mean number of implantation centres is weighted by population.

i32


100 = Ø ICD implantations per million inhabitants (weighted by population) 4th quartile > 170 ≤ 616 3rd quartile > 82 ≤ 170 2nd quartile > 13 ≤ 82 1st quartile ≥ 0 ≤ 13 Not available


Figure 26 Implantable cardioverter defibrillator (ICD) implantations in the European Society of Cardiology countries in 2013.

257

95

90

100

109


Western Europe

Northern Europe

273

292

289

295

113

99

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Southern Europe

Eastern Europe

121

118

125

125

2009 2010 2011 2012 2013

107

42

47

116

125

143

155

59

2009 2010 2011 2012 2013

68

95

86

101

2009 2010 2011 2012 2013

162

165

176

2009 2010 2011 2012 2013

ESC


108 41

113

2009 2010 2011 2012 2013

135 29

EU28

98

107

113

115

124

2009 2010 2011 2012 2013

Figure 27 Implantable cardioverter defibrillator (ICD) implantations per million inhabitants 2009– 2013 in the five geographical regions of the European Society of Cardiology (ESC) and comparison to the total ESC area and the 28 member countries of the European Union (EU28).

i33


Denmark

TOP 3

181

194

198

Norway 218

Sweden

231 184 110

199

214

193

125

198

114 71 *

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Lithuania

Lowest 3

2009 2010 2011 2012 2013

Latvia

Estonia

79 19

33

26

42

35

19

32

40 15

2009 2010 2011 2012 2013

82

45

39

2009 2010 2011 2012 2013

Figure 28 Implantable cardioverter defibrillator (ICD) implantations per million inhabitants 2009 – 2013 in Northern Europe. *No data available.

Netherlands

Germany

TOP 3 288

305

326

326

Switzerland

336 244 171

155

176

160

203

195

201

142

* 2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Luxembourg

Lowest 3

2009 2010 2011 2012 2013

Austria

Belgium

220 149 86

73

138

154

151

145

158

169

188

197

198 163

99

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Figure 29 Implantable cardioverter defibrillator (ICD) implantations per million inhabitants 2009 – 2013 in Western Europe. *No data available.


2009 2010 2011 2012 2013

16

29

i34


Poland

Czech Republic

TOP 3

251

270

277

Slovakia

301 248 183 138

117

157

182 82

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Ukraine

Lowest 3

0

1

91

1

2

2009 2010 2011 2012 2013

1

1

8

105

108

2009 2010 2011 2012 2013

Bulgaria

1

100

Romania

7

5

8

8

8

9


2009 2010 2011 2012 2013

6

Figure 30 Implantable cardioverter defibrillator (ICD) implantations per million inhabitants 2009 – 2013 in Eastern Europe.

Malta

Italy

TOP 3

174

183

196

196

Greece

204 163 132 102 82

2009 2010 2011 2012 2013

2

7

13

71

2009 2010 2011 2012 2013

7

6

2009 2010 2011 2012 2013

8

13

14

86

83

87

97

2009 2010 2011 2012 2013

Croatia


FYR Macedonia

Lowest 3

72

17

24

18

19

26

35

* 2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Figure 31 Implantable cardioverter defibrillator (ICD) implantations per million inhabitants 2009 – 2013 in Southern Europe. *No data available.

i35


Cyprus

Israel

TOP 3

178 156

Georgia

166 137

109 45

2009 2010 2011 2012 2013

Lowest 3

46

52 2

3

5

12

12

2009

2010

2011

2012

2013

2

2

Egypt

Azerbaijan

1

1

1

1

2010

2011

2012

2013

*

2

2

*

1

2009 2010 2011 2012 2013

0

1

*

2009 2010 2011 2012 2013

Figure 32 Implantable cardioverter defibrillator (ICD) implantations per million inhabitants 2009 – 2013 in non-European European Society of Cardiology (ESC) countries. *No data available.

However, in some countries (Austria, Iceland, Kazakhstan, Montenegro, Russian Federation, Slovenia, and Ukraine), the proportion of implanting cardiologists was about 50% or less (Table 5).

Implantable cardioverter defibrillator facilities and procedure rates It was reported that in 2052 national centres, a total of 85 289 ICDs were implanted in 2013 (Table 8). Table 8 also shows a comparison to previous years in each country. The number of ICD implantation centres per million inhabitants is shown in Figure 24. In the ESC area the mean number of ICD implantations per million inhabitants in 2013 was 100 compared with 96 in 2012. In Figures 25 and 26 the ESC countries are grouped into quartiles according to the number of ICD implantations per million inhabitants. Excluding San Marino, Germany (336 per million inhabitants), the Czech Republic (301), and Belarus (292) had the highest implant rates while the lowest reported were in Algeria, Azerbaijan, and Morocco (1 per million inhabitants for each). In Moldova no ICDs were implantated in 2013 (Table 8 and Figure 25). The number of ICD implantations according to the five ESC regions and the trend from 2009 to 2013, compared with the EU28 and the whole ESC area, is shown in Figure 27. In Western Europe the number of ICD implantations per million inhabitants (295) was more than twice higher than in any other ESC region. Implantable cardioverter defibrillator implantation rate exceed 100 per million

population also in the Southern (135) and Northern (113) European regions and in the non-European ESC countries (101), whereas in the Eastern European region only 59 ICDs per million population were implanted. The top and bottom three countries within the five ESC region are shown in Figures 28, 29, 30, 31 and 32. After excluding San Marino, the most active countries in each region were Germany (336 per million inhabitants), Denmark (231), the Czech Republic (301), Italy (204), and Israel (166). The mean number of implanting centres in ESC area was 2.2 per country. The change in the number of implanting centres from 2102 to 2103 is shown in Table 9 and Figure 33 and the change in the number of ICD implantations per million inhabitants during the same period is presented in Table 10 and Figure 34. These numbers are divided into de novo implantations and ICD generator replacements in Figures 35 and 36. The increase in ICD implantations per million inhabitants was greatest in Kazakhstan, Ukraine, and Serbia. Given the above reported disparities in ICD use in Europe, it was encouraging that ICD implantation rate increased by .25% in the Eastern European area. On the other hand, four countries (Bulgaria, FYR Macedonia, Belgium, and Lithuania) reported a .10% drop in the ICD implantation rate per million population (Table 10 and Figure 34). The relationship between the annual ICD implantation rate per million inhabitants and the number of ICD implanting centres per million inhabitants in the EU28 countries and the ESC area are shown in Figure 37.


2009

58

2009 2010 2011 2012 2013

Morocco

*

43

i36


Table 9 Change in the number of ICD implantation centres in year 2012 vs. 2013 Country

ISO code



Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

.....................................................

.....................................................

Change %

............................................................................................................................................................................... AL

N/A

N/A

N/A

N/A

N/A

Algeria

DZ

N/A

N/A

8

0.21

N/A

Armenia Austria

AM AT

3 21

1.01 2.55

2 21

0.65 2.55

235% 0%

Azerbaijan

AZ

N/A

N/A

2

0.21

N/A

Belarus

BY

7

0.73

N/A

N/A

N/A


BE BA

23 4

2.08 1.03

23 5

2.20 1.29

6.1% 25.1%

Bulgaria

BG

4

0.57

8

1.15

102%

Croatia Cyprus

HR CY

12 3

2.68 2.64

12 3

2.68 2.60

0% 22%

Czech Republic

CZ

17

1.67

17

1.60

24.1%

Denmark Egypt

DK EG

6 11

1.08 0.13

6 13

1.08 0.15

0% 16.0%

Estonia

EE

2

1.57

2

1.58

1%

Finland France

FI FR

19 148

3.61 2.26

19 148

3.61 2.24

0% 0%

Georgia

GE

7

1.53

7

1.42

28%

Germany Greece

DE GR

670 24

8.24 2.23

654 24

8.06 2.23

22% 0.0%

Hungary

HU

13

1.31

14

1.41

7.9%

Iceland Ireland

IS IE

1 17

3.19 3.60

1 17

3.17 3.56

21% 21%

Israel

IL

21

2.77

20

2.60

26%

Italy Kazakhstan

IT KZ

360 5

5.88 0.29

365 12

5.94 0.68

1.0% 137%

Kosovoa

XK

N/A

N/A

N/A

N/A

N/A

Kyrgyzstana Latvia

KGZ LV

2

0 0.91

N/A 2

N/A 0.92

N/A 0.6%

Lebanon

LB

N/A

N/A

10

2.42

N/A

Libyaa Lithuania

LY LT

N/A 3

N/A 0.85

N/A 3

N/A 0.85

N/A 0.3%

Luxembourg

LU

1

1.96

1

1.94

21.1%

FYR Macedonia Malta

MK MT

2 1

0.96 2.44

2 1

0.96 2.43

20.2% 20.4%

Moldova

MD

N/A

N/A

0

0.00

N/A

Montenegro Morocco

ME MA

1 7

1.52 0.22

1 5

1.53 0.15

0.6% 229.3%

Netherlands

NL

28

1.67

31

1.84

10.2%

Norway Poland

NO PL

11 111

2.20 2.89

11 115

2.16 3.00

21.7% 3.7%

Portugal

PT

24

2

27

2.50

12.3%


RO RU

17 57

0.78 0.40

17 57

0.78 0.40

0% 0%

San Marino

SM

1

31.11

1

30.82

21%

Serbia Slovakia

RS SK

10 4

1.37 0.73

8 4

1.10 0.73

219.6% 0%

Slovenia

SI

3

1.50

2

1.00

233%

Spain Sweden

ES SE

161 35

3.42 3.84

153 29

3.23 3.01

25.6% 222%

Continued


Albaniaa

i37



ISO code



Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

.....................................................

.....................................................

Change %

............................................................................................................................................................................... Switzerland Syriaa

CH SY

41 N/A

5.17 N/A

46 N/A

5.75 N/A

11% N/A

Tunisiaa

TN

N/A

N/A

N/A

N/A

N/A

Turkeya Ukraine

TR UA

N/A 9

N/A 0.20

N/A 17

N/A 0.38

N/A 92%

United Kingdom

GB

114

1.81

106

1.67

28%

a

These seven countries did not submit on ICD implantation centres in 2013 for the EHRA White Book.

2012 0.3 0.6 0.2 1.0 0.1

2.2

1.7 1.3 2.1

5.2

2.9 5.9

1.6 0.9 1.5 0.9 0.8 2.7

0.4

2.6 2.2

3.6

0.7 1.0 1.1 2.4 2.3 3.2 2.0 2.6 2.2 1.7 1.5 1.8 1.4 0.2

3.6

3.4 2.8

1.5 1.0

3.8

0.0 0.0 –0.1 –0.1 –0.2 –0.2 –0.4 –0.5 –0.7 –0.9 31.1 –1.1 –1.1 –1.5 –1.7 8.2 –2.2 –4.1 –5.6 –6.2 –7.5 –7.5 –19.6 –21.8 –29.3 –33.2 –35.4

25.1 16.0 12.3 11.2 10.2 7.9 6.1 3.7 1.0 0.7 0.6 0.6 0.3 0.3 0.1 0.0

101.6 92.5

137.1

0.7 1.1 0.4 1.3 0.2 2.5

5.8

1.8 1.4 2.2 3.0

5.9

1.6 0.9 1.5 0.9 0.8 2.7 0.4 2.6 2.2 3.6 0.7 1.0 1.1 2.4 2.2

3.2

1.9

30.8

3.6

2.6 2.2 8.1

1.6 3.2 2.6 1.4 1.7 1.1 3.0 0.2 1.0 0.7

Figure 33 Change in the number of implantable cardioverter defibrillator implanting centres per million inhabitants from 2012 to 2013.

Cardiac resynchronization therapy devices General information The 46 countries that submitted data on CRT for the EHRA White Book 2014 are listed in Table 11. Albania, Belarus, Cyprus, France, Kosovo, Kyrgyzstan, Libya, Syria, Tunisia, and Turkey did not report data related to CRT therapy. France has previously reported a high rate of CRT implantations and its absence therefore significantly affects the combined data. Germany and Portugal reported the data for CRT defibrillators (CRT-D) only. The vast majority of

implants were performed by cardiologists (Table 5), and the remaining implantations were performed by physicians having various other training backgrounds, mainly surgeons. However, in some countries (Austria, Belarus, Germany, Iceland, Kazakhstan, Russian Federation, and Ukraine), the proportion of implanting cardiologists was about 50% or less (Table 5).

Cardiac resynchronization therapy facilities and procedure rates It was reported that in 2013, a total of 51 274 CRT devices were implanted in 1701 national centres. There was a decrease in both


Kazakhstan Bulgaria Ukraine Bosnia & Herzegovina Egypt Portugal Switzerland Netherlands Hungary Belgium Poland Italy Estonia Latvia Montenegro Lithuania Romania Croatia Russian Federation Austria Greece Finland Slovakia FYR Macedonia Denmark Malta France Iceland San Marino Luxembourg Ireland Cyprus Norway Germany Czech Republic Spain Israel Georgia United Kingdom Serbia Sweden Morocco Slovenia Armenia

2013

2013 vs. 2012 in %

i38


Table 10 Change in the number of ICD implantations in year 2013 vs. 2012 Country

ISO code



Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

N/A N/A N/A 1195 N/A 114 2197 53 47 118 52 2824 1207 151 101 874 6986 53 26 536 938 844 42 682 1038 12 000 116 N/A N/A 70 N/A N/A 149 76 15 54 N/A 29 21 2669 994 7006 990 178 1580 13 277 577

N/A N/A N/A 145.38 N/A 11.82 198.24 13.66 6.68 26.34 45.69 277.48 217.73 1.80 79.23 166 106.44 11.60 326.37 87.11 84.75 134.11 144.43 136.75 195.88 6.62 N/A N/A 31.94 N/A N/A 42.26 149.29 7.20 131.76 N/A 44.11 0.65 159.53 198.80 182.38 92 8.15 11.09 404.48 38.07 105.23

N/A 38 28 1296 13 N/A 1704 65 32 156 60 3196 1285 178 104 1020 N/A 59 27 241 1050 940 54 732 1277 12 556 221 N/A N/A 88 300 N/A 124 71 12 67 0 38 34 4096 1089 9500 N/A 200 1870 20 448 591

N/A 1.00 9.14 157.63 1.36 N/A 163.15 16.77 4.58 34.86 51.93 301.23 231.26 2.09 82.12 193.69 N/A 11.94 335.70 97.47 94.57 171.28 153.27 165.69 204.22 12.46 N/A N/A 40.40 72.61 N/A 35.27 137.90 5.75 162.91 0.00 58.15 1.04 243.74 214.13 247.50 N/A 9.18 13.12 616.37 61.85 107.68

......................................................

......................................................

Change %

............................................................................................................................................................................... AL DZ AM AT AZ BY BE BA BG HR CY CZ DK EG EE FI FR GE DE GR HU IS IE IL IT KZ XK KGZ LV LB LY LT LU MK MT MD ME MA NL NO PL PT RO RU SM RS SK

N/A N/A N/A 8% N/A N/A 217.7% 22.8% 231% 32% 14% 8.6% 6% 15.7% 4% 17% N/A 3% 3% 11.9% 11.6% 28% 6% 21% 4.3% 88% N/A N/A 26.5% N/A N/A 216.5% 27.6% 220.2% 23.6% N/A 31.8% 60.2% 52.8% 7.7% 35.7% N/A 13% 18% 52% 62.5% 2%

Continued


Albaniaa Algeria Armenia Austria Azerbaijan Belarusa Belgium Bosnia & Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Egypt Estonia Finland Francea Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kosovoa Kyrgyzstana Latvia Lebanon Libyaa Lithuania Luxembourg FYR Macedonia Malta Moldova Montenegro Morocco Netherlands Norway Poland Portugala Romania Russian Federation San Marino Serbia Slovakia

i39



ISO code



Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

122 3434 1758 1549 N/A 100 N/A 52 5762

61.10 73.00 193.11 195.44 N/A 9 N/A 1.14 91.39

142 3885 1911 1604 N/A N/A N/A 85 5809

71.26 82.01 198.08 200.60 N/A N/A N/A 1.91 91.63

......................................................

Change %

......................................................

............................................................................................................................................................................... Slovenia Spain Sweden Switzerland Syriaa Tunisiaa Turkeya Ukraine United Kingdom Total ESC countries

SI ES SE CH SY TN TR UA GB 56

17% 12.4% 3% 3% N/A N/A N/A 67% 0%

a

These 10 countries did not submit data on ICD implantations for the EHRA White Book 2014.

2012

66.6 62.5 60.2 52.8 52.4

38.1

0.6

159.5 404.5

182.4 26.3 44.1 134.1 31.9

131.8

13.7 136.7

11.1 1.8 8.1

166.1 61.1

45.7 73.0 87.1 84.8 277.5

11.6

79.2

145.4 198.8 217.7 144.4 195.9 326.4 195.4 193.1

105.2 91.4 149.3 42.3 7.2 6.7

2013

2013 vs. 2012 in %

6.6 1.1

198.2

35.7 32.3 31.8 27.7 26.5 23.6 22.8 21.2 18.4 16.6 16.6 15.7 13.7 12.7 12.4 11.9 11.6 8.6 8.4 7.7 6.2 6.1 4.3 3.6 3.0 2.9 2.6 2.6 2.3 0.3

–7.6 –16.5 –17.7 –20.2 –31.4

88.2

12.5 1.9 61.9

1.0

243.7 616.4

247.5 34.9 58.2 171.3 40.4

162.9

16.8 165.7

13.1

193.7 71.3

2.1 9.2

51.9 82.0 97.5 94.6 301.2

11.9

82.1

157.6 214.1 231.3 153.3 204.2 335.7 200.6 198.1

107.7 91.6 137.9 35.3 5.7 4.6

163.2

Figure 34 Change in the number of implantable cardioverter defibrillator implantations per million inhabitants from 2012 to 2013.

absolute numbers of implants and the rate of implants per million inhabitants compared with 2012, whereas a steady growth had been witnessed from 2009 (Table 11). The absence of French data in 2013 is an important factor in this respect. The number of CRT implanting centres per million inhabitants in the ESC countries is shown in Figure 38. The mean number of implanting facilities was 183 per country, which is similar to that for 2012 (19). Italy and

Germany, both approaching six implanting facilities per million inhabitants, had the highest density of centres implanting CRT devices. Implantation rates with the countries divided into quartiles are shown as a bar graph in Figure 39 and as a geographical map in Figure 40. Figures 41 and 42 show the corresponding numbers for CRT pacemakers (CRT-P) and defibrillators (CRT-D). The ratio of CRT-D/CRT-P implants was 2.6 with a mean of 44 CRT-Ds and 17


Kazakhstan Ukraine Serbia Morocco Netherlands San Marino Poland Croatia Montenegro Iceland Latvia Malta Bosnia & Herzegovina Israel Russian Federation Finland Slovenia Egypt Cyprus Romania Spain Greece Hungary Czech Republic Austria Norway Denmark Ireland Italy Estonia Georgia Germany Switzerland Sweden Slovakia United Kingdom Luxembourg Lithuania Belgium FYR Macedonia Bulgaria

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2012

2013 vs. 2012 in % 41.5 155.6 126.0 62.1

121.9 9.3 158.7 29.2 38.0 60.7 13.7 124.5 69.7 111.8 73.7 133.2 149.6 55.7 6.9 11.4 142.9 91.2 105.4 121.8 140.7 75.9 137.5 37.4 6.0 6.2 10.1

114.3 339.0

82.2 69.8 68.6 53.9 32.9 24.0 23.2 22.6 20.7 17.8 15.2 12.0 8.5 6.0 4.9 4.3 2.4 1.4 0.3

6.6 1.0

161.6

2013

175.5 117.9

229.5 105.4 11.2 1.6 162.1 11.5 195.4 35.8 45.9 71.4 15.7 139.4 75.7 118.5 77.4 138.9 153.2 56.4 6.9 160.2

–0.9 –2.2 –4.0 –6.1 –6.7 –7.5 –8.9 –17.2 –20.9 –22.5 –28.0 –38.6 –48.3

11.1 137.1 85.6 98.3 112.7 128.2 62.9 108.8 29.0 4.3 3.8 5.2

Figure 35 Change in the number of new implantable cardioverter defibrillator implantations per million inhabitants from 2012 to 2013.

2012 Armenia Georgia Ukraine Iceland Poland Netherlands Montenegro FYR Macedonia United Kingdom Romania Latvia Slovakia Spain Switzerland Finland Lithuania Denmark Greece Norway Sweden Czech Republic Austria San Marino Italy Malta Hungary Luxembourg Belgium Russian Federation Estonia Bulgaria

2013 vs. 2012 in % 481.6 270.0

0.7 0.2 0.1

185.3 153.9 119.7 117.2 101.2 99.5 85.9 79.0 67.7 57.0 47.7 32.2 30.5 29.8 26.7 25.6 23.9 21.4 17.2 16.6 11.4 4.3

28.7 23.7 37.6 6.1 1.0 15.4 1.3 2.7 14.0 17.3 54.8 41.6 4.8 56.1 17.4 49.2 50.2 61.2 33.6

248.9 62.7 48.8 24.1 27.5 60.7 1.8 5.5 0.7

–0.4 –4.0 –8.2 –10.4 –11.0 –13.7 –59.7

2013 3.9 0.8 0.3 73.0 52.1 81.6 12.2 1.9 28.7 2.3 4.6 22.0 25.6 72.4 54.3 6.3 71.1 21.8 61.0 60.9 71.7 39.2

277.4 65.4 48.6 23.1 25.2 54.4 1.6 4.7 0.3

Figure 36 Change in the number of implantable cardioverter defibrillator replacements per million inhabitants from 2012 to 2013.


Malta San Marino Czech Republic Portugal Kazakhstan Ukraine Netherlands Russian Federation Poland Latvia Montenegro Hungary Bosnia & Herzegovina Finland Greece Austria Estonia Italy Norway Spain Romania Denmark Georgia Sweden Slovakia Iceland Luxembourg Switzerland United Kingdom Belgium Lithuania Bulgaria FYR Macedonia Armenia

i41


ESC 56

ICD implantations per million inhabitants

EU28

320

650 CZ

300

SM DE

280 300

260 NL

240

250

DK

PL NO SE

LU

120

200

FI

150

IL IS BE IE MT AT

SK

100

HU

80

20

IT

EE SI

60 40

GB

CH

UA EG DZ MD KZ AZ MA

0 0.0

RUAM

LT

RS

100

ME

GR LB

LV

CY

50 RO

MK BA BG

1.0

ES HR

GE

0 1.5

2.0

1

2

3

4

5

6

7

8 31

ICD implanting centres per million inhabitants

CRT-Ps per million inhabitants. Italy had the highest implantation rates of CRT-D, followed by Israel, the Czech Republic, and Germany. Denmark had the highest rate of CRT-P implantations and the United Kingdom had the second highest. The distribution of CRT implantations within the five geographical ESC regions is shown in Figure 43 and further data within each region are shown in Figures 44, 45, 46, 47 and 48, respectively. The number of CRT implantations per million inhabitants was only slightly higher in the Southern than the Northern region. This was followed by the Western region and the non-European ESC countries. As for ICDs the Eastern region had the lowest number of CRT implantations. The most active countries within each region were Italy (198 per million inhabitants), Denmark (180), the Czech Republic (162), Israel (158), and Austria (143), respectively. The change in the number of implanting centres per million inhabitants between 2012 and 2013 are shown in Table 12 and Figure 49. The changes between 2012 and 2013 for the number of total CRT implantations are shown in Table 13 and Figure 50 and the change according to CRT device type are shown in Figures 51 and 52. By far the highest growth rate in CRT device implantations per million was in Sweden, with a reported 106% increase between the last two years. Ukraine and Belgium reported a .50% increase in the number of CRT device implantations. In contrast, the number of CRT implantations decreased by .45% in Armenia, Malta, and Montenegro. San Marino did not report any CRT device implantations in 2013, and Germany reported only CRT-D numbers. The relationship between the annual CRT implantation rate and the number of CRT implanting centres per million population in the EU28 countries and the ESC area is shown in Figure 53.

Lead extraction General information This was the second year that information on lead extractions (LE) was included in the EHRA White Book. The number of countries submitting data on LE procedures was 31 in 2012 and 30 in 2013 (Table 14). Some of the most populated ESC countries, such as Germany, Italy, Russia, and United Kingdom, submitted incomplete or no data on LE. For example, France gave the number of LE centres but not the number of the procedures. In most countries (59%), the primary operator in LE procedures was a cardiologist.

Lead extraction facilities and procedure rates Data on LE facilities and activities are presented in Table 14 and Figure 54. According to the EHRA White Book data a total of 2655 LE procedures were performed in 193 LE centres in 2013. The density of the LE centres was highest in Luxembourg (1.94 per million inhabitants). Six countries had no LE centres (Bosnia & Herzegovina, Georgia, Iceland, Malta, Montenegro, San Marino). In the countries with high LE rates, the number of centres per million population ranged from 0.41 in Sweden to 0.71 in the Netherlands (Table 14). It has been proposed that in an active centre the minimum annual number of LE should be at least 15 per million inhabitants.11 – 13 Assuming that each centre treated an equivalent number of patients it can be calculated that in 2013 the numbers for LE per centre were higher than that in eight countries. The


Figure 37 Implantable cardioverter defibrillator (ICD) implantation centres and rates in the European Society of Cardiology (ESC) and European Union (EU28) member countries in 2013. Bubble size is related to population in the country.

i42

Table 11 Cardiac resyncronization therapy device (CRT-P and CRT-D) implantation facilities and rates in the ESC countries in 2013 and comparison to four previous years Country

ISO code

Number of CRT implanting centres 2013

CRT implantations 2013

Total CRT implantations 2013

Development potential—target number of CRT implantations . . .

CRT implantations per mil inhabitants



2009

.................................. ................................................... .................................. .............................. ............................................ Absolute number

Per mil inhabitants

CRT-P implantations Absolute number

CRT-D implantations Absolute number

Absolute number

Per mil inhabitants

2010

2011

2012

2013

............................................................................................................................................................................................................................................. Albaniaa

AL

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Algeria Armenia

DZ AM

8 2

0.21 0.65

31 0

33 10

64 10

2 3

2266 182

4155 334

N/A 3

N/A 2

N/A 3

N/A 6

2 3

Austria

AT

18

2.19

281

897

1178

143

–

–

113

119

117

107

143

Azerbaijan Belarusb

AZ BY

2 5

0.21 0.52

0 N/A

17 N/A

17 54

2 6

570 573

1046 1050

N/A 5

2 4

2 5

N/A 4

2 6

Belgium

BE

35

3.35

397

824

1221

117

–

–

N/A

49

58

77

117


BA

2

0.52

16

9

25

6

231

423

N/A

3

6

5

6

Bulgaria Croatia

BG HR

8 7

1.15 1.56

232 60

28 21

260 81

37 18

415 266

762 488

11 7

11 11

12 12

28 13

37 18

Cyprusb

CY

3

2.60

N/A

N/A

25

22

69

126

N/A

29

21

25

22

Czech Republic Denmark

CZ DK

17 5

1.60 0.90

435 405

1281 596

1716 1001

162 180

– –

– –

151 116

119 102

143 158

127 170

162 180

Egypt

EG

13

0.15

339

75

414

5

5074

9305

N/A

3

N/A

4

5

Estonia Finland

EE FI

2 14

1.58 2.66

41 158

29 279

70 437

55 83

75 –

138 575

15 42

39 50

58 62

53 72

55 83

FR

159

2.41

N/A

N/A

N/A

N/A

N/A

N/A

101

118

123

131

N/A

GE DE

6 465

1.21 5.73

6 N/A

34 8859

40 8859

8 109

294 –

539 –

2 143

3 177

3 202

7 221

8 109

Greece

GR

16

1.49

50

450

500

46

641

1175

72

33

37

45

46

Hungary Iceland

HU IS

13 1

1.31 3.17

483 8

501 6

984 14

99 44

– 19

1084 34

67 41

83 34

81 48

89 32

99 44

Ireland

IE

17

3.56

67

311

378

79

–

521

48

50

57

61

79

Israel Italy

IL IT

20 361

2.60 5.87

219 2010

997 10 138

1216 12 148

158 198

– –

– –

133 169

111 195

97 203

118 194

158 198


France Georgia Germanyb


a

KZ

9

0.51

26

183

209

12

1055

1935

N/A

N/A

N/A

9

12

XK

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Kyrgyzstana Latvia

KGZ LV

N/A 2

N/A 0.92

N/A 17

N/A 46

N/A 63

N/A 29

N/A 130

N/A 238

N/A 30

N/A 11

N/A 24

N/A 35

N/A 29

Kosovo

Lebanon

LB

5

1.21

10

90

100

24

246

451

N/A

N/A

N/A

N/A

24

Libyaa Lithuania

LY LT

N/A 3

N/A 0.85

N/A 134

N/A 31

N/A 165

N/A 47

N/A 209

N/A 384

N/A 27

N/A 22

N/A 31

N/A 39

N/A 47

Luxembourg

LU

1

1.94

7

15

22

43

31

56

8

39

40

59

43

FYR Macedonia Malta

MK MT

2 1

0.96 2.43

11 1

5 15

16 16

8 39

124 24

228 45

9 60

4 60

13 56

5 83

8 39

Moldova

MD

0

0.00

0

0

0

0

215

395

N/A

N/A

N/A

N/A

0

Montenegro Morocco

ME MA

1 5

1.53 0.15

5 41

5 34

10 75

15 2

39 1942

71 3562

24 N/A

27 N/A

21 N/A

29 2

15 2

Netherlands

NL

57

3.39

463

1606

2069

123

–

–

N/A

128

130

124

123

Norway Poland

NO PL

9 25

1.77 0.65

150 400

276 2600

426 3000

84 78

– –

555 4187

47 62

69 61

88 66

77 73

84 78

Portugal

PT

26

2.41

N/A

427

427

N/A

N/A

N/A

35

43

41

52

N/A

Romania Russian Federation San Marino

RO RU

17 42

0.78 0.29

130 382

70 630

200 1012

9 7

1296 8477

2377 15 546

7 3

10 3

10 6

7 6

9 7

SM

1

30.82

0

0

0

0

2

4

69

125

94

62

0

Serbia

RS

6

0.83

282

47

329

45

431

790

35

19

40

42

45

Slovakia Slovenia

SK SI

5 2

0.91 1.00

110 55

342 76

452 131

82 66

– –

599 217

52 33

74 46

60 45

61 70

82 66

Spain

ES

130

2.74

857

1688

2545

54

2818

5168

41

41

56

53

54

Sweden Switzerland

SE CH

N/A 31

N/A 3.88

431 157

536 320

967 477

100 60

– –

1052 872

84 70

81 73

N/A 74

49 66

100 60

Syriaa

SY

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Tunisiaa Turkeya

TN TR

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

9 N/A

8 N/A

8 N/A

23 N/A

N/A N/A

Ukraine

UA

13

0.29

67

22

89

2

2652

4863

N/A

1

1

1

2

United Kingdom

GB

109

1.72

3792

3970

7762

122

–

–

95

105

105

110

122

Total

56

12 766

38 429

51 274


Kazakhstan

a

These 10 countries did not submit data on CRT implantations in 2013. Belarus, and Cyprus reported only total CRT implantation numbers and Germany only the numbers for CRT-D implantations.

b

i43


i44


San Marino Italy Germany Switzerland Ireland Netherlands Belgium Iceland Spain 2.74 Finland 2.66 Cyprus 2.60 2.60 Israel Malta 2.43 France 2.41 Portugal 2.41 Austria 2.19 Luxembourg 1.94 Norway 1.77 1.72 United Kingdom Czech Republic 1.60 1.58 Estonia Croatia 1.56 Montenegro 1.53 Greece 1.49 Hungary 1.31 Georgia 1.21 Lebanon 1.21 1.15 Bulgaria Slovenia 1.00 FYR Macedonia 0.96 Latvia 0.92 Slovakia 0.91 Denmark 0.90 Lithuania 0.85 0.83 Serbia Romania 0.78 0.65 Armenia Poland 0.65 Belarus 0.52 Bosnia & Herzegovina 0.52 Kazakhstan 0.51 Russian Federation 0.29 Ukraine 0.29 0.21 Algeria Azerbaijan 0.21 Morocco 0.15 Egypt 0.15 Moldova 0.00

30.82 5.87 5.73 3.56 3.39 3.35 3.17

3.88

Figure 38 Cardiac resyncronization therapy (CRT) device implanting centres per million inhabitants in 2013. Mean number of CRT implantation centres is weighted by population.

Median CRT implantations = 44

Italy Denmark Czech Republic Israel Austria Netherlands United Kingdom Belgium Germany Sweden Hungary Norway Finland Slovakia Ireland Poland Slovenia Switzerland Estonia Spain Lithuania Greece Serbia Iceland Luxembourg Malta Bulgaria Latvia 29 Lebanon 24 Cyprus 22 Croatia 18 Montenegro 15 Kazakhstan 12 Romania 9 Georgia 8 FYR Macedonia 8 7 Russian Federation Bosnia & Herzegovina 6 Belarus 6 Egypt 5 Armenia 3 2 Morocco Ukraine 2 Azerbaijan 2 Algeria 2 Moldova 0 San Marino 0

117

47 46 45 44 43

55 54

60

66

79 78

84 83 82

39 37

100 99

143 123 122

162 158

180

109

59 = Ø CRT implantations per million inhabitants (weighted by population) 4th quartile > 83 ≤ 198 3rd quartile > 44 ≤ 83 2nd quartile > 8 ≤ 44 1st quartile ≥ 0 ≤ 8

Mean number of CRT implantations = Ø 59

Figure 39 Cardiac resyncronization therapy (CRT) device implantations per million inhabitants 2013.

198


Mean CRT implanting centers = Ø 1.83

i45


59 = Ø CRT implantations per million inhabitants (weighted by population) 4th quartile > 83 ≤ 198 3rd quartile > 44 ≤ 83 2nd quartile > 8 ≤ 44 1st quartile ≥ 0 ≤ 8 Not available

Denmark United Kingdom Hungary Sweden Czech Republic Serbia Lithuania Belgium Austria Bulgaria Italy Estonia Finland Norway Israel Slovenia Netherlands Iceland Slovakia Switzerland Spain Ireland Luxembourg Croatia Poland Latvia Montenegro Romania FYR Macedonia Greece Bosnia & Herzegovina Egypt Russian Federation Malta Lebanon Ukraine Kazakhstan Morocco Georgia Algeria Armenia Azerbaijan Moldova San Marino

72.9 59.8 48.6 44.7 41.0 38.9 38.1 38.0

30.0 29.5 28.4 27.6 27.6

34.2 33.2 32.7 32.4

25.4 20.0 19.6 18.1 14.0 13.6 13.4 10.4 7.8 7.7 6.0 5.3 4.6 4.1 4.0 2.7 2.4 2.4 1.5 1.5 1.3 1.2 0.8 0.0 0.0 0.0 0.0

Mean number of CRT-P implantations = Ø 17

Figure 41 Cardiac resyncronization therapy pacemaker (CRT-P) implantations per million inhabitants in 2013. Mean number of implantations is weighted by population.


Figure 40 Cardiac resyncronization therapy (CRT) device implantations in the ESC countries in 2013.

i46


Italy Israel Czech Republic Germany Austria Denmark Netherlands Belgium Poland Ireland United Kingdom Slovakia Sweden Norway Finland Hungary Greece Switzerland Portugal Slovenia Malta Spain Luxembourg Estonia Lebanon Latvia Iceland Kazakhstan Lithuania Montenegro Georgia Serbia Croatia Russian Federation Bulgaria Armenia Romania FYR Macedonia Bosnia & Herzegovina Azerbaijan Morocco Egypt Algeria Ukraine Moldova San Marino

120.7

164.9 129.4

109.2 109.1 107.3 95.6 78.9 67.7 65.1 62.6 62.3 55.6 54.3 53.0 50.4 41.8 40.0 39.5 38.1 36.5 35.6 22.9 21.8 21.1 19.0

29.1

10.3 8.8 7.7 6.9 6.5 4.7 4.4 4.0 3.3 3.2 2.4 2.3 1.8 1.0 0.9 0.9 0.5 0.0 0.0

Mean number of CRT-D implantations = Ø 44

weighted by population.

Western Europe

Northern Europe

85

92

89

98

113

134

117

114

108

78

85

88

2009 2010 2011 2012 2013

116

2009 2010 2011 2012 2013

23

26

27

78

96

108

31

2009 2010 2011 2012 2013

67

57

50

63

81

2009 2010 2011 2012 2013

118

123

106

2009 2010 2011 2012 2013

ESC


Eastern Europe

23

EU28

198

2009 2010 2011 2012 2013

Southern Europe

107

184

70

2009 2010 2011 2012 2013

99

163


70

77

84

88

78

2009 2010 2011 2012 2013

Figure 43 Cardiac resynchronization therapy device (CRT-P and CRT-D) implantations per million inhabitants 2009 – 2013 in the five geographical regions of the European Society of Cardiology (ESC) and comparison to the total ESC area and the 28 member countries of the European Union (EU28).


Figure 42 Cardiac resyncronization therapy defibrillator (CRT-D) implantations per million inhabitants in 2013. Mean number of implantations is

i47


United Kingdom

Denmark

TOP 3

158 116

170

Sweden

180

102

95

105

122

110

105

84

100

81 49 *

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Latvia

Lowest 3

30

Iceland

24

11

2009 2010 2011 2012 2013

35

29

34

48

32

44 27

2009 2010 2011 2012 2013

22

31

39

47

2009 2010 2011 2012 2013

Figure 44 Cardiac resynchronization therapy (CRT-P and CRT-D) implantations per million inhabitants 2009 – 2013 in Northern Europe. *No data available.

113

119

143 117

Belgium

Netherlands

Austria

TOP 3

128

107

130

124

123

117 49

* 2009 2010 2011 2012 2013

*

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Germany

Switzerland

Luxembourg

Lowest 3

58

77

202

221

177 143 109 39

40

59

70 43

73

74

66

60

8 2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Figure 45 Cardiac resynchronization therapy (CRT-P and CRT-D) implantations per million inhabitants 2009 – 2013 in Western Europe. *No data available. Germany reported only CRT-D implantation in 2013.


2009 2010 2011 2012 2013

41

Lithuania

i48


Hungary

Czech Republic

TOP 3

151 119

143

162 127 67

2009 2010 2011 2012 2013

1

*

1

83

89

81

99 52

2009 2010 2011 2012 2013

Ukraine

Lowest 3

Slovakia

61

82

2009 2010 2011 2012 2013

4

5

6

3

2009 2010 2011 2012 2013

3

6

6

7

2009 2010 2011 2012 2013

Figure 46 Cardiac resynchronization therapy (CRT-P and CRT-D) implantations per million inhabitants 2009 – 2013 in Eastern Europe. *No data available.

Slovenia

Italy

TOP 3

169

195

203

194

198

33

2009 2010 2011 2012 2013

*

3

6

5

6

2009 2010 2011 2012 2013

46

45

70

66

41

2009 2010 2011 2012 2013

41

56

53

54

2009 2010 2011 2012 2013

Montenegro

FYR Macedonia


Lowest 3

Spain

24

9

4

13

5

8

2009

2010

2011

2012

2013

27

21

29

15

2009 2010 2011 2012 2013

Figure 47 Cardiac resynchronization therapy (CRT-P and CRT-D) implantations per million inhabitants 2009 –2013 in Southern Europe. *No data available.


2009 2010 2011 2012 2013

4

5

2

60

Russian Federation

Belarus

1

74

i49


Cyprus

Israel

TOP 3

Kazakhstan

158 133

111

97

118

29

25

21

22

2

* 2009

2010

2011 2012

2013

2009 2010 2011 2012 2013

Azerbaijan

Lowest 3

*

2

2010

2011

* 2012

2010

2013

3

2

3

2009

2010

2011

8

2012

2013

4

5

2012

2013

Egypt

Armenia

2

2011

7

6 2012

3 2013

*

3

2009 2010

* 2011

Figure 48 Cardiac resynchronization therapy (CRT-P and CRT-D) implantations per million inhabitants 2009– 2013 in Non-European European Society of Cardiology (ESC) countries. *No data available.

mean number of LE per centre was highest in Sweden (122 per million people). On the basis of reported infections in patients with CIED, it has been estimated that in a country with 1000 CIED implantations per million inhabitants per year the annual LE activity should be between 15 and 60 procedures per million inhabitants.11 – 13 In 2013 the LE activity was within this estimate in only six countries (Norway, Sweden, Austria, the Czech Republic, the Netherlands, and Slovakia). Hungary, Poland, and Switzerland were close to the recommended level, but in the others the reported LE rate was far below the estimated need (Figure 54). For example, in Greece the LE rate would have been expected to be .5 times higher than that reported for 2013 (2.8 per million people). Interpretation of regional LE data is complicated due to the missing data and a very low LE rate in some countries. Therefore, we chose not to present regional data for LE. Nevertheless, on the basis of available data it seems that there were no clear relationship between population size and LE rates.

Catheter ablation General information A total of 46 countries (82% of the ESC countries) submitted data on catheter ablation facilities and procedures to the EHRA White Book (Table 15). Twenty-two had a national registry on catheter ablation and in the remainder the numbers originated from a survey or an

estimate by the national working groups. According to the EHRA White Book, 1 071 549 273 people lived in the ESC countries in 2013. After excluding those that did not report data on the number of ablations or ablation centres, the population covered by the EHRA White Book for ablation procedures was 789 206 090, which is about 5% less than in the previous year. The major problem in 2013 was that no ablation data were received from France and Italy, which are known to have well-developed ablation programmes. The data from Italy have been missing in previous years but this was the only time within the past 5 years that France did no provide ablation statistics.

Ablation facilities and procedure rates In 2013 the total number of ablation centres in the countries that submitted data for the EHRA White Book was 752, and the mean number of ablation centres per million population was 0.92 (Figure 55). These numbers were lower than in 2012, mainly because the French data were not submitted in 2013. In 2012 there were 195 ablation centres in France. The changes in the number or ablation centres from 2012 to 2013 are shown in Figure 56. Total number of ablation procedures in the ESC area in 2013 was 144 908 (Table 15), which is 18.5% less than that reported in 2012 (177 782). The mean number of ablations done per million population was also lower in 2013 (184) than in 2012 (216) and 2011 (205) but higher than in 2010 (180) and 2009 (180). The drop in ablation rates was probably due to the fact that data from France was


2009

2

2009

3

3

i50


Table 12 Change in the number of CRT implanting centres in year 2013 vs. 2012 Country

ISO code



Absolute number

Absolute number


Change %


............................................................................................................................................................................... Albaniaa

AL

N/A

N/A

N/A

N/A

N/A

Algeria

DZ

N/A

N/A

8

0.21

N/A

Armenia

AM

3

1.01

2

0.65

235%

Austria

AT

18

2.19

18

2.19

0%

Azerbaijan

AZ

N/A

N/A

2

0.21

N/A

Belarus

BY

1

0.10

5

0.52

400.9% 0.4%

Belgium

BE

37

3.34

35

3.35


BA

2

0.52

2

0.52

0.1%

Bulgaria

BG

4

0.57

8

1.15

102%

Croatia

HR

10

2.23

7

1.56

230%

Cyprus

CY

3

2.64

3

2.60

22%

Czech Republic

CZ

19

1.87

17

1.60

214.2%

Denmark

DK

6

1.08

5

0.90

217%

Egypt

EG

11

0.13

13

0.15

16.0%

Estonia

EE

2

1.57

2

1.58

1%

Finland

FI

12

2.28

14

2.66

17%

FR

159

2.42

159

2.41

0%

GE

6

1.31

6

1.21

28%

Germany

DE

490

6.03

465

5.73

25%

Greece

GR

16

1.49

16

1.49

0.0%

Hungary

HU

13

1.31

13

1.31

0.2%

Iceland

IS

1

3.19

1

3.17

21%

Ireland

IE

17

3.60

17

3.56

21%

Israel

IL

21

2.77

20

2.60

26%

Italy

IT

350

5.71

361

5.87

2.8%

KZ

6

0.34

9

0.51

48% N/A

Kazakhstan a

XK

N/A

N/A

N/A

N/A

Kyrgyzstana

KGZ

N/A

N/A

N/A

N/A

N/A

Latvia

LV

2

0.91

2

0.92

0.6%

Lebanon

LB

N/A

N/A

5

1.21

N/A

Kosovo

a

Libya

LY

N/A

N/A

N/A

N/A

N/A

Lithuania

LT

3

0.85

3

0.85

0.3%

Luxembourg

LU

1

1.96

1

1.94

21.1%

FYR Macedonia

MK

2

0.96

2

0.96

20.2%

Malta

MT

1

2.44

1

2.43

20.4%

Moldova

MD

N/A

N/A

0

0.00

N/A

Montenegro

ME

1

1.52

1

1.53

0.6%

Morocco

MA

7

0.22

5

0.15

229.3% 102.7%

Netherlands

NL

28

1.67

57

3.39

Norway

NO

9

1.80

9

1.77

21.7%

Poland

PL

21

0.55

25

0.65

19.1%

Portugal

PT

27

3

26

2.41

23.9%

Romania

RO

15

0.69

17

0.78

14%

Russian Federation

RU

42

0.29

42

0.29

0%

San Marino

SM

1

31.11

1

30.82

21%

Continued


France Georgia

i51



ISO code



Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

6

0.82

6

0.83

0.5% 25%

......................................................

Change %

......................................................

............................................................................................................................................................................... Serbia

a

RS

Slovakia

SK

4

0.73

5

0.91

Slovenia

SI

2

1.00

2

1.00

0%

Spain

ES

125

2.66

130

2.74

3.3%

Swedena

SE

33

3.62

N/A

N/A

N/A

Switzerland

CH

34

4.29

31

3.88

210%

Syriaa

SY

N/A

N/A

N/A

N/A

N/A

Tunisiaa

TN

5

0

N/A

N/A

N/A

Turkeya

TR

N/A

N/A

N/A

N/A

N/A

Ukraine

UA

11

0.24

13

0.29

20%

United Kingdom

GB

114

1.81

109

1.72

25%

These eight countries did not submit data on CRT implantation centres for the EHRA White Book 2014.

Belarus Netherlands Bulgaria Kazakhstan Slovakia Ukraine Poland Finland Egypt Romania Spain Italy Estonia Latvia Montenegro Serbia Belgium Lithuania Slovenia Hungary Bosnia & Herzegovina Russian Federation Austria Greece FYR Macedonia Malta France Iceland San Marino Luxembourg Ireland Cyprus Norway Portugal United Kingdom Germany Israel Georgia Switzerland Czech Republic Denmark Morocco Croatia Armenia

2013

2013 vs. 2012 in %

0.1

400.9 1.7

0.6 0.3 0.7 0.2 0.5 2.3 0.1 0.7 2.7 5.7 1.6 0.9 1.5 0.8 3.3 0.9 1.0 1.3 0.5 0.3 1.5

2.2

1.0 2.4 2.4 3.2 2.0

3.6 2.6

1.8 2.5 1.8 2.8

1.3

4.3 1.9 1.1 0.2 2.2 1.0

0.0 0.0 –0.2 –0.4 –0.5 –0.7 31.1 –0.9 –1.1 –1.1 –1.5 –1.7 –3.9 –4.9 6.0 –4.9 –6.2 –7.5 –9.6 –14.2 –16.9 –29.3 –29.9 –35.4

102.7 101.6 48.2 24.9 20.4 19.1 16.6 16.0 13.6 3.3 2.8 0.7 0.6 0.6 0.5 0.4 0.3 0.2 0.2 0.1 0.0


2012

0.5 3.4 1.1 0.5 0.9 0.3 0.7 2.7 0.2 0.8 2.7 5.9 1.6 0.9 1.5 0.8 3.4 0.9 1.0 1.3 0.5 0.3 1.5 1.0

2.2 2.4 2.4 3.2

1.9

30.8

3.6 2.6

1.8 2.4 1.7 5.7 1.2

2.6 3.9

1.6 0.9 0.2 1.6 0.7

Figure 49 Change in the number of cardiac resyncronization therapy device implanting centres per million inhabitants from 2012 to 2013.

not available and that there was a decrease in the number of ablations (from 38 000 in 2012 to 33 000 in 2013) reported by Germany. The number of catheter ablations per million inhabitants is shown in Figures 57 and 58. In these figures the ESC countries are grouped in

quartiles according to their ablation activities. As in previous years, most countries in the top quartile were from Northern and Western Europe. European Society of Cardiology countries outside Europe had low ablation activity and they are mostly found

i52


Table 13 Change in the number of total cardiac resyncronization therapy (CRT) device implantations in year 2013 vs. 2012 Country

ISO code



Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants

N/A

N/A

N/A

N/A

N/A N/A

......................................................

......................................................

Change %

............................................................................................................................................................................... Albaniaa

AL

Algeria

DZ

N/A

N/A

64

1.68

Armenia

AM

18

6

10

3.26

246%

Austria

AT

879

106.94

1178

143.28

34%

Azerbaijan

AZ

N/A

N/A

17

1.77

N/A 42.4%

Belarus

BY

38

3.94

54

5.61

Belgium

BE

858

77.42

1221

116.91

51.0%


BA

21

5.41

25

6.45

19.2%

Bulgaria

BG

198

28.13

260

37.24

32% 40%

Croatia

HR

58

12.95

81

18.10

Cyprus

CY

28

24.60

25

21.64

212%

Czech Republic

CZ

1289

126.65

1716

161.74

27.7%

Denmark

DK

941

169.75

1001

180.15

6% 14.7%

EG

354

4.23

414

4.85

EE

68

53.35

70

55.28

4%

Finland

FI

380

72

437

82.98

15%

Francea

FR

8605

131.11

N/A

N/A

N/A 12%

Georgia

GE

33

7.22

40

8.09

Germany

DE

17 949

220.76

8859

109.17

251%

Greece

GR

487

45.23

500

46.41

2.6%

Hungary

HU

884

88.77

984

99.00

11.5%

Iceland

IS

10

31.93

14

44.40

39%

Ireland

IE

286

60.57

378

79.15

31%

Israel

IL

898

118.30

1216

157.78

33%

Italy

IT

11 900

194.25

12 148

197.59

1.7%

Kazakhstan

KZ

153

8.73

209

11.78

35%

Kosovoa

XK

N/A

N/A

N/A

N/A

N/A

Kyrgyzstana

KGZ

N/A

N/A

N/A

N/A

N/A

Latvia

LV

76

34.68

63

28.92

216.6%

Lebanon

LB

N/A

N/A

100

24.20

N/A

Libyaa

LY

N/A

N/A

N/A

N/A

N/A

Lithuania

LT

139

39.42

165

46.93

19.0%

Luxembourg

LU

30

58.93

22

42.73

227.5% 45.1%

FYR Macedonia

MK

11

5.28

16

7.67

Malta

MT

34

82.96

16

38.90

253.1%

Moldova

MD

N/A

N/A

0

0.00

N/A

Montenegro

ME

19

28.90

10

15.30

247.1% 30.2%

Morocco

MA

57

1.76

75

2.30

Netherlands

NL

2076

124.08

2069

123.12

20.8%

Norway

NO

383

76.60

426

83.77

9.4%

PL

2788

72.58

3000

78.16

7.7%

Poland a

Portugal

PT

564

52

N/A

N/A

N/A

Romania

RO

163

7.46

200

9.18

23%

Russian Federation

RU

911

6.39

1012

7.10

11%

San Marino

SM

2

62.23

0

0.00

2100%

Serbia

RS

303

41.64

329

45.42

9.1%

Continued


Egypt Estonia

i53



ISO code



Absolute number

Absolute number


Change %


...............................................................................................................................................................................

a

Slovakia

SK

332

60.55

452

82.36

Slovenia

SI

139

69.62

131

65.74

36% 26%

Spain

ES

2490

52.93

2545

53.73

1.5%

Sweden

SE

443

48.66

967

100.23

106%

Switzerland

CH

520

65.61

477

59.65

29%

Syriaa

SY

N/A

N/A

N/A

N/A

N/A

Tunisiaa

TN

250

23

N/A

N/A

N/A

Turkeya

TR

N/A

N/A

N/A

N/A

N/A

Ukraine

UA

57

1.26

89

2.00

59%

United Kingdom

GB

6965

110.47

7762

122.44

11%

These nine countries did not submit data on total CRT implantations for the EHRA White Book 2014.

2012

106.0

48.7 1.3 77.4 5.3 3.9 12.9 31.9 60.5 8.7

106.9 118.3

28.1 60.6 1.8

126.7

7.5 5.4 39.4 4.2 7.2

72.2 88.8

6.4

2013

110.5 76.6 41.6 72.6

169.7 53.3 45.2

194.3

52.9

–0.8 –5.6 –9.1 –12.1 –16.6 –27.5 –46.1 –47.1 –50.5 –53.1

124.1 69.6 65.6 24.6 34.7 58.9 6.1 28.9 83.0 62.2

220.8 –100.0

59.1 51.0 45.1 42.4 39.8 39.1 36.0 34.9 34.0 33.4 32.4 30.7 30.2 27.7 23.0 19.2 19.0 14.9 14.7 12.1 11.5 11.1 10.8 9.4 9.1 7.7 6.1 3.6 2.6 1.7 1.5

100.2

2.0

116.9 7.7 5.6 18.1 44.4 82.4 11.8 143.3 157.8

37.2 79.1 2.3

161.7 9.2 6.5 46.9 83.0 4.9 8.1 99.0 7.1 83.8

122.4

45.4 78.2 180.2 55.3 46.4 197.6 53.7 123.1 65.7 59.7 21.6 28.9 42.7 3.3 15.3 109.2 38.9 0.0

Figure 50 Change in the number of cardiac resyncronization therapy device (CRT-P and CRT-D) implantions per million inhabitants from 2012 to 2013.

in the lowest (1st) quartile. Eastern European countries had a heterogeneous distribution, which spanned over the four quartiles. Detailed information on changes in ablations numbers in the ESC countries during the last five years is shown in Table 15. Changes in the

number of ablation procedures from 2012 to 2013 are shown in Figure 59. The mean number of ablations performed per centre increased from 175 in 2012 to 193 in 2013 indicating that those centres that did report their numbers were more active than in the


Sweden Ukraine Belgium FYR Macedonia Belarus Croatia Iceland Slovakia Kazakhstan Austria Israel Bulgaria Ireland Morocco Czech Republic Romania Bosnia & Herzegovina Lithuania Finland Egypt Georgia Hungary Russian Federation United Kingdom Norway Serbia Poland Denmark Estonia Greece Italy Spain Netherlands Slovenia Switzerland Cyprus Latvia Luxembourg Armenia Montenegro Germany Malta San Marino

2013 vs. 2012 in %

i54


2012

2013 vs. 2012 in %

0.7 2.3

2013 769.0

99.9 90.1 75.0 62.3 57.0 37.2 29.9 29.2 25.4 21.1 20.7 20.0 19.9 19.0 17.1 15.4 13.5 12.8 12.8 8.9 6.8 5.4 3.3 3.2 1.7

23.5 0.9 8.3 12.8 3.8 10.8

25.7 22.7 31.5 31.5 15.1 60.8 32.7 3.4

11.8 22.4 26.6 36.4 31.4 3.9

31.0 2.6

10.1 29.0 27.6 2.4

32.9 49.9 20.2 1.3

63.7 1.3

31.6 11.4 2.4

15.2 5.4

31.1

–0.2 –0.4 –1.7 –2.6 –2.7 –3.4 –6.1 –7.5 –12.5 –31.6 –38.8 –49.7 –100.0 –100.0

6.0 4.6 44.7 1.5 13.4 20.0 5.3 14.0 33.2 28.4 38.1 38.0 18.1 72.9 38.9 4.0 13.6 25.4 30.0 41.0 34.2 4.1 32.7 2.7 10.4 29.5 27.6 2.4 32.4 48.6 19.6 1.3 59.8 1.2 27.6 7.8 1.5 7.7 0.0 0.0

Figure 51 Change in the number of cardiac resyncronization pacemaker (CRT-P) implantations per million inhabitants from 2012 to 2013.

previous year. The relationship between the annual catheter ablation rate and the number of ablation centres per million population in the EU28 countries and the whole ESC area is shown in Figure 60. More detailed data on ablation activity in the five geographical ESC regions are presented in Figure 61. The mean number of ablations per million inhabitants was higher in the Western and Northern than in the Southern and Eastern Europe. In the non-European ESC countries catheter ablation rate was markedly lower than in the European ESC countries (50 vs. 257 per million population). In 2013, the most active ESC country was Denmark with 652 ablations per million population (Table 15 and Figure 54). In some of the smaller countries, no ablations were performed. Data for the last 5 years from the three most active and three least active countries in the different ESC regions are presented in Figures 62, 63, 64, 65 and 66. The most active countries in the Northern, Western, Southern and Eastern Europe were Denmark (652 ablation per million inhabitants), Belgium (580), Spain (253), and Czech Republic (482), respectively. Among the non-European ESC countries Kazakhstan was the most active with 83 catheter ablation per million population. The growth in the mean ablation rate per million population was highest in the Eastern and Southern European region. In Armenia, the increase in ablation rate was almost 103%, whereas in many Western countries the ablation rate decreased. For example, in Germany and Austria, the decrease in ablation rate was 11.9% and 13.2%, respectively (Figure 56).

In 2013 a total of 43 611 atrial fibrillation (AF) ablations were performed in the 44 ESC countries that submitted AF ablation data for the EHRA White Book (Table 16). In Figures 67 and 68 countries performing AF ablations are grouped into quartiles according to their activity. The mean number of AF ablations per million inhabitants was 58, which is almost exactly the same as in 2012 (59). The most active countries were Norway (293 AF ablations per million population) and Denmark (290). Like 2012 most countries in the top quartile were from Northern and Western European region, and the countries with the lowest activity (1st and 2nd quartiles) were mainly from the Southern Europe and outside Europe. In the Eastern region the AF ablations activity was extremely heterogeneous. The growth in AF ablation rate per million population was highest in Croatia (117%) and Estonia (110%), whereas in Georgia, Austria, and Germany the AF ablation rate decreased by 34%, 23%, and 16%, respectively (Figure 69). Detailed data on AF ablation activities in the five ESC regions and a comparison to the corresponding numbers in the ESC and EU28 countries are presented in Figure 70. In keeping with total ablation numbers the rate of AF ablations was markedly lower in the non-European than in the European ESC countries (82 vs. 5 per million population). The number of AF ablations per million inhabitants was 3 – 4 times higher in the Northern and Western than in the Southern and Eastern European regions. The most active countries in the Northern, Western,


Romania Greece Sweden Ukraine Croatia Slovakia FYR Macedonia Ireland Bulgaria Israel Lithuania Belgium Spain Denmark Serbia Egypt Luxembourg Iceland Finland Czech Republic Austria Bosnia & Herzegovina Italy Russian Federation Poland Norway Netherlands Malta Estonia Hungary Switzerland Morocco United Kingdom Georgia Slovenia Latvia Kazakhstan Montenegro Armenia San Marino

i55


2012

2013 vs. 2012 in %

2013

384.7 367.9

0.7 0.7 0.5 25.2 9.6 45.7 1.4 2.4 6.3 1.5 75.5 95.6 46.8 90.3 49.8 47.8 38.9 0.4 5.9 3.8 45.6 47.6 34.8 20.4 7.9 62.5 0.8 163.2 38.1 4.7 96.5 109.0 42.9 37.9 23.3 45.4 8.9 47.1 13.7 80.5 31.1

3.3 3.2 1.0

124.3 120.9 98.7 72.5 66.3 66.0 62.9 50.1 44.4 35.3 33.8 33.7 30.8 30.4 29.7 24.5 16.5 16.5 16.2 14.0 13.7 12.3 11.0 8.4 5.1 1.0 0.2 0.1

55.6 19.0 78.9 2.4 4.0 10.3 2.3 109.1 129.4 62.6 120.7 65.1 62.3 50.4 0.5 6.9 4.4 53.0 54.3 39.5 22.9 8.8 67.7 0.9 164.9 38.1 4.7

–0.9 –1.6 –2.6 –5.9 –9.3 –11.9 –27.4 –38.2 –43.6 193.4 –44.1 –54.7 –100.0

95.6 107.3 41.8 35.6 21.1 40.0 6.5 29.1 109.2 7.7 36.5 0.0

Figure 52 Change in the number of cardiac resyncronization therapy (CRT-D) implantations per million inhabitants from 2012 to 2013.

CRT implantations per million inhabitants

Rest ESC56 EU28

280

280

240

240 200

200

IT

DK CZ

160

160

IL AT

GB

120

120

BE

NL DE

HU

80 40

PL DZ EG RU BY MD KZ UA AM MA AZ

0 0.0

BA

0.5

NO

SK SI LT BG GR RS LB LV ME RO MK GE

1.0

1.5

FI

80

EE

IE CH

ES

LU

40

IS

MT

HR

CY

SM

0

2.0

2.0

2.5

3.0

3.5

31.0

CRT implanting centres per million inhabitants

Figure 53 Cardiac resyncronization therapy (CRT) implantation centres and rates in the European Society of Cardiology (ESC) and European Union (EU28) member countries in 2013. Bubble size is related to population in the country.


Armenia Romania Morocco Sweden Iceland Belgium FYR Macedonia Bulgaria Kazakhstan Bosnia & Herzegovina Austria Israel United Kingdom Czech Republic Ireland Slovakia Hungary Ukraine Georgia Russian Federation Finland Norway Portugal Estonia Lithuania Poland Egypt Italy Slovenia Croatia Netherlands Denmark Greece Spain Latvia Switzerland Serbia Luxembourg Germany Montenegro Malta San Marino

i56


Table 14 Lead extraction facilities and rates in the ESC countries in 2013 and comparison to the previous year Country

ISO code

Number of Lead extraction centres 2013

Lead extraction procedures 2013

Development potential— target number of lead extraction procedures . . .

Lead extraction procedures per mil inhabitants

..................................... ...................................... ......................................... ................ Absolute number

per mil inhabitants

Absolute number

Per mil inhabitants



2012

2013

............................................................................................................................................................................... AL DZ

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

Armenia

AM

1

0.33

3

1

18

29

0

1

Austria

AT

5

0.61

250

30

–

–

27

30

Azerbaijan Belarusb

AZ BY

1 10

0.10 1.04

10 N/A

1 N/A

58 N/A

92 N/A

N/A 4

1 N/A

Belgiuma

BE

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A


BA

0

0.00

0

0

23

37

N/A

0

Bulgaria Croatia

BG HR

1 3

0.14 0.67

11 0

2 0

42 27

67 43

N/A 2

2 0

Cyprus

CY

1

0.87

2

2

7

11

0

2

Czech Republic Denmarkb

CZ DK

5 4

0.47 0.72

320 N/A

30 N/A

– N/A

– N/A

29 N/A

30 N/A

Egypt

EG

2

0.02

15

0

512

819

0

0

Estoniaa Finlandb

EE FI

N/A 5

N/A 0.95

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

France

FR

50

0.76

N/A

N/A

N/A

N/A

30

N/A

Georgia Germany

GE DE

0 N/A

0.00 N/A

0 N/A

0 N/A

30 487

47 779

N/A 10

0 N/A

Greece

GR

4

0.37

30

3

65

103

2

3

Hungary Iceland

HU IS

7 0

0.70 0.00

126 0

13 0

– 2

– 3

7 0

13 0

Irelandb

IE

2

0.42

N/A

N/A

N/A

N/A

N/A

N/A

Israelb Italya

IL IT

5 N/A

0.65 N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

0 N/A

N/A N/A

Kazakhstanb

KZ

2

0.11

N/A

N/A

N/A

N/A

0

N/A

Kosovoa Kyrgyzstana

XK KGZ

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A 0

N/A N/A

Latvia

LV

1

0.46

8

4

13

21

3

4

Lebanon Libyaa

LB LY

5 N/A

1.21 N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

Lithuania

LT

2

0.57

11

3

21

34

3

3

Luxembourg FYR Macedonia

LU MK

1 2

1.94 0.96

N/A 0

N/A 0

N/A 13

N/A 20

18 3

N/A 0

Malta

MT

0

0.00

0

0

2

4

0

0

Moldova Montenegro

MD ME

1 0

0.28 0.00

2 0

1 0

22 4

35 6

N/A 0

1 0

Morocco

MA

2

0.06

10

0

196

313

0

0

Netherlands Norway

NL NO

12 3

0.71 0.59

405 214

24 42

– –

– –

N/A 36

24 42

Poland

PL

7

0.18

450

12

–

–

14

12

Portugalb Romania

PT RO

5 2

0.46 0.09

N/A 10

N/A 0

N/A 131

N/A 209

N/A 0

N/A 0

Russian Federationb

RU

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Continued


Albaniaa Algeriaa

i57



ISO code

Number of Lead extraction centres 2013

Lead extraction procedures 2013

Development potential— target number of lead extraction procedures . . .

..................................... ......................................

.........................................

Absolute number


per mil inhabitants

Absolute number

Per mil inhabitants


Lead extraction procedures per mil inhabitants

................

2012

2013

............................................................................................................................................................................... SM

0

0.00

0

0

0

0

0

0

Serbia Slovakia

RS SK

3 3

0.41 0.55

34 108

5 20

43 –

70 –

7 25

5 20

Sloveniab

SI

1

0.50

N/A

N/A

N/A

N/A

N/A

N/A

Spainb Sweden

ES SE

16 4

0.34 0.41

N/A 491

N/A 51

N/A –

N/A –

N/A 22

N/A 51

Switzerland

CH

8

1.00

90

11

–

–

N/A

11

Syriaa Tunisiaa

SY TN

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A 7

N/A N/A

Turkeya

TR

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Ukraine United Kingdomb Total ESC countries

UA GB

7 N/A

0.16 N/A

55 N/A

1 N/A

267 N/A

428 N/A

1 N/A

1 N/A

193

2655

These 10 countries submitted no data on lead extraction. These 11 countries gave only the number of LE centers for the EHRA White Book 2014.

b

Sweden

50.9

Norway

42.1

Austria

30.4

Czech Republic

30.2

Netherlands

24.1

Slovakia

19.7

Hungary

12.7

Poland

11.7

Switzerland

11.3

Serbia

4.7

Latvia

3.7

Lithuania

3.1

Greece

2.8

Cyprus

1.7

Bulgaria Ukraine

1.6 1.2

Azerbaijan

1.0

Armenia

1.0

Moldova

0.6

Romania

0.5

Morocco

0.3

Egypt

0.2

Mean number of Lead extractions = Ø 6.0

Figure 54 Lead extractions per million inhabitans in 2013. Mean number of lead extractions is weighted by population.


a

San Marino

i58

Table 15 Catheter ablation facilities and rates in the ESC countries in 2013 and comparison to four previous years Country

ISO code

National Registry for EP

Number of ablation centres 2013

Ablation procedures 2013

Development potential—target number of ablation procedures . . .

Ablation procedures per mil inhabitants

.......................................

....................................... .............................................. ............................................

Absolute number

Per mil inhabitants

Absolute number

Per mil inhabitants



2009

2010

2011

2012

2013

............................................................................................................................................................................................................................................. Albaniaa

AL

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Algeria Armenia

DZ AM

No No

1 2

0.03 0.65

230 140

6 46

6993 563

11 271 907

N/A 45

N/A 16

N/A 33

N/A 23

6 46

Austria

AT

Yes

17

2.07

2421

294

–

2433

167

214

220

339

294

Azerbaijan

AZ

No

2

0.21

232

24

1761

2838

N/A

7

20

N/A

24

Belarus Belgium

BY BE

No Yes

6 44

0.62 4.21

736 6056

76 580

1767 –

2849 –

43 447

51 474

61 534

54 531

76 580


BA

No

0

0.00

0

0

712

1147

N/A

4

5

1

0

Bulgaria

BG

No

3

0.43

378

54

1282

2066

41

40

39

60

54

Croatia Cyprus

HR CY

N/A No

5 3

1.12 2.60

817 45

183 39

822 212

1324 342

55 25

N/A 27

101 36

132 35

183 39

Czech Republic

CZ

Yes

20

1.89

5116

482

–

–

379

416

440

474

482

Denmark Egypt

DK EG

Yes No

6 13

1.08 0.15

3622 1064

652 12

– 15 661

– 25 241

486 11

491 10

457 N/A

590 11

652 12

Estonia

EE

No

2

1.58

382

302

–

–

313

333

300

260

302

Finland Francea

FI FR

No No

8 N/A

1.52 N/A

2203 N/A

418 N/A

– N/A

– N/A

194 418

284 459

362 479

415 472

418 N/A

Georgia

GE

No

7

1.42

269

54

907

1463

34

42

55

75

54

Germany Greece

DE GR

No Yes

122 29

1.50 2.69

33 420 1440

412 134

– 1978

– 3188

489 106

510 115

614 130

467 131

412 134

HU

No

11

1.11

3356

338

–

–

249

266

293

314

338

IS IE

No No

1 12

3.17 2.51

80 1000

254 209

– –

93 1413

294 179

219 179

203 214

239 212

254 209

Israel

IL

No

16

2.08

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Italya Kazakhstan

IT KZ

Yes No

N/A 7

N/A 0.39

N/A 1470

N/A 83

N/A 3257

N/A 5249

N/A N/A

N/A N/A

311 N/A

N/A 57

N/A 83

Kosovoa

XK

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A


Hungary Iceland Ireland


KGZ

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Latvia

LV

Yes

2

0.92

518

Lebanon Libyaa

LB LY

No N/A

5 N/A

1.21 N/A

100 N/A

238

–

645

140

175

247

269

238

24 N/A

759 N/A

1223 N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

24 N/A

Lithuania

LT

No

3

0.85

840

239

–

1040

235

242

227

243

239

Luxembourg FYR Macedonia

LU MK

Yes Yes

1 3

1.94 1.44

129 80

251 38

– 383

152 618

220 34

183 15

252 26

301 30

251 38

Malta

MT

Yes

1

2.43

12

29

76

122

36

31

20

24

29

Moldova Montenegro

MD ME

No No

0 1

0.00 1.53

0 45

0 69

665 120

1071 193

N/A 0

N/A 0

N/A 11

N/A 149

0 69

Morocco

MA

Yes

4

0.12

150

5

5995

9662

N/A

2

3

7

5

Netherlands Norway

NL NO

Yes No

16 5

0.95 0.98

N/A 2578

N/A 507

N/A –

N/A –

N/A 242

344 262

N/A 487

382 530

N/A 507

Poland

PL

No

75

1.95

9500

248

–

11 359

167

200

214

229

248

Portugal Romania

PT RO

Yes Yes

16 14

1.48 0.64

2062 1300

191 60

– 4001

3196 6448

157 42

152 47

187 50

186 50

191 60

Russian Federation

RU

Yes

81

0.57

21 185

149

26 165

42 170

94

98

118

120

149

San Marino

SM

Yes

0

0.00

0

0

6

10

0

0

0

0

0

Serbia Slovakia

RS SK

No Yes

3 4

0.41 0.73

1010 1071

139 195

1330 –

2143 1624

115 164

112 176

125 177

133 168

139 195

Slovenia

SI

Yes

2

1.00

279

140

366

590

120

129

162

136

140

Spain Sweden

ES SE

Yes Yes

80 10

1.69 1.04

11 987 4483

253 465

– –

14 018 –

170 313

190 378

188 450

205 478

253 465

Switzerland

CH

Yes

22

2.75

4527

566

–

–

506

511

612

598

566

Syriaa Tunisiaa

SY TN

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A 49

N/A 48

N/A 56

N/A 47

N/A N/A

Turkeya

TR

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A


UA GB

No Yes

13 54

0.29 0.85

2672 15 903

60 251

8184 –

13 190 18 761

N/A 227

41 229

47 240

55 254

60 251

Total ESC countries

752


Kyrgyzstana

144 908

a

These nine countries did not submit data on catheter ablations for the EHRA White Book 2014.

i59


i60


Belgium Iceland Switzerland Greece Cyprus Ireland Malta Israel Austria Poland Luxembourg Czech Republic Spain Estonia Montenegro Finland Germany Portugal FYR Macedonia Georgia Lebanon Croatia Hungary Denmark Sweden Slovenia Norway Netherlands Latvia Lithuania United Kingdom Slovakia Armenia Romania Belarus Russian Federation Bulgaria Serbia Kazakhstan Ukraine Azerbaijan Egypt Morocco Algeria Bosnia & Herzegovina Moldova San Marino

4.2 3.2 2.8 2.7 2.6 2.5 2.4 2.1 2.1 2.0 1.9 1.9 1.7 1.6 1.5 1.5 1.5 1.5 1.4 1.4 1.2 1.1 1.1 1.1 1.0 1.0 1.0 1.0 0.9 0.9 0.9 0.7 0.7 0.6 0.6 0.6

0.4 0.4 0.4

0.0 0.0 0.0 0.0

0.3 0.2 0.2 0.1


Mean ablation centres = Ø 0.92

Figure 55 Catheter ablation centres per million inhabitants in 2013. Mean number of ablation centres is weighted by population.

2012 Bulgaria FYR Macedonia Slovakia Belgium Austria Egypt Finland Russian Federation United Kingdom Hungary Romania Georgia Spain Switzerland Poland Ukraine Estonia Latvia Montenegro Serbia Lithuania Slovenia Belarus Croatia San Marino Greece Malta Netherlands Iceland Luxembourg Ireland Kazakhstan Cyprus Israel Norway Czech Republic Sweden Portugal Denmark Morocco Armenia Germany Bosnia & Herzegovina

0.3

2013 vs. 2012 in % 1.0

0.5

3.3 1.7

0.1

1.3 0.5 0.8 1.0 0.6 1.3 1.6

2.6 1.9

0.3

1.6 0.9

1.5

0.4

0.9 1.0 0.6 1.1

0.0

2.7 2.4 1.0

3.2

2.0 2.5

0.4 2.1

1.0

2.0

1.1 1.3 0.2 0.3

1.0

2.6

1.7

2.8

0.0 –0.4 –0.4 –0.7 –1.1 –1.1 –1.2 –1.5 –1.5 –1.7 –4.1 –5.6 –11.3 –14.5 –20.8 –35.4 –46.9

51.2 49.7 33.2 26.2 21.4 16.0 14.2 14.1 11.9 10.2 8.0 7.9 7.4 3.8 2.8 1.9 0.7 0.6 0.6 0.5 0.3 0.2 0.2 0.1 0.0

–100.0

Figure 56 Change in the number of catheter ablation centres per million inhabitants from 2012 to 2013.

2013 0.4

1.4

0.7 0.2

4.2 2.1

1.5 0.6 0.9 1.1 0.6 1.4 1.7

2.8

2.0

0.3

1.6 0.9

0.4

1.5

0.9 1.0

0.6

1.1

0.0

2.7 2.4 1.0

3.2

1.9 2.5

0.4 2.1

1.0

1.9

1.0 1.1 0.1 0.0

0.7

1.5

1.5

2.6

i61


Median ablations = 149 Denmark Belgium Switzerland Norway Czech Republic Sweden Finland Germany Hungary Estonia Austria Iceland Spain United Kingdom Luxembourg Poland Lithuania Latvia Ireland Slovakia Portugal Croatia Russian Federation Slovenia Serbia Greece Kazakhstan Belarus Montenegro Ukraine Romania Georgia Bulgaria Armenia Cyprus FYR Macedonia Malta Lebanon Azerbaijan Egypt Algeria Morocco Bosnia & Herzegovina Moldova San Marino

507

580 566

652

482 465 418 412 338

209 195 191 183

6 5 0 0 0

83 76 69 60 60 54 54 46 39 38 29 24 24 12

254 253 251 251 248 239 238

302 294

149 140 139 134

184 = Ø Ablations per million inhabitants (weighted by population)

4th quartile > 254 ≤ 652 3rd quartile > 149 ≤ 254 2nd quartile > 46 ≤149 1st quartile ≥ 0 ≤ 46


Mean number of ablations = Ø 184

Figure 57 Catheter ablations per million inhabitants in 2013.

184 = Ø Ablations per million inhabitants (weighted by population) 4th quartile > 254 ≤ 652 3rd quartile > 149 ≤ 254 2nd quartile > 46 ≤ 149 1st quartile ≥ 0 ≤ 46 Not available

Figure 58 Catheter ablations in the European Society of Cardiology countries in 2013.

i62


2012 22.6 57.4 54.3 132.4 29.8 120.2 205.4 24.4 50.3 10.6 168.2 260.5 35.1

2013 45.7 82.9 76.5

102.6 44.4 40.7 37.9 28.7 23.7 23.2 19.6 18.5 17.7 16.0 15.8 10.8 10.5 9.4 9.2 8.0 7.5 6.0 5.1 2.8 2.4 2.1 1.8 0.9 0.0

590.1 54.8

531.1 229.2 314.2 239.5 132.6 136.2 186.4 130.9 473.8 414.8 0.0

211.8 254.3 242.8

182.5 38.3 148.7 253.0 29.2 59.7 12.5 195.1 301.6 38.9 651.9 59.9 579.8 247.5 337.6 253.7 139.4 140.0 190.9 133.7 482.2 418.3 0.0 209.4 250.9 238.9

–1.1 –1.3 –1.6 –2.8 –4.3 –5.4 –9.7 –11.5 –11.9 –13.2 –16.6 –27.7 –31.3 –53.8

477.9 529.6 598.4 60.0

268.8 467.4 339.4 300.5 75.3 6.7

149.1

464.7 506.9 566.2 54.1 237.8 411.8 294.5 250.6 54.4 4.6 68.9 0.0

–100.0

0.8


Armenia Kazakhstan Belarus Croatia FYR Macedonia Russian Federation Spain Malta Romania Egypt Slovakia Estonia Cyprus Denmark Ukraine Belgium Poland Hungary Iceland Serbia Slovenia Portugal Greece Czech Republic Finland San Marino Ireland United Kingdom Lithuania Sweden Norway Switzerland Bulgaria Latvia Germany Austria Luxembourg Georgia Morocco Montenegro Bosnia & Herzegovina

2013 vs. 2012 in %

Figure 59 Change in the number of catheter ablations per million inhabitants from 2012 to 2013.

EU28

Ablations per million inhabitants

Rest ESC56 700

700 DK

600

600

BE

CH NO

500

500

CZ

SE

FI DE

400

400 HU

300

300

100

GB LT

DZ

EG

RS KZ AZ

MA 0.0

SK

LU

LV HR

BG RO 0.5

PT

IS

PL IE

200 ES

SI

GR 100

BY UA

0

RU

AT

EE

LB

AM 1.0

ME

GE MK

MT

CY

0 1.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Ablation centres per million inhabitants

Figure 60 Catheter ablation centres and rates in the European Society of Cardiology (ESC) and European Union (EU28) member countries in 2013. Bubble size is related to population in the country.

i63


Western Europe

Northern Europe


EU28

574 483

460 246

261

289

313

473

430

313 216

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Southern Europe

Eastern Europe

147

159

167

179

230

263

251

265

257

2009 2010 2011 2012 2013

118

128

145

150

299

297

ESC


227

260

248

253

174 37

2009 2010 2011 2012 2013

318

2009 2010 2011 2012 2013

213

208

284

2009 2010 2011 2012 2013

31

45

52

50

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Figure 61 Catheter ablations per million inhabitants 2009 –2013 in the five geographical regions of the European Society of Cardiology (ESC) and

Norway

Denmark

TOP 3

590 486

491

652 487

457 242

2009 2010 2011 2012 2013

179

179

214

530

507 313

262

2009 2010 2011 2012 2013

Ireland

Lowest 3

Sweden

378

209

2009 2010 2011 2012 2013

140

175

247

478

465

2009 2010 2011 2012 2013

Latvia

212

450

Lithuania

269

238

2009 2010 2011 2012 2013

235

242

227

243

239

2009 2010 2011 2012 2013

Figure 62 Catheter ablations per million inhabitants 2009 – 2013 in Northern Europe.

Southern, and Eastern European region, and among non-European ESC countries were Norway (293 AF ablation per million population), Belgium (225), Slovenia (83), Czech Republic (196), and Kazakhstan, respectively (Figures 71, 72, 73, 74 and 75). The

ratio of AF ablation to the total number of ablation varied between 1.7% in Armenia to 59.1% in Slovenia. The proportion of AF ablations compared with all ablations was more than one-third in nine countries (Figure 76).


comparison to the total ESC area and the 28 member countries of the European Union (EU28).

i64


447

474

534

531

612

580 506

2009 2010 2011 2012 2013

Lowest 3

183

252

301

598

511

566

2009 2010 2011 2012 2013

Luxembourg

220

Germany

Switzerland

Belgium

TOP 3

614 489

510

467

412

2009 2010 2011 2012 2013

Austria

339 251

2009 2010 2011 2012 2013

167

214

220

294

2009 2010 2011 2012 2013

Hungary

Czech Republic

TOP 3

379

416

440

474

Poland

482 249

266

293

314

338 167

2009 2010 2011 2012 2013

Lowest 3

2009 2010 2011 2012 2013

Bulgaria

41

40

39

54

42

47

50

214

229

248

2009 2010 2011 2012 2013

Romania

60

200

Armenia

50

60

41

47

55

60

* 2009* 2010 2011 2012 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Figure 64 Catheter ablations per million inhabitants 2009 – 2013 in Eastern Europe. *No data available.


Figure 63 Catheter ablations per million inhabitants 2009 – 2013 in Western Europe. France and the Netherlands did not provide data on catheter ablations in 2013.

i65


190

170

253

205

188

Croatia

Portugal

Spain

TOP 3

152 187

157

186

191 101

55

132

183

* 2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Lowest 3 Malta


4

*

5

1

36

0

2009 2010 2011 2012 2013

31

FYR Macedonia

24

20

34

29

2009 2010 2011 2012 2013

26

15

30

38

2009 2010 2011 2012 2013

Georgia

Kazakhstan

TOP 3

57 *

*

83 34

42

55


Figure 65 Catheter ablations per million inhabitants 2009 – 2013 in Southern Europe. *No data available.

Armenia

75

54

45

16

33

23

46

*

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Lowest 3 Egypt

Morocco

*

2

3

7

5

2009 2010 2011 2012 2013

11

10

*

Azerbaijan

11

12

2009 2010 2011 2012 2013

*

7

20

24 *

2009 2010 2011 2012 2013

Figure 66 Catheter ablations per million inhabitants 2009 – 2013 in Non-European European Society of Cardiology (ESC) countries. *No data available.

It has been estimated that there is an urgent need to increase catheter ablation activity in patients with structural heart disease and ventricular tachyarrhythmias. In many countries, these procedures are undertaken in selected high-volume centres. In 2013 the number of

centres performing .10 ventricular tachycardia (VT) ablations per million population was highest in Germany (1.0) and lowest in Ukraine (0.04) (Figure 77). To date no further data on the VT ablation numbers have been collected for the EHRA White Book.

i66


Table 16 Atrial fibrillation ablations in 2013 with comparison to four previous years Country

ISO code

AF Ablation procedures 2013

Development potential—target number of AF ablation procedures . . .

AF Ablation procedures per mil inhabitants

........................................ ................................................ ............................................ Absolute number

Per mil inhabitants



2009

2010

2011

2012

2013

............................................................................................................................................................................... AL

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Algeria

DZ

0

0

2044

3338

N/A

N/A

N/A

N/A

0

Armenia Austria

AM AT

8 771

3 94

188 –

269 –

0 36

1 54

1 62

3 122

3 94

Azerbaijan

AZ

4

0

534

840

N/A

0

0

N/A

0

Belarus Belgium

BY BE

70 2352

7 225

560 –

843 –

3 124

6 171

4 182

6 211

7 225


BA

0

0

222

340

N/A

1

0

0

0

Bulgaria

BG

47

7

440

612

4

2

0

7

7

Croatia Cyprus

HR CY

172 6

38 5

257 47

392 101

0 0

0 0

10 3

18 5

38 5

Czech Republic

CZ

2082

196

–

–

116

N/A

156

177

196

Denmark Egypt

DK EG

1609 35

290 0

– 4571

– 7474

224 N/A

232 0

194 N/A

262 0

290 0

Estonia

EE

71

56

78

111

72

84

90

27

56

Finland Francea

FI FR

654 N/A

124 N/A

– N/A

– N/A

65 99

73 118

91 100

110 130

124 N/A

Georgia

GE

35

7

256

433

1

10

9

11

7

Germany Greece

DE GR

11 697 430

144 40

– 654

– 944

134 18

146 22

184 32

172 37

144 40

Hungary

HU

859

86

–

871

50

49

61

75

86

Iceland Ireland

IS IE

23 450

73 94

– –

28 –

38 78

41 78

48 96

77 95

73 94

Israela

IL

N/A

N/A

N/A

N/A

N/A

N/A

N/A

0

N/A

Italya Kazakhstan

IT KZ

N/A 268

N/A 15

N/A 977

N/A 1554

N/A N/A

N/A N/A

N/A N/A

0 11

N/A 15

Kosovoa

XK

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Kyrgyzstana Latvia

KGZ LV

N/A 64

N/A 29

N/A 131

N/A 191

N/A 12

N/A 16

N/A 31

N/A 26

N/A 29

Lebanona

LB

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Libyaa Lithuania

LY LT

N/A 30

N/A 9

N/A 194

N/A 308

N/A 19

N/A 22

N/A 19

N/A 8

N/A 9

Luxembourg

LU

31

60

–

45

41

24

54

61

60

FYR Macedonia Malta

MK MT

0 1

0 2

118 24

183 36

0 0

0 0

0 0

0 0

0 2

Moldova

MD

0

0

219

317

N/A

N/A

N/A

N/A

0

Montenegro Moroccoa

ME MA

0 N/A

0 N/A

37 N/A

57 N/A

0 N/A

0 0

0 0

0 0

0 N/A

Netherlandsa

NL

N/A

N/A

N/A

N/A

N/A

129

N/A

156

N/A

Norway Poland

NO PL

1488 1900

293 50

– 2211

– 3363

70 19

85 31

242 N/A

249 44

293 50

Portugal

PT

556

51

616

946

30

33

43

49

51


RO RU

120 5858

6 41

1244 8225

1909 12 487

0 18

1 21

3 27

4 27

6 41

San Marino Serbia

SM RS

0 120

0 17

2 424

3 635

0 10

0 7

0 8

0 14

0 17

Slovakia

SK

150

27

314

481

24

24

17

18

27

Continued


Albaniaa

i67



ISO code

AF Ablation procedures 2013

........................................ Absolute number

Per mil inhabitants

Development potential—target number of AF ablation procedures . . .

AF Ablation procedures per mil inhabitants



2009

................................................ ............................................ 2010

2011

2012

2013

...............................................................................................................................................................................

a

Slovenia

SI

165

83

–

175

46

44

59

55

Spain

ES

2201

46

2662

4151

22

N/A

31

33

83 46

Sweden Switzerland

SE CH

1727 1469

179 184

– –

– –

97 156

122 165

157 209

178 193

179 184

Syriaa

SY

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Tunisiaa Turkeya

TN TR

N/A N/A

N/A N/A

N/A N/A

N/A N/A

2 N/A

2 N/A

2 N/A

3 N/A

N/A N/A

Ukraine

UA

680

15

2659

3906

N/A

N/A

11

14

15

United Kingdom Total ESC coutries

GB

5408 43 611

85

–

5555

62

60

74

80

85

These 12 countries did not submit data on atrial fibrillation ablation for the EHRA White Book 2014.

Norway Denmark Belgium Czech Republic Switzerland Sweden Germany Finland Ireland Austria Hungary United Kingdom Slovenia Iceland Luxembourg Estonia Portugal Poland Spain Russian Federation Greece Croatia Latvia Slovakia Serbia Ukraine Kazakhstan Lithuania Belarus Georgia Bulgaria Romania Cyprus Armenia Malta Azerbaijan Egypt Algeria Bosnia & Herzegovina FYR Macedonia Moldova Montenegro San Marino

293 290 225

144

184 179

196

124 94 94 86 85 83 73 60 56 51 50 46 41 40 38 29 27 17 15 15 9 7 7 7 6 5

58 = Ø AF ablations per million inhabitants (weighted by population) 4th quartile > 86 ≤ 293 3rd quartile > 38 ≤ 86 2nd quartile > 5 ≤38 1st quartile ≥ 0 ≤ 5

3 2 0 0 0 0 0 0 0 0

Mean number of ablations = Ø 58

Figure 67 Atrial fibrillation ablations per million inhabitants in 2013.

Discussion This comparative analysis of the EHRA White Book data show that considerable variations in use of invasive electrophysiological procedures still exist between the ESC member countries. While

several improvements have been made over a 5 year period from 2009 to 2013, there is still a clear need for improvement. As in previous years, the mean CIED implantation rates were markedly lower in the Eastern European and non-European ESC countries than in the other regions. Catheter ablation


Median ablations = 38

i68


58 = Ø AF Ablations per mil inhabitants (weighted by population) 4th quartile > 86 ≤ 293 3rd quartile > 38 ≤ 86 2nd quartile > 5 ≤ 38 1st quartile ≥ 0 ≤ 5

Not available


Figure 68 Atrial fibrillation (AF) ablations in the European Society of Cardiology countries in 2013.

2012 Croatia Estonia Slovenia Russian Federation Slovakia Romania Egypt Spain Kazakhstan Belarus Norway Hungary Serbia Finland Ukraine Poland Latvia Czech Republic Denmark Greece Lithuania Belgium United Kingdom Portugal Sweden Bosnia & Herzegovina FYR Macedonia Montenegro San Marino Luxembourg Ireland Cyprus Armenia Bulgaria Iceland Switzerland Germany Austria Georgia

2013 vs. 2012 in % 117.9 110.2 51.7 50.0 48.4 45.0 43.1 42.4 35.8 29.9 17.6 16.0 14.8 13.3 12.8 11.9 11.0 11.0 10.7 8.8 7.4 6.7 6.2 6.1 0.8 0.0 0.0 0.0 0.0

17.6 26.7 54.6 27.4 18.4 3.8 0.3 32.6 11.1 5.6 248.8 74.5 14.4 109.6 13.5 44.3 26.5 176.9 261.6

36.7 7.9

211.0 80.3 48.5 177.6 0.0 0.0 0.0 0.0

60.9 95.3 5.3 2.7 7.0

76.6

193.3 172.2 121.7 10.7

–1.1 –1.1 –1.5 –3.1 –3.3 –4.8 –5.0 –16.3 –22.9 –33.9

2013 38.4 56.1 82.8 41.1 27.3 5.5 0.4 46.5 15.1 7.3 292.6 86.4 16.6 124.2 15.3 49.5 29.4 196.2 289.6

39.9 8.5 225.2 85.3 51.5 179.0 0.0 0.0 0.0 0.0

60.2 94.2 5.2 2.6 6.7

Figure 69 Change in the number of atrial fibrillation ablations per million inhabitants from 2012 to 2013.

73.0

183.7 144.1 93.8 7.1

i69


176 173

73

76

96


Western Europe

Northern Europe

142

127

105 114

151

62

56

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Southern Europe

EU28

78

80

82

81

2009 2010 2011 2012 2013

19

27

38

31

16

2009 2010 2011 2012 2013

24

19

25

82

ESC


Eastern Europe

102 111

2009 2010 2011 2012 2013

55 18

91

61

76

79

80

36 5

1

2009 2010 2011 2012 2013

5

7

5 2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

ology (ESC) and comparison to the total ESC area and the 28 member countries of the European Union (EU28).

Sweden

Denmark

Norway

TOP 3

293 242

70

249

224

262

290

194 97

85

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

22

19

8

9

2009 2010 2011 2012 2013

12

16

157

178

179

Estonia

72 19

122

2009 2010 2011 2012 2013

Latvia

Lithuania

Lowest 3

232

31

26

29

2009 2010 2011 2012 2013

84

90 27

56

2009 2010 2011 2012 2013

Figure 71 Atrial fibrillation ablations per million inhabitants 2009 – 2013 in Northern Europe.

activity was highest in the Western and Northern Europe and lowest in the non-European and Eastern European ESC countries. However, the Eastern European countries were

characterized by large variations in the procedure rates, with numbers spanning over the four quartiles of the activity distribution.


Figure 70 Atrial fibrillation (AF) ablations per million inhabitants 2009 – 2013 in the five geographical regions of the European Society of Cardi-

i70


TOP 3

Belgium

171

182

Switzerland

211

225

209 156

124

2009 2010 2011 2012 2013

193

134

41

24

146

172

144

2009 2010 2011 2012 2013

Austria

122 54

184

184

2009 2010 2011 2012 2013

Luxembourg

Lowest 2

165

Germany

61

60

2009 2010 2011 2012 2013

36

54

62

94

2009 2010 2011 2012 2013

AF ablations in 2013.

Czech Republic

TOP 3

156

Hungary

177

Poland

196

116 50

49

61

75

86 19

2009 2010 2011 2012 2013

Romania

0

1

50

*

2009 2010 2011 2012 2013 Lowest 3

44

31

*

3

2009 2010 2011 2012 2013

Bulgaria

4

6

2009 2010 2011 2012 2013

4

2

0

Belarus

7

7

2009 2010 2011 2012 2013

3

6

4

6

7

2009 2010 2011 2012 2013

Figure 73 Atrial fibrillation ablations per million inhabitants 2009 – 2013 in Eastern Europe. *No data available.


Figure 72 Atrial fibrillation ablations per million inhabitants 2009– 2013 in Western Europe. France and the Netherlands did not provide data on

i71


Portugal

Slovenia

TOP 3

46

59

44

Spain

83

55

30

33

43

49

51

31

22

33

46

* 2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

2009 2010 2011 2012 2013

Lowest 3 Croatia

Serbia

10

7

14

8

17

0

2009 2010 2011* 2012 2013

0

10

Greece

18

38

18

2009 2010 2011 2012 2013

32

22

37

40


Figure 74 Atrial fibrillation ablations per million inhabitants 2009 – 2013 in Southern Europe. *No data available.

Kazakhstan

TOP 3

11 *

*

Cyprus

Georgia

15

*

2009 2010 2011 2012 2013

1

10

9

11

7

2009 2010 2011 2012 2013

0

0

3

5

5

2009 2010 2011 2012 2013

Lowest Morocco

0

1

1

3

3

2009 2010 2011 2012 2013

Figure 75 Atrial fibrillation ablations per million inhabitants 2009 – 2013 in non-European European Society of Cardiology (ESC) countries. * No data available. The other non-European ESC countries did not provide data on AF ablations in 2013.

Potential for improvement There was a large gap between the EU28 countries and selected Eastern European and non-European ESC countries in the CIED implantation facilities and rates. Likewise, catheter ablation facilities and

rates were markedly lower in the non-European than in the European ESC member countries. National data on health expenditures and CIED implantation rate per capita indicate that a reduced expenditure for healthcare is associated with a lower use of device therapy

i72


Slovenia Norway Ireland Denmark Czech Republic Belgium Sweden Germany United Kingdom Switzerland Austria Greece Finland Iceland Russian Federation Portugal Hungary Ukraine Luxembourg Croatia Poland Estonia Spain Kazakhstan Slovakia Cyprus Georgia Bulgaria Latvia Serbia Belarus Romania Malta Armenia Lithuania Egypt Azerbaijan

59.1 57.7 45.0 44.4 40.7 38.8 38.5 35.0 34.0 32.4 31.8 29.9 29.7 28.8 27.7 27.0 25.6 25.4 24.0 21.1 20.0 18.6 18.4 18.2 14.0 13.3 13.0 12.4 12.4 11.9 9.5 9.2 8.3 5.7 3.6 3.3 1.7

Figure 76 Proportion of atrial fibrillation ablations of total ablations in 2013.

Germany Denmark Kazakhstan Finland Croatia Belgium Norway Czech Republic Greece Sweden Israel Slovenia Latvia Spain Russian Federation Switzerland Slovakia United Kingdom Serbia Austria Poland Bulgaria Azerbaijan Belarus Hungary Romania Ukraine

1.00 0.90 0.80 0.76 0.67 0.63 0.60 0.59 0.56 0.55 0.53 0.50 0.46 0.43 0.39 0.38 0.36 0.35 0.27 0.24 0.23 0.14 0.11 0.10 0.10 0.05 0.04

Figure 77 Number of centres which performed .10 ventricular tachycardia ablations per million inhabitants in patients with structural heart disease in 2013.


Mean ratio AF ablation of total ablations = Ø30.3

i73


EU28

PM-ICD-CRT-Ablation procedures per mil inhabitants

Rest ESC56

Germany Denmark Sweden Switzerland

Austria

Norway

Luxembourg

6.000

7.000

8.000

9.000

10.000

Health expenditures per capita (in USD)

Figure 78 Healthcare spending per capita and interventional electrophysiology procedures (sum of PM-ICD-CRT-Ablation) per million inhabitants.

(Figure 78). However, in some Eastern European countries with low GDP, device implantation, and catheter ablation rates per million population exceed those of certain wealthy Western and Northern European countries. Furthermore, the number of hospitals and beds were not directly related to the financial profile or healthcare expenditure of a given country. This indicates that GDP is not the only driver for high or low utilization of complex therapies with a high upfront cost. Other potential explanations for the disparity include insufficient infrastructures and low referral rates. With regard to the potential for improvement, it is noteworthy that despite the ongoing economic difficulties across Europe, the use of device and catheter ablation therapies is consistently growing in a number of Eastern ESC countries. This is certainly a very positive trend. On the other hand, in many Western and Northern European countries, the use of device and ablation therapies has remained stable or even declined slightly. It is unclear whether this is a consequence of constraints on healthcare expenditure or that supply is already having met demand.

The role of European Heart Rhythm Association Disparities in the implementation of arrhythmia treatment is likely to continue, unless there is an investment in the required infrastructure and harmonization of training and implementation of standard clinical practice guidelines. European Heart Rhythm Association has been very active in promoting unified standards for training of cardiac

rhythm management specialists and to assure high quality in arrhythmia care in a broad sense. The ongoing White Book project has revealed many discrepancies and provided an evidence base for the harmonization of cardiac rhythm management across ESC countries. The certification programme provides an excellent platform for EHRA’s goal to improve training and the level of arrhythmia care in the ESC area. EHRA certification is acknowledged by more than half of the ESC countries and in some, it is now a mandatory requirement for practice. The introduction of the EHRA accreditation programme for teaching centres is expected to provide further support to harmonization of training requirements. EHRA fellowship grants have allowed many young physicians from emerging economies to be trained in high volume centres across the ESC area. The number applications for the EHRA Fellowship grants have been increasing steadily and the certification programme is now also available for allied professionals.

Limitations There are several limitations in the methodology of the EHRA White Book data collection. Data collection is exclusively based on voluntary activity of the national working groups. Some countries have never reported data for the White Book and many countries report incomplete data. For example, in 2013 many countries did not provide data on LE. This may possibly reflect inaccuracies in the collection of data on these procedures, which are relatively new to many centres. With regard to the analysis and interpretation


2.100 2.000 Belgium 1.900 Czech Republic Estonia 1.800 Finland 1.700 1.600 1.500 Iceland Montenegro 1.400 1.300 Poland 1.200 United Kingdom Hungary Lithuania Greece 1.100 Slovakia 1.000 Spain Latvia Ireland 900 Serbia Croatia Slovenia 800 Malta 700 Bulgaria FYR Macedonia 600 500 Georgia Russian Federation 400 Cyprus Romania 300 Armenia 200 Bosnia & Herzegovina 100 Azerbaijan Ukraine 0 0 1.000 2.000 3.000 4.000 5.000

i74

Acknowledgements EHRA White Book 2014 and this supplement was possible thanks to the efforts of several key contributors including chairmen and co-chairs of national Working Groups of the 56 ESC countries, and EHRA staff at the Heart House. We are grateful for their invaluable contribution and hope that even more countries will be reporting data for the White Book next year. In addition, we want to thank the project sponsor, BIOTRONIK SE & Co. KG, and in particular to Robert Wuestenberg and Anja Thuemen for their dedication and passion in the conduction of the project. Finally, Dr Fernando Arribas deserves special mention as the coordinator of the two previous editions of the EHRA White Book supplement. Conflict of interest: M.J.P.R. received speakers/consultant fee from Bayer, Biosense Webster, BMS/Pfizer, Boehringer-Ingelheim, Meda Pharma and research support from St Jude Medical, Bioesense Webster. D.O.A. received speakers fee from Pfizer, Bayer and grant support from Bayer, Pfizer, Boehringer Ingelheim, Medtronic, Bioesense Webster.

Funding The EHRAWhite Book 2014 and this analysis was supported by Biotronik SE & CO.

Future directions The longterm goal is to continuously improve the reliability and usefulness of the EHRA White Book data by increasing the quality and scope of the collected data. In this regard, it is our hope that the development of national registries and their coverage will improve in the future. The long-term goal is to set up an electronic database which would allow free comparisons both the ESC countries and within countries. Such a database would also provide an unique platform for online multinational registry-based clinical trials in arrhythmia therapy.15 Currently the main indications for catheter ablation are supraventricular tachycardias and atrial fibrillation. Recently, the use of catheter ablation for treatment of VT in patients with prior myocardial infarction and various cardiomyopathies has been increasing rapidly mainly due to expanding use of ICDs for both secondary and primary prevention of sudden cardiac death.16 In order to better understand the needs for VT ablations, we plan to collect more detailed data on VT ablations in the next EHRA White Book Survey.

Conclusions The White Book data has developed into a substantial asset, not only for the cardiac EP community, but also for healthcare administrators and politicians in the ESC area. The availability of high-quality information is critical to those facing the challenge of balancing healthcare budgets and allocating limited resources. The statistics presented herein show that, despite significant improvements in many areas of arrhythmia care, there still is considerable heterogeneity in the availability of invasive arrhythmia therapies across the ESC area. Reducing this gap is one of the main objectives of EHRA.

References 1. Arribas F, Auricchio A, Boriani B, Camm J, Merino JL, Merkely B et al. The EHRA White Book. Statistics on the Use of Cardiac Electronic Devices and Electrophysiological Procedures in 54 ESC countries: 2012 Report from the European Heart Rhythm Association (EHRA). Europace 2012;14(Suppl 3): 1 – 55. 2. Merkely B, Kautzner J, Milasinovic G, Hatala R, Taborsky M, Lubinski A et al. EHRA Summit 2010. Summary statement: EHRA summit 2010 with the participation of Central-Eastern European countries: ‘ICD for Life’ Initiative—fighting against sudden cardiac death in emerging economies. Europace 2011;13: 1209 – 10. 3. Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D et al. Financial crisis, austerity, and health in Europe. Lancet 2013;381:1323 –31. 4. Brand H, Rosenko¨tter N, Clemens T, Michelsen K. Austerity policies in Europe - bad for health. BMJ 2013;346:f3716. 5. Boriani G, Maniadakis N, Auricchio A, Vardas P. Health economics and outcomes research: a new challenge and field of action for the European Heart Rhythm Association. Europace 2010;12:601 –3. 6. Vardas P, Boriani G. Health economics and the European Heart Rhythm Association. Europace 2011;13(Suppl 2):ii1–2. 7. Wolpert C, Lubinski A, Bissinger A, Merkely B, Priori S, Brugada J. Barriers to implementation of evidence-based electrical therapies and the need for outcome research: role of European registries. Europace 2011;13:(Suppl 2):ii18 –20. 8. Boriani G, Maniadakis N, Auricchio A, Muller-Riemenschneider F, Fattore G, Leyva F et al. Health technology assessment in interventional electrophysiology and device therapy: a position paper of the European Heart Rhythm Association. Eur Heart J 2013;34:1869 –74. 9. World health statistics 2014. World Health Organisation 2014; URL: http://www. who.int/gho/publications/worldhealth_statistics/2014/en/). 10. EHRA White Book 2014. http://www.escardio.org/communities/EHRA/publications/ Documents/ehra-white-book-2014.pdf 11. Deharo JC, Bongiorni MG, Rozkovec A, Bracke F, Defaye P, Fernandez-Lozano I et al. Pathways for training and accreditation for transvenous lead extraction: a European Heart Rhythm Association position paper. Europace 2012;14:124 – 34. 12. Van Erven L, Morgan JM, Scientific Initiatives Committee (SIC). Attitude towards redundant leads and the practice of lead extractions: a European survey. Europace 2010;12:275 –6. 13. Bongiorni MG, Blomstro¨m-Lundqvist C, Kennergren C, Dagres N, Pison L, Svendsen JH et al. Current practice in transvenous lead extraction: a


of summary data, it was a major drawback that France, one the most populated countries in ESC area, submitted an incomplete response. In addition, there were large variations in national data collection. About 50% of the data came from national registries (22 countries) and 50% were based on surveys and other estimates conducted by the national working groups. This is relevant since the coverage of the registries in some of the ESC countries is relatively poor and many procedures are not included in the registry data. In contrast, surveys and other estimates conducted by the national working groups may overestimate the procedure numbers. This is illustrated by the fact that in 2012 the average number of procedures undertaken per million population was 9% higher in countries without than in those with a national registry on catheter ablation (223 vs. 210 ablation per million population).14 This year the data were presented separately for five geographical regions within the ESC area. In order to avoid any economic, political, or historical bias the European regions were based on the United Nations Statistics Division and all other ESC countries were included in the non-European ESC region. This classification is not free of limitations. For example, Cyprus belongs to the Western Asia although it is a member of the European Union. Nevertheless, we feel that as a well-defined and widely accepted geographical classification the UN grouping provides a neutral platform for regional comparisons within the ESC area.



European Heart Rhythm Association EP Network Survey. Europace 2012;14: 783 – 864. 14. Arribas F, Auricchio A, Boriani G, Brugada J, Deharo JC, Hindriks G et al. Statistics on the use of cardiac electronic devices and electrophysiological procedures in 55 ESC countries: 2013 report from the European Heart Rhythm Association (EHRA). Europace 2014;16(Suppl 1):i1 –78.

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