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, Jyväskylä and University of Eastern Finland, Building 1 D/9, FI-40620 Jyväskylä, 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: pekka.raatikainen@ksshp.fi
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: journals.permissions@oup.com.
Downloaded from by guest on January 28, 2015
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
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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
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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
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Total
M.J.P. Raatikainen et al.
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
Comparative analysis of EHRA White Book data 2009– 2013
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.
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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
M.J.P. Raatikainen et al.
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.
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
Table 3 Healthcare service and insurance systems in the 56 ESC countries
Kosovoa
i7
Continued
Downloaded from by guest on January 28, 2015
i8
Table 3 Continued
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
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.
M.J.P. Raatikainen et al.
Downloaded from by guest on January 28, 2015
i9
Comparative analysis of EHRA White Book data 2009– 2013
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.
Downloaded from by guest on January 28, 2015
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
M.J.P. Raatikainen et al.
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.
Downloaded from by guest on January 28, 2015
Bosnia and Herzegovina
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
Comparative analysis of EHRA White Book data 2009– 2013
Yes, it´s required for practice = 13 countries
Yes, but it´s not required for practice = 11 countries
No = 23 countries
No answer = 2 countries
Yes, it´s required for practice = 13 countries
Yes, but it´s not required for practice = 7 countries
No = 27 countries
No answer = 2 countries
Figure 7 Certification for allied professionals in the European Society of Cardiology countries in 2013.
Downloaded from by guest on January 28, 2015
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
Yes, it´s required for practice = 8 countries
Yes, but it´s not required for practice = 6 countries
No = 32 countries
No answer = 3 countries
Figure 8 Certification for training centres in the European Society of Cardiology countries in 2013.
Downloaded from by guest on January 28, 2015
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
M.J.P. Raatikainen et al.
i13
Comparative analysis of EHRA White Book data 2009– 2013
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
Downloaded from by guest on January 28, 2015
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
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
Greece
GR
No
56
5.20
7800
724
–
9016
611
713
701
691
724
Hungary
Iceland
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
M.J.P. Raatikainen et al.
Bosnia & Herzegovina
Downloaded from by guest on January 28, 2015
LV
Yes
3
Lebanon
Libyaa
Lithuania
1.38
1288
591
–
1823
450
490
550
548
591
LB
No
15
3.63
900
218
LY
LT
N/A
No
N/A
4
N/A
1.14
N/A
2716
N/A
772
2197
3458
N/A
N/A
N/A
N/A
218
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
FYR Macedonia
Malta
MK
MT
Yes
Yes
2
2
0.96
4.86
322
227
154
552
274
431
200
179
336
621
365
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
Ukraine
United Kingdom
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
Comparative analysis of EHRA White Book data 2009– 2013
Latvia
500 411
a
These seven countries did not submit data on PM implantation for the EHRA White Book 2014.
i15
Downloaded from by guest on January 28, 2015
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
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
N/A
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
Bosnia & Herzegovina
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
M.J.P. Raatikainen et al.
Iceland
Downloaded from by guest on January 28, 2015
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
Lithuania
LT
99
1
0
100
0
0
100
0
0
100
0
0
100
0
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
Malta
MT
100
0
0
100
0
0
100
0
0
100
0
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
Portugal
PT
99
1
0
100
0
0
100
0
0
100
0
0
50
50
0
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
Slovakia
SK
65
35
0
100
0
0
100
0
0
100
0
0
98
2
0
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
Comparative analysis of EHRA White Book data 2009– 2013
Lebanon
a
These seven countries did not submit data for the EHRA White Book 2014.
i17
Downloaded from by guest on January 28, 2015
i18
M.J.P. Raatikainen et al.
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
Downloaded from by guest on January 28, 2015
Mean PM implanting centres = Ø 3.80
i19
Comparative analysis of EHRA White Book data 2009– 2013
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
Downloaded from by guest on January 28, 2015
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
Latvia
Ireland
457
2009
507
451
479
2011
2012
2013
Norway
591
630
2009 2010 2011 2012 2013
2009
450
490
2011
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.
M.J.P. Raatikainen et al.
Downloaded from by guest on January 28, 2015
i21
Comparative analysis of EHRA White Book data 2009– 2013
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 January 28, 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
M.J.P. Raatikainen et al.
Italy
TOP 3
Portugal
Spain
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
Montenegro
Bosnia and Herzegovina
FYR Macedonia
150
2009 2010 2011 2012 2013
166
205
154
234
224
253
264
257
138
312
218
*
2009 2010 2011 2012 2013
2009 2010 2011 2012 2013
2009 2010 2011 2012 2013
Downloaded from by guest on January 28, 2015
Figure 17 Pacemaker implantations per million inhabitants 2009 – 2013 in Southern Europe. *No data available.
Israel
TOP 3
567
Cyprus
500
558
Georgia
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
Comparative analysis of EHRA White Book data 2009– 2013
Table 6 Changes in pacemaker implantation centres in year 2012 vs. 2013
Country
ISO code
Number of PM implanting centres 2012
Number of PM implanting centres 2013
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%
Belgium
Bosnia & Herzegovina
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%
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%
Georgia
GE
9
1.97
9
1.82
28%
Germany
Greece
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%
Romania
Russian Federation
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
Downloaded from by guest on January 28, 2015
Estonia
i24
M.J.P. Raatikainen et al.
Table 6 Continued
Country
ISO code
Number of PM implanting centres 2012
Number of PM implanting centres 2013
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
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
Table 7 Changes in pacemaker implantations in year 2012 vs. 2013
Country
ISO code
PM implantations 2012
PM implantations 2013
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
2480
65.11
N/A
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%
Bosnia & Herzegovina
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%
CZ
9150
899.06
9416
887.48
21.3%
Denmark
DK
4663
841.17
4725
850.36
1%
Egypt
EG
2500
29.87
2850
33.41
11.9%
Estonia
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%
Georgia
GE
467
102.17
620
125.45
23%
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%
26.9%
FYR Macedonia
MK
345
165.68
322
154.28
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
Downloaded from by guest on January 28, 2015
Czech Republic
i26
M.J.P. Raatikainen et al.
Table 7 Continued
Country
ISO code
PM implantations 2012
PM implantations 2013
Absolute number
Per mil inhabitants
Absolute number
Per mil inhabitants
......................................................
......................................................
Change %
...............................................................................................................................................................................
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.
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
2013 vs. 2012
2012
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
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
–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
Downloaded from by guest on January 28, 2015
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
M.J.P. Raatikainen et al.
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.
Downloaded from by guest on January 28, 2015
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
To attain
mean ESC
area level
2009
.....................................
..................................... ......................................... ............................................
Absolute
number
Absolute
number
Per mil
inhabitants
Per mil
inhabitants
To attain
mean EU-28
level
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
Comparative analysis of EHRA White Book data 2009– 2013
Table 8 Implantable cardioverter defibrillator implantation facilities and rates in the ESC countries in 2013 and comparison to four previous years
Downloaded from by guest on January 28, 2015
i30
Table 8 Continued
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
To attain
mean ESC
area level
To attain
mean EU-28
level
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
RU
Yes
57
0.40
1870
13
14 219
25 588
4
4
10
11
13
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
Sweden
SE
Yes
29
3.01
1911
198
–
–
71
114
N/A
193
198
Switzerland
Syriaa
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.
M.J.P. Raatikainen et al.
Russian Federation
San Marino
Serbia
Downloaded from by guest on January 28, 2015
i31
Comparative analysis of EHRA White Book data 2009– 2013
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.
Downloaded from by guest on January 28, 2015
Figure 24 Implantable cardioverter defibrillator (ICD) implanting centres per million inhabitants in 2013. Mean number of implantation centres
is weighted by population.
i32
M.J.P. Raatikainen et al.
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
Downloaded from by guest on January 28, 2015
Figure 26 Implantable cardioverter defibrillator (ICD) implantations in the European Society of Cardiology countries in 2013.
257
95
90
100
109
European ESC
countries
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
Non-European ESC
countries
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
Comparative analysis of EHRA White Book data 2009– 2013
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.
Downloaded from by guest on January 28, 2015
2009 2010 2011 2012 2013
16
29
i34
M.J.P. Raatikainen et al.
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
Downloaded from by guest on January 28, 2015
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
Bosnia and Herzegovina
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
Comparative analysis of EHRA White Book data 2009– 2013
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.
Downloaded from by guest on January 28, 2015
2009
58
2009 2010 2011 2012 2013
Morocco
*
43
i36
M.J.P. Raatikainen et al.
Table 9 Change in the number of ICD implantation centres in year 2012 vs. 2013
Country
ISO code
Number of ICD implanting centres 2012
Number of ICD implanting centres 2013
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
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
Belgium
Bosnia & Herzegovina
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%
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%
Romania
Russian Federation
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
Downloaded from by guest on January 28, 2015
Czech Republic
i37
Comparative analysis of EHRA White Book data 2009– 2013
Table 9 Continued
Country
ISO code
Number of ICD implanting centres 2012
Number of ICD implanting centres 2013
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
Downloaded from by guest on January 28, 2015
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
M.J.P. Raatikainen et al.
Table 10 Change in the number of ICD implantations in year 2013 vs. 2012
Country
ISO code
ICD implantations 2012
ICD implantations 2013
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
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
Table 10 Continued
Country
ISO code
ICD implantations 2012
ICD implantations 2013
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
Downloaded from by guest on January 28, 2015
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
i40
M.J.P. Raatikainen et al.
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.
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
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
Downloaded from by guest on January 28, 2015
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
To attain
mean
ESC area
level
To attain
mean
EU-28
level
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
Bosnia &
Herzegovina
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
Georgia
Germanyb
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
M.J.P. Raatikainen et al.
France
Downloaded from by guest on January 28, 2015
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
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
Kosovo
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
Comparative analysis of EHRA White Book data 2009– 2013
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
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i44
M.J.P. Raatikainen et al.
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
Downloaded from by guest on January 28, 2015
Mean CRT implanting centers = Ø 1.83
i45
Comparative analysis of EHRA White Book data 2009– 2013
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.
Downloaded from by guest on January 28, 2015
Figure 40 Cardiac resyncronization therapy (CRT) device implantations in the ESC countries in 2013.
i46
M.J.P. Raatikainen et al.
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
Non-European ESC
countries
Eastern Europe
23
EU28
198
2009 2010 2011 2012 2013
Southern Europe
107
184
70
2009 2010 2011 2012 2013
99
163
European ESC
countries
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).
Downloaded from by guest on January 28, 2015
Figure 42 Cardiac resyncronization therapy defibrillator (CRT-D) implantations per million inhabitants in 2013. Mean number of implantations is
i47
Comparative analysis of EHRA White Book data 2009– 2013
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.
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2009 2010 2011 2012 2013
41
Lithuania
i48
M.J.P. Raatikainen et al.
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
Belarus
1
2
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
FYR Macedonia
Bosnia and Herzegovina
Lowest 3
Spain
Montenegro
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.
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2009 2010 2011 2012 2013
60
Russian Federation
4
5
74
i49
Comparative analysis of EHRA White Book data 2009– 2013
TOP 3
Cyprus
Israel
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
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2009
2
2009
3
3
i50
M.J.P. Raatikainen et al.
Table 12 Change in the number of CRT implanting centres in year 2013 vs. 2012
Country
ISO code
Number of CRT implanting centres
2012
Number of CRT implanting centres
2013
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
8
0.21
N/A
Armenia
AM
3
1.01
2
0.65
235%
Austria
AT
18
2.19
18
2.19
0%
AZ
N/A
N/A
2
0.21
N/A
Belarus
BY
1
0.10
5
0.52
400.9%
Belgium
BE
37
3.34
35
3.35
0.4%
Bosnia & Herzegovina
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%
France
FR
159
2.42
159
2.41
0%
Georgia
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%
Kazakhstan
a
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
2
0.91
2
0.92
0.6%
Lebanon
LB
N/A
N/A
5
1.21
N/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
Kosovo
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
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Azerbaijan
i51
Comparative analysis of EHRA White Book data 2009– 2013
Table 12 Continued
Country
ISO code
Number of CRT implanting centres
2012
Number of CRT implanting centres
2013
Absolute number
Per mil inhabitants
Absolute number
Per mil inhabitants
6
0.82
6
0.83
0.5%
......................................................
Change %
......................................................
...............................................................................................................................................................................
a
Serbia
RS
Slovakia
SK
4
0.73
5
0.91
25%
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
Downloaded from by guest on January 28, 2015
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
M.J.P. Raatikainen et al.
Table 13 Change in the number of total cardiac resyncronization therapy (CRT) device implantations in year 2013 vs. 2012
Country
ISO code
Total CRT implantations 2012
Total CRT implantations 2013
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
64
1.68
N/A
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
Belarus
BY
38
3.94
54
5.61
42.4%
Belgium
BE
858
77.42
1221
116.91
51.0%
Bosnia & Herzegovina
BA
21
5.41
25
6.45
19.2%
Bulgaria
BG
198
28.13
260
37.24
32%
Croatia
HR
58
12.95
81
18.10
40%
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%
Egypt
EG
354
4.23
414
4.85
14.7%
Estonia
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
Georgia
GE
33
7.22
40
8.09
12%
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%
Morocco
MA
57
1.76
75
2.30
30.2%
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%
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%
Poland
a
Continued
Downloaded from by guest on January 28, 2015
Albaniaa
i53
Comparative analysis of EHRA White Book data 2009– 2013
Table 13 Continued
Country
ISO code
Total CRT implantations 2012
Total CRT implantations 2013
Absolute number
Per mil inhabitants
Absolute number
Per mil inhabitants
......................................................
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
Downloaded from by guest on January 28, 2015
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
M.J.P. Raatikainen et al.
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,
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
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.
Downloaded from by guest on January 28, 2015
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
M.J.P. Raatikainen et al.
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
To attain
mean ESC
area level
To attain
mean EU-28
level
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
Bosnia &
Herzegovina
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
Downloaded from by guest on January 28, 2015
Albaniaa
Algeriaa
i57
Comparative analysis of EHRA White Book data 2009– 2013
Table 14 Continued
Country
ISO
code
Number of Lead extraction
centres 2013
Lead extraction procedures
2013
Development potential—
target number of lead
extraction procedures . . .
..................................... ......................................
.........................................
Absolute
number
To attain
mean ESC
area level
per mil
inhabitants
Absolute
number
Per mil
inhabitants
To attain
mean EU-28
level
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.
Downloaded from by guest on January 28, 2015
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
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
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
Bosnia &
Herzegovina
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
Iceland
Ireland
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
M.J.P. Raatikainen et al.
Hungary
Downloaded from by guest on January 28, 2015
KGZ
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
Lithuania
LT
No
3
0.85
Luxembourg
FYR Macedonia
LU
MK
Yes
Yes
1
3
1.94
1.44
Malta
MT
Yes
1
Moldova
Montenegro
MD
ME
No
No
0
1
N/A
N/A
N/A
N/A
N/A
N/A
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
840
239
–
1040
235
242
227
243
239
129
80
251
38
–
383
152
618
220
34
183
15
252
26
301
30
251
38
2.43
12
29
76
122
36
31
20
24
29
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
Ukraine
United Kingdom
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
Comparative analysis of EHRA White Book data 2009– 2013
Kyrgyzstana
144 908
a
These nine countries did not submit data on catheter ablations for the EHRA White Book 2014.
i59
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i60
M.J.P. Raatikainen et al.
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
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
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
Downloaded from by guest on January 28, 2015
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
M.J.P. Raatikainen et al.
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
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
Western Europe
Northern Europe
European ESC
countries
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
257
265
2009 2010 2011 2012 2013
118
128
145
150
299
297
ESC
Non-European ESC
countries
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).
Downloaded from by guest on January 28, 2015
comparison to the total ESC area and the 28 member countries of the European Union (EU28).
i64
M.J.P. Raatikainen et al.
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.
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
Spain
TOP 3
190
170
253
205
188
Croatia
Portugal
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
Bosnia and Herzegovina
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
Downloaded from by guest on January 28, 2015
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
M.J.P. Raatikainen et al.
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
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
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
Bosnia &
Herzegovina
BA
0
0
222
340
N/A
1
0
0
0
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
Romania
Russian
Federation
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
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Bulgaria
i67
Comparative analysis of EHRA White Book data 2009– 2013
Table 16 Continued
Country
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
To attain mean
ESC area level
To attain mean
EU-28 level
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
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Median ablations = 38
i68
M.J.P. Raatikainen et al.
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
Downloaded from by guest on January 28, 2015
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
Comparative analysis of EHRA White Book data 2009– 2013
176 173
73
76
96
European ESC
countries
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
Non-European ESC
countries
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).
Denmark
Norway
TOP 3
Sweden
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.
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Figure 70 Atrial fibrillation (AF) ablations per million inhabitants 2009 – 2013 in the five geographical regions of the European Society of Cardi-
i70
M.J.P. Raatikainen et al.
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.
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Figure 72 Atrial fibrillation ablations per million inhabitants 2009– 2013 in Western Europe. France and the Netherlands did not provide data on
i71
Comparative analysis of EHRA White Book data 2009– 2013
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
2009 2010 2011 2012 2013
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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
M.J.P. Raatikainen et al.
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.
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Mean ratio AF ablation of total ablations = Ø30.3
i73
Comparative analysis of EHRA White Book data 2009– 2013
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
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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.
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11. Deharo JC, Bongiorni MG, Rozkovec A, Bracke F, Defaye P, Fernandez-Lozano I et al.
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12. Van Erven L, Morgan JM, Scientific Initiatives Committee (SIC). Attitude towards redundant leads and the practice of lead extractions: a European survey. Europace
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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.
M.J.P. Raatikainen et al.
Comparative analysis of EHRA White Book data 2009– 2013
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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15. Lauer MS, D’Agostino RB. The randomized registry trial – the next distruptive technology in clinical research. N Engl J Med 2013;369:157 – 81.
16. Braunschweig F, Boriani G, Bauer A, Hatala R, Herrmann-Lingen C, Kautzner J et al.
Management of patients receiving implantable cardiac defibrillator shocks: recommendations for acute and long-term patient management. Europace 2010;12:
1673 –90.
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