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Current use of pacemakers, implantable cardioverter defibrillators, and resynchronization devices: data from the registry of the European Heart Rhythm Association

Hugo Ector, Panos Vardas
DOI: http://dx.doi.org/10.1093/eurheartj/sum062 I44-I49 First published online: 26 November 2007

Abstract

The European pacemaker registry is based on data collected from European Pacemaker Identification Cards. A similar format was later developed for implantable cardioverter defibrillators (ICDs). According to national data collected in the registry, European practice appears to be characterized by an important degree of heterogeneity in implant rates of pacemakers, ICDs, and cardiac resynchronization therapy (CRT). Implant rates vary widely from country to country, even in adjacent countries with apparently similar populations. In 2005, the number of new implants of pacemakers ranged from 121 to 1134 per million and from 1.18 to 226 for ICDs across Europe. Overall, there remains an underuse of ICDs in Europe in comparison with what may be expected from epidemiological studies. There are increasing numbers of CRT devices being implanted with similar large discrepancies in implant rates between countries and variations in practice with respect to pacing only CRT devices (CRT-P) or their combination with an ICD (CRT-D).

  • Atrioventricular block
  • Implantable cardioverter-defibrillator
  • Pacemaker
  • Registry
  • Sinoatrial node disease

Introduction

We owe the European pacemaker registry to three colleagues: Giorgio Feruglio, Bert Thalen, and Anthony F. Rickards.13 They introduced the European Pacemaker Identification Card, in cooperation with IAPM (International Association of Medical Prosthesis Manufacturers). This registration form is still in use with only minor modifications. A similar form was developed later for implantable cardioverter defibrillator (ICD) registration. The major features of this registry, continued by Hugo Ector, have been published in articles46 and abstracts.711

Methods

National working groups on cardiac pacing and electrophysiology are invited to collect local data. Every year, they receive a questionnaire. The data are returned to Hugo Ector. At regular intervals, and at their own request, all participants receive a complete overview of this European survey. The original database was set up in SPSS for Windows, version 11.5 (SPSS Inc., 444 North Michigan Avenue, Chicago, IL 60611, USA). Presenting many numbers for three consecutive years is rather difficult. So, besides a table, we present the data in the same format as used in a previous paper.4 We report on the data of three consecutive years: 2003/2004/2005. The corresponding data are ordered in the same triple sequence. When some data are not available for one or more years, this is indicated by ‘?’.This report reflects the status of our registry on 22 May 2007. For inclusion in this survey, data from at least one of the years 2003/2004/2005 must have been available. Special attention was also paid to chronic resynchronization therapy (CRT) devices. For a comparison between countries, in general, we have reported the number of devices per million population. For comparing the indications, we have calculated the ratio (sick sinus + slow atrial fibrillation)/(second degree + third degree atrioventricular block). This method corrects for unspecified indications.

Results

For 2003/2004/2005, we have received contributions to our registry from: Belgium, Croatia, Czech Republic, Denmark, Greece, Italy, Latvia, Lithuania, Netherlands, Russia, Slovak Republic, Spain, Sweden, Switzerland, and United Kingdom (UK). Three countries have sent in the results of their registry for 2003 and 2004: France, Germany, and Norway. For Austria and Slovenia, only data of 2003 were available. For some countries, we have obtained key data from device manufacturers.

In the years 2003/2004/2005, we have registered a total number of 299 705/333 155/196 049 pacemakers (first implants 228 219/253 188/148 980) in 2910/2955/1353 hospitals of 20/18/15 European counties for a population of 535.81/536.62/390.08 million: an implantation rate per million population: total number 559/621/503, first implants 426/472/381.

The pacemaker implantation rate per million varies considerably from country to country: for the total number of pacemakers: median 544/573/602; first implants median 424/435/447.

For the countries, having reported the number of first pacemaker implants, the rate per million was: Austria 550/?/?; Belgium 813/807/789; Croatia 262/267/304; Czech Republic 518/612/590; Denmark 503/514/557; France 718/736/?; Germany 629/756/?; Greece 433/420/389; Italy 581/765/765; Latvia 256/222/213; Lithuania 315/316/397; Netherlands 368/394/394; Norway 361/410/?; Russia 83/92/101; Slovak Republic 272/287/348; Slovenia 323/?/?; Spain 415/480/488; Sweden 556/587/633; Switzerland 439/451/453; UK 405/421/447.

The total number of pacemakers implants per million, as shown in Figure 1, was: Austria 746/910/935; Belgium 1121/1077/1086; Croatia 332/346/391; Czech Republic 742/837/853; Denmark 639/666/746; France 935/957/970; Germany 1068/1100/1134; Greece 563/550/512; Italy 797/956/974; Latvia 303/281/285; Lithuania 369/371/434; Netherlands 525/554/582; Norway 437/496/501; Russia 99/111/121; Slovak Republic 361/379/465; Slovenia 382/?/?; Spain 522/607/651; Sweden 709/757/839; Switzerland 575/593/621; UK 521/547/603.

Figure 1

Total number of pacemakers implants per million in the years 2003/2004/2005.

In Europe, the number of implanting hospitals per million population was almost unchanged between 2003 and 2005: median 4.26/4.88/3.62. For 2005, we have obtained the following figures: Belgium 12.1; Croatia 2.5; Czech Republic 3.62; Denmark 2.72; France 10; Germany 11.9; Greece 6; Italy 6.6; Latvia 1.23; Lithuania 0.88; Netherlands 6.4; Norway 6.2; Russia 0.69; Slovak Republic 2.59; Spain 4.5; Sweden 4.9; Switzerland 8.4; UK 3.17.

Table 1 presents for each country the available data on the pacing mode. For the all Europe in 2003/2004/2005, the median values (%) with respect to the pacing mode were: single chamber atrial % 1.13/1.1/1.56; single chamber ventricular % 37/35.1/33.4; VDD(R) 4.85/2.75/2.1; dual chamber % 55.5/55.36/56.6; biventricular % 2.01/1.95/2.

View this table:
Table 1

Pacing mode at the time of first implant: in % for the European Countries, contributing to the Registry of the European Heart Rhythm Association

YearAAI(R) %VVI(R) %VDD(R) %DDD(R) %CRT-PM %
200320042005200320042005200320042005200320042005200320042005
Austria1326012
Belgium0.270.20.420.52019.21.6311.470.27878.73.13.63.9
Croatia0.40.90.077179.866.35.84.43.922.822.227.40.20.7
Czech Rep1.130.610.842.347.240.11.42.21.551.649.1593.263.3
Denmark10.510.99.725.825.925.911.361.862.761.862.74.265.47.3
France0.20.223.422.85.695.5563.963.62.022.79
Germany1.1138.135.82.72.356.859.40.81
Greece29.327.513.211.357.361.2
Italy00.40.33234.432.61111.310.54450.153.832.11.5
Latvia21045413043349495922
Lithuania26.722.919.845.844.445.82.541.12.124.330.731.70.60.90.5
Netherlands2.42.52.625.925.826.33.22.51.968.56969.49.113.512.6
Norway6.55.724.725.87.3361.465.6
Russia8.59.4862.97371.90.20.10.111.216.818.70.10.30.6
Slovak Rep3.55465.2676365524.32226112
Slovenia13817402
Spain0.871.921.0339.738.439.620.420.220.137.640.139.31.391.371.37
Sweden3.43.93.527.327.7271.10.20.368.168.2643.53.96
Switzerland0.91.11.73633.933.48.68.28.354.456.856.61.81.93.2
UK1.291.11.4138.741.2391.050.980.856.653.9552.352.783.72

For the years 2003/2004/2005, the ratio (sick sinus + slow atrial fibrillation)/(second degree + third degree atrioventricular block) is known in the following countries: Austria 1.65/?/?; Belgium 1.71/1.7/1.57; Croatia 0.81/0.68/0.86; Czech Republic 1.99/1.86/1.96; Denmark 1.12/1.12/1.11; France 0.85/0.82/?; Germany 1.72/?/?; Greece ?/?/1.16; Italy 0.92/0.87/0.88; Latvia ?/1.6/1.6; Netherlands 1.18/1.11/1.17; Norway 1.08/1.25/?; Russia 0.82/0.74/0.85; Slovak Republic 0.94/0.73/0.92; Slovenia 0.64/?/?; Spain 0.81/0.79/0.75; Sweden 1.48/1.51/1.41; Switzerland 1.1/1.19/1.19; U.K. 1/0.98/1.

The % VVI(R) pacing in sinoatrial node disease was: Austria 14/?/?; Belgium 17.6/13/11.5; Croatia 69.2/64/66.6; Czech Republic ?/58.5/54.4; Denmark 9/11/12; France 14/?/?; Germany 18.8/16.1/?; Greece ?/?/31.2; Italy 50.5/21.6/19.7; Latvia ?/18/30; Netherlands 19.1/18.4/17.4; Norway 13/8.1/?; Slovak Republic 51/60/62; Spain 25.8/19.5/21.9; Sweden 13/12.4/12; U.K. 22.8/25.7/23.3.

The % AAI(R) pacing in sinoatrial node disease was: Belgium 0.5/1/0.9; Croatia 1/2/0.4; Czech Republic ?/1.2/1; Denmark 28.7/31.2/27.3; Germany 3.3/3.2/?; Italy 1/1/1.1; Latvia ?/24/?; Netherlands 4.1/4.6/5.4; Norway 16/14.4/?; Slovak Republic 10/9/11; Spain 4.3/5.5/4.8; Sweden 9.8/11.1/10.

The % of unipolar ventricular leads varied from country to country: Belgium 17.2/13/10.8; Croatia 7.5/4/2.9; Czech Republic 5.8/0.5/0.5; Denmark 35.3/25.3/11.8; France 15.7/?/?; Germany 25/16.2/?; Italy 19/15.6/14.1; Latvia ?/5/5; Netherlands 5.8/3/2; Norway 41.5/78.5/?; Russia 61.2/47.1/32.6; Slovak Republic 25.1/9/5; Spain 1.24/0.74/0.58; Sweden 22.2/14.9/9.2; Switzerland 4.5/4.7/2.9; UK 2.48/?/9.2.

Unipolar atrial leads represent only a very low %: Belgium 1.85/0.2/0.7; Croatia 2/1/1.4; Czech Republic 0.3/0.2/0.2; Denmark 0.1/0.1/0.1; France 1.1/?/?; Germany 1.5/1.2/?; Italy 12/9.1/7.7; Latvia ?/0/0; Netherlands 1.2/0.5/0.4; Norway 3.2/0.8/?; Russia 40.5/26.7/18.7; Slovak Republic 4.7/0/0; Spain 0.3/0.08/0.16; Sweden 0.4/0.2/0.3; Switzerland 0.3/1.4/0.6; UK 1.5/?/1.1.

Percentages of active fixation in the atrium are: Belgium 46.6/31/33.9; Croatia 15/9/23.1; Czech Republic 43.4/52.7/52; Denmark 99.6/100/100; France 82.6/?/?; Germany ?/82.5/?; Latvia ?/100/100; Netherlands 38.1/45.8/51.1; Norway 60.2/71.6/?; Russia 16.4/20.6/19.6; Slovak Republic 31.3/44/55.6; Spain 37/37/48; Sweden 91/91.9/95; Switzerland 73.2/74.7/75.6; UK 34.5/?/15.1.

For the right ventricle, the pattern of active fixation is completely different: in %: Belgium 2.6/4/4.4; Croatia 3.5/3/12.6; Czech Republic 16.4/15.5/20; Denmark 36.4/53.7/57.3; France 18.6/?/?; Germany ?/13.5/?; Latvia ?/80/95; Netherlands 16.5/20.6/22.7; Norway 3.3/7.4/?; Russia 3.2/3.3/4.3; Slovak Republic 25.9/12/24.5; Spain 12.8/18.5/23.9; Sweden 33/34.6/36; Switzerland 12.1/16.2/20.4; UK 8.7/?/10.7.

For 2003/2004/2005, a total number of 16 295/10 662/22 721 ICDs were registered (first implants 12 236/7487/16 392). The total number of ICDs per million, as shown in Figure 2, was: Austria 94/109/130; Belgium 91.6/108/116.6; Croatia 2.5/5.1/8.2; Czech Republic 58/72.2/?; Denmark 98/108/138; France 43/58/83; Germany 136/182/226; Greece 39.4/36.3/43.5; Italy 91/143/181; Latvia 5.6/4.1/2.06; Lithuania 3.7/5.47/8.21; Netherlands 95/105.6/140.6; Norway 60.4/66/65; Russia 0.28/0.58/1.18; Slovak Republic 19.6/24.2/19.6; Slovenia 33.6/?/?; Spain 44/55/67; Sweden 48/47/62; Switzerland 80.2/80.3/114.7; UK 42.1/44.8/62.7.

Figure 2

Total number of implantable cardioverter defibrillators per million in the years 2003/2004/2005.

CRT devices have been introduced rather recently. Table 1 gives for CRT pacemakers their % with respect to the total number of first pacemaker implants. For 2003/2004/2005, the number of CRT pacemakers per million population at the time of first implant was: Austria 26/30/32; Belgium 25.8/30.1/31.01; Croatia ?/0.44/2.22; Czech Republic 16.86/27.43/?; Denmark 21.44/27.88/40.74; France 14.49/20.53/34; Germany 5.66/7.55/15; Italy 9.67/8.28/5.65; Latvia 2.59/4.49/3.31; Lithuania 2/2.88/2.05; Netherlands 34.4/54.46/71.66; Norway 8/23/22; Russia 0.1/0.23/0.6; Slovak Republic 2.78/4.26/6.48; Slovenia 6.03/?/?; Spain 9/10/10; Sweden 19.51/23.09/38; Switzerland 8.14/8.76/14.48; UK 8.23/13.6/16.01.

The numbers per million population of CRT-ICD devices implanted in 2003/2004/2005 are known for: Belgium 4.35/11.01/14.59; Czech Republic ?/13.9/?; Denmark 9.94/13.84/26.12; France 5/13/26; Germany 20/35/55; Italy 25.53/50/67.39; Netherlands 21.19/31.08/44.97; Norway 3/14.22/18; Russia 0.03/0.02/0.06; Slovak Republik 1.3/1.67/5.93; Slovenia 1.51/? ?; Spain 3.28/4.49/10.95; Sweden 9/16/18.56; Switzerland 8.14/8.09/24.53; UK 9.1/14.12 /21.11.

Discussion

European arrhythmological practice is characterized by vast heterogeneity. The pacemaker implantation rate per million varies considerably from country to country. Single chamber atrial pacing remained almost ignored, except in Denmark, Lithuania, Norway, Russia, Slovak Republic, and Sweden.

Early history of failures of bipolar leads explains some continuing interest in unipolar ventricular pacing, but the major tendency is towards bipolar ventricular leads. For atrial pacing bipolarity is the rule, except in Russia and Italy. Active fixation is important for the atrium but, except for a few countries, not for the ventricle.

For the all Europe, there remains an underuse of ICDs. There is an increasing implantation of CRT devices, with important differences between countries.

A review based on the voluntary contributions of voluntary people, can never be complete. However, this overview gives a relevant picture on the use of pacemakers and ICD devices for the years 2003–2004–2005.

Acknowledgements

The authors acknowledge the tremendous efforts of the national contact persons and apologize for any omissions or errors. It is virtually impossible that a registry is completely error free. Corrections are welcome.

Contributions to this registry have been sent to us by: K. Steinbach, Austria; H. Nelemans, Belgium; V. Goldner, D. Petrac, Croatia; V. Doupal, Czech Republic; M. Moller, Denmark; M. Salvador-Mazenq, France; A. Markewitz, Germany; P. Vardas, Greece; A. Proclemer, Italy; O. Kalejs, Latvia; P. Stirbis, Lithuania; C. Hooischuur, Netherlands; E.S. Platou, Norway; A.S. Revishvili, Russia; G. Kaliska, Slovak Republic; P. Rakovec, Slovenia; R. Coma-Samartin, Spain; F. Gadler, Sweden; I. Babotai, Switzerland; A. Cunningham, U.K.

Conflict of interest: none declared.

References

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