Access to and clinical use of cardiac implantable …...electronic devices and interventional electrophysiological procedures in the European Society of Cardiology Countries: 2016

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CLINICAL RESEARCH

Access to and clinical use of cardiac implantableelectronic devices and interventionalelectrophysiological procedures in the EuropeanSociety of Cardiology Countries: 2016 Reportfrom the European Heart Rhythm AssociationM.J. Pekka Raatikainen1*, David O. Arnar2, Bela Merkely3, A. John Camm4,5, andGerhardt Hindricks6

1Department of Cardiology, Heart and Lung Center Helsinki University Central Hospital, Helsinki and University of Eastern Finland, Meilahti Tower Hospital, PO Box 340, FI-00029HUS, Kuopio, Finland; 2Division of Cardiology, Department of Medicine, Landspitali—The National University Hospital of Iceland, Reykjavik, Iceland; 3Semmelweis University ofBudapest, Heart and Vascular Center, Budapest, Hungary; 4Division of Cardiovascular Sciences, St George’s University of London, London, UK; 5ICMS, Imperial College, London, UK;and 6Department of Electrophysiology, Heart Centre, University of Leipzig, Leipzig, Germany

Received 6 July 2016; accepted after revision 7 July 2016

Aims The aim of this analysis was to provide comprehensive information on the access to and use of cardiac implantable elec-tronic device (CIED) and catheter ablation therapy in the European Society of Cardiology (ESC) area.

Methods andresults

The European Heart Rhythm Association (EHRA) has been collecting descriptive and quantitative data on invasivearrhythmia therapies since 2008. This year 50 of the 56 ESC member countries provided data for the EHRA WhiteBook. Up-to-date information on procedure rates for the last 5 years together with information on demographics,economy, vital statistics, local healthcare systems, and training activities is presented for each country and the 5 geo-graphical ESC regions. Our analysis indicated that considerable heterogeneity in the access to arrhythmia therapies stillexists across the ESC area. In 2015, the CIED implantation rates per million population were highest in the Westernfollowed by the Southern and Northern European countries. The catheter ablation activity was largest in the Westernfollowed by the Northern and Southern areas. Overall, the procedure rates were 3–10 times higher in the Europeanthan in the non-European ESC countries. Economic resources were not the only driver for utilization of arrhythmiatherapies as in some Eastern European countries with relative low gross domestic product the procedure rates ex-ceeded the average values.

Conclusion These data will help the healthcare professionals and stakeholders to identify and to understand in more depth thetrends, disparities, and gaps in cardiac arrhythmia care and thereby promote harmonization of cardiac arrhythmias ther-apies in the ESC area.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Keywords Pacemaker † Implantable cardioverter-defibrillator (ICD) † Cardiac resynchronization pacemaker (CRT-P) †

Cardiac resynchronization defibrillator (CRT-D) † Catheter ablation † Atrial fibrillation ablation

IntroductionThe European Heart Rhythm Association (EHRA) White Book isthe key source for information on invasive electrophysiological pro-cedure (EP) rates in the European Society of Cardiology (ESC)

member countries. European Heart Rhythm Association has col-lected comprehensive information concerning the rates of invasiveelectrophysiology procedures alongside information on demo-graphics, economy, vital statistics and healthcare resources, and re-imbursements policies together with the National Cardiac Societies

* Corresponding author. Tel: +358 40 4434200; fax: +358 33 1164157. E-mail address: [email protected]

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2016. For permissions please email: [email protected].

Europace (2016) 18, iii1–iii79doi:10.1093/europace/euw244

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and Working Groups since 2008.1 This year 50 of the 56 ESC mem-ber countries provided data for the EHRA White Book 2016.2

These data have formed the backbone for the ‘ICD for life’3 andmany other strategic initiatives of the EHRA.

Like in the past,4 – 7 the objective of this analysis is to provideup-to-date information on the rates of cardiac implantable electron-ic device (CIED) and catheter ablation procedures in the ESC coun-tries over the past 5 years. In order to allow each country to view itsdata in a larger context and to facilitate detection of potential cross-national disparities and gaps in the invasive electrophysiology pro-cedure rates, the statistics for the four geographical EuropeanESC regions and for the non-European ESC countries are presentedseparately (Figure 1). In addition, we have provided descriptive andquantitative information on the demographics and economic

aspects as well as on training of electrophysiologist in the constitu-ent ESC countries.

The ability to see its own numbers in a European contextprovides each country robust means to demonstrate shortfalls in re-source allocation, reimbursement, and training requirements to thenational or local authorities. It is our hope that these data will help todesign national and international strategic initiatives and awarenessactivities to acquire more resources for cardiac arrhythmia manage-ment and eventually to champion EHRA’s mission ‘To improve thequality of life of the population by reducing the impact of cardiac rhythmdisturbances and reduce sudden cardiac death’.

Demographics and general societaland economic aspectsIn this section, we have provided an overview of the demographicand financial profiles of the 56 ESC countries. The ESC countriesare a heterogeneous group of nations with varying political, financial,and demographic characteristics. Distribution of the populationwithin these regions over the last 5 years is shown in Table 1.

Vital statistics and gross domestic productPopulation and vital statistics and gross domestic product (GDP) inthe 56 ESC countries are presented in Table 2. Total GDP rangedfrom 1.54 (San Marino) to 3371 (Germany) billion US dollars(USD). The GDP per capita was almost 100 times higher in Luxem-bourg (103 187 USD) than in Kyrgyzstan (1198 USD).

Medium- to high-quality data on cause of death are available inmost ESC countries, although they are lacking in many other partsof the world. World Health Organisation (WHO) health statistics

What’s new?† New data on use of cardiac table electronic devices and inva-

sive electrophysiology procedures in Europe is presented indetail.

† The use of CIED and invasive EP procedures is highest inWestern and Nothern Europe.

† Key areas of growth are in ablation of ventricular arrhythmiasin patients with structural heart disease and in the use of leftatrial appendage closure devices.

† For the first time, data are presented on leadless pacemakersand subcutaneous implantable defibrillators.

† The data will help better understand the disparities in the useof arrhythmia treatments in the ESC area.

ESC regions

Eastern Europe

Southern Europe

Western Europe

Northern Europe

Non-European ESC countries

Not ESC countries

Figure 1 Geographic representation of the 56 ESC countries. The European regions were composed according to the UN Statistics Division(http://unstats.un.org/unsd/methods/m49/m49regin.htm).

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Table 1 Populations in the five geographical ESC regions in 2011–15

Region Country ISOcode

2011 2012 2013 2014 2015

Northern Europe Denmark DK 5 529 888 5 543 453 5 556 452 5 569 077 5 581 503

Estonia EE 1 282 963 1 274 709 1 266 375 1 257 921 1 265 420

Finland FI 5 259 250 5 262 930 5 266 114 5 268 799 5 476 922

Iceland IS 311 058 313 183 315 281 317 351 331 918

Ireland IE 4 670 976 4 722 028 4 775 982 4 832 765 4 892 305

Latvia LV 2 204 708 2 191 580 2 178 443 2 165 165 1 986 705

Lithuania LT 3 535 547 3 525 761 3 515 858 3 505 738 2 884 433

Norway NO 4 691 849 5 000 000 5 085 582 5 147 792 5 207 689

Sweden SE 9 088 728 9 103 788 9 647 386 9 723 809 9 801 616

UK GB 62 698 362 63 047 162 63 395 574 63 742 977 64 088 222

Northern Europe total 99 273 329 99 984 594 101 003 047 101 531 394 101 516 733

Western Europe Austria AT 8 217 280 8 219 743 8 221 646 8 223 062 8 665 550

Belgium BE 10 431 477 10 438 353 10 444 268 10 449 361 11 323 973

France FR 65 102 719 65 630 692 65 951 611 66 259 012 66 553 766

Germany DE 81 471 834 81 305 856 81 147 265 80 996 685 80 854 408

Luxembourg LU 503 302 509 074 514 862 520 672 570 252

The Netherlands NL 16 653 734 16 730 632 16 805 037 16 877 351 16 947 904

Switzerland CH 7 639 961 7 925 517 7 996 026 8 061 516 8 121 830

Western Europe total 190 020 307 190 759 867 191 080 715 191 387 659 193 037 683

Eastern Europe Belarus BY 9 577 552 9 643 566 9 625 888 9 608 058 9 498 364

Bulgaria BG 7 093 635 7 037 935 6 981 642 6 924 716 7 186 893

Czech Republic CZ 10 190 213 10 177 300 10 609 762 10 627 448 10 644 842

Hungary HU 9 976 062 9 958 453 9 939 470 9 919 128 9 897 541

Moldova MD 3 694 121 3 656 843 3 619 925 3 583 288 3 546 847

Poland PL 38 441 588 38 415 284 38 383 809 38 346 279 38 562 189

Romania RO 21 904 551 21 848 504 21 790 479 21 729 871 21 666 350

Russian Federation RU 138 739 892 142 517 670 142 500 482 142 470 272 142 423 773

Slovakia SK 5 477 038 5 483 088 5 488 339 5 492 677 5 415 949

Ukraine UA 45 134 707 45 416 589 44 573 205 44 291 413 44 429 471

Eastern Europe total 290 229 359 294 155 232 293 513 001 292 993 150 293 272 219

Southern Europe Albania AL 2 994 667 3 002 859 3 011 405 3 020 209 3 029 278

Bosnia andHerzegovina

BA 4 622 163 3 879 296 3 875 723 3 871 643 3 867 055

Croatia HR 4 483 804 4 480 043 4 475 611 4 470 534 4 464 844

Greece GR 10 760 136 10 767 827 10 772 967 10 775 557 10 775 643

Italy IT 61 016 804 61 261 254 61 482 297 61 680 122 61 855 120

Kosovo XK 1 825 632 1 836 529 1 847 708 1 859 203 1 870 981

FYR Macedonia MK 2 077 328 2 082 370 2 087 171 2 091 719 2 096 015

Malta MT 408 333 409 836 411 277 412 655 413 965

Montenegro ME 661 807 657 394 653 474 650 036 647 073

Portugal PT 10 760 305 10 781 459 10 799 270 10 813 834 10 825 309

San Marino SM 31 817 32 140 32 448 32 742 33 020

Serbia RS 7 310 555 7 276 604 7 243 007 7 209 764 7 176 794

Slovenia SI 2 000 092 1 996 617 1 992 690 1 988 292 1 983 412

Spain ES 46 754 784 47 042 984 47 370 542 47 737 941 48 146 134

Southern Europe total 155 708 227 155 507 212 156 055 590 156 614 251 157 184 643

Non-European ESC countries Algeria DZ 34 994 937 37 367 226 38 087 812 38 813 722 39 542 166

Armenia AM 2 967 975 2 970 495 3 064 267 3 060 927 3 056 382

Azerbaijan AZ 9 397 279 9 493 600 9 590 159 9 686 210 9 780 780

Cyprus CY 1 120 489 1 138 071 1 155 403 1 172 458 1 189 197

Egypt EG 82 079 636 83 688 164 85 294 388 86 895 099 88 487 396

Georgia GE 4 585 874 4 570 934 4 942 157 4 935 880 4 931 226

Continued

Current trends in the use of arrhythmia procedures iii3


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reveal several important differences in the vital statistics betweenthe ESC countries.8,9 As an example, the life expectancy at birth var-ied from 70.4 years (Kyrgyzstan and Moldova) to 83.2 years (SanMarino). The death rate per 1000 population was lowest in Turkey(4.70%) and highest in Bulgaria (14.96%). It is noteworthy that inmost countries with life expectancy over 80 years, the GDP per ca-pita is also relatively high (Table 2).

Healthcare systemsThe organization of healthcare across the ESC member countriesvaries markedly. Many countries provide national healthcare ser-vices with full coverage to the whole population, while in othershealthcare services are primarily delivered by commercial health in-surance companies (Table 3). The proportion of people with nohealth insurance was highest in the Eastern European andnon-European ESC countries. In the Northern, Southern, andWestern European ESC countries, patients do not need to provideany co-payment for invasive electrophysiology procedures, whereasin many Eastern European (e.g. Armenia, Bulgaria, and Georgia) andnon-European ESC countries (e.g. Egypt and Morocco) a co-payment is necessary (Table 3).

The numbers of hospitals and hospital beds available for healthcareare shown in Figure 2. The numbers of hospitals and beds were notdirectly related to the financial profile of the countries or to health-care expenditure. Rather, these data indicate that some countrieshave directed more resources towards hospital care than ambulatoryand home care. For example, the number of beds per 100 000 inha-bitants was 828 in Germany and only 259 in Sweden, despite the rela-tively high GDP and healthcare expenditure in both countries.

Healthcare expenditureHealthcare expenditure has been escalating rapidly and nowadaysrepresents the biggest government-spending item in many coun-tries. In Figure 3, the healthcare expenditure is presented as percent-age of the national GDP and in Figure 4 as expenditure per capita.The mean healthcare expenditure in the ESC area as percentageof the GDP was 8.3%. It was highest in the Netherlands (12.9%)and lowest in Kazakhstan (4.3%).

The healthcare expenditure per capita was highest in Norway(9692 USD) and Switzerland (9208 USD) and lowest in Kyrgyzstan(85 USD). Hence, there was more than 100-fold difference betweenthe lowest and highest healthcare expenditures per capita in theESC area.8,9 Given the trend towards a progressive aging of popula-tions and unhealthy living style, there is pressure to increase thehealthcare expenditure. Despite this, the mean healthcare expend-iture per capita in the ESC area was slightly lower in 2013 (2733USD) than in 2011 (2818 USD).

Certification of professionalexcellence

General informationIn 2015, 47 countries (94% of the countries that responded to theEHRA White Book survey) provided data on certification of physi-cians and allied professionals in device therapy and invasive electro-physiology for the EHRA White Book 2016.2 National certificationprogramme for CIED therapy and invasive cardiac EPs for physicianswas available in 23 (46%) and 22 (44%) of these countries, respect-ively. A certification programme was an obligatory practice require-ment for CIED therapy in 11 countries and for EP in 12 countries(Figures 5 and 6).

A national certification for allied professionals was available in 17countries and was required for practice in 11 countries (Figure 7).Training centres were accredited in only 17 (34%) countries, andcertification of training centres was mandatory in order to train fel-lows in 13 countries (Figure 8). Several centres in various regionswere available as training centres for the EHRA Training FellowshipProgram and allowed many young physicians from emerging econ-omies to be trained in high-volume centres abroad.

European Heart Rhythm AssociationcertificationThe EHRA certification programme is the first European certifica-tion of professional excellence in the field of CIED therapies and

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Table 1 Continued

Region Country ISOcode

2011 2012 2013 2014 2015

Israel IL 7 473 052 7 590 758 7 707 042 7 821 850 8 049 314

Kazakhstan KZ 17 304 513 17 736 896 17 736 896 17 948 816 18 157 122

Kyrgyzstan KGZ 5 450 776 5 496 737 5 548 042 5 604 212 5 664 939

Lebanon LB 4 143 101 4 140 289 4 131 583 4 136 895 6 184 701

Libya LY 6 597 960 5 613 380 6 002 347 6 244 174 6 411 776

Morocco MA 31 968 361 32 309 239 32 649 130 33 478 299 33 322 699

Syria SY 22 517 750 22 530 746 22 457 336 22 597 531 17 064 854

Tunisia TN 10 629 186 10 732 900 10 835 873 10 937 521 11 037 225

Turkey TR 78 785 548 79 749 461 80 694 485 81 619 392 79 414 269

Non-European ESC countriestotal

320 016 437 325 128 896 329 896 920 334 952 986 332 294 046

Total ESC countries 1 055 247 659 1 065 535 801 1 071 549 273 1 077 479 440 1 077 305 324



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Table 2 Population, vital statistics, and GDP in the 56 ESC countries

Country Population Populationgrowth rate (%)

Life expectancyat birth (years)

Death rate per1000 population

GDP (31000billion USD)

GDP percapita (USD)

Total health expenditureas % of GDP

Albaniaa 3 029 278 0.30 78.1 5.68 11.59 4200 5.88

Algeria 39 542 166 1.86 76.6 N/A 175.08 4345 N/A

Armenia 3 056 382 20.14 74.4 9.13 10.61 3547 4.52

Austria 8 665 550 0.58 81.4 9.16 372.61 43 547 11.03

Azerbaijan 9 780 780 0.97 72.2 5.88 63.98 6794 5.58

Belarus 9 498 364 20.10 73.2 12.60 62.02 6583 6.07

Belgium 11 323 973 0.77 80.9 9.83 458.65 40 456 11.19

Bosnia and Herzegovina 3 867 055 20.12 76.6 9.12 15.57 4030 9.63

Bulgaria 7 186 893 20.57 74.4 14.96 47.17 6582 7.63

Croatia 4 464 844 20.13 76.6 11.84 48.93 11 551 7.30

Cyprus 1 189 197 1.42 78.5 6.37 19.38 21 531 7.44

Czech Republic 10 644 842 0.16 78.5 10.39 182.46 17 330 7.24

Denmark 5 581 503 0.22 79.3 9.31 291.04 51 424 10.62

Egypt 88 487 396 1.82 73.7 N/A N/A N/A N/A

Estonia 1 265 420 20.56 76.5 11.35 22.93 17 425 5.72

Finland 5 476 922 0.41 80.8 9.46 230.69 42 159 9.40

France 66 553 766 0.44 81.8 8.49 2422.65 37 728 11.66

Georgia 4 931 226 20.09 76.0 13.17 13.75 3720 9.43

Germany 80 854 408 20.18 80.6 11.08 3371.00 41 267 11.30

Greece 10 775 643 0.00 80.4 10.52 192.98 17 657 9.82

Hungary 9 897 541 20.22 75.7 12.81 118.49 12 021 8.05

Iceland 331 918 1.23 83.0 6.27 16.74 51 068 9.06

Ireland 4 892 305 1.22 80.7 6.36 227.50 48 940 8.92

Israel 8 049 314 1.61 82.3 5.15 298.87 35 702 7.24

Italy 61 855 120 0.28 82.1 10.30 1819.05 29 847 9.09

Kazakhstan 18 157 122 1.15 70.6 8.51 195.01 11 028 4.26

Kosovo 1 870 981 0.63 71.3 N/A 6.31 N/A N/A

Kyrgyzstan 5 664 939 1.08 70.4 6.10 7.16 1198 6.67

Latvia 1 986 705 21.05 74.2 14.28 27.82 13 729 5.72

Lebanona 6 184 701 5.01 77.4 N/A 54.40 11 945 N/A

Libyaa 6 411 776 2.65 76.3 N/A 29.72 4754 N/A

Lithuania 2 884 433 21.04 74.7 13.70 41.78 14 318 6.24

Luxembourg 570 252 2.17 82.2 6.76 57.93 103 187 7.10

FYR Macedonia 2 096 015 0.21 76.0 9.30 10.09 4867 6.44

Malta 413 965 0.32 80.3 7.65 9.19 21 540 8.73

Moldovaa 3 546 847 21.02 70.4 10.70 6.19 1740 11.80

Montenegro 647 073 20.46 78.4 9.29 3.99 6373 6.49

Morocco 33 322 699 1.01 76.7 6.34 103.08 3077 N/A

Netherlands 16 947 904 0.42 81.2 8.41 750.78 44 333 12.89

Norway 5 207 689 1.16 81.7 8.11 397.59 76 266 9.57

Poland 38 562 189 20.08 77.4 10.06 481.24 12 662 6.66

Portugal 10 825 309 0.11 79.2 10.22 197.51 18 984 9.71

Romania 21 666 350 20.29 74.9 11.99 174.92 8807 5.34

Russian Federation 142 423 773 20.03 70.5 13.47 1235.86 8447 6.55

San Marino 33 020 0.85 83.2 7.34 1.54 49 139.01 6.49

Serbia 7 176 794 20.46 75.3 14.00 36.56 5102 10.60

Slovakia 5 415 949 0.03 76.9 9.84 86.20 15 893 8.21

Slovenia 1 983 412 20.25 78.0 9.08 42.74 20 712 9.16

Spain 48 146 134 0.85 81.6 8.38 1221.39 26 327 8.88

Sweden 9 801 616 0.80 82.0 9.43 483.72 48 966 9.71

Switzerland 8 121 830 0.75 82.5 8.03 676.98 82 178 11.47

Syriaa 17 064 854 25.07 74.7 N/A N/A N/A N/A

Tunisiaa 11 037 225 0.91 75.9 N/A 44.27 3985 N/A

Turkey 79 414 269 1.28 74.6 4.70 722.22 9290 5.59

Ukraine 44 429 471 21.15 71.6 14.60 90.14 2109 7.77

UK 64 088 222 0.54 80.5 8.99 2864.90 44 118 9.12

aThese six countries did not submit data for the EHRA White Book 2016.



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

Country Basicinsuranceavailability

Uninsuredcitizens (% ofpopulation)

Distribution of insurance modality (%) Possibility tosubscribe toprivate healthinsurance plans

Co-payment necessaryfor therapies

Publicinsurance

Privateinsurance

Privateco-payment

ICD PM Ablation

Albaniaa

Algeria Yes 30 100 0 0 Yes No Yes No

Armenia No 67 0 100 0 Yes Yes Yes Yes

Austria Yes 2 99 0 0 Yes No No No

Azerbaijan Yes 0 80 10 10 Yes Yes No Yes

Belarus Yes 0 100 N/A N/A Yes No No No

Belgium Yes 1 90 0 10 Yes No No Yes

Bosnia and Herzegovina No 25 75 N/A 25 No Yes Yes N/A

Bulgaria Yes 20 75 1 24 Yes Yes No Yes

Croatia Yes 10 90 5 5 Yes No No No

Cyprus No 15 85 15 0 Yes No No No

Czech Republic Yes 0.1 99.8 0.1 0.1 No No No No

Denmark Yes 0 100 0 0 Yes No No No

Egypt No 35 64 1 35 Yes Yes Yes Yes

Estonia Yes N/A N/A N/A N/A N/A No No No

Finland Yes 0 75.6 3 21.4 Yes No No No

France Yes 0 100 N/A N/A Yes No No No

Georgia Yes N/A N/A N/A N/A Yes Yes Yes Yes

Germany Yes 1 87 13 N/A Yes No No No

Greece Yes 25 90 10 0 Yes N/A N/A N/A

Hungary Yes 2 99 1 0 Yes No No No

Iceland Yes 0 100 0 0 No No No No

Ireland Yes 0 100 46 46 Yes No No No

Israel Yes 0 100 0 0 Yes No No No

Italy Yes 0 100 0 0 Yes No No No

Kazakhstan No N/A N/A N/A N/A Yes No No No

Kosovo No N/A N/A N/A N/A N/A No No No

Kyrgyzstan Yes N/A N/A N/A N/A Yes Yes Yes Yes

Latvia Yes 0 81 19 N/A Yes Yes Yes No

Lebanona

Libyaa

Lithuania Yes 0 98 2 0 Yes No No No

Luxembourg Yes 0 100 N/A N/A Yes No No No

FYR Macedonia No 10 90 10 N/A Yes No No No

Malta Yes 0 N/A N/A N/A Yes No No No

Moldovaa

Montenegro Yes 1 99 N/A 1 No No No No

Morocco No 25 80 15 5 Yes Yes Yes Yes

The Netherlands Yes 0 0 100 0 Yes No No No

Norway Yes 0 99 0 1 Yes No No No

Poland Yes N/A 90 0 10 Yes No No No

Portugal Yes 0 100 0 0 Yes No No No

Romania Yes N/A 100 0 0 No Yes Yes Yes

Russian Federation Yes N/A 90 7 3 Yes No Yes No

San Marino Yes 0 100 0 0 Yes No No No

Serbia Yes 0 100 0 0 Yes No No No

Slovakia Yes 0 75 25 0 No No No No

Slovenia Yes 1 4 0 96 N/A No No No

Spain Yes 1 79 5 16 Yes No No No

Sweden N/A N/A N/A N/A N/A N/A N/A N/A N/A

Switzerland Yes N/A 0 100 0 Yes No No No

Syriaa

Tunisiaa

Turkey Yes 1 99 1 N/A Yes No No No

Ukraine No N/A N/A N/A N/A Yes No No No

UK No 95 95 0 5 Yes No No No




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Israel

Macedonia, F

YR

Portugal

Slovenia

Italy

Malta

Bosnia &

Herzegovina

Azerbaijan

Arm

enia

Greece

Kyrgyzstan

Georgia

Finland

486

Luxembourg

Estonia

Serbia

Latvia

Slovakia

Moldova

Croatia

Belgium

Rom

ania

Czech R

epublic

France

Poland

Kazakhstan

Bulgaria

Hungary

Lithuania

Austria

Russian F

ederation

Germ

any

Ukraine

Belarus

Hospitals

Beds

Figure 2 Hospitals and hospital beds per 100 000 inhabitants in the ESC countries.

4,34,5

5,35,65,6

5,75,7

5,96,1

6,26,46,56,56,6

6,76,7

7,17,27,27,37,4

7,67,8

8,18,2

8,78,98,9

9,19,19,19,2

9,49,4

9,69,69,79,79,8

10,610,6

11,011,211,3

11,511,7

11,812,9

TurkeyAzerbaijan

Mean healthcare expenditure as % of GDP = Ø8,3

LatviaEstoniaAlbaniaBelarus

LithuaniaFYR Macedonia

San MarinoMontenegro

Russian FederationPoland

KyrgyzstanLuxembourg

IsraelCzech Republic

CroatiaCyprus

BulgariaUkraine

HungarySlovakia

MaltaSpain

IrelandIceland

ItalyUnited Kingdom

SloveniaFinland

GeorgiaNorway

Bosnia & HerzegovinaSwedenPortugalGreeceSerbia

DenmarkAustria

BelgiumGermany

SwitzerlandFrance

MoldovaNetherlands

RomaniaArmenia

Kazakhstan

Figure 3 Healthcare expenditure as percentage of national GDP in the ESC countries in 2013. The mean healthcare expenditure as % of GDP isweighted by population.



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85144

237261300327336

450456461469471556565601638

854888

9729751 0371 060

1 3651 472

1 8381 9492 0062 0812 123

2 5092 612

3 0823 561

4 1064 271

4 4774 9675 0135 096

5 4335 564

6 1426 159

7 8519 208

9 692

Mean healthcare expenditures as % of GDP = 2 733 USD

KyrgyzstanArmeniaAlbania

MoldovaUkraine

FYR MacedoniaGeorgiaBelarus

AzerbaijanRomania

Bosnia & HerzegovinaMontenegroKazakhstan

BulgariaTurkeySerbiaLatvia

PolandCroatia

LithuaniaEstonia

HungaryCzech Republic

SlovakiaCyprus

MaltaPortugalSlovenia

GreeceIsraelSpain

ItalyUnited Kingdom

IcelandIrelandFinland

GermanyFrance

BelgiumAustria

SwedenNetherlands

DenmarkLuxembourgSwitzerland

Norway

Figure 4 Healthcare expenditure per capita in the ESC countries in 2013. The mean number of expenditure is weighted by population. Meanhealthcare expenditures as % of GDP ¼ 2733 USD.

No answer = 3 countries

No = 24 countries

Yes, but it´s not required for practice = 12 countries

Yes, it´s required for practice = 11 countries

Figure 5 Certification for CIED therapy in the ESC countries in 2015.



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Noanswer= 3 countries

No= 30 countries



Figure 6 Certification for invasive electrophysiology in the ESC countries in 2015.


No = 30 countries



Figure 7 Certification for allied professionals in the ESC countries in 2015.



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invasive electrophysiology. It plays an important role with regard toEHRA’s goal to promote unified and clear standards for the trainingof cardiac rhythm management specialists and to assure high qualityin arrhythmia care across the ESC area.

During the last 5 years, 1276 physicians (767 in CIED and 509 inEP) from 58 countries have participated in the EHRA examination.Over the years, most of them have submitted the case logbookwithin the required time and subsequently achieved full (Level 2)certification. In 2015, 294 physicians participated in the EHRA

certification examination. The majority of them were male (78%in the invasive electrophysiology examination and 73% in theCIED programme). Over the years, the proportion of female candi-dates has increased from ,10 to �25% (Figure 9). Last year, thehighest numbers of candidates participating in the CIED examinationwere from the Netherlands (31 candidates), Switzerland (23), andItaly (23). In the invasive electrophysiology examination, the highestnumbers of participants were from Italy (13), Spain (12), and theNetherlands (12).


No= 29 countries



Figure 8 Certification for training centres in the ESC countries in 2015.

A Invasive cardiac electrophysiology B CIED therapy C Allied professionals

0

50

100

150

200

0

50

100

150

200

0

50

100

150

200

2011 2012 2013 2014 2015 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015

Female Male Female Male Female Male

Figure 9 Number of participants in the EHRA examination during the last 5 years. CIED, cardiac implantable electronic device.



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

Table 4 Pacemaker implantation facilities and implantation rates in 2015 in comparison with 4 previous years

Country ISOcode

National registryfor PM implants

Number of PMimplanting centres 2015

PM implantations 2015 Development potential—targetnumber of PM implantations

PM implantations per milinhabitants

Absolutenumber

Per milinhabitants

Absolutenumber

Per milinhabitants

To attain meanESC area level

To attain meanEU28 level

2011 2012 2013 2014 2015

Albaniaa AL N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 44 N/A

Algeria DZ No 19 0 2915 74 20 481 34 883 N/A N/A 65 65 74

Armenia AM No 2 1 117 38 1583 2696 133 74 31 42 38

Austria AT Yes 57 7 7905 912 – – 950 957 967 1006 912

Azerbaijan AZ No 8 1 395 40 5066 8628 15 N/A 14 19 40

Belarus BY No 10 1 3149 332 4920 8379 258 275 292 309 332

Belgium BE Yes 104 9 13 073 1154 – – N/A 1228 1218 1236 1154

Bosnia and Herzegovina BA No 6 2 854 221 2003 3411 138 234 224 215 221

Bulgaria BG Yes 19 3 3953 550 – 6340 385 448 503 538 550

Croatia HR No 17 4 2855 639 – 3939 565 561 540 582 639

Cyprus CY No 5 4 280 235 616 1049 223 211 216 213 235

Czech Republic CZ Yes 37 3 8969 843 – 9391 881 899 887 889 843

Denmark DK Yes 15 3 4818 863 – 4924 795 841 850 866 863

Egypt EG No 33 0 3552 40 45 833 78 061 N/A 30 33 38 40

Estonia EE No 5 4 1085 857 – 1116 766 748 912 838 857

Finland FI No 20 4 5821 1063 – – 923 990 1020 1051 1063

France FR No 453 7 64 176 964 – – 969 958 910 1011 964

Georgia GE No 15 3 817 166 2554 4350 84 102 125 123 166

Germany DE Yes 1135 14 106 700 1320 – – 1313 1311 1152 1152 1320

Greece GR Yes 56 5 8800 817 – 9506 701 691 724 742 817

Hungary HU Yes 18 2 6432 650 – 8731 584 607 618 645 650

Iceland IS No 2 6 308 928 – – 1006 967 996 939 928

Ireland IE Yes 17 3 2277 465 2534 4316 507 451 479 N/A 465

Israel IL No 20 2 4250 528 – 7101 500 558 515 537 528

Italy IT Yes 435 7 65 234 1055 – – 1034 1001 1012 1029 1055

Kazakhstan KZ No 25 1 1801 99 9405 16 018 N/A 69 84 131 99

Kosovo XK No 3 2 122 65 969 1651 N/A N/A N/A 68 65

Kyrgyzstan KGZ N/A 2 0 126 22 2934 4997 N/A N/A N/A 22 22

Latvia LV Yes 3 2 1400 705 – 1753 550 548 591 571 705

Lebanona LB N/A N/A N/A N/A N/A N/A N/A N/A N/A 218 218 N/A

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 5 2 2583 895 – – 714 756 772 789 895

Luxembourg LU No 6 11 393 689 – 503 336 621 365 670 689

Continued

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

Table 4 Continued

Country ISOcode

National registryfor PM implants

Number of PMimplanting centres 2015

PM implantations 2015 Development potential—targetnumber of PM implantations

PM implantations per milinhabitants

Absolutenumber

Per milinhabitants

Absolutenumber

Per milinhabitants



2011 2012 2013 2014 2015

FYR Macedonia MK No 3 1 470 224 1086 1849 174 166 154 170 224

Malta MT No 1 2 400 966 – – 740 644 552 887 966

Moldovaa MD N/A N/A N/A N/A N/A N/A N/A N/A N/A 79 N/A N/A

Montenegro ME No 1 2 247 382 335 571 264 218 312 280 382

Morocco MA Yes 11 0 1801 54 17 260 29 396 39 38 34 44 54

The Netherlands NL Yes 85 5 10 000 590 – 14 951 585 560 605 600 590

Norway NO Yes 23 4 4121 791 – 4594 675 691 680 755 791

Poland PL No 145 4 30 494 791 – 34 018 710 716 716 742 791

Portugal PT Yes 40 4 8769 810 – 9550 595 825 814 817 810

Romania RO No 24 1 3918 181 11 222 19 113 139 144 110 196 181

Russian Federation RU Yes 140 1 34 492 242 73 770 125 642 216 212 244 266 242

San Marino SM Yes 1 30 11 333 17 29 503 809 431 N/A 333

Serbia RS Yes 17 2 3724 519 – 6331 448 431 546 507 519

Slovakia SK Yes 14 3 3664 677 – 4778 617 567 630 606 677

Slovenia SI Yes 9 5 1235 623 – 1750 647 668 646 736 623

Spain ES Yes 230 5 33 373 693 – 42 473 734 738 749 761 693

Swedena SE N/A 44 4 N/A N/A N/A N/A N/A 1041 995 969 N/A

Switzerland CH Yes 71 9 6401 788 – 7165 791 753 763 812 788

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

Tunisiaa TN N/A N/A N/A N/A N/A N/A N/A 155 233 N/A 201 N/A

Turkey TR No N/A N/A 9200 116 41 134 70 057 N/A N/A N/A 89 116

Ukraine UA No 38 1 4851 109 23 013 39 194 112 121 148 119 109

UK GB Yes 211 3 46 110 719 – 56 537 610 615 702 708 719

Total ESC countries 3660 3.85 528 441 518 649 648 632 660 680

aThese seven countries did not submit any data on PM implantations for the EHRA White Book 2016.

M.J.P.R

aatikainenetal.

iii12


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

Table 5 Specialty of physicians performing device implantations and LEs

Country ISOcode

Specialist performing PMimplantations (%)

Specialist performing ICDimplantations (%)

Specialist performing CRTimplantations (%)

Specialist performing looprecorder implantations (%)

Specialist performing LEs (%)

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

Albaniaa AL N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Algeria DZ 99 1 0 100 0 0 100 0 0 100 0 0 97 3 0

Armenia AM 100 0 0 100 0 0 100 0 0 100 0 0 0 0 0

Austria AT 50 50 0 10 90 0 50 50 0 80 20 0 10 90 0

Azerbaijan AZ 90 10 0 100 0 0 100 0 0 100 0 0 100 0 0

Belarus BY 0 100 0 0 100 0 0 100 0 0 100 0 0 100 0

Belgium BE N/A N/A 0 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A


BA 85 15 0 85 15 0 100 0 0 100 0 0 N/A N/A N/A

Bulgaria BG 90 10 0 100 0 0 100 0 0 100 0 0 100 0 0

Croatia HR 90 10 0 95 5 0 100 0 0 100 0 0 100 0 0

Cyprus CY 100 0 0 100 0 0 100 0 0 100 0 0 100 0 0

Czech Republic CZ 95 5 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 100 0 0 90 0 10 70 0 30 0 0 0 90 0 10

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 95 5 0 100 0 0 100 0 0 100 0 0

France FR 90 10 0 95 5 0 100 0 0 100 0 0 90 10 0

Georgia GE 90 10 0 100 0 0 100 0 0 100 0 0 N/A N/A N/A

Germany DE 60 28 12 67 21 12 68 20 12 92 2 6 17 83 0

Greece GR 97 3 0 98 2 0 98 2 0 100 0 0 90 10 0

Hungary HU 95 5 0 97 3 0 97 3 0 100 0 0 95 5 0

Iceland IS 50 50 0 50 50 0 100 0 0 100 0 0 100 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 0 100 0 0 100 0 0 99 1 0

Italy IT 100 0 0 100 0 0 100 0 0 100 0 0 100 0 0

Kazakhstan KZ N/A N/A 0 N/A N/A N/A N/A N/A N/A 100 0 0 100 0 0

Kosovo XK 100 0 0 100 N/A N/A 80 0 20 100 0 0 100 0 0

Kyrgyzstan 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 0 100 0

Lebanona LB 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

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 95 5 0

Luxembourg LU 85 15 0 98 2 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 50 50 0

Malta MT 100 0 0 100 0 0 100 0 0 100 0 0 100 0 0

Continued

Current

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proceduresiii13


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

Table 5 Continued

Country ISOcode

Specialist performing PMimplantations (%)

Specialist performing ICDimplantations (%)

Specialist performing CRTimplantations (%)

Specialist performing looprecorder implantations (%)

Specialist performing LEs (%)

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

Moldovaa MD 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

Montenegro ME 70 30 0 50 50 0 100 0 0 50 50 0 50 50 0

Morocco MA 99 1 0 N/A N/A N/A 99 1 0 0 0 0 99 1 0

The Netherlands NL 95 2 3 95 3 2 97 3 0 85 5 10 90 10 0

Norway NO 99.7 0.3 0 100 0 0 100 0 0 100 0 0 100 0 0

Poland PL 99 1 0 99 1 0 100 0 0 100 0 0 99 1 0

Portugal PT 99 1 0 100 0 0 100 0 0 100 0 0 N/A N/A N/A

Romania RO 99 1 0 100 0 0 100 0 0 100 0 0 100 0 0

Russian Federation RU 80 18 2 70 30 0 40 60 0 N/A N/A N/A N/A N/A N/A

San Marino SM 100 0 0 100 0 0 100 0 0 100 0 0 0 0 0

Serbia RS 98 2 0 100 0 0 100 0 0 100 0 0 100 0 0

Slovakia SK 98 2 0 98 2 0 100 0 0 100 0 0 95 5 0

Slovenia SI 20 80 0 N/A N/A N/A 100 0 0 50 50 0 0 100 0

Spain ES 72 24 4 92 8 0 98 2 0 100 0 0 30 70 0

Sweden SE 64 18 18 81 14 5 N/A N/A N/A N/A N/A N/A N/A N/A N/A

Switzerland CH 95 5 0 95 5 0 100 0 0 100 0 0 80 20 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

Turkey TR 95 5 0 97 3 0 99 1 0 100 0 0 75 25 0

Ukraine UA 10.3 89.7 0 14.3 85.7 0 20 80 0 50 50 0 0 100 0

UK GB 100 0 0 100 0 0 100 0 0 100 0 0 100 0 0


M.J.P.R

aatikainenetal.

iii14


0,30,40,4

0,50,7

0,80,9

1,01,11,1

1,41,41,51,51,61,6

1,71,8

2,42,42,52,62,62,7

3,03,3

3,53,5

3,73,73,83,84,0

4,24,44,54,5

4,85,0

5,26,0

6,66,8

7,08,7

9,210,5

14,0

AlgeriaArmenia

AzerbaijanUkraine

Russian FederationBelarus

RomaniaKazakhstan

FYR MacedoniaLatvia

MontenegroBosnia & Herzegovina

KosovoLithuaniaHungary

SerbiaMaltaIsrael

SlovakiaBulgaria

DenmarkGeorgia

United KingdomIreland

Czech RepublicFinland

PortugalPolandCroatiaEstoniaCyprusNorwaySwedenSlovenia

SpainNetherlands

Greece

Mean number of PM implanting centres = Ø 3,85

AustriaFrance

ItalySwitzerland

Belgium

Iceland

Germany

MoroccoKyrgyzstan

Egypt

Luxembourg

Figure 10 Number of PM implanting centres per million inhabitants in the ESC countries in 2015. The mean number of implantation centres isweighted by population.

22384040

546574

99109116

166181

221224235242

332333

382465

519528

550590

623639650

677689693

705719

788791791

810817

843857863

895912

928964966

1 0551 063

1 1541 320

Median number PM implantations = 623

Mean number of PM implantations = Ø 518

KyrgyzstanArmenia

EgyptAzerbaijan

MoroccoKosovoAlgeria

KazakhstanUkraineTurkey

GeorgiaRomania

Bosnia & HerzegovinaFYR Macedonia

CyprusRussian Federation

BelarusSan MarinoMontenegro

IrelandSerbiaIsrael

BulgariaNetherlands

SloveniaCroatia

HungarySlovakia

LuxembourgSpainLatvia

United KingdomSwitzerland

PolandNorway

PortugalGreece

Czech RepublicEstonia

DenmarkLithuania

AustriaIcelandFrance

MaltaItaly

FinlandBelgium

Germany

518 = Ø PM implantations per million inhabitants (weighted by population)

1st quartile ≥ 22 ≤ 221

2nd quartile > 221 ≤ 623

3rd quartile > 623 ≤ 817

4th quartile > 817 ≤ 1320

Figure 11 Pacemaker implantations per million inhabitants in the ESC countries in 2015. The mean number of implantations is weighted bypopulation.



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518 = Ø PM implantations per million inhabitants (weighted by population)





Not available

Figure 12 Pacemaker implantations per million inhabitants in the ESC countries in 2015. The mean number of implantations is weighted bypopulation.

903877863847836

2011 2015201420132012

388393367347347

20152014201320122011

995

2015

1.090

2014

1.036

20132012

1.085

2011

1.092

ESC

680660632648649

20152014201320122011

EU28

931992955991987

20152014201320122011

Northern Europe Western Europe

Southern Europe Eastern Europe

886866821798765

20152014201320122011

729709679694695

20152014201320122011

European ESC countries

144132122132125

20142013 201520122011


Figure 13 Pacemaker implantations per million inhabitants 2011–15 in the five geographical regions of the ESC and comparison with the totalESC area and the 28 member countries of the European Union (EU28).



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Northern Europe

Finland

106310511020990923

20152014201320122011

TOP 3

Lowest 3 United Kingdom

Iceland

9289399969671006

2015201420132012*2011

Latvia

Lithuania

895789772756714

2014 2015201320122011

Ireland

465479451507

20132011 201520142012

719708702615610

20152014201320122011

705571591548550

20152014201320122011

*

Figure 14 Pacemaker implantations per million inhabitants 2011–15 in Northern Europe. *No data available.

Western Europe

Germany

910958969 964

20152014

1.011

201320122011

TOP 3

Lowest 3 Switzerland

788812763753791

20152014201320122011

Belgium

1154123612181228

20152014201320122011

Luxembourg

689670

365

621

336

20152014201320122011

France1320

1152115213111313

20152014201320122011

Netherlands

590600605560585

20122011 2013 2014 2015

*

Figure 15 Pacemaker implantations per million inhabitants 2011–15 in Western Europe. *No data available.



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Eastern Europe

Czech Republic

843889887899881

2012 2013 2014 20152011

TOP 3

Lowest 3 Russian Federation

242266244212216

2015201420132011 2012

Poland

791742716716710

2012 20152013 20142011

Romania

181196110144139

2011 2013 20142012 2015

Slovakia

677606630

567617

2011 2014 201520132012

Ukraine

109119148121112

2015201320122011 2014

Figure 16 Pacemaker implantations per million inhabitants 2011–15 in Eastern Europe.

224170154166174

Southern Europe Italy

10551029101210011034

20152014201320122011

TOP 3

Lowest 3

Malta

966887

552644

740

20152014201320122011

San Marino

333431

809

503

20152014201320122011

Greece

817742691701 724

20152014201320122011

FYR Macedonia Bosnia and Herzegovina

20152014201320122011

221215224234138

20152014201320122011

*

Figure 17 Pacemaker implantations per million inhabitants 2011–15 in Southern Europe. *No data available.



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In 2015, the pass rate was 67% for physicians participating in theinvasive electrophysiology examination and 62% for those partici-pating in CIED examination. These numbers are markedly higherthan in 2014 when the pass rate in the EP examination was 49%and in the CIED examination 51%.

The EHRA certification programme in cardiac device therapy forallied professionals was launched in 2011. Since then, 215 allied pro-fessionals from 14 countries have participated in the EHRA examin-ation, and many of them have achieved full certification. Last year,the pass rate in the allied professional exam was 67%, which waslower than in 2014 (74%). Last year, most participants were fromItaly (41). For allied professionals, the examination is currently avail-able in six languages (English, Spanish, French, German, Italian, andGreek).

Pacemakers

General informationThe 50 countries (89% of all ESC member countries) that submit-ted the requested data on pacemaker (PM) implantation for thisyear’s edition of the EHRA White Book are listed in Table 4. Alba-nia, Lebanon, Libya, Moldova, Syria, and Tunisia did not provideany PM data this year. A national registry for PM implantationswas present in 23 countries, up 3 from the previous year (Table 4).The vast majority of implants were performed by cardiologists,and the remaining implantations were performed by physicianswith various training backgrounds, including surgeons, anaesthe-siologists, paediatricians, and internists. In three countries (Bela-rus, Slovenia, and Ukraine), the proportion of implantingcardiologists was ,50% (Table 5).

Pacemaker facilities and procedure rateIt was reported that in 3660 centres, a total of 528 441 PMs wereimplanted in 2015 (Table 4), slightly up from the last year. Themean number of centres implanting PMs per million inhabitantswas 3.85, slightly higher than the preceding year (Figure 10). Thecountry with the highest density of implanting facilities, exclud-ing San Marino, was Germany (14.0 per million inhabitants) fol-lowed by Luxembourg (10.5) and Belgium (9.2). Those with thelowest density were Egypt and Kyrgyzstan both with 0.4 per mil-lion and Morocco with 0.3 implanting centres per millioninhabitants.

In 2015, the mean PM implantation rate in the participating ESCcountries was 518 PM units per million inhabitants. The implantationrate was highest in Germany (1320), followed by Belgium (1154) andFinland (1063). The two countries with the lowest PM implantationrate were Armenia (38) and Kyrgyzstan (22). An overview of the PMimplantation rate per million inhabitants for each country is shownin Figures 11 and 12. Across the 50 countries, heterogeneity was ob-served in the distribution of PM implantation rate per million inha-bitants, as has been seen in the White Book PM data from previousyears.

The number of PM implantations according to the five ESC re-gions and the trend in implantation rate in comparison with the28 European Union member countries (EU28) and the whole ESCarea from 2011 to 2015 are shown in Figure 13. Countries with thehighest and lowest activities in each region as well as yearly trendsare shown in Figures 14–18. The number of PM implantations permillion inhabitants was highest in Western Europe and lowest inEastern Europe and in the non-European ESC countries. Themost active countries in each region were Germany (1320 per


Israel

528537515558500

2011 2012 20152013 2014

TOP 3

Lowest 3

Cyprus

235213216211223

20132012 201520142011

Azerbaijan

40191415

20122011 2013 20152014

Georgia

16612312510284

20152014201320122011

Egypt

40383330

20152014201320122011

Armenia

38423174

133

20122011 20142013 2015

**

Figure 18 Pacemaker implantations per million inhabitants 2011–15 in the non-ESC countries. *No data available.



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

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

Table 6 Changes in the number of PM implantation centres in year 2014 vs. 2015

Country ISOcode

Number of PM implanting centres 2014 Number of PM implanting centres 2015 Change %

Absolutenumber

Per millioninhabitants

Absolutenumber


Albaniaa AL 4 1.32 N/A N/A N/A

Algeria DZ 19 0.49 19 0.48 21.8

Armenia AM 3 0.98 2 0.65 233.2

Austria AT 57 6.93 57 6.58 25.1

Azerbaijan AZ 10 1.03 8 0.82 220.8

Belarus BY 10 1.04 10 1.05 1.2

Belgium BE 104 9.95 104 9.18 27.7


BA 5 1.29 6 1.55 20.1

Bulgaria BG 17 2.45 19 2.64 7.7

Croatia HR 18 4.03 17 3.81 25.4

Cyprus CY 5 4.26 5 4.20 21.4

Czech Republic CZ 37 3.48 37 3.48 20.2

Denmark DK 11 1.98 15 2.69 36.1

Egypt EG 33 0.38 33 0.37 21.8

Estonia EE 5 3.97 5 3.95 20.6

Finland FI 20 3.80 20 3.65 23.8

France FR 451 6.81 453 6.81 0.0

Georgia GE 9 1.82 15 3.04 66.8

Germany DE 980 12.10 1135 14.04 16.0

Greece GR 56 5.20 56 5.20 0.0

Hungary HU 18 1.81 18 1.82 0.2

Iceland IS 2 6.30 2 6.03 24.4

Ireland IE 17 3.52 17 3.47 21.2

Israel IL 20 2.56 20 2.48 22.8

Italy IT 433 7.02 435 7.03 0.2

Kazakhstan KZ 22 1.23 25 1.38 12.3

Kosovo XK 2 1.08 3 1.60 49.1

Kyrgyzstan KGZ 2 0.36 2 0.35 21.1

Latvia LV 3 1.39 3 1.51 9.0

Lebanona LB 15 3.63 N/A N/A N/A

Libyaa LY N/A N/A N/A N/A N/A

Lithuania LT 4 1.14 5 1.73 51.9

Luxembourg LU 5 9.60 6 10.52 9.6

FYR Macedonia MK 3 1.43 3 1.43 20.2

Malta MT 1 2.42 1 2.42 20.3

Moldovaa MD N/A N/A N/A N/A N/A

Montenegro ME 1 1.54 1 1.55 0.5

Morocco MA 11 0.33 11 0.33 0.5

The Netherlands NL 83 4.92 85 5.02 2.0

Norway NO 23 4.47 23 4.42 21.2

Poland PL 150 3.91 145 3.76 23.9

Portugal PT 39 3.61 40 3.70 2.5

Romania RO 24 1.10 24 1.11 0.3

Russian Federation RU 140 0.98 140 0.98 0.0

San Marino SM N/A N/A 1 30.28 N/A

Serbia RS 17 2.36 17 2.37 0.5

Slovakia SK 13 2.37 14 2.58 9.2

Slovenia SI 7 3.52 9 4.54 28.9

Spain ES 230 4.82 230 4.78 20.8

Continued



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million inhabitants), Finland (1063), Italy (1055), Czech Republic(843), and Israel (528).

The change in the number of implanting centres from 2014 to 2015is shown in Table 6 and Figure 19, and the change in the number of PMimplantations per million inhabitants during the same period is pre-sented in Table 7 and Figure 20. The increase in the number of PM im-plantations was highest in those countries with rather small

implantation numbers, Azerbaijan, Montenegro, and Georgia, butinterestingly there was an almost 15% increase in PM implantationrates in Germany, the country with the highest implant rates in Eur-ope. On the other hand, there was an almost 10% drop in the numberof devices implanted in neighbouring Austria. The changes in the denovo PM implantation rate are shown separately in Figure 21 and forPM generator replacements in Figure 22. The relationship between

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

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

Table 6 Continued

Country ISOcode

Number of PM implanting centres 2014 Number of PM implanting centres 2015 Change %

Absolutenumber


Absolutenumber


Sweden SE 45 4.63 44 4.49 23.0

Switzerland CH 76 9.43 71 8.74 27.3

Syriaa SY N/A N/A N/A N/A N/A

Tunisiaa TN 20 1.83 N/A N/A N/A

Turkey TR N/A N/A N/A N/A N/A

Ukraine UA 36 0.81 38 0.86 5.2

UK GB 207 3.25 211 3.29 1.4

Total ESC countries 3523 3.69 3660 3.85 4.4


1,01,0

4,06,9

6,33,93,8

4,62,6

0,50,4

4,33,5

4,50,4

4,84,0

2,41,4

3,56,8

5,21,0

7,01,8

1,11,5

2,40,3

1,03,2

4,93,6

0,82,5

1,42,4

1,2

1,33,5

2,01,11,1

1,8

SlovakiaLatvia

6,9gruobmexuLKazakhstan

UkraineBulgaria

Slovenia

Romania

SerbiaMontenegro

BelarusUnited Kingdom

Morocco

1,21ynamreGBosnia & Herzegovina

NetherlandsPortugal

Croatia9,4Switzerland

10,0BelgiumAzerbaijan

Hungary

AustriaIcelandPolandFinland

SwedenIsrael

AlgeriaEgypt

CyprusIreland

NorwayKyrgyzstan

SpainEstonia

MaltaFYR MacedoniaCzech Republic

FranceGreece

Russian FederationItaly

Lithuania

DenmarkKosovo

Armenia

2014

Georgia

-33,2-20,8

-7,7-7,3-5,4-5,1-4,4-3,9-3,8-3,0-2,8-1,8-1,8-1,4-1,2-1,2-1,1-0,8-0,6

-0,3-0,2-0,20,00,0

0,00,20,20,30,50,50,51,21,42,02,55,27,79,09,29,612,316,0

20,128,9

36,149,151,9

66,8

2015 vs. 2014 in %

0,70,8

9,28,7

3,86,6

6,03,83,7

4,52,5

0,50,4

4,23,5

4,40,4

4,84,0

2,41,4

3,56,8

5,21,0

7,01,8

1,11,5

2,40,3

1,13,3

5,03,7

0,92,6

1,52,6

10,51,4

1,64,5

2,71,61,7

3,0

14,0

2015

Figure 19 Change in the number of PM implanting centres per million inhabitants from 2014 to 2015.



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

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

Table 7 Changes in PM implantations in year 2014 vs. 2015

Country ISOcode

Number of PM implantations 2014 Number of PM implantations 2015 Change %

Absolutenumber


Absolutenumber


Albaniaa AL 134 44 N/A N/A N/A

Algeria DZ 2508 65 2915 74 14.1

Armenia AM 129 42 117 38 29.2

Austria AT 8272 1006 7905 912 29.3

Azerbaijan AZ 184 19 395 40 112.6

Belarus BY 2970 309 3149 332 7.3

Belgium BE 12 912 1236 13 073 1154 26.6


BA 831 215 854 221 2.9

Bulgaria BG 3726 538 3953 550 2.2

Croatia HR 2601 582 2855 639 9.9

Cyprus CY 250 213 280 235 10.4

Czech Republic CZ 9447 889 8969 843 25.2

Denmark DK 4823 866 4818 863 20.3

Egypt EG 3320 38 3552 40 5.1

Estonia EE 1054 838 1085 857 2.3

Finland FI 5536 1051 5821 1063 1.2

France FR 67 000 1011 64 176 964 24.6

Georgia GE 608 123 817 166 34.5

Germany DE 93 315 1152 106 700 1320 14.5

Greece GR 8000 742 8800 817 10.0

Hungary HU 6393 645 6432 650 0.8

Iceland IS 298 939 308 928 21.2

Ireland IE N/A N/A 2277 465 N/A

Israel IL 4200 537 4250 528 21.7

Italy IT 63 442 1029 65 234 1055 2.5

Kazakhstan KZ 2355 131 1801 99 224.4

Kosovo XK 127 68 122 65 24.5

Kyrgyzstan KGZ 126 22 126 22 21.1

Latvia LV 1236 571 1400 705 23.4

Lebanona LB 900 218 N/A N/A N/A


Lithuania LT 2767 789 2583 895 13.5

Luxembourg LU 349 670 393 689 2.8

FYR Macedonia MK 356 170 470 224 31.8

Malta MT 366 887 400 966 8.9


Montenegro ME 182 280 247 382 36.3

Morocco MA 1465 44 1801 54 23.5

The Netherlands NL 10 132 600 10 000 590 21.7

Norway NO 3887 755 4121 791 4.8

Poland PL 28 470 742 30 494 791 6.5

Portugal PT 8830 817 8769 810 20.8

Romania RO 4258 196 3918 181 27.7

Russian Federation RU 37 832 266 34 492 242 28.8

San Marino SM N/A N/A 11 333 N/A

Serbia RS 3657 507 3724 519 2.3

Slovakia SK 3326 606 3664 677 11.7

Slovenia SI 1464 736 1235 623 215.4

Continued



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the mean annual PM implantation rate per million inhabitants andthe number of PM implanting centres per million inhabitants in the56 ESC countries and in the EU28 is shown in Figure 23.

Leadless pacingLeadless pacing is a new therapeutic modality10,11 which has justbeen introduced in most ESC countries. This is the first time that

data on leadless PM implantations have been collected for theEHRA White Book. According to the EHRA White Book survey,a total of 244 leadless PMs were implanted in 9 countries in 2015.No leadless PMs were implanted in 23 countries, and data on thesedevices were not available from 24 ESC countries. The most activecountries in the ESC area with regard to leadless PM implantationswere France, the Netherlands, and Hungary, but the implantationrates were rather low also in these early adopters (Figure 24).

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

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

Table 7 Continued

Country ISOcode

Number of PM implantations 2014 Number of PM implantations 2015 Change %

Absolutenumber


Absolutenumber


Spain ES 36 322 761 33 373 693 28.9

Sweden SE 9421 969 N/A N/A N/A

Switzerland CH 6543 812 6401 788 22.9


Tunisiaa TN 2200 201 N/A N/A N/A

Turkey TR 7300 89 9200 116 29.5

Ukraine UA 5258 119 4851 109 28.0

UK GB 45 131 708 46 110 719 1.6

Total ESC countries 526 213 508 528 441 518 2.1


42,1

68,3

22,5

38,2

64,6

43,889,4

19,0

Kazakhstan 131,2Slovenia 736,3

0,600.1airtsuAArmenia

9,067niapSRussian Federation 265,5

Ukraine 118,7Romania 196,0

7,532.1muigleB9,888cilbupeR hcezC

2,110.1ecnarFKosovo

6,118dnalreztiwSNetherlands 600,3

Israel 537,00,939dnalecI

Kyrgyzstan5,618lagutroP

0,668kramneDHungary 644,5

7,050.1dnalniFUnited Kingdom 708,0

Bulgaria 538,1Serbia 507,2

9,738ainotsE6,820.1ylatI

Luxembourg

2014

670,3Bosnia & Herzegovina 214,6

1,557yawroNEgypt

4,247dnaloPBelarus 309,1

9,688atlaMCroatia 581,8Greece 742,4Cyprus 213,2

Slovakia 605,53,987ainauhtiL

Algeria1,251.1ynamreG

Latvia 570,9Morocco

TurkeyFYR Macedonia 170,2

Georgia 123,2Montenegro 280,0

Azerbaijan

-24,4-15,4

-9,3-9,2-8,9-8,8-8,0-7,7-6,6-5,2-4,6-4,5-2,9-1,7-1,7-1,2-1,1-0,8-0,3

0,81,21,62,22,32,32,52,82,94,85,16,57,38,99,910,010,411,713,514,114,5

23,423,5

29,531,8

34,5

2015 vs. 2014 in %

36,3112,6

99,2622,7

912,238,3

693,2242,2

109,2180,8

842,6964,3

65,2788,1

590,0528,0

927,922,2

810,0863,2

649,9

719,5550,0

518,9857,4

689,2220,8

791,340,1

790,8331,5

966,3639,4

816,7235,5

676,5895,5

73,7

704,754,0

115,8224,2

165,7381,7

40,4

2015

1.154,5

1.062,8

1.054,6

1.319,7

Figure 20 Change in the number of PM implantations per million inhabitants from 2014 to 2015.



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Implantablecardioverter-defibrillators

General informationThe 50 countries (89%) that submitted data for the EHRA WhiteBook on implantable cardioverter-defibrillators (ICDs) in 2015

are listed in Table 8. Albania, Lebanon, Libya, Moldova, Syria, and Tu-nisia did not provide data on ICD implantations, while Sweden pro-vided only limited data. In 25 countries, a national registry for ICDimplantations was in use. The vast majority of implants were per-formed by cardiologists, and the remaining implantations were per-formed by physicians having various other training backgrounds,mainly surgical. However, in some countries (Austria, Belarus, and

9,1

21,7

3,8

91,3

86,457,6

94,2

3,2

28,7

18,972,4

14,2

98,4

49,213,5

380,6Switzerland 193,5

5,342dnalniFPortugal 172,4BulgariaBelarusNorway 174,4

Hungary 152,5Poland 224,2CroatiaIceland 129,2

3,503atlaMAlgeriaGreece 194,9

EgyptLatvia

Luxembourg 157,5Slovakia 126,0

FYR MacedoniaGermany 219,0

MontenegroTurkey

2014

ArmeniaSlovenia 149,4Ukraine

Bosnia & HerzegovinaSerbia

KosovoUnited Kingdom 176,3

Denmark 209,9Netherlands 157,9

Lithuania1,382airtsuA

Spain 190,26,662cilbupeR hcezC

Estonia 112,9Belgium

-64,2-25,7-23,0

-16,3-16,3-14,8-13,7-13,5-12,2-11,5-10,6

-8,9-8,7-8,3-7,7-7,5-6,8-3,8-2,5-0,9

-0,51,93,54,44,96,09,010,015,7

22,824,725,2

38,044,6

2015 vs. 2014 in %

57,0110,2

3,3110,9

16,715,8

60,63,2

152,2181,5

138,780,8

253,2173,3

243,5103,5

179,0227,0

165,884,2

57,1173,6

155,5232,1

98,3135,6

15,5214,4

3,7120,8

196,4157,7

39,6

77,328,3

2015

351,4

323,7

316,7

Figure 22 Change in the number of PM replacements per million inhabitants from 2014 to 2015.

97,1

35,0

33,0

76,0

50,4

64,5

2014

Russian Federation 226,09,685ainevolS

7,075niapS8,227airtsuA

3,007nedewS1,558muigleB

UkraineKosovo

Luxembourg 512,84,226cilbupeR hcezC

8,908dnalecI1,816dnalreztiwS2,446lagutroP

Hungary 492,0Bulgaria 451,7

Netherlands 442,42,708dnalniF

1,656kramneD0,527ainotsE

EgyptSerbia 434,8

Armenia6,085yawroN

United Kingdom 531,71,339ynamreG

Poland 518,3Slovakia 479,5Belarus 251,6Greece 547,5Turkey

6,185atlaMCroatia 487,6Algeria

0,896ainauhtiLLatvia 472,5

FYR Macedonia 141,5Montenegro 230,8

-8,9-8,8

-7,0-6,1-4,7-3,9-3,9-3,7-2,2-1,5-0,2

0,50,71,4

3,63,84,04,15,46,16,46,77,57,88,29,110,010,210,511,0

15,516,7

23,630,531,9

2015 vs. 2014 in %

-79,7-12,8

45,8511,7519,9

659,0651,1

803,192,5

62,0492,8

599,1792,4

609,1642,8

494,4454,9448,4

835,9681,2

753,936,4

458,335,0

617,7567,2

558,6518,8

274,5602,3

83,7642,6

541,158,2

814,7583,9

184,6304,4

2015

1.002,9

Figure 21 Change in the number of new PM implantations per million inhabitants from 2014 to 2015.



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0

100

200

300

400

500

600

700

800

900

1000

0 1 2 3

PM implantations per million inhabitants

MAKGZ

EG DZ

AM AZ

UA

RU

BY

RO

KZ

MK

LV

ME

BA

XK

LT

HU

RS

MT

IL

SK

BG

DK

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

1400

85 313 12 13016 114 9 417

CH

DE

IT

FR

LU

AT

GR

NL

ES

SI

NO

CY

EE

HR

PL

PT

SM

IS

GE

FI

CZ

IE

GB

PM implanting centresper million inhabitants

BE

ESC 56

EU28

Figure 23 Pacemaker implantation centres and rates in the ESC and European Union (EU28) member countries in 2015. Bubble size is relatedto population in the country. The ISO codes of the countries are explained in Table 1.

000

0

0

00

0

0

0

00

0

000

00

00

0

0

3

55

710

16

2450

124

0

San Marino

Romania

Morocco

Montenegro

Malta

Lithuania

Latvia

Kyrgyzstan

Iceland

Greece

Estonia

Cyprus

Bulgaria

Bosnia & Herzegovina

Belgium

Azerbaijan

Armenia

Algeria

Denmark

Sweden

Norway

Serbia

Israel

Portugal

Hungary

Netherlands

France

United Kingdom

Ukraine

Turkey

Slovenia

Slovakia

Figure 24 Number of leadless PM implantations in 2015.



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

Table 8 Implantable cardioverter-defibrillator implantation facilities and rates in 2015 and comparison with 4 previous years

Country ISOcode

National registryfor ICD implants

Number of ICDimplanting centres 2015

ICD implantations 2015 Development potential—targetnumber of ICD implantations

ICD implantations per milinhabitants

Absolutenumber


Absolutenumber




2011 2012 2013 2014 2015

Albaniaa AL N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 N/A

Algeria DZ No 9 0.23 91 2 4030 6992 N/A N/A 1 2 2

Armenia AM No 3 0.98 21 7 311 540 12 N/A 9 8 7

Austria AT Yes 21 2.42 1393 161 – 1532 220 145 158 166 161

Azerbaijan AZ No 7 0.72 21 2 997 1729 2 N/A 1 2 2

Belarus BY No 10 1.05 133 14 968 1680 14 12 16 18 14

Belgium BE Yes 23 2.03 1531 135 – 2002 197 210 163 154 135

Bosnia and Herzegovina BA No 6 1.55 87 22 394 684 13 14 17 14 22

Bulgaria BG Yes 10 1.39 51 7 732 1271 8 7 5 7 7

Croatia HR No 11 2.46 388 87 455 789 19 26 35 39 87

Cyprus CY No 4 3.36 75 63 121 210 58 46 52 62 63

Czech Republic CZ Yes 18 1.69 2039 192 – – 270 277 301 201 192

Denmark DK Yes 6 1.07 1208 216 – – 198 218 231 217 216

Egypt EG No 17 0.19 253 3 9018 15 647 N/A 2 2 3 3

Estonia EE No 2 1.58 91 72 129 224 45 79 82 76 72

Finland FI No 18 3.29 1198 219 – – 134 166 194 220 219

France FR No 161 2.42 7825 118 – 11 768 102 106 N/A 207 118

Georgia GE No 12 2.43 140 28 503 872 5 12 12 21 28

Germany DE No 745 9.21 28 914 358 – – 326 326 336 295 358

Greece GR Yes 24 2.23 1188 110 – 1905 83 87 97 100 110

Hungary HU Yes 13 1.31 986 100 1009 1750 80 85 95 96 100

Iceland IS No 1 3.01 59 178 – – 113 134 171 186 178

Ireland IE Yes 17 3.47 740 151 – 865 140 144 153 N/A 151

Israel IL Yes 20 2.48 1300 162 – 1423 156 137 166 215 162

Italy IT Yes 396 6.40 14 709 238 – – 196 196 204 223 238

Kazakhstan KZ No 19 1.05 527 29 1850 3211 N/A 7 12 22 29

Kosovo XK No 1 0.53 12 6 191 331 N/A N/A N/A 2 6

Kyrgyzstan KGZ N/A 2 0.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A

Latvia LV Yes 3 1.51 90 45 202 351 29 32 40 35 45



Lithuania LT No 3 1.04 123 43 294 510 33 42 35 38 43

Luxembourg LU Yes 1 1.75 65 114 – 101 99 149 138 119 114

FYR Macedonia MK No 3 1.43 29 14 214 371 13 7 6 5 14

Malta MT No 1 2.42 35 85 42 73 71 132 163 87 85

M.J.P.R

aatikainenetal.

iii26



Montenegro ME No 1 1.55 53 82 66 114 47 44 58 63 82

Morocco MA N/A 6 0.18 57 2 3396 5892 1 1 1 1 2

The Netherlands NL Yes 29 1.71 3500 207 – – 155 160 244 212 207

Norway NO Yes 11 2.11 1214 233 – – 184 199 214 220 233

Poland PL No 122 3.16 8526 221 – – 157 182 234 219 221

Portugal PT Yes 29 2.68 1224 113 – 1914 95 92 N/A N/A 113

Romania RO No 16 0.74 300 14 2208 3831 8 8 9 15 14

Russian Federation RU Yes 48 0.34 1553 11 14 515 25 184 10 11 13 12 11

San Marino SM Yes 1 30.28 8 242 – – 597 404 616 N/A 242

Serbia RS Yes 11 1.53 437 61 731 1269 44 38 62 63 61

Slovakia SK Yes 4 0.74 665 123 – 958 100 105 108 120 123

Slovenia SI Yes 3 1.51 228 115 – 351 72 61 71 88 115

Spain ES Yes 180 3.74 5348 111 – 8513 74 73 82 81 111

Sweden SE N/A 30 3.06 N/A N/A N/A N/A N/A 193 198 216 N/A

Switzerland CH Yes 49 6.03 1830 225 – – 142 195 201 166 225



Turkeya TR No N/A N/A 6381 80 8093 14 042 N/A N/A N/A 77 80

Ukraine UA No 14 0.32 52 1 4528 7856 1 1 2 1 1

UK GB Yes 125 1.95 6701 105 – 11 332 86 91 92 102 105

Total ESC countries 2266 2.38 103 399 102 102 106 108 118 113

aThese six countries did not submit any data on ICD implantations for the EHRA White Book 2016.

Current

trendsin

theuse

ofarrhythmia

proceduresiii27


0,20,20,2

0,30,30,4

0,50,70,70,7

1,01,01,01,11,1

1,31,41,41,51,51,51,51,61,6

1,71,71,8

2,02,02,1

2,22,42,42,42,42,52,5

2,73,03,1

3,23,33,4

3,53,7

6,06,4

9,2

Mean number of ICD implanting centres = Ø 2,38

MoroccoEgypt

AlgeriaUkraine

Russian FederationKyrgyzstan

KosovoAzerbaijan

RomaniaSlovakiaArmenia

LithuaniaKazakhstan

BelarusDenmarkHungaryBulgaria

FYR MacedoniaLatvia

SloveniaSerbia

MontenegroBosnia & Herzegovina

EstoniaCzech Republic

NetherlandsLuxembourg

United KingdomBelgiumNorwayGreece

MaltaFranceAustria

GeorgiaCroatia

IsraelPortugalIceland

SwedenPolandFinlandCyprusIrelandSpain

SwitzerlandItaly

Germany

Figure 25 Implantable cardioverter-defibrillator implanting centres per million inhabitants in 2015. The mean number of implantation centres isweighted by population.

12223

677

11141414

222829

4345

6163

728082

8587

100105

110111

113114115

118123

135151

161162

178192

207216

219221

225233

238

Median number of ICD implantations = 93

UkraineMorocco

AzerbaijanAlgeria

EgyptKosovo

ArmeniaBulgaria

Russian FederationFYR Macedonia

RomaniaBelarus

Bosnia & HerzegovinaGeorgia

KazakhstanLithuania

LatviaSerbiaCyprusEstoniaTurkey

MontenegroMalta

CroatiaHungary

United KingdomGreece

SpainPortugal

LuxembourgSlovenia

FranceSlovakiaBelgium

IrelandAustria

Mean number of ICD implantations = Ø 102

IcelandCzech Republic

NetherlandsDenmark

FinlandPoland

Israel

NorwayItaly

San Marino 242Germany 358

Switzerland

102 = Ø ICD implantations per million inhabitants (weighted by population)





Figure 26 Implantable cardioverter-defibrillator implantations per million inhabitants in 2015. The mean number of implantations is weightedby population.



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102 = Ø ICD implantations per million inhabitants (weighted by population)





Not available

Figure 27 Implantable cardioverter-defibrillator implantations in the ESC countries in 2015.

159139131122122

201420132012 20152011

4950554641

201420132012 20152011

294255

288273273

201420132012 20152011

ESC

113118108106102

20152014201320122011

EU28

188170178165162

201420132012 20152011



12312011110798

20152014201320122011

131119125115112

201420132012 20152011


3340312629

20152014201320122011


Figure 28 Implantable cardioverter-defibrillator implantations per million inhabitants 2011–15 in the five geographical regions of the ESC andcomparison with the total ESC area and the 28 member countries of the European Union (EU28).



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Northern Europe

Norway

233220214199184

20152014201320122011

TOP 3

Lowest 3

Estonia

Finland

219220194

166134

20152014201320122011

Latvia

Denmark

216217231218198

201420132012 20152011

Lithuania

7276827945

201420132012 20152011

4535403229

20152014201320122011

4338354233

2014 2015201220122011

Figure 29 Implantable cardioverter-defibrillator implantations per million inhabitants 2011–15 in Northern Europe.

Western Europe

Germany358

295336326326

201420132012 20152011

TOP 3

Lowest 3 Belgium

135154163

210197

20152014201320122011

Switzerland

225

166201195

142

20152014201320122011

France

118

207

106102

20152014201320122011

Netherlands

207212244

160155

20152014201320122011

Luxembourg

114119138149

99

201420132012 20152011

*

Figure 30 Implantable cardioverter-defibrillator implantations per million inhabitants 2011–15 in Western Europe. *No data available.



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Eastern Europe

Slovakia

123120108105100

201420132012 20152011

TOP 3

Lowest 3 Russian Federation

1112131110

201420132012 20152011

Czech Republic

192201

301277270

201420132012 20152011

Bulgaria

77578

201420132012 20152011

Poland221219

234

182157

20142013 201520122011

Ukraine

11211

201420132011 20152012

Figure 31 Implantable cardioverter-defibrillator implantations per million inhabitants 2011–15 in Eastern Europe.

1456713

Southern Europe

Slovenia

11588716172

201420132012 20152011

TOP 3

Lowest 3

Italy

238204196196 223

20152014201320122011

Serbia

6163623844

20152014201320122011

San Marino

242

616

404

597

20152014201320122011

Bosnia and Herzegovina

2214171413

2011 201420132012 2015

FYR Macedonia

201420132012 20152011

*

Figure 32 Implantable cardioverter-defibrillator implantations per million inhabitants 2011–15 in Southern Europe. *No data available.



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Ukraine), the proportion of implanting cardiologists was ,50%(Table 5).

Implantable cardioverter-defibrillatorfacilities and procedure ratesIt was reported that in 2266 national centres, a total of 103 399ICDs were implanted in 2015 (Table 8), an almost 2% increasefrom 2014. Table 8 also shows a comparison with the previous 4years in each country. As shown in Figure 25, the mean number ofimplanting centres in the ESC area was 2.38 per country. In theESC area, the mean number of ICD implantations per million inha-bitants in 2015 was 102. In Figures 26 and 27, the ESC countries aregrouped into quartiles according to the number of ICD implanta-tions per million inhabitants. Germany (358 per million inhabitants)had by far the highest implant rate followed by San Marino (242),Italy (238), and Norway (233). The lowest reported implant ratewas in Ukraine (one per million inhabitants).

The number of ICD implantations according to the five ESC re-gions and the trend from 2011 to 2015, compared with the EU28and the whole ESC area, is shown in Figure 28. In Western Europe(294), the number of ICD implantations per million inhabitants wasalmost twice higher than in any other ESC region. Implantablecardioverter-defibrillator implantation rate also exceeds 100 permillion population in the Southern (159), Northern (123), and Euro-pean regions. The top and bottom three countries within the fiveESC regions are shown in Figures 29–33. The most active countriesin each region were Germany (358 per million inhabitants) in thewest, Norway (233) in the north, Poland (221) in the east, San Mar-ino (242) and Italy (238) in the south, and Israel (162) in thenon-European ESC region.

The changes in the number of implanting centres from 2014 to2015 are shown in Table 9 and Figure 34, and the change in the num-ber of ICD implantations per million inhabitants during the sameperiod is presented in Table 10 and Figure 35. These numbers are di-vided into de novo implantations and ICD generator replacements inFigures 36 and 37.

The relationship between the annual ICD implantation rate per mil-lion inhabitants and the number of ICD implanting centres per millioninhabitants in the EU28 countries and the ESC area is shown in Figure 38.

Subcutaneous implantablecardioverter-defibrillatorimplantationsSubcutaneous ICD (S-ICD) is a novel therapeutic modality for pre-vention of sudden cardiac death. The device is implanted entirelyunder the skin avoiding the need for intravascular leads. It is best sui-ted for patients with no need for pacing and increased risk for trans-venous lead complications.12,13

This is the first time that data on S-ICD implantations havebeen collected for the EHRA White Book. As with the other newtherapies and procedures, the response rate for this question in theEHRA White Book survey was markedly lower than that of the con-ventional arrhythmia treatments. A total of 1049 S-ICDs were im-planted in 13 countries in 2015. No S-ICDs were implanted in 24countries, and 19 countries reported no data on these devices. Themost active countries with regard to the S-ICD implantations wereItaly with 561 implantations followed by the UK (196 implantations)and the Netherlands (150 implantations) (Figure 39).


Kazakhstan

2922127

20152014201320122011

TOP 3

Lowest 3

Cyprus

6362524658

2012 2014 201520132011

Algeria

221

2013 201420122011 2015

Israel

162

215

166137

156

201420132012 20152011

Azerbaijan

2212

20152014201320122011

Morocco

21111

201420132012 20152011

* * *

*

Figure 33 Implantable cardioverter-defibrillator implantations per million inhabitants 2011–15 in the non-European ESC countries. *No dataavailable.



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

Table 9 Changes in the number of ICD implantation centres in year 2014 vs. 2015

Country ISO code Number of ICD implantingcentres 2014

Number of ICD implantingcentres 2015

Change %

Absolutenumber


Absolutenumber



Algeria DZ 8 0.21 9 0.23 10.4

Armenia AM 3 0.98 3 0.98 0.1

Austria AT 21 2.55 21 2.42 25.1

Azerbaijan AZ 7 0.72 7 0.72 21.0

Belarus BY 10 1.04 10 1.05 1.2

Belgium BE 23 2.20 23 2.03 27.7

Bosnia and Herzegovina BA 5 1.29 6 1.55 20.1

Bulgaria BG 9 1.30 10 1.39 7.1

Croatia HR 12 2.68 11 2.46 28.2

Cyprus CY 4 3.41 4 3.36 21.4


Denmark DK 6 1.08 6 1.07 20.2

Egypt EG 16 0.18 17 0.19 4.3

Estonia EE 2 1.59 2 1.58 20.6

Finland FI 19 3.61 18 3.29 28.9

France FR 162 2.44 161 2.42 21.1

Georgia GE 8 1.62 12 2.43 50.1

Germany DE 670 8.27 745 9.21 11.4

Greece GR 24 2.23 24 2.23 0.0

Hungary HU 13 1.31 13 1.31 0.2

Iceland IS 1 3.15 1 3.01 24.4

Ireland IE 17 3.52 17 3.47 21.2

Israel IL 20 2.56 20 2.48 22.8

Italy IT 397 6.44 396 6.40 20.5

Kazakhstan KZ 15 0.84 19 1.05 25.2

Kosovo XK 1 0.54 1 0.53 20.6

Kyrgyzstan KGZ 0 0.00 2 0.35 N/A

Latvia LV 3 1.39 3 1.51 9.0



Lithuania LT 3 0.86 3 1.04 21.5

Luxembourg LU 1 1.92 1 1.75 28.7


Malta MT 1 2.42 1 2.42 20.3


Montenegro ME 1 1.54 1 1.55 0.5

Morocco MA 7 0.21 6 0.18 213.9


Norway NO 11 2.14 11 2.11 21.2

Poland PL 120 3.13 122 3.16 1.1

Portugal PT 31 2.87 29 2.68 26.6

Romania RO 15 0.69 16 0.74 7.0



Serbia RS 10 1.39 11 1.53 10.5

Slovakia SK 4 0.73 4 0.74 1.4

Continued



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

Table 9 Continued

Country ISO code Number of ICD implantingcentres 2014

Number of ICD implantingcentres 2015

Change %

Absolutenumber


Absolutenumber


Slovenia SI 2 1.01 3 1.51 50.4

Spain ES 112 2.35 180 3.74 59.4

Sweden SE 35 3.60 30 3.06 215.0

Switzerland CH 52 6.45 49 6.03 26.5



Turkey TR N/A N/A N/A N/A N/A

Ukraine UA 8 0.18 14 0.32 74.5

UK GB 126 1.98 125 1.95 21.3



3,60,20,4

3,61,9

2,72,2

2,96,5

2,63,2

2,63,4

2,03,5

2,12,4

0,70,5

1,66,4

2,41,1

2,21,0

1,31,5

3,11,0

0,71,7

0,21,6

0,71,31,4

0,21,4

8,31,3

0,90,81,0

1,61,0

2,30,2

AustriaSwitzerland

BelgiumCroatia

LuxembourgFinland

Russian FederationMoroccoSweden

NetherlandsEgypt

Czech RepublicRomaniaBulgaria

LatviaAlgeriaSerbia

GermanyBosnia & Herzegovina

LithuaniaKazakhstan

FYR MacedoniaGeorgia

SloveniaSpain

Ukraine

2014

IcelandIsrael

CyprusUnited Kingdom

IrelandNorwayFrance

Azerbaijan

Portugal

EstoniaItaly

MaltaDenmark

Greece

Kosovo

HungaryMontenegro

PolandBelarus

Slovakia

Armenia

-15,0-13,9-12,7

-8,9-8,7-8,2-7,7-6,6-6,5-5,1-4,4-2,8-1,4-1,3-1,2-1,2-1,1-1,0-0,6-0,6-0,5-0,3-0,20,0

0,10,20,51,11,21,43,14,35,77,07,19,010,410,511,4

20,121,5

25,249,750,150,4

59,474,5

2015 vs. 2014 in %

3,10,20,3

3,31,8

2,52,0

2,76,0

2,43,0

2,53,4

2,03,5

2,12,4

0,70,5

1,66,4

2,41,1

2,21,01,31,5

3,21,1

0,71,7

0,21,7

0,71,41,5

0,21,5

9,21,6

1,01,0

1,42,4

1,53,7

0,3

2015

Figure 34 Change in the number of ICD implanting centres per million inhabitants from 2014 to 2015.



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

Table 10 Changes in the number of ICD implantations in year 2015 vs. 2014

Country ISO code Number of ICD implants 2014 Number of ICD implants 2015 Change %

Absolute number Per million inhabitants Absolute number Per million inhabitants


Algeria DZ 60 1.55 91 2.30 48.9

Armenia AM 25 8.17 21 6.87 215.9

Austria AT 1362 165.63 1393 160.75 22.9

Azerbaijan AZ 20 2.06 21 2.15 4.0

Belarus BY 172 17.90 133 14.00 221.8

Belgium BE 1611 154.17 1531 135.20 212.3


Bulgaria BG 47 6.79 51 7.10 4.6

Croatia HR 173 38.70 388 86.90 124.6

Cyprus CY 73 62.26 75 63.07 1.3


Denmark DK 1208 216.91 1208 216.43 20.2

Egypt EG 236 2.72 253 2.86 5.3

Estonia EE 96 76.32 91 71.91 25.8

Finland FI 1161 220.35 1198 218.74 20.7

France FR 13 700 206.76 7825 117.57 243.1

Georgia GE 104 21.07 140 28.39 34.7

Germany DE 23 898 295.05 28 914 357.61 21.2

Greece GR 1080 100.23 1188 110.25 10.0

Hungary HU 956 96.38 986 99.62 3.4

Iceland IS 59 185.91 59 177.75 24.4

Ireland IE N/A N/A 740 151.26 N/A

Israel IL 1685 215.42 1300 161.50 225.0

Italy IT 13 729 222.58 14 709 237.80 6.8

Kazakhstan KZ 402 22.40 527 29.02 29.6

Kosovo XK 3 1.61 12 6.41 297.5

Kyrgyzstana KGZ 0 0.00 N/A N/A N/A

Latvia LV 75 34.64 90 45.30 30.8



Lithuania LT 134 38.22 123 42.64 11.6

Luxembourg LU 62 119.08 65 113.98 24.3

FYR Macedonia MK 11 5.26 29 13.84 163.1

Malta MT 36 87.24 35 84.55 23.1


Montenegro ME 41 63.07 53 81.91 29.9

Morocco MA 27 0.81 57 1.71 112.1


Norway NO 1134 220.29 1214 233.12 5.8

Poland PL 8399 219.03 8526 221.10 0.9

Portugal PT N/A N/A 1224 113.07 N/A

Romania RO 332 15.28 300 13.85 29.4



Serbia RS 457 63.39 437 60.89 23.9

Slovakia SK 658 119.80 665 122.79 2.5

Slovenia SI 174 87.51 228 114.95 31.4

Spain ES 3869 81.05 5348 111.08 37.1

Swedena SE 2097 215.66 N/A N/A N/A

Switzerland CH 1341 166.35 1830 225.32 35.5



Turkey TR 6300 77.19 6381 80.35 4.1

Ukraine UA 57 1.29 52 1.17 29.1

UK GB 6474 101.56 6701 104.56 2.9


aThese eight countries did not submit data for ICD implantations for the EHRA White Book 2016.



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8,2

15,31,3

63,487,2

62,3

96,4

6,82,7

38,2

63,1

87,521,1

81,01,5

14,20,8

38,75,31,6

17,9

12,4

76,3

2,177,2

22,4

34,6

France

UkraineEstonia

2,102cilbupeR hcezC9,581dnalecI

Luxembourg 119,1SerbiaMalta

Slovakia 119,8United Kingdom 101,6

HungaryAzerbaijan

TurkeyBulgaria

Egypt3,022yawroN6,222ylatI

Greece 100,2Lithuania

0,592ynamreGKazakhstan

2014

4,512learsIBelarus

ArmeniaBelgium 154,2

Russian FederationRomania

Austria 165,69,112sdnalrehteN4,022dnalniF9,612kramneD0,912dnaloP

Cyprus

MontenegroLatvia

SloveniaGeorgia

Switzerland 166,3Spain

AlgeriaBosnia & Herzegovina

MoroccoCroatia

FYR MacedoniaKosovo

206,8 -43,1-25,0-21,8-15,9-12,3-12,2

-9,4-9,1-5,8-4,8-4,4-4,3-3,9-3,1-2,9-2,6-0,7-0,2

0,91,32,52,93,44,04,14,65,35,86,810,011,621,2

29,629,930,831,434,735,537,1

48,958,4

112,1124,6

2015 vs. 2014 in %

163,1297,5

161,514,0

6,9135,2

10,913,8

1,271,9

191,5177,8

114,060,9

84,5160,8

206,5218,7216,4221,1

63,1122,8

104,699,6

2,180,4

7,12,9

233,1237,8

110,242,6

357,629,0

81,945,3

115,028,4

225,3111,1

2,322,5

1,786,9

13,86,4

117,6

2015

Figure 35 Change in the number of ICD implantations per million inhabitants from 2014 to 2015.

1,110,6

86,470,0

98,1

63,0

54,666,2

2,427,7

4,692,0

75,975,973,7

4,675,778,5

53,830,9

20,358,9

1,312,4

4,334,0

2014

9,451nedewS3,371dnalecI

UkraineRussian Federation

Belgium 112,0Luxembourg

Estonia6,041sdnalrehteN

Slovakia4,471dnaloP

Malta4,851kramneD

2,251cilbupeR hcezCSerbiaTurkey

0,922ynamreGAustria 118,7

2,951dnalniFEgypt

LithuaniaBulgaria

Switzerland0,651yawroN

GreeceHungary

United KingdomArmeniaPortugalSlovenia

MontenegroLatvia

GeorgiaSpain

AlgeriaBosnia & Herzegovina

FYR MacedoniaCroatia

-42,7-30,5

-17,3-16,1-14,7

-4,6-4,0-3,5-3,3-2,9

-0,30,30,41,0

1,51,61,73,85,38,49,69,79,911,112,1

21,622,1

31,132,033,435,135,4

66,969,0

121,8129,2

1,2

2015 vs. 2014 in %

88,8120,5

0,98,9

95,582,4

67,2135,7

94,9169,3

62,8158,9

152,855,2

66,9232,6

120,6162,0

2,529,1

5,0100,8

171,183,484,482,6

5,692,5102,9

71,141,3

27,479,8

2,120,9

9,577,9

2015

Figure 36 Change in the number of new ICD implantations per million inhabitants from 2014 to 2015.



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Cardiac resynchronization therapydevices

General informationThe 49 (87.5%) countries that submitted data on cardiac resynchro-nization therapy (CRT) for the EHRA White Book 2016 are listed in

Table 11. Albania, Kyrgyzstan, Lebanon, Libya, Moldova, Syria, andTunisia did not report any data related to CRT. The vast majorityof implants were performed by cardiologists (Table 5), and the re-maining implantations were performed by physicians having variousother training backgrounds, mainly surgeons. In Belarus, however, allCRT implantations were done by surgeons, and the majority of CRT

0,38,7

74,320,5

6,427,9

48,946,9

1,871,3

24,261,1

42,22,2

64,332,7

58,544,6

3,724,3

1,89,2

0,311,0

0,810,6

21,70,2

9,122,1

66,04,7

1,012,6

3,6Armenia

2014

AlgeriaSerbia

SwitzerlandHungaryEstonia

United KingdomCzech Republic

AustriaBosnia & Herzegovina

NetherlandsMalta

FinlandBelgiumBulgariaNorway

LuxembourgDenmark

PolandLatvia

GreeceRussian Federation

MontenegroEgypt

TurkeyGeorgia

LithuaniaSlovakiaUkraine

SloveniaSpain

GermanyCroatia

FYR MacedoniaIceland

-41,1-34,6-33,4

-25,5-25,4-21,2-20,9-14,4-14,2-13,2-10,3

-7,1-5,8-3,6-3,5-3,3-1,8

5,49,010,311,517,218,721,725,128,128,729,633,7

41,670,7

-63,6

2015 vs. 2014 in %

90,7349,1354,2

1,30,2

5,749,5

15,34,7

22,038,740,2

1,662,0

21,756,8

39,72,1

62,031,6

57,547,1

4,026,8

2,010,8

0,313,4

1,013,5

27,90,3

12,131,3

112,79,0

4,357,2

2015

Figure 37 Change in the number of ICD replacements per million inhabitants from 2014 to 2015.

0

20

40

60

80

100

120

140

160

180

200

220

0,0 0,5 1,0 1,5 2,0

MA

EGDZ UA

RUXK AZRO

SK

LT

BY

DK

HU

BG

MK

LV

SI

RS

ME

BA

EE

CZ

NL

LU GB

AM

ICD implantations per million inhabitants

KZ

0

20

40

60

80

100

120

140

160

180

200

220

240

260

280

300

320

340

360

2,5 3,0 5,5 6,5 7,0 8,04,0 5,035,85,70,2 9,04,5 5,0 6,03,5

ICD implanting centres per million inhabitants

MT

IS

BE

NOSM

DE

IT

CH

ES

CY

FIPL

PT

IEIL

HR

GE

AT

FR

GR

ESC 56

EU28

Figure 38 Implantable cardioverter-defibrillator implantation centres and rates in the ESC and European Union (EU28) member countries in2015. Bubble size is related to population in the country. The ISO codes of the countries are explained in Table 1.



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implantations in the Ukraine and Russia were likewise done byothers than cardiologists (Table 5).

Cardiac resynchronization therapyfacilities and procedure ratesIt was reported that in 2015 a total of 84 205 CRT devices were im-planted in 1527 national centres (Table 11). There was an increase inboth absolute numbers of implants and the rate of implants per mil-lion inhabitants compared with 2014, but a fall in the number of im-planting centres (Table 11). The number of CRT implanting centresper million inhabitants in the ESC countries is shown in Figure 40.The mean number of implanting centres was 1.68 per country,which is a decrease from the previous year. The mean number ofCRT devices implanted in 2015 was 82. Germany (261 implantsper million), Italy (207), and Czech Republic (183) had the highestnumber of implants of all CRT devices. Implantation rates withthe countries divided into quartiles are shown as a bar graph in Fig-ure 41 and as a geographical map in Figure 42.

Figures 43 and 44 show the corresponding numbers for CRT PMs(CRT-P) and CRT defibrillators (CRT-D). The ratio of CRT-D/CRT-P implants was 2.77 with a mean of 61 CRT-Ds and 22 CRT-Psper million inhabitants. The ratio between CRT-D and CRT-P isslightly higher than the last year representing a continuation in thetrend that the growth in CRT-D use is more than that in CRT-P

use, while there is nevertheless an increase in the use of both types.Denmark had the highest rate of CRT-P implantations followed bythe UK (Figure 43), while CRT-D implantation rate was highest inGermany followed by Italy and Israel (Figure 44).

The use of CRT devices within the five geographical ESC regionsis shown in Figure 45, and further data from within each region areshown in Figures 46–50. The most active countries within each re-gion were Germany (261 per million inhabitants), Denmark (176),Czech Republic (183), Italy (207), and Israel (180).

The changes in the number of implanting centres per million inha-bitants between 2014 and 2015 are shown in Table 12 and Figure 51.The changes between 2014 and 2015 for the number of total CRTimplantations are shown in Table 13 and Figure 52, and the changesaccording to CRT device type are shown in Figures 53 and 54.

The relationship between the annual CRT implantation rate and thenumber of CRT implanting centres per million population in the EU28countries and the ESC area is shown in Figure 55.

Lead extraction

General informationThis was the fourth year that information on lead extractions (LEs)was included in the EHRA White Book. The number of countriessubmitting data on LE procedures is not as high as for PMs and

00

0

0

000

0

00

0

0

0

000

0

000

0

0

0

01

12

3

38

15

16

2182

150

196

551

Estonia

Norway

Lithuania

Israel

Georgia

Slovakia

Slovenia

Iceland

Montenegro

Malta

Germany

Serbia

Greece

Luxembourg

Morocco

United Kingdom

Belgium

Italy

Hungary

Netherlands

Portugal

Finland

Switzerland

Denmark

Romania

Azerbaijan

Cyprus

San Marino


Algeria

Bulgaria

Egypt

Armenia

Croatia

Turkey

Latvia

Ukraine

Figure 39 Number of S-ICD implantation in 2015.



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

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

Table 11 Cardiac resynchronization therapy device (CRT-P and CRT-D) implantation facilities and rates in the ESC countries in 2015 and comparison with 4previous years

Country ISOcode

Number of CRTimplanting centres 2015

CRT implantations 2015 Total CRTimplantations 2015

Development potential—target number of CRTimplantations

CRT implantations per millioninhabitants

Absolutenumber


CRT-PimplantationsAbsolutenumber

CRT-DimplantationsAbsolutenumber

Absolutenumber


To attainmean ESCarea level

To attainmean EU28level

2011 2012 2013 2014 2015

Albaniaa AL N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 N/A

Algeria DZ 8 0.20 53 55 108 3 3250 5810 N/A N/A 2 1 3

Armenia AM 2 0.65 1 9 10 3 251 449 3 6 3 1 3

Austria AT 18 2.08 470 894 1364 157 – – 117 107 143 150 157

Azerbaijan AZ 2 0.20 0 24 24 2 804 1437 2 N/A 2 2 2

Belarus BY 6 0.63 N/A N/A 100 11 781 1396 5 4 6 5 11

Belgium BE 40 3.53 528 957 1485 131 – 1664 58 82 117 127 131

Bosnia and Herzegovina BA 2 0.52 11 6 17 4 318 568 6 5 6 6 4

Bulgaria BG 9 1.25 253 43 296 41 591 1056 12 28 37 44 41

Croatia HR 8 1.79 125 136 261 58 367 656 12 13 18 28 58

Cyprus CY 4 3.36 N/A N/A 30 25 98 175 21 25 22 25 25

Czech Republic CZ 18 1.69 465 1487 1952 183 – – 143 127 162 176 183

Denmark DK 5 0.90 441 544 985 176 – – 158 170 180 173 176

Egypt EG 17 0.19 429 116 545 6 7274 13 001 N/A 4 5 6 6

Estonia EE 2 1.58 49 24 73 58 104 186 58 53 55 41 58

Finland FI 15 2.74 184 343 527 96 – 805 62 72 83 100 96

France FR 174 2.61 3888 6544 10 432 157 – – 123 131 N/A 144 157

Georgia GE 10 2.03 10 52 62 13 405 725 3 7 8 11 13

Germany DE 250 3.09 3305 17 834 21 139 261 – – 202 221 109 128 261

Greece GR 16 1.48 88 550 638 59 886 1583 37 45 46 54 59

Hungary HU 14 1.41 496 595 1091 110 – 1454 81 89 99 95 110

Iceland IS 1 3.01 13 8 21 63 27 49 48 32 44 82 63

Ireland IE 17 3.47 88 231 319 65 402 719 57 61 79 N/A 65

Israel IL 20 2.48 115 1337 1452 180 – – 97 118 158 170 180

Italy IT 380 6.14 2153 10 662 12 815 207 – – 203 194 198 200 207

Kazakhstan KZ 18 0.99 0 314 314 17 1493 2668 N/A 9 12 15 17

Kosovo XK 1 0.53 N/A 4 4 2 154 275 N/A N/A N/A 0 2

Kyrgyzstana KGZ 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

Latvia LV 2 1.01 22 85 107 54 163 292 24 35 29 48 54

Lebanona LB N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 24 39 N/A

Continued

Current

trendsin

theuse

ofarrhythmia

proceduresiii39


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

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

Table 11 Continued

Country ISOcode

Number of CRTimplanting centres 2015

CRT implantations 2015 Total CRTimplantations 2015

Development potential—target number of CRTimplantations

CRT implantations per millioninhabitants

Absolutenumber


CRT-PimplantationsAbsolutenumber

CRT-DimplantationsAbsolutenumber

Absolutenumber


To attainmean ESCarea level

To attainmean EU28level

2011 2012 2013 2014 2015

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

Lithuania LT 3 1.04 150 45 195 68 237 424 31 39 47 55 68

Luxembourg LU 1 1.75 8 26 34 60 47 84 40 59 43 65 60

FYR Macedonia MK 3 1.43 26 12 38 18 172 308 13 5 8 13 18

Malta MT 1 2.42 10 31 41 99 – 61 56 83 39 116 99

Moldovaa MD 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

Montenegro ME 1 1.55 14 5 19 29 53 95 21 29 15 34 29

Morocco MA 6 0.18 42 42 84 3 2739 4896 N/A 2 2 2 3

The Netherlands NL 29 1.71 400 1600 2000 118 – 2490 130 124 123 114 118

Norway NO 9 1.73 214 348 562 108 – 765 88 77 84 100 108

Poland PL N/A N/A 645 3319 3964 103 – 5666 66 73 78 97 103

Portugal PT 26 2.40 210 562 772 71 890 1591 41 52 N/A 64 71

Romania RO 12 0.55 156 120 276 13 1781 3183 10 7 9 13 13

Russian Federation RU 37 0.26 340 666 1006 7 11 708 20 926 6 6 7 6 7

San Marino SM 1 30.28 0 2 2 61 3 5 94 62 0 N/A 61

Serbia RS 6 0.84 234 79 313 44 590 1054 40 42 45 45 44

Slovakia SK 4 0.74 209 379 588 109 – 796 60 61 82 96 109

Slovenia SI 2 1.01 47 117 164 83 – 291 45 70 66 75 83

Spain ES 130 2.70 910 1818 2728 57 3958 7074 56 53 54 62 57

Sweden SE 25 2.55 440 594 1034 105 – 1440 N/A 49 100 88 105

Switzerland CH 36 4.43 395 738 1133 140 – 1193 74 66 60 72 140

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 TN N/A N/A N/A N/A N/A N/A N/A N/A 8 23 N/A 16 N/A

Turkey TR N/A N/A 230 2580 2810 35 6528 11 668 N/A N/A N/A 30 35

Ukraine UA 10 0.23 60 13 73 2 3652 6528 1 1 2 2 2

UK GB 126 1.97 4160 6038 10 198 159 – – 105 110 122 149 159

Total ESC countries 1527 1.68 22 087 61 988 84 205 82 80 83 79 96 102

aThese seven countries did not submit any data on CRT implantations for the EHRA White Book 2016.

M.J.P.R

aatikainenetal.

iii40


0,180,190,200,200,230,26

0,520,530,55

0,630,65

0,740,840,90

0,991,011,011,04

1,251,411,43

1,481,551,58

1,691,711,731,751,79

1,972,032,08

2,402,42

2,482,55

2,612,702,74

3,013,09

3,363,47

3,534,43

6,14

UkraineRussian Federation

Bosnia & HerzegovinaKosovo

RomaniaBelarus

ArmeniaSlovakia

SerbiaDenmark

KazakhstanLatvia

SloveniaLithuaniaBulgariaHungary

FYR MacedoniaGreece

MontenegroEstonia

Czech RepublicNetherlands

NorwayLuxembourg

CroatiaUnited Kingdom

GeorgiaAustria

PortugalMaltaIsrael

SwedenFranceSpain

Mean number CRT implanting centers = Ø 1,68

IcelandGermany

CyprusIreland

BelgiumSwitzerland

Finland

Italy

MoroccoEgypt

AlgeriaAzerbaijan

Figure 40 Cardiac resynchronization therapy device implanting centres per million inhabitants in 2015. The mean number of CRT implantationcentres is weighted by population.

222333467

111313

1718

2529

354144

54575858596061

6365

6871

8396

99103

105108109110

118131

140157157159

176180

183207

261

Median number of CRT implantations = 60

Mean number of CRT implantations = Ø 82

GreeceLuxembourgSan Marino

IcelandIreland

LithuaniaPortugalSlovenia

FinlandMalta

PolandSwedenNorway

SlovakiaHungary

NetherlandsBelgium

SwitzerlandFranceAustria

United KingdomDenmark

IsraelCzech Republic

ItalyGermany

UkraineKosovo

AzerbaijanMorocco

AlgeriaArmenia

Bosnia & HerzegovinaEgypt

Russian FederationBelarusGeorgia

RomaniaKazakhstan

FYR MacedoniaCyprus

MontenegroTurkey

BulgariaSerbiaLatviaSpain

EstoniaCroatia

82 = Ø CRT implantations per million inhabitants (weighted by population)





Figure 41 Cardiac resynchronization therapy device implantations per million inhabitants 2015. The mean number of CRT implantations isweighted by population.



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82 = Ø CRT implantations per million inhabitants (weighted by population)





Not available

Figure 42 Cardiac resynchronization therapy device implantations in the ESC countries in 2015.

0,31,31,31,42,02,42,82,9

4,87,2

8,211,1

12,414,014,3

16,718,0

18,919,4

21,623,623,724,2

28,032,6

33,634,835,2

38,638,739,2

40,941,1

43,744,9

46,648,6

50,152,0

54,258,4

64,979,0

Mean number of CRT-P implantations = Ø 22

San Marino 0Kazakhstan 0Azerbaijan 0

ArmeniaMorocco

AlgeriaUkraineGeorgia

Russian FederationBosnia & Herzegovina

TurkeyEgypt

RomaniaGreece

LatviaFYR Macedonia

LuxembourgIsrael

PolandIrelandSpain

PortugalMontenegroNetherlands

SloveniaMalta

CroatiaSerbia

FinlandItaly

BulgariaSlovakiaEstoniaIceland

GermanyNorway

Czech RepublicSwedenBelgium

SwitzerlandHungary

LithuaniaAustriaFrance

United KingdomDenmark

Figure 43 Cardiac resynchronization therapy PM implantations per million inhabitants in 2015. The mean number of implantations is weightedby population.



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0,31,31,31,41,62,12,52,94,75,55,76,07,7

10,511,0

15,617,319,0

24,130,532,5

37,842,8

45,647,2

51,959,059,260,160,660,662,6

66,870,0

74,984,586,1

90,994,294,4

97,598,3

103,2139,7

166,1172,4

220,6

FinlandSweden

San Marino

SwitzerlandPoland

United KingdomNetherlands

DenmarkFranceAustria

Czech RepublicIsrael

ItalyGermany

MaltaSlovakia

Belgium

Hungary

AzerbaijanArmenia

Russian FederationRomania

FYR MacedoniaBulgaria

MontenegroGeorgia

SerbiaLithuania

KazakhstanEstoniaIcelandCroatia

Norway

SpainLatvia

LuxembourgIreland

PortugalSlovenia

Greece

Turkey

Mean number of CRT-D implantations = Ø 61

UkraineMorocco

EgyptAlgeria

Bosnia & HerzegovinaKosovo

Figure 44 Cardiac resynchronization therapy defibrillator implantations per million inhabitants in 2015. The mean number of implantations isweighted by population.

120118113111114

2012 20152011 20142013

3230272322

201420132012 20152011

215197

137178166

20152014201320122011

ESC

10296798380

20152014201320122011

EU28

149142115122118

20152014201320122011



14613811510499

201420132012 20152011

10396798381

20152014201320122011


9083776048

201420132012 20152011


Figure 45 Cardiac resynchronization therapy device implantations per million inhabitants 2011–15 in the five geographical regions of the ESCand comparison with the total ESC area and the 28 member countries of the European Union (EU28).



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Northern Europe

Denmark

176173180170158

20152014201320122011

TOP 3

Lowest 3 Iceland

United Kingdom

159149122110105

20152014201320122011

Estonia

Norway

108100847788

201420132012 20152011

Latvia

6382

443248

20152014201320122011

5841

555358

20152014201320122011

5448293524

2012 201520122011 2014

Figure 46 Cardiac resynchronization therapy implantations per million inhabitants 2011–15 in Northern Europe.

Western Europe

Germany261

128109

221202

20152014201320122011

TOP 3

Lowest 3 Belgium

13112711782

58

20152014201320122011

Austria

157150143107117

20152014201320122011

Netherlands

118114123124130

20152014201320122011

France

157144131123

20152014201320122011

Luxembourg

60654359

40

201420132012 20152011

*

Figure 47 Cardiac resynchronization therapy implantations per million inhabitants 2011–15 in Western Europe. *No data available.



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Eastern Europe

Slovakia

10996826160

201420132012 20152011

TOP 3

Lowest 3 Belarus

115645

20122011 201520142013

Hungary

11095998981

20152014201320122011

Russian Federation

76766

20152014201320122011

Czech Republic

183176162127143

20152012 2013 20142011

Ukraine

22211

2011 201420132012 2015

Figure 48 Cardiac resynchronization therapy implantations per million inhabitants 2011–15 in Eastern Europe.

18138513

Southern Europe

Slovenia

8375667045

201420132012 20152011

TOP 3

Lowest 3

Malta

99116

39

8356

201420132012 20152011

Montenegro

293415

2921

20152014201320122011

Italy

207200198194203

2011 20132012 20152014

FYR Macedonia

20152011 2012 2013 2014

Bosnia and Herzegovina

46656

2014 20152012 20132011

Figure 49 Cardiac resynchronization therapy implantations per million inhabitants 2011–15 in Southern Europe.



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ICDs (Table 14). Seventeen countries did not submit any data onLEs, and four submitted incomplete data. In most countries, the pri-mary operators in LE procedures were cardiologists.

Lead extraction facilities and procedureratesA total of 8748 LE procedures (Table 14) were performed in 326LE centres in 2015. The mean number of LEs was 12.8 per million,but this needs to be put into context with a large number of miss-ing data (Figure 56). It has been suggested that in an active centrethe minimum annual number of LE should be at least 15 per mil-lion inhabitants.14,15 Assuming that each centre treated an equiva-lent number of patients, it can be extrapolated that the numbersof LE per centre in 2015 were lower than that recommended inmost of the countries. The mean number of LE was highest inFrance (45.1 per million population) followed by Norway (37.3)and Germany (29.2) (Figure 56). Due to missing or incompletedata and a very low LE rate in some countries, we chose not toprovide full representation of the regional LE data.

Catheter ablation

General informationA total of 46 countries (82% of the ESC countries) submitted dataon catheter ablation facilities and procedures to the EHRA White

Book (Table 15). Sixteen had a national registry on catheter ablation,and in the remainder the numbers originated from a survey or anestimate by the national working groups. In 2015, a total of1 077 305 324 people lived in the ESC countries. After excludingthose countries that did not report the number of ablations or ab-lation centres, the population covered by the EHRA White Book forablation procedures was 967 796 331 (�90% coverage), which isabout the same in the previous year. Like in previous years, a majorproblem in 2015 was that no ablation data were received from Italy,which is known to have well-developed ablation programmes.

Catheter ablation facilities and procedureratesIn 2015, the total number of ablation centres in the countries thatsubmitted data for the EHRA White Book was 1159 (Table 15),and the mean number of ablation centres per million populationwas 1.34 (Figure 57). The changes in the number of ablation centresfrom 2014 to 2015 are shown in Table 16 and Figure 58.

The total number of catheter ablations in the ESC area in 2015was 243 808 (Table 15), which was �3% more than that reportedin 2014 (235 793). The mean number of ablations done per millionpopulation was also slightly higher in 2015 (259) than in 2014 (244).

The number of catheter ablations per million inhabitants is shownin Figures 59 and 60. In these figures, the ESC countries are groupedinto quartiles according to their ablation activities. As in previousyears, most countries in the top quartile were from Northern and


Tunisia

1715129

20152014201320122011

TOP 3

Lowest 3

Cyprus

2525222521

201420132012 20152011

Algeria

312

2011 201520132012 2014

Israel

180170158118

97

201420132012 20152011

Morocco

3222

2012 2015201420132011

Azerbaijan

2222

20152014201320122011

*

*** *

Figure 50 Cardiac resynchronization therapy implantations per million inhabitants 2011–15 in the non-European ESC countries. *No dataavailable.



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

Table 12 Changes in the number of CRT implanting centres in year 2015 vs. 2014

Country ISO code Number of CRT implanting centres 2014 Number of CRT implanting centres 2015 Change %



Algeria DZ 8 0.21 8 0.20 21.8

Armenia AM 3 0.98 2 0.65 233.2

Austria AT 18 2.19 18 2.08 25.1

Azerbaijan AZ 3 0.31 2 0.20 234.0

Belarus BY 6 0.62 6 0.63 1.2

Belgium BE 40 3.83 40 3.53 27.7


Bulgaria BG 7 1.01 9 1.25 23.9

Croatia HR 11 2.46 8 1.79 227.2

Cyprus CY 4 3.41 4 3.36 21.4


Denmark DK 5 0.90 5 0.90 20.2

Egypt EG 16 0.18 17 0.19 4.3

Estonia EE 2 1.59 2 1.58 20.6

Finland FI 15 2.85 15 2.74 23.8

France FR 146 2.20 174 2.61 18.7

Georgia GE 7 1.42 10 2.03 43.0

Germany DE 670 8.27 250 3.09 262.6

Greece GR 16 1.48 16 1.48 0.0

Hungary HU 13 1.31 14 1.41 7.9

Iceland IS 1 3.15 1 3.01 24.4

Ireland IE 17 3.52 17 3.47 21.2

Israel IL 20 2.56 20 2.48 22.8

Italy IT 378 6.13 380 6.14 0.2

Kazakhstan KZ 13 0.72 18 0.99 36.9

Kosovo XK 0 0.00 1 0.53 N/A

Kyrgyzstana KGZ 0 0.00 N/A N/A N/A

Latvia LV 2 0.92 2 1.01 9.0



Lithuania LT 3 0.86 3 1.04 21.5

Luxembourg LU 1 1.92 1 1.75 28.7


Malta MT 1 2.42 1 2.42 20.3


Montenegro ME 1 1.54 1 1.55 0.5

Morocco MA 7 0.21 6 0.18 213.9


Norway NO 10 1.94 9 1.73 211.0

Polanda PL 35 0.91 N/A N/A N/A

Portugal PT 24 2.22 26 2.40 8.2

Romania RO 12 0.55 12 0.55 0.3


Continued



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8,30,3

1,01,1

2,56,0

0,20,3

1,91,9

3,81,82,2

3,22,8

2,02,6

0,23,43,5

2,71,6

2,40,9

1,50,5

6,11,0

0,61,5

0,80,6

0,21,6

1,32,2

0,90,2

2,20,91,0

0,71,4

1,01,5

2014

BelgiumNetherlands

AustriaIcelandFinland

United KingdomIsrael

AlgeriaCyprusIrelandSpain

EstoniaMalta

DenmarkGreece

Bosnia & HerzegovinaItaly

SloveniaRomania

MontenegroSerbia

BelarusEgypt

Czech RepublicHungaryPortugal

LatviaUkraineFrance

LithuaniaBulgaria

KazakhstanGeorgia

FYR MacedoniaSweden

Luxembourg

Russian FederationNorway

MoroccoSwitzerland

CroatiaSlovakiaArmenia

AzerbaijanGermany -62,6

-34,0-33,2-32,4

-27,2-25,6

-13,9-11,9-11,0

-8,7-7,7-6,8-5,1-4,4-3,8-2,9-2,8-1,8-1,4-1,2-0,8-0,6

-0,3-0,2

0,00,10,20,20,30,50,51,24,35,77,98,29,010,8

18,721,523,9

36,943,0

49,765,3

2015 vs. 2014 in %

3,10,2

0,70,7

1,84,4

0,20,3

1,71,8

3,51,7

2,13,0

2,72,0

2,50,2

3,43,5

2,71,6

2,40,9

1,50,5

6,11,0

0,61,5

0,80,6

0,21,7

1,42,4

1,00,2

2,6

1,31,0

2,01,4

2,6

1,0

2015

Figure 51 Change in the number of CRT implanting centres per million inhabitants from 2014 to 2015.

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

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

Table 12 Continued

Country ISO code Number of CRT implanting centres 2014 Number of CRT implanting centres 2015 Change %



Serbia RS 6 0.83 6 0.84 0.5

Slovakia SK 6 1.09 4 0.74 232.4

Slovenia SI 2 1.01 2 1.01 0.2

Spain ES 130 2.72 130 2.70 20.8

Sweden SE 15 1.54 25 2.55 65.3

Switzerland CH 48 5.95 36 4.43 225.6



Turkeya TR N/A N/A N/A N/A N/A

Ukraine UA 9 0.20 10 0.23 10.8

UK GB 129 2.02 126 1.97 22.9


aThese nine countries did not submit any data on CRT implanting centres for the EHRA White Book 2016.



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

Table 13 Change in the number of total CRT device (CRT-D 1 CRT-P) implantations in year 2015 vs. 2014

Country ISO code Total CRT implantations 2014 Total CRT implantations 2015 Change %

Absolutenumber


Absolutenumber


Albaniaa AL 2 1 N/A N/A N/A

Algeria DZ 56 1 108 3 89.3

Armenia AM 4 1 10 3 150.4

Austria AT 1236 150 1364 157 4.7

Azerbaijan AZ 18 2 24 2 32.0

Belarus BY 49 5 100 11 106.4

Belgium BE 1332 127 1485 131 2.9

Bosnia and Herzegovina BA 23 6 17 4 226.0

Bulgaria BG 303 44 296 41 25.9

Croatia HR 124 28 261 58 110.8

Cyprus CY 29 25 30 25 2.0


Denmark DK 965 173 985 176 1.8

Egypt EG 530 6 545 6 1.0

Estonia EE 51 41 73 58 42.3

Finland FI 526 100 527 96 23.6

France FR 9570 144 10 432 157 8.5

Georgia GE 55 11 62 13 12.8

Germany DE 10 378 128 21 139 261 104.0

Greece GR 580 54 638 59 10.0

Hungary HU 941 95 1091 110 16.2

Iceland IS 26 82 21 63 222.8


Israel IL 1330 170 1452 180 6.1

Italy IT 12 336 200 12 815 207 3.6

Kazakhstan KZ 262 15 314 17 18.5

Kosovo XK 0 0 4 2 N/A

Kyrgyzstana KGZ 0 0 N/A N/A N/A

Latvia LV 105 48 107 54 11.1



Lithuania LT 192 55 195 68 23.4

Luxembourg LU 34 65 34 60 28.7

FYR Macedonia MK 28 13 38 18 35.4

Malta MT 48 116 41 99 214.9


Montenegro ME 22 34 19 29 213.2

Morocco MA 62 2 84 3 36.1

The Netherlands NL 1931 114 2000 118 3.1

Norway NO 514 100 562 108 8.1

Poland PL 3718 97 3964 103 6.0

Portugal PT 696 64 772 71 10.8

Romania RO 289 13 276 13 24.2

Continued



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

Table 13 Continued

Country ISO code Total CRT implantations 2014 Total CRT implantations 2015 Change %

Absolutenumber


Absolutenumber


Russian Federation RU 863 6 1006 7 16.6


Serbia RS 321 45 313 44 22.0

Slovakia SK 529 96 588 109 12.7

Slovenia SI 150 75 164 83 9.6

Spain ES 2974 62 2728 57 29.0

Sweden SE 854 88 1034 105 20.1

Switzerland CH 583 72 1133 140 92.9



Turkey TR 2460 30 2810 35 17.4

Ukraine UA 85 2 73 2 214.4

UK GB 9516 149 10 198 159 6.6


aThese seven countries did not submit any data on CRT implantations for the EHRA White Book 2016.

5,981,9

1,933,8

62,365,3

43,813,3

99,844,5

6,1

24,7

97,0

99,8

75,453,8

64,448,5

96,311,1

94,96,1

30,114,6

87,854,8

1,913,4

1,940,5

1,472,3

5,127,7

1,3

KazakhstanSweden

LithuaniaAzerbaijan

FYR MacedoniaMoroccoEstoniaAlgeria

Switzerland1,821ynamreG

BelarusCroatia

Armenia

IcelandBosnia & Herzegovina

2014

Malta 116,3Ukraine

MontenegroSpain

LuxembourgBulgaria

RomaniaFinlandSerbiaEgypt

3,371kramneDCyprus

5,721muigleBNetherlands 114,4

0,002ylatI1,671cilbupeR hcezC

3,051airtsuAPoland

0,071learsI3,941modgniK detinU

Norway4,441ecnarF

SloveniaGreece

PortugalLatvia

SlovakiaGeorgiaHungary

Russian FederationTurkey

-26,0-22,8

-14,9-14,4-13,2

-9,0-8,7-5,9-4,2-3,6-2,0

1,01,82,02,93,13,64,14,76,06,16,68,18,59,610,010,811,112,712,816,216,617,418,520,123,4

32,035,436,142,3

89,392,9

104,0106,4110,8

150,4

2015 vs. 2014 in %

4,463,3

99,01,6

29,456,759,6

41,212,7

96,243,6

6,2176,5

25,2131,1

118,0207,2

183,4157,4

102,8180,4

159,1107,9

156,782,7

59,271,3

53,9108,6

12,6110,2

7,135,4

17,3105,5

67,62,5

18,12,5

57,72,7

139,5

10,558,5

3,3

2015

261,4

Figure 52 Change in the number of total CRT implantations per million inhabitants from 2014 to 2015.



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3,830,5

50,41,63,4

12,918,7

38,72,21,3

7,619,9

33,734,4

65,028,7

24,84,8

34,212,0

47,574,5

51,143,8

38,37,4

52,839,1

45,618,516,5

10,231,7

19,021,5

25,812,1

16,00,50,3

19,2Luxembourg

2014

TurkeyNetherlands

IcelandUkraine

Bosnia & HerzegovinaLatvia

PolandBulgariaGeorgia

MoroccoRomania

SpainSerbia

FinlandUnited Kingdom

SloveniaSlovakia

EgyptItaly

FYR MacedoniaHungary

DenmarkAustria

BelgiumNorwayGreeceFrance

Czech RepublicLithuania

MontenegroPortugal

IsraelSwedenCroatiaEstonia

SwitzerlandMalta

GermanyAlgeria

Russian Federation

-23,7-22,5-22,3-16,9-15,3-14,4-10,5

-9,0-9,0-6,2-5,7-4,9-3,3-2,2-0,2

0,00,00,31,73,85,56,06,26,47,410,010,611,613,917,217,9

39,741,747,2

80,488,5

99,4155,9

-27,0

2015 vs. 2014 in %

160,1655,8

14,02,9

23,639,2

1,42,8

11,116,7

35,22,01,3

7,218,9

32,633,6

64,923,7

38,64,8

34,812,4

50,179,0

54,246,6

41,18,2

58,443,7

52,021,6

19,414,3

44,928,0

38,748,6

24,240,9

1,32,4

2015

Figure 53 Change in the number of CRT-P implantations per million inhabitants from 2014 to 2015.

15,42,6

31,55,7

42,465,571,5

5,798,8

46,119,1

0,383,6

10,8

1,3

99,2

91,656,2

47,961,6

78,384,384,0

8,95,1

35,626,3

46,847,446,4

1,90,9

9,146,5

1,30,5

8,71,4

Iceland

2014

2,401atlaMBosnia & Herzegovina

Montenegro

Russian FederationSpain

FinlandSlovakiaRomaniaDenmark

LuxembourgEstoniaUkraineBelgium

Serbia0,731cilbupeR hcezC

Egypt8,951learsI

Austria8,561ylatI

FranceSwedenPortugalNorwayPoland

United KingdomNetherlands

GeorgiaBulgaria

LatviaTurkey

SloveniaHungaryGreece

AzerbaijanAlgeria

LithuaniaSwitzerland

2,211ynamreGArmeniaMorocco

CroatiaFYR Macedonia

-39,9-28,1-23,5-18,6-11,0

-4,4-2,2-2,2-1,3-1,1-0,6-0,3

1,01,72,03,63,94,04,07,37,98,48,510,011,812,418,318,420,323,326,126,927,632,0

50,070,9

95,396,7

125,3148,2

249,2299,2

-49,8

2015 vs. 2014 in %

1,674,9

24,14,7

37,862,670,0

5,597,5

45,619,0

0,384,5

11,0139,7

1,3166,1

103,2172,4

98,360,6

51,966,8

86,194,294,4

10,56,0

42,832,5

59,060,159,2

2,51,4

15,690,9

220,62,91,3

30,55,7

7,7

2015

Figure 54 Change in the number of CRT-D implantations per million inhabitants from 2014 to 2015.



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Western Europe. European Society of Cardiology countries outsideEurope had low ablation activity, and they are mostly found in thelowest (first) quartile. Eastern European countries had a heteroge-neous distribution, which spanned over all four quartiles. Data onthe number of catheter ablations during the last 5 years are shownin Table 15, and detailed information on the changes in the numberof ablation procedures from 2014 to 2015 is presented in Table 17and Figure 61. The mean number of ablations performed per centrewas almost exactly the same in 2015 (259) as in 2014 (260), indicat-ing the ablation activities in the centres that reported their numberswere constant. The relationship between the annual catheter abla-tion rate and the number of ablation centres per million populationin the EU28 countries and the whole ESC area is shown in Figure 62.

More detailed data on ablation activity in the five geo-graphical ESC regions are presented in Figure 63. The meannumber of ablations per million inhabitants was higher in the West-ern than in the other European regions and in the non-EuropeanESC countries. In the non-European ESC countries, catheter abla-tion rate was almost 30 times lower than in the European ESC coun-tries (13 vs. 310 per million population). In 2015, the most activecountries were Germany, Denmark, and Switzerland with 789,703, and 703 ablations per million population, respectively (Table 15and Figure 59). In San Marino, no ablations were performed.

Data for the last 5 years from the 3 most active and 3 least activecountries in the different ESC regions are presented in Figures 64–68. The most active countries in the Northern, Western, Southern,and Eastern Europe were Denmark (703 ablations per million inha-bitants), Germany (789), Slovenia (359), and Czech Republic (578),respectively. Among the non-European ESC countries, Kazakhstan

was the most active with 136 catheter ablations per million popula-tion. In 2015, the rate of ablations per million population increasedin most of the ESC countries, but Cyprus, Armenia, and Moroccoreported more than 50% decrease in catheter ablation activities.The growth in the mean ablation rate per million population washighest in the Eastern and Southern European regions. In Slovenia,the increase in ablation rate was 63%.

Atrial fibrillation ablation ratesIn 2015, a total of 87 527 atrial fibrillation (AF) ablations were per-formed in the 43 ESC countries that submitted AF ablation data forthe EHRA White Book (Table 18). In Figures 69 and 70, countriesperforming AF ablations are grouped into quartiles according totheir activity. The mean number of AF ablations per million inhabi-tants was 96, which is about the same as in 2014 (96 per million).The most active countries were Germany (416 AF ablations per mil-lion population), Denmark (337), and Belgium (289). Like 2014,most countries in the top quartile were from the Northern andWestern European regions, and the countries with the lowest activ-ity (first and second quartiles) were mainly from Southern Europeand from the non-European ESC region. In the Eastern region, theAF ablations activity was extremely heterogeneous. The growth inAF ablation rate per million population was highest in Azerbaijan(197%), Turkey (87%), and Bulgaria (79%), whereas in Armenia, Cy-prus, and Serbia the AF ablation rate decreased by 91, 81, and 36%,respectively (Table 19 and Figure 71). In Armenia, Algeria, Bosniaand Herzegovina, Malta, and San Marino, no AF ablations wereperformed in 2015 (Figure 69).

0

20

40

60

80

100

120

140

160

180

200

220

240

260

280

0,0 0,5 1,0 1,5 2,0

MA

EGDZ

AZUA

RUBA

XK

RO

BY

AM

SK

DK

KZ

LV

SI

LT

BG

HU

MK

GR

ME

EE

CZ

NL

NO

LU HR

GB

CRT implantations per million inhabitants

RS

0

20

40

60

80

100

120

140

160

180

200

220

240

260

280

0,60,4 5,55,2 5,03,5 5,035,40,32,0

IT

SM

CRT implanting centres per million inhabitants

BE

IE

CY

DE

AT

GE

PT

MT

IL

SE

FR

CH

ES

FI

IS

ESC 56

EU28

Figure 55 Cardiac resynchronization therapy implantation centres and rates in the ESC and European Union (EU28) member countries in2015. Bubble size is related to population in the country.



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

Table 14 Lead extraction facilities and rates in 2015 and comparison with 3 previous years

Country ISOcode

Number of LE centres2015

Number of LEprocedures 2015

Development potential—targetnumber of LE procedures

LE procedures permillion inhabitants

Absolutenumber


Absolutenumber




2012 2013 2014 2015

Albaniaa AL N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Algeria DZ 3 0.08 41 1.04 507 945 N/A N/A 1 1

Armenia AM 0 0.00 0 0.00 39 73 0 1 0 0

Austria AT 5 0.58 250 28.85 – – 27 30 34 29

Azerbaijan AZ 1 0.10 5 0.51 125 234 N/A 1 1 1

Belarus BY 3 0.32 11 1.16 122 227 4 N/A 1 1

Belgiuma BE N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A


BA 0 0.00 0 0.00 50 92 N/A 0 0 0

Bulgariaa BG N/A N/A N/A N/A N/A N/A N/A 2 0 N/A

Croatia HR 5 1.12 49 10.97 57 107 2 0 7 11

Cyprus CY 2 1.68 4 3.36 15 28 0 2 3 3

Czech Republic CZ 6 0.56 300 28.18 – – 29 30 17 28

Denmarkb DK 4 0.72 N/A N/A N/A N/A N/A N/A N/A N/A

Egypt EG 3 0.03 20 0.23 1134 2114 0 0 0 0

Estoniaa EE N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Finlandb FI 5 0.91 N/A N/A N/A N/A N/A N/A 3 N/A

France FR 30 0.45 3000 45.08 – – 30 N/A 33 45

Georgiaa GE N/A N/A N/A N/A N/A N/A N/A 0 1 N/A

Germany DE 126 1.56 2357 29.15 – – 10 N/A 61 29

Greece GR 4 0.37 55 5.10 138 257 2 3 5 5

Hungary HU 8 0.81 105 10.61 127 237 7 13 10 11

Iceland IS 0 0.00 0 0.00 4 8 0 0 3 0

Irelandb IE 2 0.41 N/A N/A N/A N/A N/A N/A N/A N/A

Israel IL 5 0.62 80 9.94 103 192 0 N/A 10 10

Italya IT N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Kazakhstan KZ 1 0.06 16 0.88 233 434 0 N/A 0 1

Kosovoa XK N/A N/A N/A N/A N/A N/A N/A N/A 0 N/A

Kyrgyzstana KGZ N/A N/A N/A N/A N/A N/A 0 N/A N/A N/A

Latvia LV 1 0.50 19 9.56 25 47 3 4 5 10

Lebanona LB N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Libyaa LY N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Lithuania LT 2 0.69 19 6.59 37 69 3 3 3 7

Luxembourg LU 1 1.75 6 10.52 7 14 18 N/A 13 11

FYR Macedonia MK 2 0.95 1 0.48 27 50 3 0 0 0

Malta MT 1 2.42 9 21.74 – 10 0 0 17 22

Moldovaa MD N/A N/A N/A N/A N/A N/A N/A 1 N/A N/A

Montenegro ME 0 0.00 0 0.00 8 15 0 0 0 0

Morocco MA 3 0.09 10 0.30 427 796 0 0 0 0

The Netherlands NL 12 0.71 120 7.08 217 405 N/A 24 30 7

Norway NO 3 0.58 194 37.25 – – 36 42 43 37

Poland PL 30 0.78 1050 27.23 – – 14 12 16 27

Portugala PT N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Continued



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

Table 14 Continued

Country ISOcode

Number of LE centres2015

Number of LEprocedures 2015

Development potential—targetnumber of LE procedures

LE procedures permillion inhabitants

Absolutenumber


Absolutenumber




2012 2013 2014 2015

Romania RO 4 0.18 15 0.69 278 518 0 0 0 1

Russian Federationa RU N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

San Marino SM 0 0.00 0 0.00 0 1 0 0 N/A 0

Serbia RS 3 0.42 28 3.90 92 171 7 5 9 4

Slovakia SK 3 0.55 119 21.97 – 129 25 20 25 22

Sloveniab SI 1 0.50 N/A N/A N/A N/A N/A N/A N/A N/A

Spain ES 35 0.73 400 8.31 617 1150 N/A N/A N/A 8

Swedena SE N/A N/A N/A N/A N/A N/A 22 51 46 N/A

Switzerlandb CH 6 0.74 N/A N/A N/A N/A N/A 11 11 N/A

Syriaa SY 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 7 N/A 2 N/A

Turkey TR N/A N/A 420 5.29 1018 1898 N/A N/A 4 5

Ukraine UA 6 0.14 45 1.01 569 1062 1 1 1 1

UKa GB N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Total ESCcountries

56 326 0.52 8748 13 5 6 6 8

aThese 17 countries did not submit any data on LE for the EHRA White Book 2016.bThese 5 countries only submitted data on LE centres for the EHRA White Book 2016.

0,20,30,50,50,70,91,01,01,2

3,43,9

5,15,3

6,67,1

8,39,69,9

10,510,611,0

21,722,0

27,228,2

28,829,2

37,345,1

NorwayGermany

AustriaCzech Republic

PolandSlovakia

MaltaCroatia

HungaryLuxembourg

IsraelLatviaSpain

NetherlandsLithuania

TurkeyGreeceSerbiaCyprusBelarusAlgeria

UkraineKazakhstan

RomaniaAzerbaijan

FYR MacedoniaMorocco

0Egypt

France

Armenia

0Bosnia & Herzegovina

0

0

0Montenegro

Mean number of Lead extractions = Ø 12,8

San Marino

Iceland

Figure 56 Lead extractions per million inhabitants in 2015. The mean number of LEs is weighted by population.



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

Table 15 Catheter ablation facilities and rates in 2015 and in comparison with 4 previous years

Country ISOcode

NationalRegistryfor EP

Number of ablationcentres 2015

Ablation procedures2015

Developmentpotential—targetnumber of ablationprocedures

Ablation procedures permillion inhabitants

Absolutenumber


Absolutenumber


To attainmeanESC arealevel

To attainmeanEU28level

2011 2012 2013 2014 2015

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 DZ No 3 0.08 303 8 10 259 18 867 N/A N/A 6 6 8

Armenia AM No 3 0.98 48 16 793 1458 33 23 46 43 16

Austria AT Yes 19 2.19 2777 320 – 4135 220 339 294 319 320

Azerbaijan AZ No 5 0.51 398 41 2538 4667 20 N/A 24 40 41

Belarus BY No 7 0.74 993 105 2464 4532 61 54 76 84 105

Belgium BE No N/A N/A 7091 626 – – 534 564 580 586 626


BA No 1 0.26 N/A N/A N/A N/A 5 1 0 0 N/A

Bulgaria BG Yes 5 0.70 961 134 1865 3429 39 60 54 96 134

Croatia HR No 6 1.34 1348 302 – 2130 101 132 183 191 302

Cyprus CY No 3 2.52 60 50 309 567 36 35 39 121 50

Czech Republic CZ Yes 23 2.16 6158 578 – – 440 474 482 551 578

Denmark DK Yes 6 1.07 3925 703 – – 457 590 652 694 703

Egypt EG No 15 0.17 1448 16 22 958 42 221 N/A 11 12 16 16

Estonia EE No 2 1.58 426 337 – 604 300 260 302 327 337

Finland FI No 9 1.64 2550 466 – 2613 362 415 418 422 466

France FR No 196 2.94 39 596 595 – – 479 472 N/A 503 595

Georgia GE No 8 1.62 403 82 1279 2353 55 75 54 72 82

Germany DE No 346 4.28 63 790 789 – – 614 467 412 741 789

Greece GR Yes 29 2.69 1710 159 2796 5142 130 131 134 153 159

Hungary HU No 11 1.11 3723 376 – 4723 293 314 338 350 376

Iceland IS No 1 3.01 78 235 86 158 203 239 254 239 235

Ireland IE No 12 2.45 N/A N/A N/A N/A 214 212 209 N/A N/A

Israel IL No 16 1.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A

Italya IT No N/A N/A N/A N/A N/A N/A 311 N/A N/A N/A N/A

Kazakhstan KZ No 13 0.72 2461 136 4711 8664 N/A 57 83 112 136

Kosovoa XK No N/A N/A N/A N/A N/A N/A N/A N/A N/A 0 N/A

Kyrgyzstan KGZ No 2 0.35 59 10 1470 2703 N/A N/A N/A 10 10

Latvia LV Yes 2 1.01 726 365 – 948 247 269 238 295 365



Lithuania LT No 3 1.04 1078 374 – 1376 227 243 239 252 374

Luxembourg LU Yes 1 1.75 145 254 148 272 252 301 251 303 254

FYR Macedonia MK No 2 0.95 166 79 544 1000 26 30 38 50 79

Malta MT No 1 2.42 32 77 107 198 20 24 29 73 77


Montenegro ME No 1 1.55 83 128 168 309 11 149 69 102 128

Morocco MA Yes 5 0.15 60 2 8646 15 900 3 7 5 5 2

The Netherlands NL Yes 16 0.94 8500 502 – – N/A 382 N/A 495 502

Norway NO No 5 0.96 3067 589 – – 487 530 507 575 589

Poland PL No 85 2.20 10 795 280 – 18 400 214 229 248 285 280

Portugal PT Yes 25 2.31 2580 238 2809 5165 187 186 191 215 238

Romania RO No 12 0.55 1194 55 5621 10 338 50 50 60 62 55

Continued



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

Table 15 Continued

Country ISOcode

NationalRegistryfor EP

Number of ablationcentres 2015

Ablation procedures2015

Developmentpotential—targetnumber of ablationprocedures

Ablation procedures permillion inhabitants

Absolutenumber


Absolutenumber


To attainmeanESC arealevel

To attainmeanEU28level

2011 2012 2013 2014 2015

Russian Federation RU Yes 69 0.48 21 482 151 36 953 67 957 118 120 149 168 151

San Marino SM No 0 0.00 0 0 9 16 0 0 0 N/A 0

Serbia RS No 3 0.42 700 98 1862 3424 125 133 139 113 98

Slovakia SK Yes 4 0.74 1204 222 1405 2584 177 168 195 202 222

Slovenia SI Yes 3 1.51 712 359 – 946 162 136 140 220 359

Spain ES Yes 80 1.66 12 353 257 12 492 22 973 188 205 253 270 257

Swedena SE N/A N/A N/A N/A N/A N/A N/A 450 478 465 494 N/A

Switzerland CH Yes 25 3.08 5709 703 – – 612 598 566 637 703



Turkey TR No N/A N/A 13 000 164 20 604 37 892 N/A N/A N/A 137 164

Ukraine UA No 11 0.25 2294 52 11 527 21 199 47 55 60 54 52

UK GB Yes 65 1.01 17 622 275 – 30 579 240 254 251 276 275

Total ESCcountries

1159 1.34 243 808 259 227 217 223 282 289

aThese 10 countries did not submit any data on catheter ablations for the EHRA White Book 2016.

0,00,10,10,10,1

0,10,2

0,30,4

0,40,4

0,50,50,5

0,60,60,60,6

0,60,70,70,70,70,7

0,80,8

0,91,0

1,11,6

1,71,8

2,4

Switzerland

DenmarkSpain

HungaryPoland

Mean number of ablation centres = Ø 1,34

San Marino 0Montenegro 0

Iceland 0Bosnia & Herzegovina 0

Armenia 0Egypt

KazakhstanAlgeria

MoroccoAzerbaijan

UkraineRomania

BelarusGreeceIrelandSerbiaFranceLatvia

SloveniaSlovakia

Finland

NorwayAustria

IsraelLithuania

Netherlands

Czech Republic

FYR MacedoniaCroatia

GermanyCyprus

LuxembourgMalta

Figure 57 Catheter ablation centres per million inhabitants in 2015. The mean number of catheter ablation centres is weighted by population.



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

Table 16 Change in the number of catheter ablation centres in year 2015 vs. 2014

Country ISO code Number of ablation centres2014

Number of ablation centres2015

Change %

Absolutenumber


Absolutenumber



Algeria DZ 2 0.05 3 0.08 47.2

Armenia AM 3 0.98 3 0.98 0.1

Austria AT 17 2.07 19 2.19 6.1

Azerbaijan AZ 3 0.31 5 0.51 65.1

Belarus BY 6 0.62 7 0.74 18.0

Belgiuma BE 44 4.21 N/A N/A N/A

Bosnia and Herzegovina BA 0 0.00 1 0.26 N/A

Bulgaria BG 4 0.58 5 0.70 20.4

Croatia HR 5 1.12 6 1.34 20.2

Cyprus CY 3 2.56 3 2.52 21.4


Denmark DK 6 1.08 6 1.07 20.2

Egypt EG 15 0.17 15 0.17 21.8

Estonia EE 2 1.59 2 1.58 20.6

Finland FI 9 1.71 9 1.64 23.8

France FR 130 1.96 196 2.94 50.1

Georgia GE 7 1.42 8 1.62 14.4

Germany DE 200 2.47 346 4.28 73.3

Greece GR 29 2.69 29 2.69 0.0

Hungary HU 11 1.11 11 1.11 0.2

Iceland IS 1 3.15 1 3.01 24.4

Ireland IE 12 2.48 12 2.45 21.2

Israel IL 16 2.05 16 1.99 22.8

Italya IT 0 0.00 N/A N/A N/A

Kazakhstan KZ 9 0.50 13 0.72 42.8

Kosovoa XK 0 0.00 N/A N/A N/A

Kyrgyzstan KGZ 2 0.36 2 0.35 21.1

Latvia LV 2 0.92 2 1.01 9.0



Lithuania LT 3 1.03 3 1.04 1.0

Luxembourg LU 1 1.92 1 1.75 28.7

FYR Macedonia MK 3 1.43 2 0.95 233.5

Malta MT 1 2.42 1 2.42 20.3


Montenegro ME 1 1.54 1 1.55 0.5

Morocco MA 5 0.15 5 0.15 0.5


Norway NO 5 0.97 5 0.96 21.2

Poland PL 83 2.16 85 2.20 1.8

Portugal PT 24 2.22 25 2.31 4.1

Romania RO 12 0.55 12 0.55 0.3

Continued



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

Table 16 Continued

Country ISO code Number of ablation centres2014

Number of ablation centres2015

Change %

Absolutenumber


Absolutenumber




Serbia RS 2 0.28 3 0.42 50.7

Slovakia SK 4 0.73 4 0.74 1.4

Slovenia SI 3 1.51 3 1.51 0.2

Spain ES 85 1.78 80 1.66 26.7

Swedena SE 10 1.03 N/A N/A N/A

Switzerland CH 23 2.85 25 3.08 7.9



Turkeya TR 0 0.00 N/A N/A N/A

Ukraine UA 8 0.18 11 0.25 37.1

UK GB 61 0.96 65 1.01 6.0


aThese 11 countries did not submit any data on ablation centres for the EHRA White Book 2016.

1,40,6

1,91,8

3,21,7

2,00,2

2,62,5

1,00,4

1,60,9

1,12,7

2,41,0

1,11,5

0,61,5

0,10,7

2,22,2

2,11,0

2,12,9

0,91,4

0,61,1

0,60,9

0,20,5

0,12,0

0,30,3

2,5

Russian FederationLuxembourg

SpainIcelandFinland

IsraelEgypt

CyprusIreland

NorwayKyrgyzstan

EstoniaNetherlands

DenmarkGreece

MaltaArmeniaHungarySloveniaRomania

MontenegroMoroccoSlovakia

PolandPortugal

Czech RepublicUnited Kingdom

AustriaSwitzerland

LatviaGeorgiaBelarusCroatia

BulgariaLithuania

UkraineKazakhstan

AlgeriaFranceSerbia

AzerbaijanGermany

2014

FYR Macedonia -33,5-14,8

-8,7-6,7-4,4-3,8-2,8-1,8-1,4-1,2-1,2-1,1-0,6-0,4

-0,20,0

0,00,10,20,20,30,50,51,41,84,14,46,06,17,99,0

14,418,020,220,421,5

37,142,8

47,250,150,7

65,173,3

2015 vs. 2014 in %

1,00,5

1,81,7

3,01,6

2,00,2

2,52,5

1,00,4

1,60,91,1

2,72,4

1,01,1

1,50,6

1,50,2

0,72,22,3

2,21,0

2,23,1

1,01,6

0,71,3

0,71,0

0,20,7

0,12,9

0,40,5

4,3

2015

Figure 58 Change in the number of catheter ablation centres per million inhabitants from 2014 to 2015.



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02

8101616

41505255

777982

98105

128134136

151159164

222235238

254257

275280

302320

337359365

374376

466502

578589

595626

703703

789

Mean number of ablations = Ø 259

Median number of ablations = 229

San MarinoMorocco

AlgeriaKyrgyzstan

ArmeniaEgypt

AzerbaijanCyprus

UkraineRomania

MaltaFYR Macedonia

GeorgiaSerbia

BelarusMontenegro

BulgariaKazakhstan

Russian FederationGreeceTurkey

SlovakiaIceland

PortugalLuxembourg

SpainUnited Kingdom

PolandCroatiaAustriaEstonia

SloveniaLatvia

LithuaniaHungaryFinland

NetherlandsCzech Republic

NorwayFrance

BelgiumSwitzerland

DenmarkGermany

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





Figure 59 Catheter ablations per million inhabitants in 2015. The mean number of ablations is weighted by population.

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





Not available

Figure 60 Catheter ablations in the ESC countries in 2015.



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

Table 17 Change in the number of catheter ablations in year 2015 vs. 2014

Country ISOcode

Total ablations 2014 Total ablations 2015 Change %

Absolutenumber


Absolutenumber


Albaniaa AL N/A N/A N/A N/A N/A

Algeria DZ 240 6 303 8 23.9

Armenia AM 132 43 48 16 263.6

Austria AT 2622 319 2777 320 0.5

Azerbaijan AZ 384 40 398 41 2.6

Belarus BY 807 84 993 105 24.5

Belgium BE 6126 586 7091 626 6.8

Bosnia andHerzegovinaa

BA 0 0 N/A N/A N/A

Bulgaria BG 663 96 961 134 39.7

Croatia HR 852 191 1348 302 58.4

Cyprus CY 142 121 60 50 258.3


Denmark DK 3867 694 3925 703 1.3

Egypt EG 1354 16 1448 16 5.0

Estonia EE 411 327 426 337 3.0

Finland FI 2222 422 2550 466 10.4

France FR 33 300 503 39 596 595 18.4

Georgia GE 356 72 403 82 13.3

Germany DE 60 000 741 63 790 789 6.5

Greece GR 1653 153 1710 159 3.4

Hungary HU 3469 350 3723 376 7.6

Iceland IS 76 239 78 235 21.9

Irelanda IE N/A N/A N/A N/A N/A

Israela IL N/A N/A N/A N/A N/A

Italya IT N/A N/A N/A N/A N/A

Kazakhstan KZ 2018 112 2461 136 20.6

Kosovoa XK 0 0 N/A N/A N/A

Kyrgyzstan KGZ 58 10 59 10 0.6

Latvia LV 638 295 726 365 24.0



Lithuania LT 885 304 1078 374 23.1

Luxembourg LU 158 303 145 254 216.2

FYR Macedonia MK 105 50 166 79 57.8

Malta MT 30 73 32 77 6.3


Montenegro ME 66 102 83 128 26.3

Morocco MA 170 5 60 2 264.5


Norway NO 2959 575 3067 589 2.5

Poland PL 10 922 285 10 795 280 21.7

Portugal PT 2324 215 2580 238 10.9

Romania RO 1358 62 1194 55 211.8

Russian Federation RU 23 874 168 21 482 151 210.0

Continued



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

Table 17 Continued

Country ISOcode

Total ablations 2014 Total ablations 2015 Change %

Absolutenumber


Absolutenumber



Serbia RS 815 113 700 98 213.7

Slovakia SK 1111 202 1204 222 9.9

Slovenia SI 437 220 712 359 63.3

Spain ES 12 871 270 12 353 257 24.8

Swedena SE 4803 494 N/A N/A N/A

Switzerland CH 5135 637 5709 703 10.4



Turkey TR 11 218 137 13 000 164 19.1

Ukraine UA 2371 54 2294 52 23.5

UK GB 17 578 276 17 622 275 20.3


aThese 12 countries did not submit any data on ablations for the EHRA White Book 2016.

5,143,1

62,5

53,5

10,3

39,6

15,672,7

72,1

6,2

84,0

95,7

50,2

Morocco

2014

ArmeniaCyprus 121,1

Luxembourg 303,5Serbia 113,0

RomaniaRussian Federation 167,6

Spain 269,6UkraineIceland 239,5Poland 284,8

United Kingdom 275,8Austria 318,9

Kyrgyzstan4,496kramneD

2,594sdnalrehteN8,475yawroN

AzerbaijanEstonia 326,7Greece 153,4

9,055cilbupeR hcezCEgyptMalta

8,047ynamreG3,685muigleB

Hungary 349,7Slovakia 202,3

0,736dnalreztiwSFinland 421,7

Portugal 214,9Georgia

6,205ecnarFTurkey 137,4

Kazakhstan 112,4AlgeriaLatvia 294,7

BelarusMontenegro 101,5

BulgariaLithuania 252,4

FYR MacedoniaCroatia 190,6

Slovenia 219,8

-4,8-3,5-1,9-1,7

-0,30,50,61,31,32,52,63,03,45,05,06,36,56,87,69,9

2015 vs. 2014 in %

-63,6-58,3

-16,2-13,7-11,8-10,0

10,410,410,913,318,419,120,623,924,024,526,3

39,748,0

57,858,463,3

-64,515,7

50,5254,3

97,555,1

150,8256,6

51,6235,0

279,9275,0

320,510,4

703,2501,5

588,940,7

336,6158,7

578,516,4

77,3788,9

626,2376,2

222,3702,9

465,6238,3

81,7594,9

163,7135,5

7,7365,4

104,5128,3133,7

373,779,2

301,9359,0

1,8

2015

Figure 61 Change in the number of catheter ablations per million inhabitants from 2014 to 2015.



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0

50

100

150

200

250

300

350

400

450

500

550

600

650

700

750

800

0,0 0,5 1,0 1,5

Ablations per million inhabitants

KZ

BY

SK

NL

MK

NO

AM

LV

GB

LT

DK

HU

HR

BG

ROAZ

RURSKGZ

UA

EG

MA

DZ

SM 0

50

100

150

200

250

300

350

400

450

500

550

600

650

700

750

800

1,5 2,0 2,5 3,0 3,5 4,0 4,5

FR

GR

CYMT

CH

ISPT

LUAT

CZ

PL

Ablation centres per million inhabitants

DE

ES

FI

GE

EE

ME

SI

ESC 56

EU28

Figure 62 Catheter ablation centres and rates in the ESC and European Union (EU28) member countries in 2015. Bubble size is related topopulation in the country.

227222207176164

20142013201220112010

168174156135129

201420132012 20152011

726684

430476

574

201420132012 20152011

ESC

289282223217227

20152014201320122011

EU28

404387292294313

20152014201320122011



339331302302276

20152014201320122011

310302238231242

20152014201320122011


1319141612

20122011 201520142013


Figure 63 Catheter ablations per million inhabitants 2011–15 in the five geographical regions of the ESC and comparison with the total ESCarea and the 28 member countries of the European Union (EU28).



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Northern Europe

Denmark

703694652590

457

201420132012 20152011

TOP 3

Lowest 3 Estonia

Norway

United Kingdom

Finland

466422418415

362

20152014201320122011

Iceland

589575507530487

201420132012 20152011

337327302260300

20152014201320122011

235239254239203

201420132012 20152011

275276251254240

20152014201320122011

Figure 64 Catheter ablations per million inhabitants 2011–15 in Northern Europe.

Western Europe

Germany

789741

412467

614

20132012 201520142011

TOP 3

Lowest 3 Austria

320319294339220

201420132012 20152011

Switzerland

703637

566598612

201420132012 20152011

Netherlands

502495382

20152014201320122011

Belgium

626586580564534

20152012 2013 20142011

254303251

301252

20132012 2014 20152011

Luxembourg

* *

Figure 65 Catheter ablations per million inhabitants 2011–15 in Western Europe. *No data available.



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Eastern Europe

Czech Republic

578551482474440

201420132012 20152011

TOP 3

Lowest 3 Belarus

10584765461

20122011 201520142013

Hungary

376350338314293

201420132012 20152011

Romania

5562605050

20152014201320122011

Poland

280285248229214

201420132012 20152011

Ukraine

5254605547

201420122011 2013 2015

Figure 66 Catheter ablations per million inhabitants 2011–15 in Eastern Europe.

7950383026

Southern EuropeSlovenia

359220

140136162

20152014201320122011

TOP 3

Lowest 3

Croatia

302191183132101

20152014201320122011

Serbia

98113139133125

20152014201320122011

Spain

257270253205188

20152014201320122011

FYR Macedonia

2012 20152011 20142013

Malta

7773292420

20152014201320122011

Figure 67 Catheter ablations per million inhabitants 2011–15 in Southern Europe.



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Detailed data on AF ablation activities in the five ESC regions anda comparison with the corresponding numbers in the ESC and EU28countries are presented in Figure 72. The rate of AF ablations wasmarkedly lower in the non-European countries than in the EuropeanESC countries (8 vs. 125 per million population). The most activecountries in the Northern, Western, Southern, and Eastern Euro-pean regions and among the non-European ESC countries wereDenmark (337 AF ablation per million population), Germany(416), Slovenia (108), Czech Republic (238), and Kazakhstan (42),respectively (Figures 73–77). The proportion of AF ablations outof the total number of ablations varied between 1.5% in Azerbaijanand 52.7% in Germany. The mean ratio of AF ablations out of thetotal ablations was 35.7%, and the proportion of AF ablations com-pared with all ablations was more than 40% in 7 countries(Figure 78).

Ventricular tachyarrhythmia ablationratesIn 2015, the number of centres performing more than 10 ventriculartachyarrhythmia ablations for patients with structural heart diseaseper million population was highest in Germany (1.71) and lowest inUkraine (0.02) (Figure 79). Data on ventricular tachyarrhythmia ab-lations in patients with structural heart disease were collected forthe second time in 2015. A total of 35 (63%) countries reporteddata on ventricular tachycardia (VT) or ventricular fibrillation (VF)ablations. The mean number of VT/VF ablations per million

population in the ESC countries had increased from 9.2 in 2014to 16.0 in 2015. It was highest in Germany (83 per million popula-tion) followed by Finland (30), Czech Republic (28), and Denmark(26) (Figures 80 and 81). Many countries did not report any dataon VT/VF ablation (n ¼ 21) or did not perform any VT/VF ablations(n ¼ 5) in 2015.

Percutaneous left atrial appendageclosuresDuring recent years, percutaneous left atrial appendage (LAA) clos-ure has become an attractive option to prevent AF-relatedthromboembolic complications among patients with high riskof bleeding and contraindications to oral anticoagulationtherapy.16,17 The mean number of centres performing LAA closuresin the ESC area was 0.9 per million population (Figure 82). In 2015,however, only 26 of the 56 ESC member countries (46%) submittedthe requested data on the numbers of LAA closures for the EHRAWhite Book. The mean number of procedures in the ESC countriesperforming LAA closures was the same in 2015 as that in 2014 (8.9per million inhabitants). Germany was by far the most active country(54.8 LAA closure per million inhabitants) followed by Finland(22.5) and Latvia (14.1) (Figure 83). Of note is that in Kazakhstan,where the CIED implantation and catheter ablations numberswere generally quite low, 4.5 LAA occlusions were performed permillion inhabitants.


Kazakhstan

136112

8357

20152014201320122011

TOP 3

Lowest 3

Georgia

8272547555

20142013*201320122011

Armenia

164346

2333

20152014201320122011

Cyprus

50

121

393536

20152014201320122011

Algeria

866

2014201320122011 2015

Morocco

25573

20152014201320122011

*

* *

Figure 68 Catheter ablations per million inhabitants 2011–15 in the non-European ESC countries. *No data available.



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

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

Table 18 Atrial fibrillation ablations in 2015 in comparison with 4 previous years

Country ISO code AF ablation procedures 2015 Development potential—targetnumber of AF ablation procedures

AF ablation procedures per millioninhabitants

Absolute number Per million inhabitants To attain meanESC area level


2011 2012 2013 2014 2015

Albaniaa AL N/A N/A N/A N/A N/A N/A N/A N/A N/A

Algeria DZ 0 0 3814 6590 N/A N/A 0 0 0

Armenia AM 1 0 295 509 1 3 3 4 0

Austria AT 966 111 – 1444 62 122 94 107 111

Azerbaijan AZ 6 1 943 1630 0 N/A 0 0 1

Belarus BY 106 11 916 1583 4 6 7 7 11

Belgium BE 3273 289 – – 182 224 225 245 289

Bosnia and Herzegovina BA 0 0 373 644 0 0 0 0 0

Bulgaria BG 147 20 693 1198 0 7 7 11 20

Croatia HR 385 86 431 744 10 18 38 50 86

Cyprus CY 10 8 115 198 3 5 5 45 8

Czech Republic CZ 2537 238 – – 156 177 196 216 238

Denmark DK 1882 337 – – 194 262 290 305 337

Egypt EG 65 1 8536 14 747 N/A 0 0 1 1

Estonia EE 110 87 122 211 90 27 56 78 87

Finland FI 926 169 – – 91 110 124 140 169

France FR 10 138 152 – 11 091 100 130 N/A 166 152

Georgia GE 64 13 476 822 9 11 7 10 13

Germany DE 33 628 416 – – 184 172 144 494 416

Greece GR 650 60 1039 1796 32 37 40 52 60

Hungary HU 1204 122 – 1649 61 75 86 109 122

Iceland IS 36 108 – 55 48 77 73 104 108

Ireland IE 650 133 – 815 96 95 94 N/A 133

Israela IL N/A N/A N/A N/A N/A 0 N/A 70 N/A

Italya IT N/A N/A N/A N/A N/A 0 N/A N/A N/A

Kazakhstan KZ 762 42 1751 3026 6 11 15 29 42

Kosovoa XK N/A N/A N/A N/A N/A N/A N/A 0 N/A

Kyrgyzstana KGZ N/A N/A N/A N/A N/A N/A N/A N/A N/A

Latvia LV 88 44 192 331 31 26 29 35 44

Lebanona LB N/A N/A N/A N/A N/A N/A N/A N/A N/A

Libyaa LY N/A N/A N/A N/A N/A N/A N/A N/A N/A

Lithuania LT 81 28 278 481 19 8 9 21 28

Luxembourg LU 48 84 55 95 54 61 60 109 84

FYR Macedoniaa MK N/A N/A N/A N/A 0 0 0 0 N/A

Malta MT 0 0 40 69 0 0 2 0 0

Moldovaa MD N/A N/A N/A N/A N/A N/A 0 N/A N/A

Montenegro ME 18 28 62 108 0 0 0 26 28

Moroccoa MA N/A N/A N/A N/A 0 0 N/A N/A N/A

The Netherlands NL 3600 212 – – N/A 156 N/A 202 212

Norway NO 1460 280 – – 242 249 293 278 280

Poland PL 3253 84 3720 6427 N/A 44 50 57 84

Portugal PT 743 69 1044 1804 43 49 51 63 69

Romania RO 132 6 2090 3611 3 4 6 4 6

Russian Federation RU 6329 44 13 739 23 735 27 27 41 45 44

San Marino SM 0 0 3 6 0 0 0 N/A 0

Serbia RS 150 21 692 1196 8 14 17 33 21

Slovakia SK 224 41 522 903 17 18 27 23 41

Slovenia SI 214 108 – 331 59 55 83 75 108

Spain ES 2426 50 4644 8024 31 33 46 52 50

Swedena SE N/A N/A N/A N/A 157 178 179 184 N/A

Switzerland CH 1991 245 – – 209 193 184 209 245

Syriaa SY 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 2 3 N/A 4 N/A

Turkey TR 2200 28 7660 13 235 N/A N/A N/A 15 28

Ukraine UA 634 14 4286 7404 11 14 15 14 14

UK GB 6390 100 – 10 681 74 80 85 102 100

Total ESC countries 56 87 527 123 66 69 72 122 123

aThese 13 countries did not submit any data on AF ablations for the EHRA White Book 2016.



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0000011

68111314

2021

282828

41424444

5060

6984848687

100108108111

122133

152169

212238

245280

289337

416Germany

Algeria

Serbia

Median number of ablations = 50

Mean number of ablations = Ø 96

Bulgaria

San Marino

UkraineGeorgiaBelarusCyprus

RomaniaEgypt

AzerbaijanArmenia

Bosnia & HerzegovinaMalta

Lithuania

Switzerland

SlovakiaKazakhstan

France

MontenegroTurkey

Finland

Latvia

Czech Republic

IrelandHungary

Netherlands

PortugalLuxembourg

Belgium

CroatiaEstonia

United KingdomSlovenia

Iceland

Poland

GreeceSpain

Russian Federation

Denmark

Norway

Austria

96 = Ø AF ablations per million inhabitants (weighted by population)





Figure 69 Atrial fibrillation ablations per million inhabitants in 2015. The mean number of AF ablations is weighted by population.

96 = Ø AF Ablations per million inhabitants (weighted by population)





Not available

Figure 70 Atrial fibrillation ablations in the ESC countries in 2015.



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

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

Table 19 Change in the number of catheter ablations of AF in year 2015 vs. 2014

Country ISOcode

AF ablation procedures 2014 AF ablation procedures 2015 Change %

Absolutenumber


Absolutenumber


Albaniaa AL N/A N/A N/A N/A N/A

Algeria DZ 0 0 0 0 0.0

Armenia AM 11 4 1 0 290.9

Austria AT 878 107 966 111 4.4

Azerbaijan AZ 2 0 6 1 197.1

Belarus BY 69 7 106 11 55.4

Belgium BE 2560 245 3273 289 18.0


BA 0 0 0 0 0.0

Bulgaria BG 79 11 147 20 79.3

Croatia HR 223 50 385 86 72.9

Cyprus CY 53 45 10 8 281.4


Denmark DK 1698 305 1882 337 10.6

Egypt EG 60 1 65 1 6.4

Estonia EE 98 78 110 87 11.6

Finland FI 736 140 926 169 21.0

France FR 11 000 166 10 138 152 28.2

Georgia GE 50 10 64 13 28.1

Germany DE 35 000 432 33 628 416 23.8

Greece GR 560 52 650 60 16.1

Hungary HU 1081 109 1204 122 11.6

Iceland IS 33 104 36 108 4.3


Israela IL 550 70 N/A N/A N/A

Italya IT N/A N/A N/A N/A N/A

Kazakhstan KZ 524 29 762 42 43.8

Kosovoa XK 0 0 N/A N/A N/A

Kyrgyzstana KGZ N/A N/A N/A N/A N/A

Latvia LV 75 35 88 44 27.9

Lebanona LB N/A N/A N/A N/A N/A


Lithuania LT 74 25 81 28 10.6

Luxembourg LU 57 109 48 84 223.1

FYR Macedoniaa MK 0 0 N/A N/A N/A

Malta MT 0 0 0 0 0.0


Montenegro ME 17 26 18 28 6.4

Moroccoa MA N/A N/A N/A N/A N/A


Norway NO 1432 278 1460 280 0.8

Poland PL 2169 57 3253 84 49.1

Portugal PT 684 63 743 69 8.5

Romania RO 88 4 132 6 50.4

Russian Federation RU 6462 45 6329 44 22.0


Serbia RS 236 33 150 21 236.1

Slovakia SK 129 23 224 41 76.1

Slovenia SI 149 75 214 108 44.0

Continued



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DiscussionFor almost a decade, the EHRA White Book has been a key resourcefor healthcare professionals and stakeholders with an interest in theadvancement of cardiac arrhythmia therapies in Europe. It has al-ready played an important role in the ICD for life programme3

and many other strategic initiatives and awareness activities of theEHRA. Current analysis of the EHRA White Book data showed

that considerable variations in access to and use of invasive EPs con-tinue to exist within the ESC area. Despite several improvementsover the last 5 years, there is still a clear need to improve the avail-ability of invasive procedures for complex arrhythmias in many ESCcountries.

As in previous years, the mean CIED implantation rates weremarkedly lower in the Eastern European and non-European ESCcountries than in the other regions. The catheter ablation activity

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

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

Table 19 Continued

Country ISOcode

AF ablation procedures 2014 AF ablation procedures 2015 Change %

Absolutenumber


Absolutenumber


Spain ES 2498 52 2426 50 23.7

Swedena SE 1791 184 N/A N/A N/A

Switzerland CH 1684 209 1991 245 17.4



Turkey TR 1208 15 2200 28 87.2

Ukraine UA 622 14 634 14 1.6

UK GB 6505 102 6390 100 22.3


aThese seven countries did not submit any data on AF ablations for the EHRA White Book 2016.

3,645,2

32,7

52,3

45,4

14,0

63,3

77,9

52,0

34,610,121,129,2

74,956,6

4,07,2

49,923,5

11,4

0,2

26,20,7

14,8

2014

ArmeniaCyprusSerbia

Luxembourg 109,5France 166,0

1,234ynamreGSpain

United Kingdom 102,1Russian Federation

2,872yawroNUkraineIceland 104,0Austria 106,8

Netherlands 202,2Montenegro

EgyptPortugal

Czech Republic 216,19,403kramneD

EstoniaHungary 109,0Greece

Switzerland 208,9Belgium 245,0Finland 139,7

LatviaGeorgia

LithuaniaKazakhstan

SloveniaPoland

RomaniaBelarusCroatia

SlovakiaBulgaria

TurkeyAzerbaijan

-8,2-3,8-3,7-2,3-2,0

0,81,64,34,45,06,46,48,5

2015 vs. 2014 in %

-90,9-81,4

-36,1-23,1

10,310,611,611,616,117,418,021,027,928,133,0

43,844,049,150,455,4

72,976,179,387,2

197,1

0,24,023,5

74,914,0

278,27,2

26,20,00,00,0

184,2304,9

245,0216,1

139,752,3

208,9106,8

56,634,6

102,163,3

109,049,952,0

3,677,9

104,010,1

0,711,4

109,529,232,7

21,1493,8

45,2

2014

Figure 71 Change in the number of AF ablations per million inhabitants from 2014 to 2015.



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was substantially higher in the Western and Northern Europeanthan in the non-European ESC countries. The Eastern EuropeanESC countries were characterized by large variations in the proced-ure rates, with numbers spanning over all four quartiles of the

activity distribution. Surprisingly, there was a drop in the numberof LEs between 2014 and 2015, although continued increase in num-bers was expected. The reasons for this are unclear, and it cannot beexcluded that this was related to a reporting bias.

5250423128

20152014201320122011

4543392927

201420132012 20152011

364371

151174176

201420132012 20152011

ESC

123122

726966

20152014201320122011

EU28

178177

949692

20152014201320122011



1261231089889

20152014201320122011

125124

737067

20122011 201520142013


812575

201420132012 20152011


Figure 72 Atrial fibrillation ablations per million inhabitants 2011–15 in the five geographical regions of the ESC and comparison with the totalESC area and the 28 member countries of the European Union (EU28).

Northern Europe

Denmark

337305290

262

194

201420132012 20152011

TOP 3

Lowest 3 Estonia

87785627

90

201420132012 20152011

Norway

280278293249242

201420132012 20152011

Latvia

4435292631

201420132012 20152011

Finland

16914012411091

20152014201320122011

Lithuania

28219819

201420132012 20152011

Figure 73 Atrial fibrillation ablations per million inhabitants 2011–15 in Northern Europe.



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Potential explanations for the disparitiesbetween the European Society ofCardiology countriesAs shown in Figure 3, the healthcare expenditure currentlyabsorbs from 4.3 to 12.9% of GDP in the ESC countries. Hence, it

is not surprising that there continues to be a large gap between theEU28 countries and selected Eastern European and non-EuropeanESC countries in the CIED implantation facilities and rates. Likewise,catheter ablation facilities and rates were markedly lower in thenon-European than in the European ESC member countries.

Western Europe

Germany416432

144172184

201420132012 20152011

TOP 3

Lowest 2 France

152166130

100

20152014201320122011

Belgium

289245

225224182

201420132012 20152011

Austria

11110794122

62

20152014201320122011

Switzerland

245209184193209

201420132012 20152011

84109606154

20152014201320122011

Austria

*

Figure 74 Atrial fibrillation ablations per million inhabitants 2011–15 in Western Europe. *No data available.

Eastern Europe

Czech Republic

238216196177156

201420132012 20152011

TOP 3

Lowest 3 Ukraine

1414151411

20152014201320122011

Hungary

122109867561

201420132012 20152011

Belarus

117764

201420132012 20152011

Poland

84575044

20152014201320122011

Romania

64643

201420132012 20152011

*

Figure 75 Atrial fibrillation ablations per million inhabitants 2011–15 in Eastern Europe. *No data available.



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Data on health expenditures and CIED implantation rate per ca-pita indicate that a low proportion of healthcare expenditure is, aswould be expected, associated with a lower use of device therapyand the use of complex interventional electrophysiology proce-dures (Figure 83). However, in some Eastern European countries

with relatively low GDP, device implantation and catheter ablationrates per million population exceed those of certain Western andNorthern European countries. Good examples of this are CzechRepublic and Hungary, which were in the most active quartile forCRT therapy and AF ablations. Furthermore, despite the economic

Southern Europe

Slovenia

1087583

5559

201420132012 20152011

TOP 3 Croatia

8650381810

20152014201320122011

Portugal

6963514943

20152014201320122011

Lowest 3 Bosnia & Herzegovina Malta

00200

20152014201320122011

00000

20152014201320122011

0000

20152014201320122011

San Marino

*

Figure 76 Atrial fibrillation ablations per million inhabitants 2011–15 in Southern Europe. *No data available.


Kazakhstan

4229

15116

20152014201320122011

TOP 3

Lowest

Georgia

13107119

201420132012 20152011

Azerbaijan

1000

20152014201320122011

Cyprus

8

45

553

20152014201320122011

Armenia

04331

20152014201320122011

000

20152014201320122011

Cyprus

* * *

Figure 77 Atrial fibrillation ablations per million inhabitants 2011–15 in the non-European ESC countries. *No data available.



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1,52,1

4,57,5

10,711,1

12,115,3

15,916,716,9

18,619,6

21,421,7

25,625,8

27,628,628,8

29,530,130,1

31,032,3

33,134,834,9

36,336,3

38,041,2

42,446,246,2

47,647,9

52,7

Proportion of AF ablation of total ablations = Ø 35,7

Malta 0Algeria 0

AzerbaijanArmenia

EgyptLithuania

BelarusRomania

LatviaBulgariaGeorgiaCyprusTurkey

SlovakiaSpain

SerbiaMontenegro

FranceEstoniaUkraineCroatia

PortugalRussian Federation

SloveniaPoland

KazakhstanHungary

LuxembourgAustria

SwitzerlandUnited Kingdom

FinlandGreece

Czech RepublicNetherlands

IcelandBelgiumNorway

DenmarkGermany

Figure 78 Proportion of AF ablations of total ablations in 2015.

0,020,09

0,170,20

0,240,28

0,300,350,36

0,450,46

0,490,500,500,50

0,550,56

0,580,66

0,730,79

0,860,90

0,941,71

Ukraine

Azerbaijan

RomaniaSpain

Russian FederationSerbia

HungaryFrance

United KingdomCroatiaAustriaPoland

IsraelLatvia

SloveniaSlovakiaGreeceNorway

Czech RepublicFinlandEstonia

SwitzerlandDenmark

NetherlandsGermany

Figure 79 Number of centres which performed more than 10 VT or VF ablations per million inhabitants in patients with structural heart diseasein 2015. The mean number of VT/VF ablation centres is weighted by population.



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0000011112

23

99

10101111111111

1214

1517

181818

2022

2326

2830

83

MaltaCyprus

EgyptAlgeria

BelarusUkraineArmeniaBulgaria

TurkeyRomaniaLithuaniaHungaryCroatiaEstoniaSerbia

United KingdomLuxembourgMontenegro

AustriaFrance

Russian FederationSlovenia

IcelandGreecePolandLatvia

Mean number of VT/VF-ablations = Ø 16

SlovakiaIreland

Median number of VT/VF-ablations = 11

San Marino

Switzerland

DenmarkCzech Republic

FinlandGermany

Spain

16 = Ø VT/VF-ablations per million inhabitants (weighted by population)




4th quartile > 18≤ 83

Figure 80 Ablations for VT or VF per million inhabitants in patients with structural heart disease in 2015. The mean number of VT/VF ablationsis weighted by population.

16 = Ø VT/VF-ablations per million inhabitants (weighted by population)





Not available

Figure 81 Ablations for VT or VF in patients with structural heart disease in 2015.



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0,20,2

0,2

0,2

0,30,5

0,5

0,50,7

0,7

0,70,9

0,9

1,2

1,82,4

2,6

2,8

San Marino

Mean number of centres performing LAA closures = Ø 0,9

Montenegro

0

Lithuania

0

Iceland

0

Cyprus

0


0

Azerbaijan

0

Armenia

0

Algeria

0

Kazakhstan

0

Greece

0

Belarus

Croatia

Netherlands

Slovenia

Hungary

Sweden

Turkey

France

Denmark

Israel

Finland

Austria

Czech Republic

Malta

Germany

Serbia

Latvia 10,6

Luxembourg

Figure 82 Number of centres performing LAA closures per million inhabitants in 2015. The mean number of the centres is weighted bypopulation.

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Mean number of LAA closures = Ø 8,9

Turkey

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San Marino

Montenegro 0

Lithuania 0

Iceland 0

Cyprus 0

Bosnia & Herzegovina 0

Azerbaijan 0

Armenia 0

Algeria 0

Croatia

Greece

Belarus

Hungary

Luxembourg

Kazakhstan

Serbia

Sweden

Austria

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Czech Republic

France

Malta

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Finland

Germany

Figure 83 Percutaneous LAA closures per million inhabitants in 2015. The mean number of the centres is weighted by population.



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difficulties all across Europe in the past 7–8 years, the use of deviceand catheter ablation therapies has been growing in a number ofcountries with relatively low GDP. On the other hand, in manyWestern and Northern European countries with high GDP, theuse of device and ablation therapies has remained stable or evenin some cases declined slightly. It is unclear whether this is a conse-quence of constraints on healthcare expenditure in the wake of thefinancial crisis or if that supply has already met the demand or both.Nevertheless, these data indicate that relatively high GDP is not theonly explanation for early adaptation of novel healthcare innova-tions with a relatively high initial cost. Other potential excuses forthe observed disparity include lack of manpower, training, facilities,and likely low referral rates.18 A personal co-payment for the pro-cedures may limit access to CIED and catheter ablation therapies incountries not providing full coverage for the whole population.

Impact of the economic crisisIn recent years, a clear limitation for improvements in arrhythmiamanagement across the ESC area has been a difficult economic situ-ation. Due to the ongoing financial problems, many countries havemade substantial budget cuts for healthcare.18 –22 At the same time,the number of elderly people requiring vast medical and social carehas grown rapidly. In this context, socioeconomic disparities pose amajor threat to healthcare systems and may limit the use of innova-tive technologies such as ICD therapy for primary prevention ofsudden cardiac death and catheter ablation of AF and VT/VF,

unless the effectiveness and efficacy of the healthcare system areimproved.18– 22

The cost of health and social care is escalating not only due topopulation aging and costly developments in the medical technologyfield but also as a result of unhealthy life styles, higher expectationsfor better services, unit cost inflation, inefficiency, and suboptimaluse of resources. Therefore, we need an integrated and comprehen-sive approach to improve patient access arrhythmia care. With re-gard to this, it was interesting to note that the numbers of hospitalsand beds were not directly related to the financial profile or health-care expenditure of a given country. Rather, some countries havedirected more resources towards hospital care than ambulatoryand home care (Figure 84).

Evolving areas in cardiac arrhythmiatherapyMost of the innovative medical technologies have a high initial cost.Therefore, their efficacy and safety need to be proved before theycan reach wide acceptance and clinical use. Evolving areas in the car-diac arrhythmia therapy include leadless pacing, subcutaneous ICDtherapy, use of percutaneous LAA occlusion devices for preventionof thromboembolic complications in patients with AF, and catheterablation of complex atrial and ventricular tachyarrhythmias. Themain problem in analysing the current access and use of the evolvingarrhythmia therapies was that many countries did not report data onthese developing therapies.

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Health expenditures per capita (in USD)

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IS

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Rest ESC56

Figure 84 Healthcare spending per capita and interventional electrophysiology procedures (sum of PM-ICD-CRT ablation procedures per mil-lion inhabitants). The ISO codes of the countries are explained in Table 1.



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Leadless pacing has recently been introduced in most ESC coun-tries. The most active countries in the ESC area with regard to lead-less PM implantations were France and the Netherlands, whichwere active also in the studies evaluating the safety and efficacy ofthis therapy.10 Although the overall implantation rates were ratherlow also in these early adopters, leadless pacing is expected to growrapidly.

The results of numerous randomized, multicentre trials have estab-lished the role of traditional ICD therapy in secondary and primarypreventions of sudden cardiac death.23 However, transvenous ICDleads have significant short- and long-term complications, offsettingsome of the benefits of this therapy. This has led to the developmentof the entirely subcutaneous ICD.12,13 This was the first year that theWhite Book questionnaire asked about S-ICD implantation. Italy re-ported by far the highest implantation rate for these devices. Obvi-ously, the limited data do not allow for much interpretation, butthe plan is to continue to gather data in coming years on this emergingprocedure.

According to the White Book data, the role of catheter ablationin treatment of symptomatic AF is well established in Western andNorthern Europe and in some countries in Southern and EasternEurope, whereas in the non-European ESC countries the accessto AF ablation is limited. Catheter ablation of VT has been one ofthe key areas of growth in electrophysiology in recent years. Thegrowing need for VT/VF ablations in patients with structural heartdisease23 –25 was reflected in the White Book data where the num-ber of VT/VF ablation procedures per million inhabitants increasedfrom 9.2 in 2014 to 16.0 in 2015.

Another important evolving area in cardiac rhythm managementis the use of percutaneous LAA closure devices to preventAF-related thromboembolic complications.16,17 According to a re-cent meta-analysis, LAA occlusion is non-inferior to warfarin in pa-tients at high risk of thromboembolic and bleeding events.16 As withVT/VF ablations, the number reported for LAA occlusion has grownsignificantly within the last 2 years. The number of LAA occlusionwas largest in Germany, but interestingly many of the countries inthe top 10 were from Eastern Europe.

The role of European Heart RhythmAssociationEuropean Heart Rhythm Association has collected information onthe resources and characteristics of procedures performedthroughout the ESC area in the field of cardiac arrhythmias for al-most a decade. The White Book data have formed a backbonefor many national and cross-national strategic initiatives and aware-ness activities such as the ‘ICD for Life’ campaign.

Disparity in the implementation of arrhythmia treatment andpractice guidelines is likely to continue, unless there is an improvedinvestment in the infrastructure. This includes electrophysiology la-boratories, specialized equipment, and not least-improved trainingopportunities. Likewise, standardization of training requirementsand implementation of current clinical practice guidelines are im-portant steps. European Heart Rhythm Association has been veryactive in promoting unified standards for training of cardiac rhythmmanagement specialists and to try to assure high quality in arrhyth-mia care in a broad sense. The ongoing White Book project has

revealed important disparities in this field also and provided a solidbase to improve and align arrhythmia management strategies acrossESC countries. The ability to see its own numbers in a Europeancontext provides each country robust means to demonstrate short-falls in resource allocation, reimbursement and training require-ments to the national or local authorities, and to makerecommendations to improve decision- and policymaking concern-ing the cardiac arrhythmia care field at national and cross-nationallevels.

The EHRA certification programme provides an excellent plat-form to improve and harmonize the training and the level of ar-rhythmia care in the ESC area. The introduction of the EHRAaccreditation programme for teaching centres will provide furthersupport to standardization of training. European Heart RhythmAssociation fellowship grants have already allowed many juniorphysicians from countries with low procedure rates to receivetraining in high-volume centres across the ESC area. The numberof applications for the EHRA fellowship grants has been increasingsteadily, and the certification programme is now available for al-lied professionals. Last year, the EHRA Training Fellowship com-mittee awarded 10 grants for young physicians. In addition, aspecific proctor programme was recently launched in order toprovide further education in the field of cardiac arrhythmiamanagement.

In summary, the EHRA White Book data indicate that there arestill significant differences in training and certification requirementsbetween the ESC countries. Accordingly, there is a need to involvemore physicians and allied professionals in the EHRA certificationsystem to assure uniform and high-level theoretical and practicaltraining for all healthcare professionals, regardless of their countryof origin.

LimitationsThere are several limitations in the methodology of the EHRAWhite Book data collection. Data collection is exclusively basedon voluntary activity of the National Cardiac Societies or Arrhyth-mia Working Groups. This year 50 out of the 56 ESC nations re-sponded to the White Book questionnaire. Some countries, onthe other hand, have never reported data for the White Book,and many countries reported incomplete data. In particular, manycountries did not provide data on new therapies like leadless pacing,S-ICD, and VT/VF ablations. This may be related to incomplete col-lection of data on these procedures, which are relatively new andperformed only in a few select centres.

With regard to the analysis and interpretation of summarydata, it was a major drawback that Italy, one of the most popu-lated countries in the ESC area, once again, did not submit anydata on catheter ablations. In addition, there were large variationsin national data sources. About 50% of the data came from na-tional registries (20 countries), and the other half was based onsurveys and other estimates conducted by the National Societies.This is relevant since the coverage of the registries in some of theESC countries is relatively poor and many procedures are not in-cluded in the registry data. In contrast, surveys and other esti-mates may overestimate the procedure numbers. The lack of anational quality control institution in many countries (Figure 85)



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also reflects the need for centralized data collection and qualityassurance.

Comparison of results between nations or regions can be a majordriver in leading to changes within health systems. Therefore, for thethird year in row, the data were presented separately for the fivegeographical regions within the ESC area. In order to avoid any eco-nomic, political, or historical bias, the European regions were com-posed according to the United Nations Statistics Division, and allother ESC countries were included in the non-European ESC re-gion. This classification is not free of limitations. Nevertheless, wefeel that as a well-defined and widely accepted geographical classifi-cation, the UN grouping provides a neutral platform for regionalcomparisons within the ESC area.

Future directions of the European HeartRhythm Association White Book projectThe goal is to continue to improve the reliability of the EHRA WhiteBook data and to ensure the quality of the collected data. In this re-gard, it is important that the national registries continue to developand that their coverage will expand in the future. We also encouragethe adoption of such a registry if not already present.

Next year, we will celebrate the 10-year anniversary of the EHRAWhite Book data collection. Our goal is, together with the NationalCardiac Societies and Working Groups, to recheck the prior data andto complete the missing values in the dataset before the end of thisyear. All National Societies will receive a copy of the previously re-ported data after the ESC Congress, and we hope to get the updateddata within a couple of months after that. Collection of the 2016 datawill be launched as previously in February 2017. We hope to reach100% coverage for the anniversary edition of the White Book.

An attractive long-term goal with regard to the data collectionand analysis is to develop an internet-based electronic database,which would allow free comparisons between and within the ESCcountries. Such a database would also provide a unique future plat-form for online multicentre registry-based clinical trials in arrhyth-mia therapy.26 The ESC recently launched the Atlas onCardiology project27 with similar goals as the White Book. The At-las will provide descriptive and quantitative information on econ-omy, demographics, health system, and health policies alongsidedata concerning healthcare resources and a wide range of cardi-ology interventions in the ESC member countries. There are cur-rently no plans to discontinue the White Book, but eventually it ispossible that these two projects will merge.

ConclusionsDuring the past 9 years, the White Book has developed into a sub-stantial asset not only for the cardiac electrophysiology communitybut also for healthcare administrators and politicians in the ESCarea. The availability of up-to-date information is critical to those fa-cing the challenge of balancing healthcare budgets and allocating lim-ited resources. The statistics presented herein show that, despitesignificant improvements in many areas of arrhythmia care, therestill is considerable heterogeneity in the availability of invasive ar-rhythmia therapies across the ESC area. Reducing this gap continuesto be one of the main goals of the EHRA.

AcknowledgementsThe EHRA White Book 2016 and this analysis were possible thanksto the continuing efforts of several key contributors including chair-persons and co-chairs of the National Societies and Working


No = 32 countries

Yes = 15 countries

Figure 85 Availability of national institution to coordinate and guide device recalls in the ESC countries in 2015.



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Groups of the ESC countries that have provided data. We are grate-ful for their invaluable contribution and hope that even more coun-tries will be reporting data for the White Book next year. Inaddition, we want to thank Yasmine Carrasset, Lauren Tapp, andother members of the EHRA staff at the Heart House as well asBIOTRONIK SE & Co. KG for continuous support to the project.In particular, special thanks to Robert Wuestenberg and Anja Thue-men from BIOTRONIK for their dedication and passion in the con-duction of the project. Finally, Prof. Panos Vardas and Prof. ChristianWolpert deserve special thanks as the ‘founding fathers’ of theWhite Book project.

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