The registry of the European Working Group on Cardiac Pacing (EWGCP)

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1 Europace (2000) 2, doi: /eupc , available online at on The registry of the European Working Group on Cardiac Pacing (EWGCP) H. Ector, A. F. Rickards, L. Kappenberger, P. Vardas, A. Oto, M. Santini and R. Sutton on behalf of the Working Group on Cardiac Pacing, a working group of the European Society of Cardiology Introduction The late Giorgio Feruglio, the late Bert Thalen and Anthony F. Rickards [1 3] were the founders of the European pacemaker registry. Their particular merit was the development and introduction of the European Pacemaker Patient Identification Card, in close cooperation with IAPM (International Association of Medical Prosthesis Manufacturers). Nowadays A. F. Rickards remains responsible for the website of EWGCP: The major features of our registry have been published in abstracts [4 6]. Methods During the past 20 years, national registration centres have started collecting their national data. The results have been centralized, so that an annual European survey can be constructed. All contributors receive a complete set of the data; for their own information and for possible corrections. The data are also presented on the website of the EWGCP. Access to the data is limited by the requirement to obtain a password from A. F. Rickards. Collection of data is based on the European Pacemaker Patient Identification Card, first designed in July The card offers appropriate codes for symptoms, ECG indications, aetiology, pacing mode, generator and lead changes, file closure. Questionnaires are sent out every year to the national registration centres. They request information concerning demographic data, numbers of devices implanted, symptoms at initial implant, ECG indications, pacing modes vs indication, rate responsive systems, aetiology, explantation of leads and generators, lead extractions. In recent years, data on ICDs and ablations have also been collected. The original database was set up in SPSS for Windows, version (SPSS Inc., 444 North Michigan Avenue, Chicago, IL 60611). The database can be translated to Excel, Dbase and other formats. Herewith we report on the data of the four consecutive years When some data are not available for one or more years, this is indicated by?. Manuscript submitted 1 December 1999, and accepted 8 May Correspondence: Hugo Ector, Department of Cardiology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Belgium. For the year 1997, Figs 1 and 2 contain data from some non-european countries, as reported by HG Mond and V. Parsonnet [7,8]. Tables 1 5 summarize relevant data for the year Results In total numbers of / / / pacemakers (first implants / / / ) were registered in 2642/2680/2785/2792 hospitals of 22/23/21/18 European countries for a population of 456/467/445/421 million: an implantation rate population: total number 399/416/434/469, first implants 287/296/301/351. The pacemaker implantation rate varies considerably from country to country: for the total number of pacemakers: median 333/340/367/377; first implants median 253/266/280/290. For , the rate of first implants was: Austria 363/412/444/435; Belgium 625/632/626/ 585; Croatia 100/112/157/161; Czech R 443/459/467/ 468; Denmark 314/300/301/309; FR Yugosl 42/53/67/?; France 495/540/528/552; Germany 449/439/423/440; Greece 309/287/286/313; Hungary 210/160/?/?; Italy?/?/ 241/228; Lithuania 153/151/94/104; Moldova 19/18/13/?; Netherlands 255/261/275/283; Norway 225/215/235/247; Poland 177/186/196/203; Portugal?/299/?/?; Russia?/?/?/57; Slovak R 247/266/280/286; Slovenia 184/204/210/ 213; Spain 252/260/262/289; Sweden 380/356/382/411; Switzerland 280/318/328/348; the U.K. 312/277/301/291. Figure 1 illustrates the data for the year 1997 and compares the European data with the figures from the U.S.A., Australia, Israel, New Zealand, Japan, Hong Kong. For the number of implanting hospitals, we have obtained the following figures: median 3 3/3/3 8/ 5 3 min 0 45/0 45/0 45/0 63 max 19 5 (Belgium). The of pacing modes in the different countries gives the following trends. VVI-VVIR pacers (median 67/57/ 49/46), while AAI-AAIR show little change (median 1 8/1 8/2 6/1 9 max 14/14/39/19) and DDD-DDDR progressively rise (median 24/29/38/43). The VVI(R) pacing in sinoatrial node disease showed a trend toward reduction, but remains high in some countries: Austria 41/36/45/28; Belgium /00/ $35.00/ The European Society of Cardiology

2 252 H. Ector et al New PM implants Belgium U.S.A. France Czech R Germany Austria Sweden Switzerland Australia Greece Denmark Israel U.K. Spain Slovak R Netherl Norway Italy New Zealand Slovenia Poland Croatia Japan Lithuania Hong Kong Russia Year 1997 Figure 1 New pacemaker implants population by country in ICD total number U.S.A. Germany Israel Denmark Austria Norway Belgium Australia Switzerland Netherl Italy Sweden New Zealand Greece Czech R Slovenia France Spain U.K. Slovak R Poland Figure 2 Total ICD implants population by country in /28/26/19; Croatia 71/76/70/63; Czech R 51/43/39/39; Denmark 37/21/16/12; FR Yugosl 77/47/16/?; France 30/ 29/27/23; Germany 62/54/50/43; Italy?/?/35/32; Moldova 93/95/60/?; Netherlands 56/45/41/31; Poland 68/52/44/41; Slovak R?/86/88/66; Spain 60/59/58/34; Sweden 44/37/27/ 23; Turkey 80/75/?/?; the U.K. 49/44/33/33. The AAI(R) pacing in sinoatrial node disease was mostly low and mostly not increasing: Austria 4/4/6/3; Belgium 0 2/0 5/0 5/0 7; Croatia 10/3/6/2; Czech R 8/6/ 4/3; Denmark 37/34/37/35; FR Yugosl 5/11/51/?; France 4/2/2/2; Germany 7/6/5/5; Italy?/?/5/4; Netherlands 12/14/11/11; Poland 21/28/27/27; Slovak R 25/9/4/16;

3 EWGCP registry 253 Table 1 Year 1997: demographic data and numbers of pacemakers (PM) Population in millions PM centres population PM total no. per million New PM implants all males females New implants in males New implants in females 1 Austria Belgium Croatia Czech R Denmark France Germany Greece Italy Lithuania Netherland Norway Poland Slovak R Slovenia Spain Sweden Switzerland U.K Russia Table 2 Year 1997: pacing mode Single chamber atrial Single chamber ventricular VDD, P, M and VDDR Dual chamber 1 Austria Belgium Croatia Czech R Denmark France Germany Greece Italy Netherland Norway Poland Slovak R Slovenia Spain Sweden Switzerland U.K Slovenia?/?/7/4; Spain 8/5/6/11; Sweden 29/30/30/24; the U.K. 10/10/9/9. The of unipolar ventricular leads varied very widely from country to country: Austria 5/5/5/10; Belgium 51/46/45/41; Croatia 78/95/95/97; Czech R 80/65/25/25; Denmark 60/61/63/66; FR Yugosl 92/74/78/?; France 58/?/53/53; Germany 67/62/60/59; Hungary 90/94/?/?; Italy?/?/51/48; Moldova 100/100/100/?; Netherlands 25/16/?/11; Norway 82/83/73/74; Poland 87/78/86/46; Slovak R 94/73/68/50; Sweden?/66/71/69; Switzerland?/17/15/14. There is also a variable pattern in the use of active fixation in the atrium: : Austria 80/80/80/100; Belgium 27/41/44/43; Croatia 2/5/5/0 2; Czech R 15/25/3/8; Denmark 11/27/34/39; France 76/?/78/79; Netherlands 8/5/?/?; Norway 41/42/32/41; Poland 6/3/14/53; Slovak R 4/3/15/8; Sweden?/?/?/62; Switzerland?/59/56/59; the U.K. 27/27/26/23. For , the total number of ICDs was: Austria 15/10/13/31; Belgium 19/21/24/28; Croatia 0 4/0 8/0 8/0 6; Czech R 2/5/8/11; Denmark 15/15/24/33; FR Yugosl?/?/0 4/?; France 4/4/?/8; Germany 23/27/24/ 49; Greece 3/5/7/11; Italy?/9/10/16; Netherlands?/10/10/ 16; Norway 10/12/15/28; Poland 0/0 5/1/3; Slovak R 1/3/4/5; Slovenia 0 5/1/3/8; Spain?/?/7/?; Sweden 12/11/?/?; Switzerland 9/12/14/22; UK 3/5/6/7. Figure 2

4 254 H. Ector et al. Table 3 Year 1997: pacing mode and indication VVI in ECG diagn C1-7 AVB VVI in VVI in E6 atrial Fl/fib+brady AAI in DDD in C1-7 AVB DDD in 1 Austria Belgium Croatia Czech R Denmark France Germany Italy Netherland Poland Slovak R Slovenia Spain Sweden U.K AVB, atrioventricular block; SSS, sick sinus syndrome; Fl/fib, flutter/fibrillation. Table 4 Year 1997: lead data Total no. replaced leads unipolar bipolar act fixation pass fixation unipolar bipolar act fixation pass fixation 1 Austria Belgium Croatia Czech R Denmark France Germany Italy Netherland Norway Poland Slovak R Slovenia Sweden Switzerland U.K Act, active; pass, passive. illustrates the ICD data for the year 1997 and compares the European data with the figures from the U.S.A., Australia, Israel and New Zealand. Discussion The registry demonstrates the restricted use of AAI(R) pacing in Europe. Except for a few countries the ICD implantation rate is low. So, in comparison with the United States, Europeans have only limited access to ICD treatment. When used, there is an absolute preference for single lead transvenous systems and for devices with brady- and antitachy-pacing modes. It is extremely difficult to obtain ICD data from all countries. The differences between countries in the use of unipolar or bipolar leads, and in the use of active or passive fixation demonstrate that these controversies continue. Despite the continuous promotion of bipolar pacing by the manufacturers and despite its preference in the U.S., unipolar ventricular pacing continues to have substantial acceptance in Europe. Contrasts in pacing practice were also reported for the United States and Canada [9]. In 1993, for the U.S.A./ Canada, total pacemaker implantations population was 515/341; pacemaker implantation centres 16 8/4 4; bipolar ventricular leads 84/63; primary ICDs 43 6/6 2; replaced ICDs 17 4/1 3. In the same year, 1993 in the U.S.A., bipolar atrial leads were used in 85 of the

5 EWGCP registry 255 Table 5 Year 1997: ICD data ICD first implants ICD replacements ICD: total number Number of ICD centres ICD total number per million New ICDs 1 Austria Belgium Croatia Czech R Denmark France Germany Greece Italy Netherland Norway Poland Slovak R Slovenia Switzerland U.K cases. Active fixation leads were used in 58 of atrial and in 14 of ventricular implants [10]. The authors emphasize that pacing practices are affected by the availability of medical and technical resources and influenced by economic constraints inherent in healthcare administration and insurance-cover patterns. In the interest of clinical priorities, non-clinical influences should be differentiated clearly from differences in medical thinking [9]. The dilemmas of modern medicine remain. At the IVth International Symposium on Cardiac Pacing in Groningen, 1973, HRH Prince Claus of the Netherlands discussed this matter in his opening address [11]. As in other fields of scientific exploration, we face the dilemma that the more progress we make, the more complex the ethical implications become. As medical science advances, the demand for its services also increases. Consequently, it is most regrettable that the medical skill available is still insufficient to meet the demand, certainly where complicated medical techniques are involved. In the organizational sense the limits are set by the availability of equipment and manpower. A doctor sees his patient in the first place as a person instead of a case, as a human being whom he is trying to help to the best of his ability. The question is not only what doctors and their staff can offer, but also what the people, that is all of us can afford and are willing to afford. These remarks are as pertinent today as they were in The data presented here are the result of tremendous effort by the national contact persons. It is virtually impossible to ensure that figures are error free. We welcome any corrections. References [1] Shaudig A, Rickards AF, Thalen HJTh. Multi-purpose pacemaker registration card. In: Meere C, ed. Cardiac Pacing: State of the art 1979; Proceedings of the VIth World Symposium on Cardiac Pacing. Montreal: 1979: Section [2] Feruglio GA, Steinbach K. Cardiac pacing in Europe after two decades: a comprehensive survey. In: Feruglio G., ed. Cardiac Pacing: proceedings of the 2nd European Symposium on Cardiac Pacing. Padova: Piccin Medical Books 1982: [3] Rickards AF. The European Registration Card. Stimulation June ; [4] Ector H, Feruglio G, Kappenberger L, den Dulk K, Santini M. Cardiac pacing in Europe PACE 1996; 19: 744 (abstract 714). [5] Ector H, Rickards AF, Vardas P, Santini M, Sutton R, Kappenberger L. The Registry of the European Working Group on Cardiac Pacing: PACE 1998; 21: 960 (abstract 682). [6] Ector H, Rickards AF, Kappenberger L, Vardas P, Oto A, Santini M, Sutton R. The Registry of the European Working Group on Cardiac Pacing: PACE 1999; 22: 782 (abstract 329). [7] Parsonnet V. World survey on implantable devices North American experience. XIth World Symposium on Cardiac Pacing and Electrophysiology, Berlin, June 27 30, Personal Communication. [8] Mond H. World survey on implantable devices Asia Pacific experience. XIth World Symposium on Cardiac Pacing and Electrophysiology, Berlin, June 27 30, Personal Communication. [9] Bernstein AD, Goldman BS, Nishimura S, Parsonnet V. Contrasts in cardiac pacing practice in the United States and Canada: clinical and non-clinical influences. PACE 1996; 19: 621 (abstract 223). [10] Bernstein AD, Parsonnet V. Pacing practices in the United States: the 1993 survey. PACE 1996; 19: 576 (abstract 43). [11] HRH Prince Claus of the Netherlands. Opening Address. In: Thalen HJT, ed. Cardiac Pacing: Proceedings of the IVth International Symposium on Cardiac Pacing, Groningen Van Gorcum, Assen, the Netherlands 1973: XII.