Introduction CLINICAL RESEARCH. M.J. Pekka Raatikainen 1 *, David O. Arnar 2, Bela Merkely 3, A. John Camm 4,5, and Gerhard Hindricks 6.

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1 Europace (216) 18, iii1 iii79 doi:1.193/europace/euw244 CLINICAL RESEARCH Access to and clinical use of cardiac implantable electronic devices and interventional electrophysiological procedures in the European Society of Cardiology Countries: 216 Report from the European Heart Rhythm Association M.J. Pekka Raatikainen 1 *, David O. Arnar 2, Bela Merkely 3, A. John Camm 4,5, and Gerhard Hindricks 6 1 Department of Cardiology, Heart and Lung Center Helsinki University Central Hospital, Helsinki and University of Eastern Finland, Meilahti Tower Hospital, PO Box 34, FI-29 HUS, Kuopio, Finland; 2 Division of Cardiology, Department of Medicine, Landspitali The National University Hospital of Iceland, Reykjavik, Iceland; 3 Semmelweis University of Budapest, Heart and Vascular Center, Budapest, Hungary; 4 Division of Cardiovascular Sciences, St George s University of London, London, UK; 5 ICMS, Imperial College, London, UK; and 6 Department of Electrophysiology, Heart Centre, University of Leipzig, Leipzig, Germany Received 6 July 216; accepted after revision 7 July 216 Aims The aim of this analysis was to provide comprehensive information on the access to and use of cardiac implantable electronic device (CIED) and catheter ablation therapy in the European Society of Cardiology (ESC) area.... Methods and The European Heart Rhythm Association (EHRA) has been collecting descriptive and quantitative data on invasive results arrhythmia therapies since 28. This year 5 of the 56 ESC member countries provided data for the EHRA White Book. 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 geographical ESC regions. Our analysis indicated that considerable heterogeneity in the access to arrhythmia therapies still exists across the ESC area. In 215, the CIED implantation rates per million population were highest in the Western followed by the Southern and Northern European countries. The catheter ablation activity was largest in the Western followed by the Northern and Southern areas. Overall, the procedure rates were 3 1 times higher in the European than in the non-european ESC countries. Economic resources were not the only driver for utilization of arrhythmia therapies as in some Eastern European countries with relative low gross domestic product the procedure rates exceeded the average values.... Conclusion These data will help the healthcare professionals and stakeholders to identify and to understand in more depth the trends, disparities, and gaps in cardiac arrhythmia care and thereby promote harmonization of cardiac arrhythmias therapies 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 Introduction The European Heart Rhythm Association (EHRA) White Book is the key source for information on invasive electrophysiological procedure (EP) rates in the European Society of Cardiology (ESC) member countries. European Heart Rhythm Association has collected comprehensive information concerning the rates of invasive electrophysiology procedures alongside information on demographics, economy, vital statistics and healthcare resources, and reimbursements policies together with the National Cardiac Societies * Corresponding author. Tel: ; fax: address: pekka.raatikainen@uta.fi Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 216. For permissions please journals.permissions@oup.com.

2 iii2 M.J.P. Raatikainen et al. What s new? New data on use of cardiac table electronic devices and invasive electrophysiology procedures in Europe is presented in detail. The use of CIED and invasive EP procedures is highest in Western and Nothern Europe. Key areas of growth are in ablation of ventricular arrhythmias in patients with structural heart disease and in the use of left atrial appendage closure devices. For the first time, data are presented on leadless pacemakers and subcutaneous implantable defibrillators. The data will help better understand the disparities in the use of arrhythmia treatments in the ESC area. and Working Groups since This year 5 of the 56 ESC member countries provided data for the EHRA White Book Thesedatahaveformedthebackboneforthe ICDforlife 3 and many other strategic initiatives of the EHRA. Like in the past, 4 7 the objective of this analysis is to provide up-to-date information on the rates of cardiac implantable electronic device (CIED) and catheter ablation procedures in the ESC countries over the past 5 years. In order to allow each country to view its data in a larger context and to facilitate detection of potential crossnational disparities and gaps in the invasive electrophysiology procedure rates, the statistics for the four geographical European ESC regions and for the non-european ESC countries are presented separately (Figure 1). In addition, we have provided descriptive and quantitative information on the demographics and economic aspects as well as on training of electrophysiologist in the constituent ESC countries. The ability to see its own numbers in a European context provides each country robust means to demonstrate shortfalls in resource allocation, reimbursement, and training requirements to the national or local authorities. It is our hope that these data will help to design national and international strategic initiatives and awareness activities to acquire more resources for cardiac arrhythmia management and eventually to champion EHRA s mission To improve the quality of life of the population by reducing the impact of cardiac rhythm disturbances and reduce sudden cardiac death. Demographics and general societal and economic aspects In this section, we have provided an overview of the demographic and financial profiles of the 56 ESC countries. The ESC countries are a heterogeneous group of nations with varying political, financial, and demographic characteristics. Distribution of the population within these regions over the last 5 years is shown in Table 1. Vital statistics and gross domestic product Population and vital statistics and gross domestic product (GDP) in the 56 ESC countries are presented in Table 2. Total GDP ranged from 1.54 (San Marino) to 3371 (Germany) billion US dollars (USD). The GDP per capita was almost 1 times higher in Luxembourg ( USD) than in Kyrgyzstan (1198 USD). Medium- to high-quality data on cause of death are available in most ESC countries, although they are lacking in many other parts of the world. World Health Organisation (WHO) health statistics ESC regions Northern Europe Western Europe Southern Europe Eastern 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 (

3 Current trends in the use of arrhythmia procedures iii3 Table 1 Populations in the five geographical ESC regions in 15 Region Country ISO code... Northern Europe Denmark DK Estonia EE Finland FI Iceland IS Ireland IE Latvia LV Lithuania LT Norway NO Sweden SE UK GB Northern Europe total Western Europe Austria AT Belgium BE France FR Germany DE Luxembourg LU The Netherlands NL Switzerland CH Western Europe total Eastern Europe Belarus BY Bulgaria BG Czech Republic CZ Hungary HU Moldova MD Poland PL Romania RO Russian Federation RU Slovakia SK Ukraine UA Eastern Europe total Southern Europe Albania AL Bosnia and BA Herzegovina Croatia HR Greece GR Italy IT Kosovo XK FYR Macedonia MK Malta MT Montenegro ME Portugal PT San Marino SM Serbia RS Slovenia SI Spain ES Southern Europe total Non-European ESC countries Algeria DZ Armenia AM Azerbaijan AZ Cyprus CY Egypt EG Georgia GE Continued

4 iii4 M.J.P. Raatikainen et al. Table 1 Continued Region Country ISO code... Israel IL Kazakhstan KZ Kyrgyzstan KGZ Lebanon LB Libya LY Morocco MA Syria SY Tunisia TN Turkey TR Non-European ESC countries total Total ESC countries reveal several important differences in the vital statistics between the ESC countries. 8,9 As an example, the life expectancy at birth varied from 7.4 years (Kyrgyzstan and Moldova) to 83.2 years (San Marino). The death rate per 1 population was lowest in Turkey (4.7%) and highest in Bulgaria (14.96%). It is noteworthy that in most countries with life expectancy over 8 years, the GDP per capita is also relatively high (Table 2). Healthcare systems The organization of healthcare across the ESC member countries varies markedly. Many countries provide national healthcare services with full coverage to the whole population, while in others healthcare services are primarily delivered by commercial health insurance companies (Table 3).The proportion of people with no health insurance was highest in the Eastern European and non-european ESC countries. In the Northern, Southern, and Western European ESC countries, patients do not need to provide any co-payment for invasive electrophysiology procedures, whereas in many Eastern European (e.g. Armenia, Bulgaria, and Georgia) and non-european ESC countries (e.g. Egypt and Morocco) a copayment is necessary (Table 3). The numbers of hospitals and hospital beds available for healthcare are shown in Figure 2. The numbers of hospitals and beds were not directly related to the financial profile of the countries or to healthcare expenditure. Rather, these data indicate that some countries have directed more resources towards hospital care than ambulatory and home care. For example, the number of beds per 1 inhabitants was 828 in Germany and only 259 in Sweden, despite the relatively high GDP and healthcare expenditure in both countries. Healthcare expenditure Healthcare expenditure has been escalating rapidly and nowadays represents the biggest government-spending item in many countries. In Figure 3, the healthcare expenditure is presented as percentage of the national GDP and in Figure 4 as expenditure per capita. The mean healthcare expenditure in the ESC area as percentage of 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 (928 USD) and lowest in Kyrgyzstan (85 USD). Hence, there was more than 1-fold difference between the lowest and highest healthcare expenditures per capita in the ESC area. 8,9 Given the trend towards a progressive aging of populations and unhealthy living style, there is pressure to increase the healthcare expenditure. Despite this, the mean healthcare expenditure per capita in the ESC area was slightly lower in 213 (2733 USD) than in (2818 USD). Certification of professional excellence General information In 215, 47 countries (94% of the countries that responded to the EHRA White Book survey) provided data on certification of physicians and allied professionals in device therapy and invasive electrophysiology for the EHRA White Book National certification programme for CIED therapy and invasive cardiac EPs for physicians was available in 23 (46%) and 22 (44%) of these countries, respectively. A certification programme was an obligatory practice requirement 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 17 countries and was required for practice in 11 countries (Figure 7). Training centres were accredited in only 17 (34%) countries, and certification of training centres was mandatory in order to train fellows in 13 countries (Figure 8). Several centres in various regions were available as training centres for the EHRA Training Fellowship Program and allowed many young physicians from emerging economies to be trained in high-volume centres abroad. European Heart Rhythm Association certification The EHRA certification programme is the first European certification of professional excellence in the field of CIED therapies and

5 Current trends in the use of arrhythmia procedures iii5 Table 2 Population, vital statistics, and GDP in the 56 ESC countries Country Population Population growth rate (%) Life expectancy at birth (years) Death rate per 1 population GDP (31 billion USD) GDP per capita (USD) Total health expenditure as % of GDP... Albania a Algeria N/A N/A Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Egypt N/A N/A N/A N/A Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kosovo N/A 6.31 N/A N/A Kyrgyzstan Latvia Lebanon a N/A N/A Libya a N/A N/A Lithuania Luxembourg FYR Macedonia Malta Moldova a Montenegro Morocco N/A Netherlands Norway Poland Portugal Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Syria a N/A N/A N/A N/A Tunisia a N/A N/A Turkey Ukraine UK a These six countries did not submit data for the EHRA White Book 216.

6 iii6 M.J.P. Raatikainen et al. Table 3 Healthcare service and insurance systems in the 56 ESC countries Country Basic insurance availability Uninsured citizens (% of population) Distribution of insurance modality (%) Possibility to subscribe to private health insurance plans Co-payment necessary for therapies Public insurance Private insurance Private co-payment ICD PM Ablation... Albania a Algeria Yes 3 1 Yes No Yes No Armenia No 67 1 Yes Yes Yes Yes Austria Yes 2 99 Yes No No No Azerbaijan Yes Yes Yes No Yes Belarus Yes 1 N/A N/A Yes No No No Belgium Yes Yes No No Yes Bosnia and Herzegovina No N/A 25 No Yes Yes N/A Bulgaria Yes Yes Yes No Yes Croatia Yes Yes No No No Cyprus No Yes No No No Czech Republic Yes No No No No Denmark Yes 1 Yes No No No Egypt No Yes Yes Yes Yes Estonia Yes N/A N/A N/A N/A N/A No No No Finland Yes Yes No No No France Yes 1 N/A N/A Yes No No No Georgia Yes N/A N/A N/A N/A Yes Yes Yes Yes Germany Yes N/A Yes No No No Greece Yes Yes N/A N/A N/A Hungary Yes Yes No No No Iceland Yes 1 No No No No Ireland Yes Yes No No No Israel Yes 1 Yes No No No Italy Yes 1 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 N/A Yes Yes Yes No Lebanon a Libya a Lithuania Yes 98 2 Yes No No No Luxembourg Yes 1 N/A N/A Yes No No No FYR Macedonia No N/A Yes No No No Malta Yes N/A N/A N/A Yes No No No Moldova a Montenegro Yes 1 99 N/A 1 No No No No Morocco No Yes Yes Yes Yes The Netherlands Yes 1 Yes No No No Norway Yes 99 1 Yes No No No Poland Yes N/A 9 1 Yes No No No Portugal Yes 1 Yes No No No Romania Yes N/A 1 No Yes Yes Yes Russian Federation Yes N/A Yes No Yes No San Marino Yes 1 Yes No No No Serbia Yes 1 Yes No No No Slovakia Yes No No No No Slovenia Yes N/A No No No Spain Yes 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 1 Yes No No No Syria a Tunisia a Turkey Yes N/A Yes No No No Ukraine No N/A N/A N/A N/A Yes No No No UK No Yes No No No a These six countries did not submit data for the EHRA White Book 216.

7 Current trends in the use of arrhythmia procedures iii7 Hospitals Beds Georgia Sweden Turkey Ireland Albania Spain Israel Iceland Portugal Cyprus Italy San Marino Bosnia & Herzegovina Montenegro Armenia Macedonia, FYR Kyrgyzstan Slovenia Netherlands Malta Switzerland Azerbaijan Greece Finland Luxembourg Estonia Serbia Latvia Slovakia Moldova Croatia Belgium Romania Czech Republic France Poland Kazakhstan Bulgaria Hungary Lithuania Austria Russian Federation Germany Ukraine Belarus Figure 2 Hospitals and hospital beds per 1 inhabitants in the ESC countries. Netherlands Moldova France Switzerland Germany Belgium Austria Denmark Serbia Greece Portugal Sweden Bosnia & Herzegovina Norway Georgia Finland Slovenia United Kingdom Italy Iceland Ireland Spain Malta Slovakia Hungary Ukraine Bulgaria Cyprus Croatia Czech Republic Israel Luxembourg Kyrgyzstan Poland Russian Federation Montenegro San Marino FYR Macedonia Lithuania Belarus Albania Estonia Latvia Turkey Azerbaijan Romania Armenia Kazakhstan 7,8 8,18,2 7,4 7,6 7,2 7,3 7,2 6,7 7,1 6,7 6,6 6,5 6,5 6,1 6,26,4 5,7 5,9 5,7 5,6 5,6 5,3 4,3 4,5 9,8 9,6 9,7 9,7 9,4 9,6 9,4 9,2 9,1 9,1 8,7 8,9 8,9 9,1 11,8 11,5 11,7 11,3 11,2 11, 1,6 1,6 12,9 Mean healthcare expenditure as % of GDP = Ø8,3 Figure 3 Healthcare expenditure as percentage of national GDP in the ESC countries in 213. The mean healthcare expenditure as % of GDP is weighted by population.

8 iii8 M.J.P. Raatikainen et al. Norway Switzerland Luxembourg Denmark Netherlands Sweden Austria Belgium France Germany Finland Ireland Iceland United Kingdom Italy Spain Israel Greece Slovenia Portugal Malta Cyprus Slovakia Czech Republic Hungary Estonia Lithuania Croatia Poland Latvia Serbia Turkey Bulgaria Kazakhstan Montenegro Bosnia & Herzegovina Romania Azerbaijan Belarus Georgia FYR Macedonia Ukraine Moldova Albania Armenia Kyrgyzstan Mean healthcare expenditures as % of GDP = USD Figure 4 Healthcare expenditure per capita in the ESC countries in 213. The mean number of expenditure is weighted by population. Mean healthcare expenditures as % of GDP ¼ 2733 USD. Yes, it s required for practice = 11 countries Yes, but it s not required for practice = 12 countries No = 24 countries No answer = 3 countries Figure 5 Certification for CIED therapy in the ESC countries in 215.

9 Current trends in the use of arrhythmia procedures iii9 Yes, it s required for practice = 11 countries Yes, but it s not required for practice = 6 countries No= 3 countries Noanswer= 3 countries Figure 6 Certification for invasive electrophysiology in the ESC countries in 215. Yes, it s required for practice = 11 countries Yes, but it s not required for practice = 6 countries No = 3 countries No answer = 3 countries Figure 7 Certification for allied professionals in the ESC countries in 215.

10 iii1 M.J.P. Raatikainen et al. Yes, it s required for practice = 13 countries Yes, but it s not required for practice = 4 countries No= 29 countries No answer = 4 countries Figure 8 Certification for training centres in the ESC countries in 215. A Invasive cardiac electrophysiology B CIED therapy C Allied professionals 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. invasive electrophysiology. It plays an important role with regard to EHRA s goal to promote unified and clear standards for the training of cardiac rhythm management specialists and to assure high quality in arrhythmia care across the ESC area. During the last 5 years, 1276 physicians (767 in CIED and 59 in EP) from 58 countries have participated in the EHRA examination. Over the years, most of them have submitted the case logbook within the required time and subsequently achieved full (Level 2) certification. In 215, 294 physicians participated in the EHRA certification examination. The majority of them were male (78% in the invasive electrophysiology examination and 73% in the CIED programme). Over the years, the proportion of female candidates has increased from,1 to 25% (Figure 9). Last year, the highest numbers of candidates participating in the CIED examination were from the Netherlands (31 candidates), Switzerland (23), and Italy (23). In the invasive electrophysiology examination, the highest numbers of participants were from Italy (13), Spain (12), and the Netherlands (12).

11 Table 4 Pacemaker implantation facilities and implantation rates in 215 in comparison with 4 previous years Country ISO National registry Number of PM PM implantations 215 Development potential target PM implantations per mil code for PM implants implanting centres number of PM implantations... inhabitants... Absolute Per mil Absolute Per mil To attain mean To attain mean number inhabitants number inhabitants ESC area level EU28 level... Albania a 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 N/A N/A Armenia AM No Austria AT Yes Azerbaijan AZ No N/A Belarus BY No Belgium BE Yes N/A Bosnia and Herzegovina BA No Bulgaria BG Yes Croatia HR No Cyprus CY No Czech Republic CZ Yes Denmark DK Yes Egypt EG No N/A Estonia EE No Finland FI No France FR No Georgia GE No Germany DE Yes Greece GR Yes Hungary HU Yes Iceland IS No Ireland IE Yes N/A 465 Israel IL No Italy IT Yes Kazakhstan KZ No N/A Kosovo XK No N/A N/A N/A Kyrgyzstan KGZ N/A N/A N/A N/A Latvia LV Yes Lebanon a LB N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Libya a 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 Luxembourg LU No Continued Current trends in the use of arrhythmia procedures iii11

12 iii12 Table 4 Continued Country ISO National registry Number of PM PM implantations 215 Development potential target PM implantations per mil code for PM implants implanting centres number of PM implantations... inhabitants... Absolute Per mil Absolute Per mil To attain mean To attain mean number inhabitants number inhabitants ESC area level EU28 level... FYR Macedonia MK No Malta MT No Moldova a 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 Morocco MA Yes The Netherlands NL Yes Norway NO Yes Poland PL No Portugal PT Yes Romania RO No Russian Federation RU Yes San Marino SM Yes N/A 333 Serbia RS Yes Slovakia SK Yes Slovenia SI Yes Spain ES Yes Sweden a SE N/A 44 4 N/A N/A N/A N/A N/A N/A Switzerland CH Yes Syria a 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 Tunisia a TN N/A N/A N/A N/A N/A N/A N/A N/A 21 N/A Turkey TR No N/A N/A N/A N/A N/A Ukraine UA No UK GB Yes Total ESC countries a These seven countries did not submit any data on PM implantations for the EHRA White Book 216. M.J.P. Raatikainen et al.

13 Table 5 Specialty of physicians performing device implantations and LEs Country ISO Specialist performing PM Specialist performing ICD Specialist performing CRT Specialist performing loop Specialist performing LEs (%) code implantations (%) implantations (%) implantations (%) recorder implantations (%) Cardiologists Surgeons Other Cardiologists Surgeons Other Cardiologists Surgeons Other Cardiologists Surgeons Other Cardiologists Surgeons Other... Albania a 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 Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium BE N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Bosnia and BA N/A N/A N/A Herzegovina Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE N/A N/A N/A Finland FI France FR Georgia GE N/A N/A N/A Germany DE Greece GR Hungary HU Iceland IS Ireland IE Israel IL Italy IT Kazakhstan KZ N/A N/A N/A N/A N/A N/A N/A N/A 1 1 Kosovo XK 1 1 N/A N/A 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 Lebanon a 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 Libya a 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 Luxembourg LU FYR Macedonia MK Malta MT Continued Current trends in the use of arrhythmia procedures iii13

14 iii14 Table 5 Continued Country ISO Specialist performing PM Specialist performing ICD Specialist performing CRT Specialist performing loop Specialist performing LEs (%) code implantations (%) implantations (%) implantations (%) recorder implantations (%) Cardiologists Surgeons Other Cardiologists Surgeons Other Cardiologists Surgeons Other Cardiologists Surgeons Other Cardiologists Surgeons Other... Moldova a 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 Morocco MA 99 1 N/A N/A N/A The Netherlands NL Norway NO Poland PL Portugal PT N/A N/A N/A Romania RO Russian Federation RU N/A N/A N/A N/A N/A N/A San Marino SM Serbia RS Slovakia SK Slovenia SI 2 8 N/A N/A N/A Spain ES Sweden SE N/A N/A N/A N/A N/A N/A N/A N/A N/A Switzerland CH Syria a 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 Tunisia a 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 Ukraine UA UK GB a These six countries did not submit data for the EHRA White Book 216. M.J.P. Raatikainen et al.

15 Current trends in the use of arrhythmia procedures iii15 Germany Luxembourg Belgium Switzerland Italy France Austria Iceland Greece Netherlands Spain Slovenia Sweden Norway Cyprus Estonia Croatia Poland Portugal Finland Czech Republic Ireland United Kingdom Georgia Denmark Bulgaria Slovakia Israel Malta Serbia Hungary Lithuania Kosovo Bosnia & Herzegovina Montenegro Latvia FYR Macedonia Kazakhstan Romania Belarus Russian Federation Ukraine Azerbaijan Armenia Algeria Egypt Kyrgyzstan Morocco,4,5,7,4,3 2,7 3,3,3 2,5 2,6 2,6 2,4 2,4 1,6 1,7 1,8 1,6 1,1 1,4 1,4 1,5 1,5,9 1, 1,1,8 3,7 3,8 3,8 4,4,24,4 3,7 3,5 3,5 5,2 4,5 4,85, 4,5 6, 6,6 6,87, 8,7 9,2 1,5 14, Mean number of PM implanting centres = Ø 3,85 Figure 1 Number of PM implanting centres per million inhabitants in the ESC countries in 215. The mean number of implantation centres is weighted by population. Median number PM implantations = 623 Germany Belgium Finland Italy Malta France Iceland Austria Lithuania Denmark Estonia Czech Republic Greece Portugal Norway Poland Switzerland United Kingdom Latvia Spain Luxembourg Slovakia Hungary Croatia Slovenia Netherlands Bulgaria Israel Serbia Ireland Montenegro San Marino Belarus Russian Federation Cyprus FYR Macedonia Bosnia & Herzegovina Romania Georgia Turkey Ukraine Kazakhstan Algeria Kosovo Morocco Azerbaijan Egypt Armenia Kyrgyzstan = Ø PM implantations per million inhabitants (weighted by population) th quartile > rd quartile > nd quartile > st quartile Mean number of PM implantations = Ø 518 Figure 11 Pacemaker implantations per million inhabitants in the ESC countries in 215. The mean number of implantations is weighted by population.

16 iii16 M.J.P. Raatikainen et al. 518 = Ø PM implantations per million inhabitants (weighted by population) 4 th quartile > rd quartile > nd quartile > st quartile Not available Figure 12 Pacemaker implantations per million inhabitants in the ESC countries in 215. The mean number of implantations is weighted by population. Northern Europe Western Europe European ESC countries EU Southern Europe Eastern Europe Non-European ESC countries ESC Figure 13 Pacemaker implantations per million inhabitants 15 in the five geographical regions of the ESC and comparison with the total ESC area and the 28 member countries of the European Union (EU28).

17 Current trends in the use of arrhythmia procedures iii17 Northern Europe TOP 3 Finland Iceland Lithuania * Lowest 3 United Kingdom Latvia Ireland * Figure 14 Pacemaker implantations per million inhabitants 15 in Northern Europe. *No data available. Western Europe TOP Germany Belgium France * Lowest 3 Switzerland Luxembourg Netherlands Figure 15 Pacemaker implantations per million inhabitants 15 in Western Europe. *No data available.

18 iii18 M.J.P. Raatikainen et al. Eastern Europe TOP 3 Czech Republic Poland Slovakia Lowest 3 Russian Federation Romania Ukraine Figure 16 Pacemaker implantations per million inhabitants 15 in Eastern Europe. Southern Europe TOP 3 Italy Malta Greece Lowest 3 San Marino 89 FYR Macedonia Bosnia and Herzegovina * Figure 17 Pacemaker implantations per million inhabitants 15 in Southern Europe. *No data available.

19 Current trends in the use of arrhythmia procedures iii19 Non-European ESC countries TOP 3 Israel Cyprus Georgia Lowest 3 Azerbaijan Egypt Armenia 15 * * Figure 18 Pacemaker implantations per million inhabitants 15 in the non-esc countries. *No data available. In 215, the pass rate was 67% for physicians participating in the invasive electrophysiology examination and 62% for those participating in CIED examination. These numbers are markedly higher than in 214 when the pass rate in the EP examination was 49% and in the CIED examination 51%. The EHRA certification programme in cardiac device therapy for allied professionals was launched in. Since then, 215 allied professionals from 14 countries have participated in the EHRA examination, and many of them have achieved full certification. Last year, the pass rate in the allied professional exam was 67%, which was lower than in 214 (74%). Last year, most participants were from Italy (41). For allied professionals, the examination is currently available in six languages (English, Spanish, French, German, Italian, and Greek). Pacemakers General information The 5 countries (89% of all ESC member countries) that submitted the requested data on pacemaker (PM) implantation for this year s edition of the EHRA White Book are listed in Table 4.Albania, Lebanon, Libya, Moldova, Syria, and Tunisia did not provide any PM data this year. A national registry for PM implantations was 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 physicians with various training backgrounds, including surgeons, anaesthesiologists, paediatricians, and internists. In three countries (Belarus, Slovenia, and Ukraine), the proportion of implanting cardiologists was,5% (Table 5). Pacemaker facilities and procedure rate It was reported that in 366 centres, a total of PMs were implanted in 215 (Table 4), slightly up from the last year. The mean number of centres implanting PMs per million inhabitants was 3.85, slightly higher than the preceding year (Figure 1). The country with the highest density of implanting facilities, excluding San Marino, was Germany (14. per million inhabitants) followed by Luxembourg (1.5) and Belgium (9.2). Those with the lowest density were Egypt and Kyrgyzstan both with.4 per million and Morocco with.3 implanting centres per million inhabitants. In 215, the mean PM implantation rate in the participating ESC countries was 518 PM units per million inhabitants. The implantation rate was highest in Germany (132), followed by Belgium (1154) and Finland (163). The two countries with the lowest PM implantation rate were Armenia (38) and Kyrgyzstan (22). An overview of the PM implantation rate per million inhabitants for each country is shown in Figures 11 and 12. Across the 5 countries, heterogeneity was observed in the distribution of PM implantation rate per million inhabitants, as has been seen in the White Book PM data from previous years. The number of PM implantations according to the five ESC regions and the trend in implantation rate in comparison with the 28 European Union member countries (EU28) and the whole ESC area from to 215 are shown in Figure 13. Countries with the highest and lowest activities in each region as well as yearly trends are shown in Figures The number of PM implantations per million inhabitants was highest in Western Europe and lowest in Eastern Europe and in the non-european ESC countries. The most active countries in each region were Germany (132 per

20 iii2 M.J.P. Raatikainen et al. Table 6 Changes in the number of PM implantation centres in year 214 vs. 215 Country ISO Number of PM implanting centres 214 Number of PM implanting centres 215 Change % code Absolute Per million Absolute Per million number inhabitants number inhabitants... Albania a AL N/A N/A N/A Algeria DZ Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium BE Bosnia and BA Herzegovina Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE Finland FI France FR Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE Israel IL Italy IT Kazakhstan KZ Kosovo XK Kyrgyzstan KGZ Latvia LV Lebanon a LB N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia MK Malta MT Moldova a MD N/A N/A N/A N/A N/A Montenegro ME Morocco MA The Netherlands NL Norway NO Poland PL Portugal PT Romania RO Russian Federation RU San Marino SM N/A N/A N/A Serbia RS Slovakia SK Slovenia SI Spain ES Continued

21 Current trends in the use of arrhythmia procedures iii21 Table 6 Continued Country ISO Number of PM implanting centres 214 Number of PM implanting centres 215 Change % code Absolute Per million Absolute Per million number inhabitants number inhabitants... Sweden SE Switzerland CH Syria a SY N/A N/A N/A N/A N/A Tunisia a TN N/A N/A N/A Turkey TR N/A N/A N/A N/A N/A Ukraine UA UK GB Total ESC countries a These six countries did not submit data for the EHRA White Book vs. 214 in % 215 Georgia Lithuania Kosovo Denmark Slovenia Bosnia & Herzegovina L Kazakhstan Germany uxembourg Slovakia Latvia Bulgaria Ukraine Portugal Netherlands United Kingdom Belarus Morocco Serbia Montenegro Romania Hungary Italy Russian Federation Greece France Czech Republic FYR Macedonia Malta Estonia Spain Kyrgyzstan Norway Ireland Cyprus Egypt Algeria Israel Sweden Finland Poland Iceland Austria Croatia Switzerland Belgium Azerbaijan Armenia,8 2,5 3,6 4,9,3 1, 3,2,4 1,,4,5 1,1 1,8 1,1 2, 1,3 1,2 1,4 2,4 2,4 1,1 1,5 1,8 3,5 1,4 2,4 4, 4,8 1, 1, 2,6 3,5 3,5 4,5 4,3 3,8 4,6 3,9 4, 5,2 7, 6,8 6,3 6,9 9,6 9,4 1, 2,1 28,936,1 12,1 9,6 12,3 16, 9,2 9, 5,2 7,7 2,5 2, 1,4 1,2,5,5,5,3,2,2,,, -,2 -,2 -,6 -,3 -,8-1,1-1,2-1,2-1,4-1,8-1,8-2,8-3, -3,8-3,9-4,4-5,1-5,4-7,3-7,7-2,8-33,2 51,9 66,8 49,1,4,5,8,7 1,7 3, 1,6 2,7 1,6 1,4 1,5 2,6 1,5,9 2,6 3,7 5,,3 1,1 3,3 2,4 1,1 1,5 1,8 7, 1, 5,2 6,8 3,5 1,4 2,4 4, 4,8,4 2,5 3,5 4,4 4,2 3,7 4,5 3,8 3,8 4,5 6, 6,6 8,7 9,2 14, Figure 19 Change in the number of PM implanting centres per million inhabitants from 214 to 215. million inhabitants), Finland (163), Italy (155), Czech Republic (843), and Israel (528). The change in the number of implanting centres from 214 to 215 is shown in Table 6 and Figure 19, and the change in the number of PM implantations per million inhabitants during the same period is presented in Table 7 and Figure 2. The increase in the number of PM implantations was highest in those countries with rather small implantation numbers, Azerbaijan, Montenegro, and Georgia, but interestingly there was an almost 15% increase in PM implantation rates in Germany, the country with the highest implant rates in Europe. On the other hand, there was an almost 1% drop in the number of devices implanted in neighbouring Austria. The changes in the de novo PM implantation rate are shown separately in Figure 21 and for PM generator replacements in Figure 22. The relationship between

22 iii22 M.J.P. Raatikainen et al. Table 7 Changes in PM implantations in year 214 vs. 215 Country ISO Number of PM implantations 214 Number of PM implantations 215 Change % code Absolute Per million Absolute Per million number inhabitants number inhabitants... Albania a AL N/A N/A N/A Algeria DZ Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium BE Bosnia and BA Herzegovina Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE Finland FI France FR Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE N/A N/A N/A Israel IL Italy IT Kazakhstan KZ Kosovo XK Kyrgyzstan KGZ Latvia LV Lebanon a LB N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia MK Malta MT Moldova a MD N/A N/A N/A N/A N/A Montenegro ME Morocco MA The Netherlands NL Norway NO Poland PL Portugal PT Romania RO Russian Federation RU San Marino SM N/A N/A N/A Serbia RS Slovakia SK Slovenia SI Continued

23 Current trends in the use of arrhythmia procedures iii23 Table 7 Continued Country ISO Number of PM implantations 214 Number of PM implantations 215 Change % code Absolute Per million Absolute Per million number inhabitants number inhabitants... Spain ES Sweden SE N/A N/A N/A Switzerland CH Syria a SY N/A N/A N/A N/A N/A Tunisia a TN N/A N/A N/A Turkey TR Ukraine UA UK GB Total ESC countries a These six countries did not submit data for the EHRA White Book Azerbaijan 19, Montenegro 28, Georgia 123,2 FYR Macedonia 17,2 Turkey 89,4 Morocco 43,8 Latvia 57,9 Germany 64,6 Lithuania Algeria 1.152, 1 789,3 Slovakia 65,5 Cyprus 213,2 Greece 742,4 Croatia 581,8 Malta 886,9 Belarus 39,1 Poland 38,2 Norway Egypt 742, 4 755,1 Bosnia & Herzegovina 214,6 Luxembourg 67,3 Italy 1.28,6 Estonia 837,9 Serbia 57,2 Bulgaria 538,1 United Kingdom 78, Finland 1.5, D Hungary enmark 7 866, -,3 Portugal 816,5 -,8 Kyrgyzstan 22,5-1,1 Iceland 939, -1,2 Israel Netherlands 537, 6,3-1,7-1,7 Switzerland 811,6-2,9 Kosovo France 68,3 1.11,2-4,5-4,6 Czech Republic Belgium 888, ,7-5,2-6,6 Romania 196, -7,7 Ukraine 118,7-8, Russian Federation 265,5-8,8 Spain 76,9-8,9 Armenia 42,1-9,2 Austria 1.6, Slovenia 736,3 Kazakhstan 131,2-24,4-15,4-9,3 215 vs. 214 in % 34,5 23,5 29,5 31,8 14,5 23,4 14,1 13,5 11,7 1,4 1, 5,1 6,5 7,3 8,9 9,9 4,8 2,9 2,8 2,5 2,3 2,3 2,2 1,6 1,2,8 112,6 36, ,4 381,7 165,7 115,8 224,2 54, 73,7 4,1 22,2 65,2 18,8 19,2 242,2 38,3 99,2 235,5 22,8 331,5 74,7 676,5 895,5 816,7 639,4 966,3 689,2 1.54,6 857,4 518,9 55, 719,5 649,9 863,2 81, 927,9 528, 59, 788,1 693,2 79,8 791,3 842,6 964, ,5 622,7 912,2 1.62, ,7 Figure 2 Change in the number of PM implantations per million inhabitants from 214 to 215. the mean annual PM implantation rate per million inhabitants and the number of PM implanting centres per million inhabitants in the 56 ESC countries and in the EU28 is shown in Figure 23. Leadless pacing Leadless pacing is a new therapeutic modality 1,11 which has just been introduced in most ESC countries. This is the first time that data on leadless PM implantations have been collected for the EHRA White Book. According to the EHRA White Book survey, a total of 244 leadless PMs were implanted in 9 countries in 215. No leadless PMs were implanted in 23 countries, and data on these devices were not available from 24 ESC countries. The most active countries in the ESC area with regard to leadless PM implantations were France, the Netherlands, and Hungary, but the implantation rates were rather low also in these early adopters (Figure 24).

24 iii24 M.J.P. Raatikainen et al vs. 214 in % 215 Montenegro 23,8 FYR Macedonia 141,5 Latvia 472,5 Lithuania Algeria 5,4 698, Croatia 487,6 Malta Turkey 76, 581,6 Greece 547,5 Belarus Slovakia 251,6 479,5 Poland 518,3 Germany United Kingdom 531,7 933,1 Norway Armenia 33, 58,6 Serbia 35, Estonia Egypt 434,8 725, Denmark 656,1 Finland 87,2 Netherlands 442,4 Bulgaria Hungary 451,7 492, Portugal 644,2 -,2 Switzerland 618,1-1,5 Iceland 89,8-2,2 Czech Republic 622,4-3,7 Luxembourg 512,8-3,9 64,5 97,1 B Ukraine Kosovo -3,9-4,7 elgium 855,1-6,1 Sweden 7,3 Austria 722,8-8,8 Spain 57,7-8,9 Slovenia 586,9-12,8 Russian Federation 226, -79,7 31,9 3,5 11, 15,5 16,7 23,6 1,5 1,2 8,2 9,1 1, 7,8 7,5 6,7 4,1 5,4 6,1 6,4 4, 1,4 3,6 3,8,7,5 58,2 83,7 35, 36,4 62, 92,5 45,8 184,6 34,4 274,5 458,3 583,9 541,1 642,6 62,3 518,8 558,6 567,2 617,7 814,7 753,9 681,2 835,9 448,4 454,9 494,4 642,8 69,1 792,4 599,1 492,8 83,1 519,9 659, 651,1 511,7 1.2,9 Figure 21 Change in the number of new PM implantations per million inhabitants from 214 to Turkey Montenegro 13,5 49,2 Germany FYR Macedonia 28,7 219, Slovakia 126, Luxembourg 157,5 Latvia 98,4 Egypt 3,2 Greece Algeria 14,2 Malta 35,3 Iceland Croatia 94,2 Poland 224,2 Hungary 152,5 Belarus 57,6 174,4 Bulgaria Portugal 86,4 172,4 Finland 243,5 Switzerland Belgium 193,5 38,6 Estonia 112,9 Czech Republic 266, 6 A Spain ustria 283,1 Lithuania 91,3 Netherlands 157,9 Denmark 29,9 United Kingdom 176,3 3,8 18,9 72,4 21,7 Slovenia Armenia 9,1 149,4 Kosovo Serbia Bosnia & Herzegovina Ukraine -64,2 215 vs. 214 in % 44,6 25,2 38, 15,7 22,8 24,7 6, 9, 1, 4,9 4,4 3,5 -,9 -,5 1,9-2,5-3,8-6,8-7,5-7,7-8,3-8,7-8,9-1,6-11,5-12,2-13,5-13,7-14,8-16,3-16,3-23, -25,7 11,2 57, 215 3,7 15,5 3,2 15,8 6,6 16,7 3,3 28,3 77,3 39,6 57,1 84,2 8,8 157,7 196,4 12,8 98,3 135,6 13,5 138,7 152,2 181,5 11,9 155,5 173,6 165,8 179, 227, 173,3 214,4 232,1 243,5 253,2 316,7 323,7 351,4 Figure 22 Change in the number of PM replacements per million inhabitants from 214 to 215. Implantable cardioverter-defibrillators General information The 5 countries (89%) that submitted data for the EHRA White Book on implantable cardioverter-defibrillators (ICDs) in 215 are listed in Table 8. Albania, Lebanon, Libya, Moldova, Syria, and Tunisia did not provide data on ICD implantations, while Sweden provided only limited data. In 25 countries, a national registry for ICD implantations was in use. The vast majority of implants were performed by cardiologists, and the remaining implantations were performed by physicians having various other training backgrounds, mainly surgical. However, in some countries (Austria, Belarus, and

25 Current trends in the use of arrhythmia procedures iii PM implantations per million inhabitants EG DZ RU BY RO MK 1 UA KZ MA XK KGZ AM AZ LV ME BA LT HU RS MT IL SK DK BG DE BE FI IT EE PT CZ FR IS AT GR GB NO CH HR ES LU NL PL SI IE SM CY GE PM implanting centresper million inhabitants ESC 56 EU28 Figure 23 Pacemaker implantation centres and rates in the ESC and European Union (EU28) member countries in 215. Bubble size is related to population in the country. The ISO codes of the countries are explained in Table 1. France Netherlands Hungary Portugal Israel Serbia Norway Sweden Denmark Algeria Armenia Azerbaijan Belgium Bosnia & Herzegovina Bulgaria Cyprus Estonia Greece Iceland Kyrgyzstan Latvia Lithuania Malta Montenegro Morocco Romania San Marino Slovakia Slovenia Turkey Ukraine United Kingdom Figure 24 Number of leadless PM implantations in 215.

26 Table 8 Implantable cardioverter-defibrillator implantation facilities and rates in 215 and comparison with 4 previous years Country ISO National registry Number of ICD ICD implantations 215 Development potential target ICD implantations per mil code for ICD implants implanting centres number of ICD implantations... inhabitants... Absolute Per million Absolute Per million To attain mean To attain mean number inhabitants number inhabitants ESC area level EU28 level... Albania a 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 N/A N/A Armenia AM No N/A Austria AT Yes Azerbaijan AZ No N/A Belarus BY No Belgium BE Yes Bosnia and Herzegovina BA No Bulgaria BG Yes Croatia HR No Cyprus CY No Czech Republic CZ Yes Denmark DK Yes Egypt EG No N/A Estonia EE No Finland FI No France FR No N/A Georgia GE No Germany DE No Greece GR Yes Hungary HU Yes Iceland IS No Ireland IE Yes N/A 151 Israel IL Yes Italy IT Yes Kazakhstan KZ No N/A Kosovo XK No N/A N/A N/A 2 6 Kyrgyzstan KGZ N/A 2.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A Latvia LV Yes Lebanon a LB N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Libya a 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 Luxembourg LU Yes FYR Macedonia MK No Malta MT No iii26 M.J.P. Raatikainen et al.

27 Moldova a MD N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Montenegro ME No Morocco MA N/A The Netherlands NL Yes Norway NO Yes Poland PL No Portugal PT Yes N/A N/A 113 Romania RO No Russian Federation RU Yes San Marino SM Yes N/A 242 Serbia RS Yes Slovakia SK Yes Slovenia SI Yes Spain ES Yes Sweden SE N/A N/A N/A N/A N/A N/A N/A Switzerland CH Yes Syria a 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 Tunisia a TN N/A N/A N/A N/A N/A N/A N/A 8 9 N/A 13 N/A Turkey a TR No N/A N/A N/A N/A N/A 77 8 Ukraine UA No UK GB Yes Total ESC countries a These six countries did not submit any data on ICD implantations for the EHRA White Book 216. Current trends in the use of arrhythmia procedures iii27

28 iii28 M.J.P. Raatikainen et al. Germany Italy Switzerland Spain Ireland Cyprus Finland Poland Sweden Iceland Portugal Israel Croatia Georgia Austria France Malta Greece Norway Belgium United Kingdom Luxembourg Netherlands Czech Republic Estonia Bosnia & Herzegovina Montenegro Serbia Slovenia Latvia FYR Macedonia Bulgaria Hungary Denmark Belarus Kazakhstan Lithuania Armenia Slovakia Romania Azerbaijan Kosovo Kyrgyzstan Russian Federation Ukraine Algeria Egypt Morocco,4,5,7,3,2,2,3,2 1,1 1,31,4 1,1,7 1, 1, 1,,7 2,1 2,22,4 2, 1,6 1,7 1,7 1,82, 1,6 1,5 1,5 1,4 1,5 1,5 3,1 3,23,3 3, 2,7 2,4 2,5 2,5 2,4 2,4 3,7 3,5 3,4 6, 6,4 9,2 Mean number of ICD implanting centres = Ø 2,38 Figure 25 Implantable cardioverter-defibrillator implanting centres per million inhabitants in 215. The mean number of implantation centres is weighted by population. Median number of ICD implantations = 93 Germany 358 San Marino Italy 238 Norway Switzerland Poland Finland Denmark Netherlands Czech Republic Iceland Israel Austria Ireland Belgium Slovakia France Slovenia Luxembourg Portugal Spain Greece United Kingdom Hungary Croatia Malta Montenegro Turkey Estonia Cyprus Serbia Latvia Lithuania Kazakhstan Georgia Bosnia & Herzegovina Belarus Romania FYR Macedonia Russian Federation Bulgaria Armenia Kosovo Egypt Algeria Azerbaijan Morocco Ukraine = Ø ICD implantations per million inhabitants (weighted by population) 4 th quartile > rd quartile > nd quartile > st quartile 1 2 Mean number of ICD implantations = Ø 12 Figure 26 Implantable cardioverter-defibrillator implantations per million inhabitants in 215. The mean number of implantations is weighted by population.

29 Current trends in the use of arrhythmia procedures iii29 12 = Ø ICD implantations per million inhabitants (weighted by population) 4 th quartile > rd quartile > nd quartile > st quartile 1 2 Not available Figure 27 Implantable cardioverter-defibrillator implantations in the ESC countries in 215. Northern Europe Western Europe European ESC countries EU Southern Europe Eastern Europe Non-European ESC countries ESC Figure 28 Implantable cardioverter-defibrillator implantations per million inhabitants 15 in the five geographical regions of the ESC and comparison with the total ESC area and the 28 member countries of the European Union (EU28).

30 iii3 M.J.P. Raatikainen et al. Northern Europe TOP 3 Norway Finland Denmark Lowest 3 Estonia Latvia Lithuania Figure 29 Implantable cardioverter-defibrillator implantations per million inhabitants 15 in Northern Europe. Western Europe TOP Germany Switzerland Netherlands Lowest 3 Belgium France Luxembourg * Figure 3 Implantable cardioverter-defibrillator implantations per million inhabitants 15 in Western Europe. *No data available.

31 Current trends in the use of arrhythmia procedures iii31 Eastern Europe TOP Poland Czech Republic Slovakia Lowest 3 Russian Federation Bulgaria Ukraine Figure 31 Implantable cardioverter-defibrillator implantations per million inhabitants 15 in Eastern Europe. Southern Europe TOP 3 San Marino Italy Slovenia 44 * Lowest 3 Serbia Bosnia and Herzegovina FYR Macedonia Figure 32 Implantable cardioverter-defibrillator implantations per million inhabitants 15 in Southern Europe. *No data available.

32 iii32 M.J.P. Raatikainen et al. Non-European ESC countries TOP 3 Israel 215 Cyprus Kazakhstan * Lowest 3 Algeria Azerbaijan Morocco * * * Figure 33 Implantable cardioverter-defibrillator implantations per million inhabitants 15 in the non-european ESC countries. *No data available. Ukraine), the proportion of implanting cardiologists was,5% (Table 5). Implantable cardioverter-defibrillator facilities and procedure rates It was reported that in 2266 national centres, a total of ICDswereimplantedin215(Table 8), an almost 2% increase from 214. Table 8 also shows a comparison with the previous 4 years in each country. As shown in Figure 25, the mean number of implanting centres in the ESC area was 2.38 per country. In the ESC area, the mean number of ICD implantations per million inhabitants in 215 was 12. In Figures 26 and 27, the ESC countries are grouped into quartiles according to the number of ICD implantations 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 rate was in Ukraine (one per million inhabitants). The number of ICD implantations according to the five ESC regions and the trend from to 215, compared with the EU28 and the whole ESC area, is shown in Figure 28. In Western Europe (294), the number of ICD implantations per million inhabitants was almost twice higher than in any other ESC region. Implantable cardioverter-defibrillator implantation rate also exceeds 1 per million population in the Southern (159), Northern (123), and European regions. The top and bottom three countries within the five ESC regions are shown in Figures The most active countries in each region were Germany (358 per million inhabitants) in the west, Norway (233) in the north, Poland (221) in the east, San Marino (242) and Italy (238) in the south, and Israel (162) in the non-european ESC region. The changes in the number of implanting centres from 214 to 215 are shown in Table 9 and Figure 34, and the change in the number of ICD implantations per million inhabitants during the same period is presented in Table 1 and Figure 35. These numbers are divided into de novo implantations and ICD generator replacements in Figures 36 and 37. The relationship between the annual ICD implantation rate per million inhabitants and the number of ICD implanting centres per million inhabitants in the EU28 countries and the ESC area is shown in Figure 38. Subcutaneous implantable cardioverter-defibrillator implantations Subcutaneous ICD (S-ICD) is a novel therapeutic modality for prevention of sudden cardiac death. The device is implanted entirely under the skin avoiding the need for intravascular leads. It is best suited for patients with no need for pacing and increased risk for transvenous lead complications. 12,13 This is the first time that data on S-ICD implantations have been collected for the EHRA White Book. As with the other new therapies and procedures, the response rate for this question in the EHRA White Book survey was markedly lower than that of the conventional arrhythmia treatments. A total of 149 S-ICDs were implanted in 13 countries in 215. No S-ICDs were implanted in 24 countries, and 19 countries reported no data on these devices. The most active countries with regard to the S-ICD implantations were Italy with 561 implantations followed by the UK (196 implantations) and the Netherlands (15 implantations) (Figure 39).

33 Current trends in the use of arrhythmia procedures iii33 Table 9 Changes in the number of ICD implantation centres in year 214 vs. 215 Country ISO code Number of ICD implanting centres Number of ICD implanting centres Change % Absolute Per million Absolute Per million number inhabitants number inhabitants... Albania a AL 2.66 N/A N/A N/A Algeria DZ Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium BE Bosnia and Herzegovina BA Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE Finland FI France FR Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE Israel IL Italy IT Kazakhstan KZ Kosovo XK Kyrgyzstan KGZ N/A Latvia LV Lebanon a LB N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia MK Malta MT Moldova a MD N/A N/A N/A N/A N/A Montenegro ME Morocco MA The Netherlands NL Norway NO Poland PL Portugal PT Romania RO Russian Federation RU San Marino SM N/A N/A N/A Serbia RS Slovakia SK Continued

34 iii34 M.J.P. Raatikainen et al. Table 9 Continued Country ISO code Number of ICD implanting centres Number of ICD implanting centres Change % Absolute Per million Absolute Per million number inhabitants number inhabitants... Slovenia SI Spain ES Sweden SE Switzerland CH Syria a SY N/A N/A N/A N/A N/A Tunisia a TN 8.73 N/A N/A N/A Turkey TR N/A N/A N/A N/A N/A Ukraine UA UK GB Total ESC countries a These six countries did not submit data for the EHRA White Book vs. 214 in % 215 Ukraine Spain Slovenia Georgia FYR Macedonia Kazakhstan Lithuania Bosnia & Herzegovina Germany Serbia Algeria Latvia Bulgaria Romania Czech Republic Egypt Netherlands Slovakia Belarus Poland Montenegro Hungary Armenia Greece Denmark Malta Italy Estonia Kosovo Azerbaijan France Norway Ireland United Kingdom Cyprus Israel Iceland Austria Switzerland Portugal Belgium Croatia Luxembourg Finland Russian Federation Morocco Sweden,2 2,3 1, 1, 1,6,8,9 1,3,2 1,4 8,3 1,4 1,3,7,2 1,6 1,7,7 1, 1, 1,3 1,5 3,1 1,1 2,2 2,4 6,4 1,6,5,7 2,1 2,4 3,5 2, 2,6 3,4 2,6 3,2 2,2 2,9 6,5 1,9 2,7,2,4 3,6 3,6 25,2 21,5 2,1 11,4 1,5 7,1 9, 1,4 1,4 3,1 4,3 5,7 7, 1,2 1,1,5,,1,2 -,2 -,3 -,5 -,6 -,6-1, -1,1-1,2-1,2-1,3-1,4-2,8-4,4-5,1-6,5-6,6-7,7-8,2-12,7-8,9-8,7-13,9-15, 59,4 74,5 5,4 5,1 49,7,3 1,5 2,4 1,4 1, 1, 1,6,2 1,5 9,2 1,5 1,4,7,2 1,7 1,7,7 1,1 1, 1,3 1,5 3,2 1,1 2,2 2,4 6,4 1,6,5,7 2,1 2,4 3,5 2, 2,5 3,4 2,4 3, 3,7 2, 2,7 6, 1,8 2,5,2,3 3,3 3,1 Figure 34 Change in the number of ICD implanting centres per million inhabitants from 214 to 215.

35 Current trends in the use of arrhythmia procedures iii35 Table 1 Changes in the number of ICD implantations in year 215 vs. 214 Country ISO code Number of ICD implants 214 Number of ICD implants 215 Change % Absolute number Per million inhabitants Absolute number Per million inhabitants... Albania a AL N/A N/A N/A Algeria DZ Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium BE Bosnia and Herzegovina BA Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE Finland FI France FR Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE N/A N/A N/A Israel IL Italy IT Kazakhstan KZ Kosovo XK Kyrgyzstan a KGZ. N/A N/A N/A Latvia LV Lebanon a LB N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia MK Malta MT Moldova a MD N/A N/A N/A N/A N/A Montenegro ME Morocco MA The Netherlands NL Norway NO Poland PL Portugal PT N/A N/A N/A Romania RO Russian Federation RU San Marino SM N/A N/A N/A Serbia RS Slovakia SK Slovenia SI Spain ES Sweden a SE N/A N/A N/A Switzerland CH Syria a SY N/A N/A N/A N/A N/A Tunisia a TN N/A N/A N/A Turkey TR Ukraine UA UK GB Total ESC countries a These eight countries did not submit data for ICD implantations for the EHRA White Book 216.

36 iii36 M.J.P. Raatikainen et al vs. 214 in % Kosovo FYR Macedonia 1,6 5,3 Croatia Morocco,8 38,7 Bosnia & Herzegovina 1,5 14,2 58,4 Algeria 48,9 Spain 81, 37,1 Switzerland 166,3 35,5 Georgia 21,1 34,7 Slovenia 87,5 31,4 Latvia 34,6 3,8 Montenegro 63,1 29,9 Kazakhstan 22,4 29,6 Germany 295, 21,2 Lithuania 38,2 11,6 Greece 1,2 1, Italy 222,6 6,8 Norway 22,3 5,8 Egypt 2,7 5,3 Bulgaria 6,8 4,6 Turkey 77,2 4,1 Azerbaijan 2,1 4, Hungary 96,4 3,4 United Kingdom 11,6 2,9 Slovakia 119,8 2,5 Cyprus 62,3 1,3 Poland 219, Denmark 216,9 -,2,9 Finland 22,4 -,7 Netherlands 211,9-2,6 Austria Malta 63,4 87,2 165,6-2,9-3,1 Serbia -3,9 Luxembourg 119,1-4,3 Iceland 185,9-4,4 Czech Republic 21,2-4,8 Estonia 76,3-5,8 Ukraine 1,3-9,1 Romania 15,3-9,4 Russian Federation 12,4-12,2 Belgium 154,2-12,3 Armenia 8,2-15,9 Belarus 17,9-21,8 Israel 215,4 France 26,8-43,1 297,5 163,1 124,6 112, ,4 13,8 1,7 2,3 22,5 2,9 7,1 28,4 2,1 99,6 14,6 63,1 122,8 221,1 216,4 6,9 84,5 16,8 26,5 218,7 114, 177,8 191,5 71,9 1,2 13,8 1,9 6,9 14, 45,3 115, 29, 81,9 42,6 86,9 8,4 111,1 11,2 135,2 161,5 117,6 225,3 237,8 233,1 357,6 Figure 35 Change in the number of ICD implantations per million inhabitants from 214 to vs. 214 in % 215 Croatia FYR Macedonia Bosnia & Herzegovina Algeria Spain Georgia Latvia Montenegro Slovenia Portugal Armenia United Kingdom Hungary N Greece orway Switzerland 4,3 34, 1,3 12,4 2,3 58,9 3,9 53,8 78,5 75,7 4,6 73,7 75,9 75,9 92, 156, 4 Bulgaria 4,6 Lithuania 2,4 27,7 Finland Egypt 159, 2 Germany Austria 118,7 Turkey Serbia 54,6 Czech Republic 152,2 Denmark 158, 4 63, Poland Malta 174, 98,1 Netherlands 14,6 Estonia Luxembourg 7, 86,4 Belgium 112, Russian Federation Ukraine 1,1 1,6 Iceland 173,3 Sweden 154,9 229, 35,4 66,9 69, 35,1 33,4 32, 12,1 21,6 22,1 31,1 11,1 9,9 9,7 9,6 8,4 5,3 3,8 1,7 1,6 1,5 1,2 1,,4,3-2,9 -,3-3,3-3,5-4, -4,6-14,7-3,5-17,3-16,1-42,7 129,2 121,8 9,5 5, 2,5 29,1 77,9 2,1 2,9 79,8 27,4 41,3 71,1 12,9 92,5 5,6 82,6 84,4 83,4 1,8 171,1 12,6 162, 66,9 55,2 152,8 158,9 62,8 169,3 94,9 135,7 67,2 82,4,9 8,9 95,5 88,8 12,5 232,6 Figure 36 Change in the number of new ICD implantations per million inhabitants from 214 to 215.

37 Current trends in the use of arrhythmia procedures iii37 Iceland FYR Macedonia Croatia Germany Spain Slovenia Ukraine Slovakia Lithuania Georgia Turkey Egypt Montenegro Russian Federation Greece Latvia Poland Denmark Luxembourg Norway Bulgaria Belgium Finland Malta Netherlands Bosnia & Herzegovina Austria Czech Republic United Kingdom Estonia Hungary Switzerland Serbia Algeria Armenia 214 1, 12,6 4,7 9,1 22,1 66,,2 21,7,8 1,6,3 11, 9,2 1,8 24,3 3,7 44,6 58,5 32,7 64,3 2,2 42,2 61,1 24,2 71,3 1,8 46,9 48,9 27,9 6,4 2,5,3 8,7 74,3 3,6-63,6-1,8-3,3-3,5-3,6-5,8-7,1-1,3-13,2-14,2-14,4-2,9-21,2-25,4-25,5-33,4-34,6-41,1 215 vs. 214 in % 354,2 349,1 41,6 7,7 9,7 33,7 29,6 28,7 28,1 25,1 21,7 18,7 17,2 11,5 1,3 9, 5,4 4,3 9, ,2 12,1 31,3 112,7,3 27,9 1, 13,5,3 13,4 1,8 2, 26,8 4, 47,1 57,5 31,6 62, 2,1 39,7 56,8 21,7 62, 1,6 4,2 38,7 22, 4,7 15,3,2 5,7 49,5 1,3 Figure 37 Change in the number of ICD replacements per million inhabitants from 214 to 215. ICD implantations per million inhabitants SK 4 EG LT LV 2 DZ UA KZ RU XK RO AZ BY MK BA MA AM BG,,5 1, 1,5 2, DK HU ME NL SI LU EE RS CZ GB NO BE PL FI AT IS IL FR GR IE ES HR PT MT CY GE CH 2, 2,5 3, 3,5 4, 4,5 5, 5,5 6, 6,5 7, 7,5 8, 8,5 9, 3, 5 ICD implanting centres per million inhabitants IT DE SM ESC 56 EU28 Figure 38 Implantable cardioverter-defibrillator implantation centres and rates in the ESC and European Union (EU28) member countries in 215. Bubble size is related to population in the country. The ISO codes of the countries are explained in Table 1. Cardiac resynchronization therapy devices General information The 49 (87.5%) countries that submitted data on cardiac resynchronization therapy (CRT) for the EHRA White Book 216 are listed in Table 11. Albania, Kyrgyzstan, Lebanon, Libya, Moldova, Syria, and Tunisia did not report any data related to CRT. The vast majority of implants were performed by cardiologists (Table 5), and the remaining implantations were performed by physicians having various other training backgrounds, mainly surgeons. In Belarus, however, all CRT implantations were done by surgeons, and the majority of CRT

38 iii38 M.J.P. Raatikainen et al. Italy United Kingdom Netherlands Belgium Switzerland Finland Denmark Portugal Hungary Latvia Turkey Romania San Marino Algeria Armenia Azerbaijan Bosnia & Herzegovina Bulgaria Croatia Cyprus Egypt Estonia Georgia Germany Greece Iceland Israel Lithuania Luxembourg Malta Montenegro Morocco Norway Serbia Slovakia Slovenia Ukraine Figure 39 Number of S-ICD implantation in 215. implantations in the Ukraine and Russia were likewise done by others than cardiologists (Table 5). Cardiac resynchronization therapy facilities and procedure rates It was reported that in 215 a total of CRT devices were implanted in 1527 national centres (Table 11). There was an increase in both absolute numbers of implants and the rate of implants per million inhabitants compared with 214, but a fall in the number of implanting centres (Table 11). The number of CRT implanting centres per million inhabitants in the ESC countries is shown in Figure 4. The mean number of implanting centres was 1.68 per country, which is a decrease from the previous year. The mean number of CRT devices implanted in 215 was 82. Germany (261 implants per million), Italy (27), and Czech Republic (183) had the highest number of implants of all CRT devices. Implantation rates with the countries divided into quartiles are shown as a bar graph in Figure 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-Ps per million inhabitants. The ratio between CRT-D and CRT-P is slightly higher than the last year representing a continuation in the trend 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 by the UK (Figure 43), while CRT-D implantation rate was highest in Germany followed by Italy and Israel (Figure 44). The use of CRT devices within the five geographical ESC regions is shown in Figure 45, and further data from within each region are shown in Figures The most active countries within each region were Germany (261 per million inhabitants), Denmark (176), Czech Republic (183), Italy (27), and Israel (18). The changes in the number of implanting centres per million inhabitants between 214 and 215 are shown in Table 12 and Figure 51. The changes between 214 and 215 for the number of total CRT implantations are shown in Table 13 and Figure 52, and the changes according to CRT device type are shown in Figures 53 and 54. The relationship between the annual CRT implantation rate and the number of CRT implanting centres per million population in the EU28 countries and the ESC area is shown in Figure 55. Lead extraction General information This was the fourth year that information on lead extractions (LEs) was included in the EHRA White Book. The number of countries submitting data on LE procedures is not as high as for PMs and

39 Table 11 Cardiac resynchronization therapy device (CRT-P and CRT-D) implantation facilities and rates in the ESC countries in 215 and comparison with 4 previous years Country ISO code Number of CRT CRT implantations 215 Total CRT Development potential CRT implantations per million implanting centres 215 implantations 215 target number of CRT inhabitants implantations Absolute Per million CRT-P CRT-D Absolute Per million To attain To attain number inhabitants implantations implantations number inhabitants mean ESC mean EU28 Absolute Absolute area level level number number... Albania a 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 N/A N/A Armenia AM Austria AT Azerbaijan AZ N/A Belarus BY 6.63 N/A N/A Belgium BE Bosnia and Herzegovina BA Bulgaria BG Croatia HR Cyprus CY N/A N/A Czech Republic CZ Denmark DK Egypt EG N/A Estonia EE Finland FI France FR N/A Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE N/A 65 Israel IL Italy IT Kazakhstan KZ N/A Kosovo XK 1.53 N/A N/A N/A N/A 2 Kyrgyzstan a KGZ N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Latvia LV Lebanon a LB N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Continued Current trends in the use of arrhythmia procedures iii39

40 iii4 Table 11 Continued Country ISO code Number of CRT CRT implantations 215 Total CRT Development potential CRT implantations per million implanting centres 215 implantations 215 target number of CRT inhabitants implantations Absolute Per million CRT-P CRT-D Absolute Per million To attain To attain number inhabitants implantations implantations number inhabitants mean ESC mean EU28 Absolute Absolute area level level number number... Libya a 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 Luxembourg LU FYR Macedonia MK Malta MT Moldova a 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 Montenegro ME Morocco MA N/A The Netherlands NL Norway NO Poland PL N/A N/A Portugal PT N/A Romania RO Russian Federation RU San Marino SM N/A 61 Serbia RS Slovakia SK Slovenia SI Spain ES Sweden SE N/A Switzerland CH Syria a 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 Tunisia a 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 N/A N/A N/A 3 35 Ukraine UA UK GB Total ESC countries a These seven countries did not submit any data on CRT implantations for the EHRA White Book 216. M.J.P. Raatikainen et al.

41 Current trends in the use of arrhythmia procedures iii41 Italy Switzerland Belgium Ireland Cyprus Germany Iceland Finland Spain France Sweden Israel Malta Portugal Austria Georgia United Kingdom Croatia Luxembourg Norway Netherlands Czech Republic Estonia Montenegro Greece FYR Macedonia Hungary Bulgaria Lithuania Slovenia Latvia Kazakhstan Denmark Serbia Slovakia Armenia Belarus Romania Kosovo Bosnia & Herzegovina Russian Federation Ukraine Azerbaijan Algeria Egypt Morocco 2,8 1,79 1,97 2,3 1,75 1,73 1,71 1,58 1,69 1,55 1,48 1,25 1,41 1,43 1,4 1,1,74,84,9,99 1,1,65,63,55,26,52,53,23,2,2,19,18 3,53 3,47 3,36 2,74 3,1 3,9 2,55 2,61 2,7 2,48 2,42 2,4 4,43 6,14 Mean number CRT implanting centers = Ø 1,68 Figure 4 Cardiac resynchronization therapy device implanting centres per million inhabitants in 215. The mean number of CRT implantation centres is weighted by population. Median number of CRT implantations = 6 Germany Italy Czech Republic Israel Denmark United Kingdom Austria France Switzerland Belgium Netherlands Hungary Slovakia Norway Sweden Poland Malta Finland Slovenia Portugal Lithuania Ireland Iceland San Marino Luxembourg Greece Croatia Estonia Spain Latvia Serbia Bulgaria Turkey Montenegro Cyprus FYR Macedonia Kazakhstan Romania Georgia Belarus Russian Federation Egypt Bosnia & Herzegovina Armenia Algeria Morocco Azerbaijan Kosovo Ukraine = Ø CRT implantations per million inhabitants (weighted by population) 4 th quartile > rd quartile > nd quartile > st quartile Mean number of CRT implantations = Ø 82 Figure 41 Cardiac resynchronization therapy device implantations per million inhabitants 215. The mean number of CRT implantations is weighted by population.

42 iii42 M.J.P. Raatikainen et al. 82 = Ø CRT implantations per million inhabitants (weighted by population) 4 th quartile > rd quartile > nd quartile > st quartile 2 17 Not available Figure 42 Cardiac resynchronization therapy device implantations in the ESC countries in 215. Denmark United Kingdom France Austria Lithuania Hungary Switzerland Belgium Sweden Czech Republic Norway Germany Iceland Estonia Slovakia Bulgaria Italy Finland Serbia Croatia Malta Slovenia Netherlands Montenegro Portugal Spain Ireland Poland Israel Luxembourg FYR Macedonia Latvia Greece Romania Egypt Turkey Bosnia & Herzegovina Russian Federation Georgia Ukraine Algeria Morocco Armenia Azerbaijan Kazakhstan San Marino 4,8 7,28,2 2,9 2,8 1,4 2, 2,4 1,3 1,3,3 54,2 58,4 5,1 46,6 48,6 44,9 41,1 43,7 4,9 39,2 38,7 35,2 38,6 34,8 33,6 24,2 28, 32,6 23,7 23,6 19,4 21,6 18,9 18, 14,3 16,7 14, 12,4 11,1 64,9 79, Mean number of CRT-P implantations = Ø 22 Figure 43 Cardiac resynchronization therapy PM implantations per million inhabitants in 215. The mean number of implantations is weighted by population.

43 Current trends in the use of arrhythmia procedures iii43 Germany Italy Israel Czech Republic Austria France Denmark Netherlands United Kingdom Switzerland Poland Belgium Malta Slovakia Norway Finland Sweden San Marino Hungary Greece Slovenia Portugal Ireland Luxembourg Latvia Spain Turkey Croatia Iceland Estonia Kazakhstan Lithuania Serbia Georgia Montenegro Bulgaria FYR Macedonia Romania Russian Federation Armenia Azerbaijan Kosovo Bosnia & Herzegovina Algeria Egypt Morocco Ukraine 6, 7,71,5 5,7 5,5 4,7 2,9 2,5 2,1 1,6 1,4 1,3 1,3,3 19, 24,13,5 17,3 15,6 11, 98,3 13,2 139,7 97,5 9,9 94,2 94,4 86,1 84,5 74,9 7, 62,6 66,8 6,6 6,6 6,1 59,2 59, 47,2 51,9 45,6 42,8 32,5 37,8 172,4 166,1 22,6 Mean number of CRT-D implantations = Ø 61 Figure 44 Cardiac resynchronization therapy defibrillator implantations per million inhabitants in 215. The mean number of implantations is weighted by population. Northern Europe Western Europe European ESC countries EU Southern Europe Eastern Europe Non-European ESC countries ESC Figure 45 Cardiac resynchronization therapy device implantations per million inhabitants 15 in the five geographical regions of the ESC and comparison with the total ESC area and the 28 member countries of the European Union (EU28).

44 iii44 M.J.P. Raatikainen et al. Northern Europe TOP 3 Denmark United Kingdom Norway Lowest 3 Iceland Estonia Latvia Figure 46 Cardiac resynchronization therapy implantations per million inhabitants 15 in Northern Europe. Western Europe TOP 3 22 Germany Austria France * Lowest 3 Belgium Netherlands Luxembourg Figure 47 Cardiac resynchronization therapy implantations per million inhabitants 15 in Western Europe. *No data available.

45 Current trends in the use of arrhythmia procedures iii45 Eastern Europe TOP 3 Czech Republic Hungary Slovakia Lowest 3 Belarus Russian Federation Ukraine Figure 48 Cardiac resynchronization therapy implantations per million inhabitants 15 in Eastern Europe. Southern Europe TOP 3 Italy Malta Slovenia Lowest 3 Montenegro FYR Macedonia Bosnia and Herzegovina Figure 49 Cardiac resynchronization therapy implantations per million inhabitants 15 in Southern Europe.

46 iii46 M.J.P. Raatikainen et al. Non-European ESC countries TOP 3 Israel Cyprus Tunisia * Lowest 3 Algeria Morocco Azerbaijan * * * * Figure 5 Cardiac resynchronization therapy implantations per million inhabitants 15 in the non-european ESC countries. *No data available. ICDs (Table 14). Seventeen countries did not submit any data on LEs, and four submitted incomplete data. In most countries, the primary operators in LE procedures were cardiologists. Lead extraction facilities and procedure rates A total of 8748 LE procedures (Table 14) were performed in 326 LE centres in 215. The mean number of LEs was 12.8 per million, but this needs to be put into context with a large number of missingdata(figure 56). It has been suggested that in an active centre the minimum annual number of LE should be at least 15 per million inhabitants. 14,15 Assuming that each centre treated an equivalent number of patients, it can be extrapolated that the numbers of LE per centre in 215 were lower than that recommended in most of the countries. The mean number of LE was highest in France (45.1 per million population) followed by Norway (37.3) and Germany (29.2) (Figure 56). Due to missing or incomplete dataandaverylowlerateinsomecountries,wechosenotto provide full representation of the regional LE data. Catheter ablation General information A total of 46 countries (82% of the ESC countries) submitted data on catheter ablation facilities and procedures to the EHRA White Book (Table 15). Sixteen had a national registry on catheter ablation, and in the remainder the numbers originated from a survey or an estimate by the national working groups. In 215, a total of people lived in the ESC countries. After excluding those countries that did not report the number of ablations or ablation centres, the population covered by the EHRA White Book for ablation procedures was ( 9% coverage), which is about the same in the previous year. Like in previous years, a major problem in 215 was that no ablation data were received from Italy, which is known to have well-developed ablation programmes. Catheter ablation facilities and procedure rates In 215, the total number of ablation centres in the countries that submitted data for the EHRA White Book was 1159 (Table 15), and the mean number of ablation centres per million population was 1.34 (Figure 57). The changes in the number of ablation centres from 214 to 215 are shown in Table 16 and Figure 58. The total number of catheter ablations in the ESC area in 215 was (Table 15), which was 3% more than that reported in 214 ( ). The mean number of ablations done per million population was also slightly higher in 215 (259) than in 214 (244). The number of catheter ablations per million inhabitants is shown in Figures 59 and 6. In these figures, the ESC countries are grouped into quartiles according to their ablation activities. As in previous years, most countries in the top quartile were from Northern and

47 Current trends in the use of arrhythmia procedures iii47 Table 12 Changes in the number of CRT implanting centres in year 215 vs. 214 Country ISO code Number of CRT implanting centres Number of CRT implanting centres Change % Absolute number Per million inhabitants Absolute number Per million inhabitants... Albania a AL 1.33 N/A N/A N/A Algeria DZ Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium BE Bosnia and Herzegovina BA Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE Finland FI France FR Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE Israel IL Italy IT Kazakhstan KZ Kosovo XK N/A Kyrgyzstan a KGZ. N/A N/A N/A Latvia LV Lebanon a LB N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia MK Malta MT Moldova a MD N/A N/A N/A N/A N/A Montenegro ME Morocco MA The Netherlands NL Norway NO Poland a PL N/A N/A N/A Portugal PT Romania RO Russian Federation RU Continued

48 iii48 M.J.P. Raatikainen et al. Table 12 Continued Country ISO code Number of CRT implanting centres Number of CRT implanting centres Change % Absolute number Per million inhabitants Absolute number Per million inhabitants... San Marino SM N/A N/A N/A Serbia RS Slovakia SK Slovenia SI Spain ES Sweden SE Switzerland CH Syria a SY N/A N/A N/A N/A N/A Tunisia a TN 8.73 N/A N/A N/A Turkey a TR N/A N/A N/A N/A N/A Ukraine UA UK GB Total ESC countries a These nine countries did not submit any data on CRT implanting centres for the EHRA White Book vs. 214 in % 215 Sweden FYR Macedonia Georgia Kazakhstan Bulgaria Lithuania France Ukraine Latvia Portugal Hungary Czech Republic Egypt Belarus Serbia Montenegro Romania Slovenia Italy Bosnia & Herzegovina Greece Denmark Malta Estonia Spain Ireland Cyprus Algeria Israel United Kingdom Finland Iceland Austria Netherlands Belgium Luxembourg Norway Russian Federation Morocco Switzerland Croatia Slovakia Armenia Azerbaijan,7 1,4,9 1, 2,2,2,9 1,3 2,2,2 1,6,6,8,6 1,5 1,,5,9 1,5,2,3,2 1, 1,5 1,6 2,4 2,7 3,5 3,4 2, 2,6 2,8 2,2 3,2 1,8 1,9 1,9 3,8 6,1 2,5 6,,3 1, Germany 8,3-62,6 65,3 49,7 23,9 36,9 43, 21,5 1,8 18,7 5,7 7,9 8,2 9, 4,3 1,2,5,5,3,2,2,,1 -,2 -,6 -,3 -,8-1,2-1,4-1,8-2,8-2,9-3,8-4,4-5,1-6,8-7,7-8,7-11, -25,6-13,9-11,9-27,2-32,4-33,2-34, 2,6 1,4 2, 1, 1,3 1, 2,6,2 1, 2,4 1,4 1,7,2,6,8 1,5,6 1,,5,2,3,2,7,2,7,9 1,5 1,6 2,4 2,7 3,4 3,5 2, 2,5 2,7 3, 2,1 1,7 1,8 1,7 1,8 3,1 3,5 4,4 6,1 Figure 51 Change in the number of CRT implanting centres per million inhabitants from 214 to 215.

49 Current trends in the use of arrhythmia procedures iii49 Table 13 Change in the number of total CRT device (CRT-D 1 CRT-P) implantations in year 215 vs. 214 Country ISO code Total CRT implantations Total CRT implantations Change % Absolute Per million Absolute Per million number inhabitants number inhabitants... Albania a AL 2 1 N/A N/A N/A Algeria DZ Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium BE Bosnia and Herzegovina BA Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE Finland FI France FR Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE N/A N/A N/A Israel IL Italy IT Kazakhstan KZ Kosovo XK 4 2 N/A Kyrgyzstan a KGZ N/A N/A N/A Latvia LV Lebanon a LB N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia MK Malta MT Moldova a MD N/A N/A N/A N/A N/A Montenegro ME Morocco MA The Netherlands NL Norway NO Poland PL Portugal PT Romania RO Continued

50 iii5 M.J.P. Raatikainen et al. Table 13 Continued Country ISO code Total CRT implantations Total CRT implantations Change % Absolute Per million Absolute Per million number inhabitants number inhabitants... Russian Federation RU San Marino SM N/A N/A 2 61 N/A Serbia RS Slovakia SK Slovenia SI Spain ES Sweden SE Switzerland CH Syria a SY N/A N/A N/A N/A N/A Tunisia a TN N/A N/A N/A Turkey TR Ukraine UA UK GB Total ESC countries a These seven countries did not submit any data on CRT implantations for the EHRA White Book vs. 214 in % 215 Armenia G Belarus Croatia ermany Switzerland Algeria Estonia Morocco FYR Macedonia Azerbaijan Lithuania Sweden Kazakhstan Turkey Russian Federation Hungary Georgia Slovakia Latvia Portugal Greece Slovenia France 1,3 5,1 27,7 72,3 1,4 4,5 1,9 1,9 13,4 14,6 6,1 3,1 11,1 54,8 87,8 94,9 128,1 96,3 48,5 64,4 53,8 75,4 Norway 99,8 144,4 United Kingdom 149,3 Israel Poland 97, 17, Austria 15,3 Czech Republic 176,1 Italy 2, Netherlands 114,4 Belgium 24,7 Denmark Cyprus 127, 5 173,3 Iceland Bosnia & Herzegovina Egypt 6,1 44,5 99,8 13,3 43,8 65,3 62,3 1,9 33,8 Malta 116,3 81,9 5,9 Serbia Finland Romania Bulgaria Luxembourg Spain Montenegro Ukraine -2, -3,6-4,2-5,9-8,7-9, -13,2-14,4-14,9-22,8-26, 42,3 36,1 35,4 32, 23,4 2,1 18,5 17,4 16,6 16,2 12,8 12,7 11,1 1,8 1, 9,6 6,6 8,1 8,5 6,1 6, 4,7 4,1 3,6 3,1 2,9 2, 1,8 1, 11,8 92,9 14, 16,4 89,3 15,4 3,3 1,5 2,7 2,5 2,5 18,1 17,3 7,1 35,4 12,6 6,2 43,6 96,2 12,7 41,2 59,6 56,7 1,6 29,4 4,4 25,2 58,5 57,7 67,6 15,5 18,6 53,9 71,3 59,2 82,7 17,9 156,7 159,1 18,4 12,8 63,3 99, 11,2 139,5 157,4 183,4 27,2 118, 131,1 176,5 261,4 Figure 52 Change in the number of total CRT implantations per million inhabitants from 214 to 215.

51 Current trends in the use of arrhythmia procedures iii51 Russian Federation Algeria Germany Malta Switzerland Estonia Croatia Sweden Israel Portugal Montenegro Lithuania Czech Republic France Greece Norway Belgium Austria Denmark Hungary FYR Macedonia Italy Egypt Slovakia Slovenia United Kingdom Finland Serbia Spain Romania Morocco Georgia Bulgaria Poland Latvia Bosnia & Herzegovina Ukraine Iceland Netherlands Turkey Luxembourg 214,3,5 7,4 4,8 34,4 33,7 19,9 7,6 1,3 2,2 38,7 3,4 12,9 18,7 1,6 3,8 12,1 16, 21,5 25,8 19, 1,2 16,5 18,5 12, 31,7 24,8 28,7 19,2 34,2 3,5 39,1 45,6 52,8 38,3 43,8 51,1 47,5 5,4 65, 74,5 215 vs. 214 in % 655,8 16,1 88,5 99,4 155,9 47,2 8,4 41,7 17,9 39,7 17,2 13,9 11,6 1,6 1, 7,4 6,4 6,2 6, 5,5 3,8 1,7,3 -,2,, -2,2-3,3-4,9-5,7-6,2-9, -9, -1,5-14,4-15,3-16,9-22,3-22,5-23,7-27, 215 1,3 2,4 4,8 4,9 24,2 38,7 48,6 28, 44,9 14,3 19,4 21,6 43,7 52, 58,4 8,2 12,4 23,7 34,8 38,6 33,6 32,6 18,9 7,2 1,3 2, 35,2 2,8 11,1 16,7 1,4 39,2 23,6 2,9 14, 41,1 46,6 54,2 5,1 64,9 79, Figure 53 Change in the number of CRT-P implantations per million inhabitants from 214 to vs. 214 in % 215 FYR Macedonia Croatia Morocco G Armenia ermany Switzerland Lithuania Algeria Azerbaijan Greece Hungary Slovenia Turkey Latvia Bulgaria Georgia Netherlands United Kingdom Poland Norway Portugal Sweden France Italy Austria Israel Egypt Czech Republic Serbia Belgium Ukraine Estonia Luxembourg Denmark Romania Slovakia Finland Spain Russian Federation Iceland Malta Bosnia & Herzegovina Montenegro 1,4 8,7,5 1,3 46,5,9 9,1 1,9 5,1 8,9 1,3 1,8,3 19,1 5,7 5,7 2,6 15,4 46,4 47,4 26,3 46,8 35,6 47,9 61,678,3 56,2 91,6 31,5 46,1 84, 84,3 83,6 42,4 65,5 71,5 99,2 98,8 112,2 14,2 137, 165,8 159,8 96,7 125,3 148,2 95,3 32, 5, 7,9 27,6 26,9 26,1 23,3 2,3 18,4 18,3 12,4 11,8 1, 8,5 8,4 7,9 7,3 4, 4, 3,9 3,6 2, 1,7 1, -,3 -,6-1,1-1,3-2,2-2,2-4,4-11, -18,6-23,5-28,1-39,9-49,8 249,2 299,2 5,7 3,5 1,3 2,9 9,9 1,4 15,6 2,5 6, 1,5 1,3 11,,3 19, 45,6 5,5 59,2 32,5 59, 6,1 42,8 94,4 94,2 86,1 51,9 66,8 6,6 98,3 84,5 7, 4,7 37,862,6 24,1 74,9 1,6 7,7 13,2 97,5 139,7 172,4 166,1 22,6 Figure 54 Change in the number of CRT-D implantations per million inhabitants from 214 to 215.

52 iii52 M.J.P. Raatikainen et al. CRT implantations per million inhabitants NL SK HU 1 NO 8 SI LT 6 MA RS GR LU DZ LV HR 4 EG RU EE BA BG RO 2 AM ME KZ BY AZ UA XK MK,,5 1, 1,5 2, DK CZ GB DE AT IL FR SE MT FI PT IS ES GE IT CH BE IE SM CY 2, 2,5 3, 3,5 4, 4,5 5, 5, 5 6, 3, 5 CRT implanting centres per million inhabitants ESC 56 EU28 Figure 55 Cardiac resynchronization therapy implantation centres and rates in the ESC and European Union (EU28) member countries in 215. Bubble size is related to population in the country. Western Europe. European Society of Cardiology countries outside Europe had low ablation activity, and they are mostly found in the lowest (first) quartile. Eastern European countries had a heterogeneous distribution, which spanned over all four quartiles. Data on the number of catheter ablations during the last 5 years are shown in Table 15, and detailed information on the changes in the number of ablation procedures from 214 to 215 is presented in Table 17 and Figure 61. The mean number of ablations performed per centre was almost exactly the same in 215 (259) as in 214 (26), indicating the ablation activities in the centres that reported their numbers were constant. The relationship between the annual catheter ablation rate and the number of ablation centres per million population in the EU28 countries and the whole ESC area is shown in Figure 62. More detailed data on ablation activity in the five geographical ESC regions are presented in Figure 63. Themean number of ablations per million inhabitants was higher in the Western than in the other European regions and in the non-european ESC countries. In the non-european ESC countries, catheter ablation rate was almost 3 times lower than in the European ESC countries (13 vs. 31 per million population). In 215, the most active countries were Germany, Denmark, and Switzerland with 789, 73, and 73 ablations per million population, respectively (Table 15 and Figure 59). In San Marino, no ablations were performed. Data for the last 5 years from the 3 most active and 3 least active countries in the different ESC regions are presented in Figures The most active countries in the Northern, Western, Southern, and Eastern Europe were Denmark (73 ablations per million inhabitants), 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 population. In 215, the rate of ablations per million population increased in most of the ESC countries, but Cyprus, Armenia, and Morocco reported more than 5% decrease in catheter ablation activities. The growth in the mean ablation rate per million population was highest in the Eastern and Southern European regions. In Slovenia, the increase in ablation rate was 63%. Atrial fibrillation ablation rates In 215, a total of atrial fibrillation (AF) ablations were performed in the 43 ESC countries that submitted AF ablation data for the EHRA White Book (Table 18). In Figures 69 and 7, countries performing AF ablations are grouped into quartiles according to their activity. The mean number of AF ablations per million inhabitants was 96, which is about the same as in 214 (96 per million). The most active countries were Germany (416 AF ablations per million population), Denmark (337), and Belgium (289). Like 214, most countries in the top quartile were from the Northern and Western European regions, and the countries with the lowest activity (first and second quartiles) were mainly from Southern Europe and from the non-european ESC region. In the Eastern region, the AF ablations activity was extremely heterogeneous. The growth in AF ablation rate per million population was highest in Azerbaijan (197%), Turkey (87%), and Bulgaria (79%), whereas in Armenia, Cyprus, and Serbia the AF ablation rate decreased by 91, 81, and 36%, respectively (Table 19 and Figure 71). In Armenia, Algeria, Bosnia and Herzegovina, Malta, and San Marino, no AF ablations were performed in 215 (Figure 69).

53 Current trends in the use of arrhythmia procedures iii53 Table 14 Lead extraction facilities and rates in 215 and comparison with 3 previous years Country ISO Number of LE centres Number of LE Development potential target LE procedures per code 215 procedures 215 number of LE procedures million inhabitants Absolute Per million Absolute Per million To attain mean To attain mean number inhabitants number inhabitants ESC area level EU28 level... Albania a AL N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Algeria DZ N/A N/A 1 1 Armenia AM Austria AT Azerbaijan AZ N/A Belarus BY N/A 1 1 Belgium a BE N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Bosnia and BA N/A Herzegovina Bulgaria a BG N/A N/A N/A N/A N/A N/A N/A 2 N/A Croatia HR Cyprus CY Czech Republic CZ Denmark b DK 4.72 N/A N/A N/A N/A N/A N/A N/A N/A Egypt EG Estonia a EE N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Finland b FI 5.91 N/A N/A N/A N/A N/A N/A 3 N/A France FR N/A Georgia a GE N/A N/A N/A N/A N/A N/A N/A 1 N/A Germany DE N/A Greece GR Hungary HU Iceland IS Ireland b IE 2.41 N/A N/A N/A N/A N/A N/A N/A N/A Israel IL N/A 1 1 Italy a IT N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Kazakhstan KZ N/A 1 Kosovo a XK N/A N/A N/A N/A N/A N/A N/A N/A N/A Kyrgyzstan a KGZ N/A N/A N/A N/A N/A N/A N/A N/A N/A Latvia LV Lebanon a LB N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU N/A FYR Macedonia MK Malta MT Moldova a MD N/A N/A N/A N/A N/A N/A N/A 1 N/A N/A Montenegro ME Morocco MA The Netherlands NL N/A Norway NO Poland PL Portugal a PT N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Continued

54 iii54 M.J.P. Raatikainen et al. Table 14 Continued Country ISO Number of LE centres Number of LE Development potential target LE procedures per code 215 procedures 215 number of LE procedures million inhabitants Absolute Per million Absolute Per million To attain mean To attain mean number inhabitants number inhabitants ESC area level EU28 level... Romania RO Russian Federation a RU N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A San Marino SM.. 1 N/A Serbia RS Slovakia SK Slovenia b SI 1.5 N/A N/A N/A N/A N/A N/A N/A N/A Spain ES N/A N/A N/A 8 Sweden a SE N/A N/A N/A N/A N/A N/A N/A Switzerland b CH 6.74 N/A N/A N/A N/A N/A N/A Syria a SY N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Tunisia a 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 N/A N/A 4 5 Ukraine UA UK a GB N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Total ESC countries a These 17 countries did not submit any data on LE for the EHRA White Book 216. b These 5 countries only submitted data on LE centres for the EHRA White Book 216. France Norway Germany Austria Czech Republic Poland Slovakia Malta Croatia Hungary Luxembourg Israel Latvia Spain Netherlands Lithuania Turkey Greece Serbia Cyprus Belarus Algeria Ukraine Kazakhstan Romania Azerbaijan FYR Macedonia Morocco Egypt Armenia Bosnia & Herzegovina Iceland Montenegro San Marino 1,2 1, 1,,7,9,5,3,5,2 11, 1,6 1,5 9,6 9,9 8,3 6,6 7,1 5,3 5,1 3,9 3,4 22, 21,7 29,2 27,2 28,228,8 37,3 45,1 Mean number of Lead extractions = Ø 12,8 Figure 56 Lead extractions per million inhabitants in 215. The mean number of LEs is weighted by population.

55 Current trends in the use of arrhythmia procedures iii55 Table 15 Catheter ablation facilities and rates in 215 and in comparison with 4 previous years Country ISO code National Registry for EP Number of ablation Ablation procedures Development Ablation procedures per centres potential target million inhabitants number of ablation procedures Absolute Per million Absolute Per million To attain To attain number inhabitants number inhabitants mean mean ESC area EU28 level level... Albania a 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 N/A N/A Armenia AM No Austria AT Yes Azerbaijan AZ No N/A Belarus BY No Belgium BE No N/A N/A Bosnia and BA No 1.26 N/A N/A N/A N/A 5 1 N/A Herzegovina Bulgaria BG Yes Croatia HR No Cyprus CY No Czech Republic CZ Yes Denmark DK Yes Egypt EG No N/A Estonia EE No Finland FI No France FR No N/A Georgia GE No Germany DE No Greece GR Yes Hungary HU No Iceland IS No Ireland IE No N/A N/A N/A N/A N/A N/A Israel IL No N/A N/A N/A N/A N/A N/A N/A N/A N/A Italy a 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 N/A Kosovo a XK No N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Kyrgyzstan KGZ No N/A N/A N/A 1 1 Latvia LV Yes Lebanon a LB N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Libya a 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 Luxembourg LU Yes FYR Macedonia MK No Malta MT No Moldova a MD N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Montenegro ME No Morocco MA Yes The Netherlands NL Yes N/A 382 N/A Norway NO No Poland PL No Portugal PT Yes Romania RO No Continued

56 iii56 M.J.P. Raatikainen et al. Table 15 Continued Country ISO code National Registry for EP Number of ablation Ablation procedures Development Ablation procedures per centres potential target million inhabitants number of ablation procedures Absolute Per million Absolute Per million To attain To attain number inhabitants number inhabitants mean mean ESC area EU28 level level... Russian Federation RU Yes San Marino SM No N/A Serbia RS No Slovakia SK Yes Slovenia SI Yes Spain ES Yes Sweden a SE N/A N/A N/A N/A N/A N/A N/A N/A Switzerland CH Yes Syria a 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 Tunisia a TN N/A N/A N/A N/A N/A N/A N/A N/A 78 N/A Turkey TR No N/A N/A N/A N/A N/A Ukraine UA No UK GB Yes Total ESC countries a These 1 countries did not submit any data on catheter ablations for the EHRA White Book 216. Malta Luxembourg Cyprus Germany Croatia FYR Macedonia Finland Hungary Poland Switzerland Spain Denmark Netherlands Lithuania Israel Austria Norway Czech Republic Slovakia Slovenia Latvia France Serbia Ireland Greece Belarus Romania Ukraine Azerbaijan Morocco Algeria Kazakhstan Egypt Armenia Bosnia & Herzegovina Iceland Montenegro San Marino,1,2,1,1,1,,1,8,7,7,7,8,6,7,7,6,6,6,5,6,5,4,5,4,3,4,9 1, 1,1 1,6 1,7 1,8 2,4 Mean number of ablation centres = Ø 1,34 Figure 57 Catheter ablation centres per million inhabitants in 215. The mean number of catheter ablation centres is weighted by population.

57 Current trends in the use of arrhythmia procedures iii57 Table 16 Change in the number of catheter ablation centres in year 215 vs. 214 Country ISO code Number of ablation centres Number of ablation centres Change % Absolute Per million Absolute Per million number inhabitants number inhabitants... Albania a AL 1.33 N/A N/A N/A Algeria DZ Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium a BE N/A N/A N/A Bosnia and Herzegovina BA N/A Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE Finland FI France FR Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE Israel IL Italy a IT. N/A N/A N/A Kazakhstan KZ Kosovo a XK. N/A N/A N/A Kyrgyzstan KGZ Latvia LV Lebanon a LB 5.85 N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia MK Malta MT Moldova a MD N/A N/A N/A N/A N/A Montenegro ME Morocco MA The Netherlands NL Norway NO Poland PL Portugal PT Romania RO Continued

58 iii58 M.J.P. Raatikainen et al. Table 16 Continued Country ISO code Number of ablation centres Number of ablation centres Change % Absolute Per million Absolute Per million number inhabitants number inhabitants... Russian Federation RU San Marino SM N/A N/A. N/A Serbia RS Slovakia SK Slovenia SI Spain ES Sweden a SE N/A N/A N/A Switzerland CH Syria a SY N/A N/A N/A N/A N/A Tunisia a TN 9.82 N/A N/A N/A Turkey a TR. N/A N/A N/A Ukraine UA UK GB Total ESC countries a These 11 countries did not submit any data on ablation centres for the EHRA White Book vs. 214 in % 215 Germany Azerbaijan Serbia France Algeria Kazakhstan Ukraine Lithuania Bulgaria Croatia Belarus Georgia Latvia Switzerland Austria United Kingdom Czech Republic Portugal Poland Slovakia Morocco Montenegro Romania Slovenia Hungary Armenia Malta Greece Denmark Netherlands Estonia Kyrgyzstan Norway Ireland Cyprus Egypt Israel Finland Iceland Spain Luxembourg Russian Federation,3,3,1,5,2,6,9,1,6 1,1,6,7,9 1,4 1, 1,5 2,1 2,2 2,2 1,5 1,1 1, 2,4,9 1,1 2,7 1,6,4 1, 2,5 2,6,2 1,7 2, 3,2 1,8 1,9,6 FYR Macedonia 1,4-33,5-14,8 2, 2,1 2,5 2,9 5,7 65,173,3 5,1 47,2 42,8 21,5 37,1 2,4 2,2 18, 6,1 7,9 9, 14,4 6, 4,4 4,1 1,8 1,4,5,5,3,2,2,,,1 -,4 -,2 -,6-1,1-1,2-1,2-1,4-1,8-2,8-3,8-4,4-6,7-8,7,2,5,4,1,7,2,7 1,,4,6,7 1,3 2,2 1, 2,2 2,3,2,7 2,2 1,,5 1, 1, 1,6 1,5 1,5 1,1 1, 2,4,9 1,1 2,7 1,6 1,6 2, 1,7 1,8 2,5 2,5 2,9 3,1 3, 4,3 Figure 58 Change in the number of catheter ablation centres per million inhabitants from 214 to 215.

59 Current trends in the use of arrhythmia procedures iii59 Median number of ablations = 229 Germany Denmark Switzerland Belgium France Norway Czech Republic Netherlands Finland Hungary Lithuania Latvia Slovenia Estonia Austria Croatia Poland United Kingdom Spain Luxembourg Portugal Iceland Slovakia Turkey Greece Russian Federation Kazakhstan Bulgaria Montenegro Belarus Serbia Georgia FYR Macedonia Malta Romania Ukraine Cyprus Azerbaijan Egypt Armenia Kyrgyzstan Algeria Morocco San Marino = Ø Ablations per million inhabitants (weighted by population) 4 th quartile > rd quartile > nd quartile > st quartile Mean number of ablations = Ø 259 Figure 59 Catheter ablations per million inhabitants in 215. The mean number of ablations is weighted by population. 259 = Ø Ablations per million inhabitants (weighted by population) 4 th quartile > rd quartile > nd quartile > st quartile 79 Not available Figure 6 Catheter ablations in the ESC countries in 215.

60 iii6 M.J.P. Raatikainen et al. Table 17 Change in the number of catheter ablations in year 215 vs. 214 Country ISO Total ablations 214 Total ablations 215 Change % code Absolute Per million Absolute Per million number inhabitants number inhabitants... Albania a AL N/A N/A N/A N/A N/A Algeria DZ Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium BE Bosnia and BA N/A N/A N/A Herzegovina a Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE Finland FI France FR Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland a IE N/A N/A N/A N/A N/A Israel a IL N/A N/A N/A N/A N/A Italy a IT N/A N/A N/A N/A N/A Kazakhstan KZ Kosovo a XK N/A N/A N/A Kyrgyzstan KGZ Latvia LV Lebanon a LB N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia MK Malta MT Moldova a MD N/A N/A N/A N/A N/A Montenegro ME Morocco MA The Netherlands NL Norway NO Poland PL Portugal PT Romania RO Russian Federation RU Continued

61 Current trends in the use of arrhythmia procedures iii61 Table 17 Continued Country ISO Total ablations 214 Total ablations 215 Change % code Absolute Per million Absolute Per million number inhabitants number inhabitants... San Marino SM N/A N/A N/A Serbia RS Slovakia SK Slovenia SI Spain ES Sweden a SE N/A N/A N/A Switzerland CH Syria a SY N/A N/A N/A N/A N/A Tunisia a TN N/A N/A N/A Turkey TR Ukraine UA UK GB Total ESC countries a These 12 countries did not submit any data on ablations for the EHRA White Book vs. 214 in % 215 Slovenia 219,8 Croatia 19,6 FYR Macedonia 5,2 Lithuania 252,4 Bulgaria 95,7 Montenegro 11,5 Belarus 84, Latvia 294,7 Algeria 6,2 Kazakhstan 112,4 Turkey 137,4 France 52,6 Georgia 72,1 Portugal 214,9 Finland 421,7 Switzerland 637, Slovakia 22,3 Hungary 349,7 Belgium 586,3 Germany 74,8 Malta 72,7 Egypt 15,6 Czech Republic 55,9 Greece 153,4 Estonia 326,7 Azerbaijan 39,6 Norway 574,8 Netherlands 495,2 Denmark 694,4 Kyrgyzstan 1,3 Austria 318,9 United Kingdom 275,8 Poland 284,8 Iceland 239,5 Ukraine 53,5 Spain 269,6 Russian Federation 167,6 Romania 62,5 Serbia 113, Luxembourg 33,5 Cyprus 121,1 Armenia Morocco 5,1 43,1-58,3-63,6-64,5-1,7-1,9-3,5-4,8-1, -11,8-13,7-16,2 63,3 58,4 57,8 48, 39,7 26,3 24,5 24, 23,9 2,6 19,1 18,4 13,3 1,9 1,4 1,4 9,9 7,6 6,8 6,5 6,3 5, 5, 3,4 3, 2,6 2,5 1,3 1,3,6,5 -,3 7,7 4,7 1,4 79,2 77,3 16,4 51,6 133,7 128,3 14,5 135,5 163,7 81,7 158,7 238,3 222,3 359, 31,9 336,6 32,5 275, 279,9 235, 15,8 256,6 55,1 97,5 254,3 5,5 15,7 1,8 373,7 365,4 376,2 465,6 594,9 626,2 578,5 51,5 588,9 72,9 73,2 788,9 Figure 61 Change in the number of catheter ablations per million inhabitants from 214 to 215.

62 iii62 M.J.P. Raatikainen et al. Ablations per million inhabitants NL NO DK 4 LT 4 SI 35 LV HU 35 EE AT 3 HR 3 GB LU PL SK ES PT IS 2 2 KZ 15 KGZ RS RU 15 GR BY 1 DZ EG ME BG 1 MK 5 UA GE MT AZ 5 CY RO MA AM SM,,5 1, 1,5 1,5 2, 2,5 3, 3,5 4, 4, FI CZ FR CH Ablation centres per million inhabitants DE EU28 ESC 56 Figure 62 Catheter ablation centres and rates in the ESC and European Union (EU28) member countries in 215. Bubble size is related to population in the country. Northern Europe Western Europe European ESC countries EU Southern Europe Eastern Europe Non-European ESC countries ESC Figure 63 Catheter ablations per million inhabitants 15 in the five geographical regions of the ESC and comparison with the total ESC area and the 28 member countries of the European Union (EU28).

63 Current trends in the use of arrhythmia procedures iii63 Northern Europe TOP 3 Denmark Norway Finland Lowest 3 Estonia United Kingdom Iceland Figure 64 Catheter ablations per million inhabitants 15 in Northern Europe. Western Europe TOP 3 Germany Switzerland Belgium Lowest 3 Netherlands Austria Luxembourg * * Figure 65 Catheter ablations per million inhabitants 15 in Western Europe. *No data available.

64 iii64 M.J.P. Raatikainen et al. Eastern Europe TOP 3 Czech Republic Hungary Poland Lowest 3 Belarus Romania Ukraine Figure 66 Catheter ablations per million inhabitants 15 in Eastern Europe. Southern Europe TOP 3 Slovenia Croatia Spain Lowest 3 Serbia FYR Macedonia Malta Figure 67 Catheter ablations per million inhabitants 15 in Southern Europe.

65 Current trends in the use of arrhythmia procedures iii65 Non-European ESC countries TOP 3 Kazakhstan Georgia Cyprus * * Lowest 3 Armenia Algeria Morocco * * Figure 68 Catheter ablations per million inhabitants 15 in the non-european ESC countries. *No data available. Detailed data on AF ablation activities in the five ESC regions and a comparison with the corresponding numbers in the ESC and EU28 countries are presented in Figure 72. The rate of AF ablations was markedly lower in the non-european countries than in the European ESC countries (8 vs. 125 per million population). The most active countries in the Northern, Western, Southern, and Eastern European regions and among the non-european ESC countries were Denmark (337 AF ablation per million population), Germany (416), Slovenia (18), Czech Republic (238), and Kazakhstan (42), respectively (Figures 73 77). The proportion of AF ablations out of the total number of ablations varied between 1.5% in Azerbaijan and 52.7% in Germany. The mean ratio of AF ablations out of the total ablations was 35.7%, and the proportion of AF ablations compared with all ablations was more than 4% in 7 countries (Figure 78). Ventricular tachyarrhythmia ablation rates In 215, the number of centres performing more than 1 ventricular tachyarrhythmia ablations for patients with structural heart disease per million population was highest in Germany (1.71) and lowest in Ukraine (.2) (Figure 79). Data on ventricular tachyarrhythmia ablations in patients with structural heart disease were collected for the second time in 215. A total of 35 (63%) countries reported data 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 214 to 16. in 215. It was highest in Germany (83 per million population) followed by Finland (3), Czech Republic (28), and Denmark (26) (Figures 8 and 81). Many countries did not report any data on VT/VF ablation (n ¼ 21) or did not perform any VT/VF ablations (n ¼ 5) in 215. Percutaneous left atrial appendage closures During recent years, percutaneous left atrial appendage (LAA) closure has become an attractive option to prevent AF-related thromboembolic complications among patients with high risk of bleeding and contraindications to oral anticoagulation therapy. 16,17 The mean number of centres performing LAA closures in the ESC area was.9 per million population (Figure 82). In 215, however, only 26 of the 56 ESC member countries (46%) submitted the requested data on the numbers of LAA closures for the EHRA White Book. The mean number of procedures in the ESC countries performing LAA closures was the same in 215 as that in 214 (8.9 per million inhabitants). Germany was by far the most active country (54.8LAAclosurepermillioninhabitants)followedbyFinland (22.5) and Latvia (14.1) (Figure 83). Of note is that in Kazakhstan, where the CIED implantation and catheter ablations numbers were generally quite low, 4.5 LAA occlusions were performed per million inhabitants.

66 iii66 M.J.P. Raatikainen et al. Table 18 Atrial fibrillation ablations in 215 in comparison with 4 previous years Country ISO code AF ablation procedures 215 Development potential target number of AF ablation procedures AF ablation procedures per million inhabitants Absolute number Per million inhabitants To attain mean ESC area level To attain mean EU28 level... Albania a AL N/A N/A N/A N/A N/A N/A N/A N/A N/A Algeria DZ N/A N/A Armenia AM Austria AT Azerbaijan AZ N/A 1 Belarus BY Belgium BE Bosnia and Herzegovina BA Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG N/A 1 1 Estonia EE Finland FI France FR N/A Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE N/A 133 Israel a IL N/A N/A N/A N/A N/A N/A 7 N/A Italy a IT N/A N/A N/A N/A N/A N/A N/A N/A Kazakhstan KZ Kosovo a XK N/A N/A N/A N/A N/A N/A N/A N/A Kyrgyzstan a KGZ N/A N/A N/A N/A N/A N/A N/A N/A N/A Latvia LV Lebanon a LB N/A N/A N/A N/A N/A N/A N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia a MK N/A N/A N/A N/A N/A Malta MT Moldova a MD N/A N/A N/A N/A N/A N/A N/A N/A Montenegro ME Morocco a MA N/A N/A N/A N/A N/A N/A N/A The Netherlands NL N/A 156 N/A Norway NO Poland PL N/A Portugal PT Romania RO Russian Federation RU San Marino SM 3 6 N/A Serbia RS Slovakia SK Slovenia SI Spain ES Sweden a SE N/A N/A N/A N/A N/A Switzerland CH Syria a SY N/A N/A N/A N/A N/A N/A N/A N/A N/A Tunisia a TN N/A N/A N/A N/A 2 3 N/A 4 N/A Turkey TR N/A N/A N/A Ukraine UA UK GB Total ESC countries a These 13 countries did not submit any data on AF ablations for the EHRA White Book 216.

67 Current trends in the use of arrhythmia procedures iii67 Median number of ablations = 5 Germany Denmark Belgium Norway Switzerland Czech Republic Netherlands Finland France Ireland Hungary Austria Iceland Slovenia United Kingdom Estonia Croatia Poland Luxembourg Portugal 69 Greece Spain Russian Federation Latvia Kazakhstan 4244 Slovakia Lithuania Montenegro 28 Turkey Serbia 2128 Bulgaria Ukraine 142 Georgia 13 Belarus 11 Cyprus Romania Egypt Azerbaijan Armenia Algeria Bosnia & Herzegovina Malta San Marino = Ø AF ablations per million inhabitants (weighted by population) 4 th quartile > rd quartile > nd quartile > st quartile Mean number of ablations = Ø 96 Figure 69 Atrial fibrillation ablations per million inhabitants in 215. The mean number of AF ablations is weighted by population. 96 = Ø AF Ablations per million inhabitants (weighted by population) 4 th quartile > rd quartile > nd quartile > st quartile 14 Not available Figure 7 Atrial fibrillation ablations in the ESC countries in 215.

68 iii68 M.J.P. Raatikainen et al. Table 19 Change in the number of catheter ablations of AF in year 215 vs. 214 Country ISO AF ablation procedures 214 AF ablation procedures 215 Change % code Absolute Per million Absolute Per million number inhabitants number inhabitants... Albania a AL N/A N/A N/A N/A N/A Algeria DZ. Armenia AM Austria AT Azerbaijan AZ Belarus BY Belgium BE Bosnia and BA. Herzegovina Bulgaria BG Croatia HR Cyprus CY Czech Republic CZ Denmark DK Egypt EG Estonia EE Finland FI France FR Georgia GE Germany DE Greece GR Hungary HU Iceland IS Ireland IE N/A N/A N/A Israel a IL 55 7 N/A N/A N/A Italy a IT N/A N/A N/A N/A N/A Kazakhstan KZ Kosovo a XK N/A N/A N/A Kyrgyzstan a KGZ N/A N/A N/A N/A N/A Latvia LV Lebanon a LB N/A N/A N/A N/A N/A Libya a LY N/A N/A N/A N/A N/A Lithuania LT Luxembourg LU FYR Macedonia a MK N/A N/A N/A Malta MT. Moldova a MD N/A N/A N/A N/A N/A Montenegro ME Morocco a MA N/A N/A N/A N/A N/A The Netherlands NL Norway NO Poland PL Portugal PT Romania RO Russian Federation RU San Marino SM N/A N/A N/A Serbia RS Slovakia SK Slovenia SI Continued

69 Current trends in the use of arrhythmia procedures iii69 Table 19 Continued Country ISO AF ablation procedures 214 AF ablation procedures 215 Change % code Absolute Per million Absolute Per million number inhabitants number inhabitants... Spain ES Sweden a SE N/A N/A N/A Switzerland CH Syria a SY N/A N/A N/A N/A N/A Tunisia a TN 4 4 N/A N/A N/A Turkey TR Ukraine UA UK GB Total ESC countries a These seven countries did not submit any data on AF ablations for the EHRA White Book vs. 214 in % 214,2 14,8 11,4 23,5 49,9 7,2 4, 56,6 74,9 29,2 21,1 1,1 34,6 Finland 139,7 Azerbaijan Turkey Bulgaria Slovakia Croatia Belarus Romania Poland Slovenia Kazakhstan Lithuania Georgia Latvia Belgium 245, Switzerland 28,9 Greece 52, Hungary 19, Estonia 77,9 Denmark 34,9 Czech Republic 216,1 Portugal 63,3 Egypt,7 Montenegro 26,2 Netherlands 22,2 Austria 16,8 Iceland 14, 14, Ukraine Norway Russian Federation 45,4 United Kingdom 12,1 Spain 52,3 Germany France 166, Luxembourg 19,5 Serbia 32,7 Cyprus 45,2 Armenia 3,6 278,2 432,1-23,1-36,1-81,4-9,9-2, -2,3-3,7-3,8-8,2 197,1 87,2 79,3 76,1 72,9 55,4 5,4 49,1 44, 43,8 33, 28,1 27,9 21, 18, 17,4 16,1 11,6 11,6 1,6 1,3 8,5 6,4 6,4 5, 4,4 4,3 1,6,8 45,2 21,1 32,7 29,2 19,5 11,4,7 1,1 77,9 14, 3,6 52, 49,9 19, 63,3 34,6 12,1 56,6 16,8 28,9 52,3 139,7 216,1 245, 34,9 184,2,,, 26,2 7,2 278,2 14, 74,9 23,5 4,,2 493,8 Figure 71 Change in the number of AF ablations per million inhabitants from 214 to 215. Discussion For almost a decade, the EHRA White Book has been a key resource for healthcare professionals and stakeholders with an interest in the advancement of cardiac arrhythmia therapies in Europe. It has already played an important role in the ICD for life programme 3 and many other strategic initiatives and awareness activities of the EHRA. Current analysis of the EHRA White Book data showed that considerable variations in access to and use of invasive EPs continue to exist within the ESC area. Despite several improvements over the last 5 years, there is still a clear need to improve the availability of invasive procedures for complex arrhythmias in many ESC countries. As in previous years, the mean CIED implantation rates were markedly lower in the Eastern European and non-european ESC countries than in the other regions. The catheter ablation activity

70 iii7 M.J.P. Raatikainen et al. Northern Europe Western Europe European ESC countries EU Southern Europe Eastern Europe Non-European ESC countries ESC Figure 72 Atrial fibrillation ablations per million inhabitants 15 in the five geographical regions of the ESC and comparison with the total ESC area and the 28 member countries of the European Union (EU28). Northern Europe TOP 3 Denmark Norway Finland Lowest 3 Estonia Latvia Lithuania Figure 73 Atrial fibrillation ablations per million inhabitants 15 in Northern Europe. was substantially higher in the Western and Northern European than in the non-european ESC countries. The Eastern European ESC countries were characterized by large variations in the procedure rates, with numbers spanning over all four quartiles of the activity distribution. Surprisingly, there was a drop in the number of LEs between 214 and 215, although continued increase in numbers was expected. The reasons for this are unclear, and it cannot be excluded that this was related to a reporting bias.

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