One of the most important tasks of the steering committee of the Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) is to record and produce an annual report on interventional cardiology activities across Spain. The association has been doing this now for over 3 decades.1–32 The ACI-SEC Catheterization and Interventional Cardiology Registry provides an overview of the current situation in Spain and also shows changes over time as new techniques are adopted. The reports also help identify regional differences and facilitate comparisons with other countries. Although participation in this national registry is voluntary, most hospitals, both in the public and private sector, are cognisant of the importance of the data and have made it an annual tradition to submit information. Because the data are not audited, the registry has several limitations. Nonetheless, it contains vital information. The fields to be completed are updated annually to reflect the emergence of new procedures or devices. The database is managed externally by an independent company that supplies the data to the ACI-SEC steering committee for cleaning. The registry was presented at the ACI-SEC conference held in Santander, Spain, on June 9, 2022.

In short, the Spanish Catheterization and Interventional Cardiology Registry is one of the most important initiatives of the ACI-SEC each year: it is an exercise in collaboration and transparency, and sheds light on the latest trends in interventional cardiology in Spain and enables comparison across the country's different regions. The registry is also important as it can help inform investment policies by highlighting the need to promote certain procedures in given geographic areas.

In this article, we present the 32nd report on interventional cardiology in Spain in 2022.

The ACI-SEC registry contains data on interventional cardiology activity undertaken in most public and private hospitals in Spain in 2022. The registry describes diagnostic and therapeutic procedures performed for cardiovascular and other diseases in catheterization laboratories across the country. Data are submitted to the registry on a voluntary basis and are not audited. An implicit margin of error is, therefore, expected. When anomalies are detected, the corresponding hospital is contacted for clarification. Data are submitted via an online form updated by the ACI-SEC steering committee each year to cover new techniques and devices. In 2022, this task was undertaken, for the first time, in conjunction with the person responsible for the Spanish Congenital Heart Disease Registry to ensure a more global vision of congenital heart conditions. The data on interventional cardiology activity in Spain for 2022 were analyzed by an external company aided by a member of the steering committee, who then collated the information and compared it with findings from previous years. As in other years, population rates for Spain and each autonomous community were calculated using data from the Spanish National Institute of Statistics website.33 The total Spanish population for 2022, 47 615 034 inhabitants, was used to calculate rates per million population. Data are expressed as numbers and percentages.

The ACI-SEC Spanish Catheterization and Interventional Cardiology Registry reveals a number of remarkable findings for 2022. First, the latest report confirms a return to normal hospital activity in the wake of the COVID-19 pandemic, with the overall number of interventional cardiology procedures exceeding those reported for 2019. Second, the use of intracoronary diagnostic techniques, including functional tests with a pressure wire, also increased, and for the first time ever, centers submitted information on microcirculation and vasospasm studies. Third, there was an overall increase in intracoronary imaging techniques, in particular IVUS. Fourth, the upward trend for PCI assist devices, in particular intra-aortic balloon pumps, was maintained; the use of Impella devices and extracorporeal membrane oxygenators also increased but less so. Fifth, structural heart disease procedures continued a strong upward trend, with pronounced increases in TAVR, mitral valve repairs, and left atrial appendage closures. Sixth, renal denervations made a comeback, and there was also a marked increase in percutaneous treatments for chronic thromboembolic pulmonary hypertension. Finally, the use of treatments with a proven prognostic impact, such as primary PCI and TAVR, continued to vary across the different regions of Spain.

The 2021 ACI-SEC report showed that hospitals had resumed near-normal operations in the wake of the COVID-19 pandemic.31 This recovery was confirmed by the 2022 report, with similar and in some cases even higher procedure volumes than those reported in 2019.31

The number of centers participating in the registry fell, an important consideration when comparing data from 2022 and 2021. Nevertheless, most of the hospitals invited to participate responded, and we believe that the data provide an accurate picture of interventional cardiology activity in Spain for 2022. Considering that overall activity increased from 2021 to 2022, we were surprised to see a decrease in the number of interventional cardiologists and an increase in that of cardiology fellows.

A number of aspects are worth highlighting in the area of coronary procedures. Radial access continued to dominate, accounting for almost 95% of all access sites used in both diagnostic procedures and PCI. Intracoronary imaging-guided PCI and invasive functional studies (with the first-ever reports of the use of microcirculation and vasospasm procedures) experienced further growth in 2022. The evidence on the usefulness of these procedures is growing, but uptake is probably also up due to a greater awareness of their benefits among interventional cardiologists34 and an increase in the number of complex heart conditions. These circumstances may also have influenced the marked increase observed in calcified plaque modification procedures, for which there is a growing body of information.35 There was also a notable increase in left coronary artery PCIs from 2021 to 2022 and a more modest increase in chronic total occlusion repairs. The growth in drug-eluting balloon angioplasty is also remarkable.

The use of rescue and facilitated PCIs for acute myocardial infarction increased at different stages of the COVID-19 pandemic,30 but this trend was reversed in both 2021 and 2022. The volume of primary PCI activity largely returned to prepandemic levels.29 Although most autonomous communities reported a growth in primary PCI activity, significant regional disparities persist (figure 5), despite clear evidence of the positive impact of this procedure on prognosis.36 Targeted strategies to increase uptake in areas with low volumes of activity may be worth considering.

New records were set for percutaneous treatments for structural heart disease,1–31 with significant increases observed for all procedures compared with 2021. The growth of TAVR activity seems to be unstoppable, with a 16.6% increase vs 2022. The rate per million population also increased significantly (from 120.7 per million population in 2021 to 140.1 per million population in 2022) (figure 6), and is now close to the European mean.37 Although TAVRs increased in practically all the autonomous communities of Spain, significant regional differences remain.

Percutaneous treatment of mitral regurgitation showed one of the steepest growths with respect to 2021, confirming yet again the recovery of normal operations following the COVID-19 pandemic.31 This recovery, together with growing evidence on the benefits of this technique,38 has cemented the use of edge-to-edge mitral valve repairs in Spain, although, again, activity varies across both regions and centers. Tricuspid regurgitation treatments also increased in 2022. Edge-to-edge repair continues to be the most widely used technique,39 but there was also a growth in bicaval prostheses and percutaneous annuloplasties.

Of note, some of the largest increases compared with previous years were observed for percutaneous left atrial appendage closures, renal denervations, and percutaneous treatment of chronic pulmonary thromboembolic pulmonary hypertension (figure 8 and figure 9). The data for 2022 confirm that left atrial appendage closure has come of age and is being increasingly embraced by interventional cardiologists in Spain. The growth can probably be attributed to greater experience and stronger evidence.40–42 Renal denervation is undergoing something of a revival, most likely driven by recent recommendations.43 Finally, percutaneous treatment of pulmonary artery disease deserves a separate mention. Although the volume of acute pulmonary thromboembolism treatments was similar to that in 2021, there was a notable increase in the use of specific devices, a trend that is likely to continue.44,45 Percutaneous treatments for chronic thromboembolism pulmonary hypertension also increased in number. Considering the lack of sufficiently powered randomized trials, this increase may be partly due to experience accumulated in recent years46 and the inclusion of more centers offering this treatment.

Figure 8.

Overview of coronary procedures in 2022 vs 2021. IVUS, intravascular ultrasound; OCT, optical coherence tomography; PCI, percutaneous coronary intervention.

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Figure 9.

Overview of noncoronary procedures in 2022 vs 2021. A: TAVR (transcatheter aortic valve replacement) and left atrial appendage (LAA) and patent oval foramen (POF) closures. B: edge-to-edge mitral and tricuspid valve repair, renal denervation, and chronic thromboembolic pulmonary hypertension (CTEPH).

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This latest report on the Spanish Catheterization and Interventional Cardiology Registry confirms that Spanish hospitals have resumed normal operations in the wake of the COVID-19 pandemic. It also shows that an increase in more complex heart conditions and structural interventions, with the main procedures in this area reaching record numbers.

This study received no funding.

All the authors contributed to writing and critically reviewing this article.

X. Freixa is a proctor for Abbott Medical and Lifetech Science; A. Jurado-Román is a proctor for Boston Scientific, World Medica, Philips-Biomenco, and Medtronic; and I. Cruz-is a proctor for Abbott Medical, Lifetech Science, and Boston Scientific.