For more than 30 years, or, more specifically, since 1990, one of the main tasks of the Steering Committee of the Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) has been to report the activity recorded in interventional cardiology laboratories in Spain.1–30 These data are collected with considerable interest because they allow us to assess the changes over time in activity vs previous years, the incorporation and growth of new techniques, and the differences among Spanish regions.

Data collection is voluntary; nonetheless, due to the major impact of the national registry data, virtually all publicly-funded and private health centers contribute their data, which has become an annual tradition in all hospitals wishing to participate. Because the registry is not audited, it has several implicit limitations.30 The variables requested are modified annually based on the arrival of new techniques or devices. The database is managed by an independent external company that cleans the data before providing them to the Steering Community of the ACI-SEC. The registry data were presented at the ACI-SEC congress, celebrated on June 10, 2022, in Alicante.

Ultimately, the annual ACI-SEC registry is a testament to the engagement and transparency of the centers involved. It provides a series of vitally important data for describing the trends in interventional cardiology and comparing the data not only among Spanish autonomous communities, but also with those of other countries. This registry could be crucial for investment policies, by justifying the need for growth in certain techniques and in specific regions. In addition, the enormous amount of information gathered provides an opportunity to produce various scientific publications.

This article represents the 31st report on interventional activity in Spain and collects activity from public and private centers corresponding to 2021.

The present registry reports diagnostic and therapeutic procedural activity undertaken in 2021 in interventional cardiology laboratories from most Spanish centers. The registry is voluntary and the data are not audited. In the case of anomalous data, the responsible center was contacted to minimize the margin of error. However, because the registry comprises individual reports from each center, it has an implicit margin of error. Data collection was performed using an electronic form that is modified annually by the members of the ACI-SEC Steering Committee to adapt the variables to new techniques and procedures.31 Nonetheless, the forms may omit a variable related to a new device or procedure. The data were analyzed by an external company with the help of one of the members of the committee. The members of the Steering Committee of the ACI-SEC were in charge of reporting the activity data for 2021 and comparing them with those of previous years.

As in previous years, the population-based calculations for both Spain and each autonomous community were based on the data published by the Spanish National Institute of Statistics on its website.32 The Spanish population was considered to have increased to 47 385 107 individuals; this total population figure was used for calculations per million population. Absolute (No.) and relative (%) data are reported.

The main findings of the ACI-SEC registry of interventional activity in 2021 were the following: a) overall activity clearly recovered compared with 2020, the year in which the SARS-CoV-2 pandemic probably had the greatest impact (figure 9); b) the numbers of procedures in ischemic heart disease increased vs 2020 and reached numbers similar to those of 2021; c) an increase was reported in the use of intracoronary diagnostic techniques (IVUS, pressure guidewire, OCT) and PCI support systems (Impella and extracorporeal membrane oxygenation); d) activity in structural heart disease maintained its strong upward trend, with highly marked increases in TAVI, mitral and tricuspid procedures, atrial appendage closure, and PFO closure; and e) there was once again marked heterogeneity among autonomous communities in the penetration of treatments with proven prognostic impact, such as primary angioplasty and TAVI.

Figure 9.

Overview of the relative increase or decrease in each procedure in 2021 vs 2020. IVUS, intravascular ultrasound; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; PFOC, patent foramen ovale closure; TAVI, transcatheter aortic valve implantation; TEER, transcatheter edge-to-edge repair.

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The last registry published, which collected the activity from 2020, showed a major fall in activity, particularly in diagnostic coronary angiography, primary angioplasty, and TAVI.30 Undoubtedly, 2021 can be defined as a year of recovery after the COVID-19 pandemic, because most of the diagnostic and interventional procedures practically returned to the activity levels of 2019.29 Special mention must be made of the growth in intracoronary diagnostic techniques such as pressure guidewire, IVUS, and OCT. This increase probably reflects the recovery from the pandemic but also a growing recognition by interventional cardiologists of their usefulness.33 Indeed, the use of these techniques increased not only above 2020, but also above that of any of the previous prepandemic years, including 2019 (figure 2).

The current registry also revealed a slight increase in left main coronary artery lesions and chronic occlusions vs 2020. In addition, the data indicated the more than probable awareness of operators of the management of coronary plaque with specific techniques, with a notable increase in the use of lithotripsy balloons, special balloons (mainly cutting), and intracoronary laser or rotational atherectomy.34

Angioplasty in the context of acute myocardial infarction showed a clear decrease in treatments such as rescue and facilitated angioplasties, which became more useful during the pandemic,30 while there was a recovery in primary angioplasties, which reached a level similar to that of the prepandemic period. Notably, despite the unquestionable evidence showing that primary angioplasty is associated with reduced mortality,35 differences remain among autonomous communities, with higher rates per million population in Castile and León and Cantabria and lower rates in the Canary Islands and Balearic Islands. Particularly worrying is the reduction in this rate vs 2020 in these 2 communities. For this reason, the implementation would be recommended of specific measures in the communities with the lowest rates of primary angioplasty (figure 5).

Special mention is required of the increased activity in structural heart diseases and adult congenital heart diseases. It could be said that 2021 represents not only the year of recovery from the pandemic, but also the year with the highest structural heart disease activity of all time. In general, activity has not only increased vs 2020, but has also clearly exceeded that of 2019, the year with the greatest penetration of structural techniques to date.28–30 The increase in TAVI seems unstoppable, with a 34.9% increase vs 2020. Particularly important is the rate of procedures per million population, which increased to 120.7 (figure 7), a clearly higher rate than that of 2020 and which approaches the European average.36 The differences among communities in TAVI use are highly pronounced, with Galicia at the top of the list with 190.3 procedures per million population and La Rioja with less than 60 per million population. Although it is true that all communities underwent an increase vs 2020, the use of TAVI tripled in some communities compared with others.

Mitral and tricuspid interventions also require special mention due to their highly significant increases. The postpandemic recovery, together with the very strong scientific evidence,37 have probably contributed to the consolidation of edge-to-edge mitral repair techniques in Spain. Once again, there were major differences among autonomous communities in the penetration of this technique. Tricuspid valve interventions also markedly increased. Specifically, edge-to-edge tricuspid repair interventions demonstrated the greatest growth and practically tripled the 2020 rate (98 procedures in 2021 vs 38 in 2020). Some recent publications supporting its safety and efficacy have likely contributed to the consolidation of the technique in Spain.38

Other procedures such as left atrial appendage closure and PFO closure showed highly marked increases. Indeed, the greatest growth vs 2020 was seen in atrial appendage closure, at 42.8% (Figure 8 and figure 9). These data confirm the maturity of this technique and its penetration in Spain. Recent articles have supported its use39–41 and augur a probable paradigmatic shift in the management of patients with nonvalvular atrial fibrillation and relative/absolute contraindications to anticoagulation. Regarding PFO closure, 2021 has been the year with the greatest penetration of the technique. Indeed, this technique was one of the few that grew in 2020. The total number of interventions in 2021 increased to 924, reaching a historic annual high since its introduction. This growth may be explained by the recovery from the COVID-19 pandemic, the maturity of the technique, and the general acceptance of the scientific evidence supporting PFO closure.42–44

In the first full year after the beginning of the COVID-19 pandemic, the Spanish Cardiac Catheterization and Interventional Cardiology Registry showed a clear overall recovery in activity vs 2020. Specifically, ischemic heart disease activity largely returned to the values recorded in 2019, and structural heart disease interventional activity progressively increased, exceeding not only that of 2020, but also that of 2019.

This article has not received funding.

All authors have contributed to the drafting and critical revision of the article.

X. Freixa is proctor for Abbott Medical and Lifetech Science. A. Jurado-Román has received honoraria for talks from Boston Scientific. B. Cid declares no conflicts of interest. I. Cruz-González is proctor for Abbott Medical, Lifetech Science, and Boston Scientific.