Publish in this journal
Journal Information
Vol. 71. Issue 12.
Pages 1047-1058 (December 2018)
Share
Share
Download PDF
More article options
Visits
992
Vol. 71. Issue 12.
Pages 1047-1058 (December 2018)
Special article
DOI: 10.1016/j.rec.2018.08.024
Full text access
Spanish Implantable Cardioverter-defibrillator Registry. 14th Official Report of the Spanish Society of Cardiology Electrophysiology and Arrhythmias Section (2017)
Registro Español de Desfibrilador Automático Implantable. XIV Informe Oficial de la Sección de Electrofisiología y Arritmias de la Sociedad Española de Cardiología (2017)
Visits
992
Ignacio Fernández Lozanoa,
Corresponding author
iflozano@secardiologia.es

Corresponding author: Unidad de Arritmias, Hospital Puerta de Hierro, Manuel de Falla 1, 28222 Majadahonda, Madrid, Spain.
, Joaquín Osca Asensib, Javier Alzueta Rodríguezc
a Servicio de Cardiología, Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
b Servicio de Cardiología, Hospital La Fe, Valencia, Spain
c Servicio de Cardiología, Hospital Virgen de la Victoria, Málaga, Spain
This item has received
992
Visits
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (8)
Show moreShow less
Tables (4)
Table 1. Implantations Performed by Autonomous Community, Province, and Hospital
Table 2. Number of First-time Implantations by Type of Heart Disease, Type of Clinical Arrhythmia, and Form of Presentation, 2013 to 2017
Table 3. Changes in the Main Indications for Implantable Cardioverter-defibrillators (Percentage of First-time Implantations, 2008-2017)
Table 4. Percent Distribution of Implanted Devices by Type
Show moreShow less
Abstract
Introduction and objectives

The Spanish Automatic Defibrillator Registry has provided activity data since 2002.

Methods

The data in this registry are submitted by implantation centers that voluntarily complete a data collection sheet.

Results

During 2017, a total of 6273 implant sheets were received, compared with 6429 reported by Eucomed (European Confederation of Medical Suppliers Associations). Therefore, the registry contains data on 97.6% of the devices implanted in Spain. Compliance ranged from 99.7% for the field “name of the implanting hospital” to 46.1% for the variable “New York Heart Association functional class”. A total of 181 hospitals reported data to the registry, representing an increase compared with the number of participating hospitals in 2016 (177) and in previous years (169 in 2015, 162 in 2014, 154 in 2013, and 153 in 2012).

Conclusions

The number of implants per million inhabitants in Spain increased for several years but decreased in 2017. As in previous years, the total number of implants in Spain is still much lower than the European Union average, and the gap continues to widen. There are still substantial differences between autonomous communities.

Keywords:
Implantable cardioverter-defibrillator
Registry
Sudden death
Abbreviations:
CRT
ICD
Eucomed
SEC
Resumen
Introducción y objetivos

El Registro Español de Desfibrilador Automático aporta datos de actividad desde el año 2002.

Métodos

Los datos de este registro provienen de los centros implantadores, que cumplimentaron voluntariamente una hoja de recogida de datos.

Resultados

Durante 2017 se han recibido 6.273 hojas de implante, frente a las 6.429 comunicadas por Eucomed (European Confederation of Medical Suppliers Associations); por lo tanto, se han recogido datos del 97,6% de los dispositivos implantados en España. El cumplimiento osciló entre el 99,7% en el campo «nombre del hospital implantador» y el 46,1% en la variable «clase funcional de la New York Heart Association». Comunicaron sus datos al registro 181 hospitales, lo que supone un aumento respecto a los que participaron en 2016 (177) y años anteriores (169 en 2015, 162 en 2014, 154 en 2013 o 153 en 2012).

Conclusiones

Después de varios años de crecimiento en el número de implantes por millón de habitantes, este año se ha reducido. Como en los años previos, el número total de implantes en España sigue siendo muy inferior a la media de la Unión Europea, y la diferencia continúa aumentando, al igual que persisten las importantes diferencias entre comunidades autónomas españolas.

Palabras clave:
Desfibrilador automático implantable
Registro
Muerte súbita
Full Text
INTRODUCTION

Implantable cardioverter-defibrillator (ICD) placement is the most effective treatment for preventing sudden cardiac death secondary to ventricular arrhythmia. Various clinical trials and meta-analyses have substantiated the ICD indications compiled in clinical practice guidelines for the treatment of patients with ventricular arrhythmias or a risk of sudden cardiac death; these include both primary and secondary prevention measures for sudden cardiac death.1–5 Sudden cardiac death secondary to ventricular arrhythmia has a huge socioeconomic impact, with an incidence in Europe of 400 000 deaths per year, 40% of which occur before the age of 65 years.

It is important to know how patients are selected for ICD placement in clinical practice, the degree to which the guidelines are followed, the yearly incidence of implantations, and the potential impact of other therapies such as the sacubitril/valsartan combination.6 There is also a great deal of interest in determining the impact of the latest reported clinical trials on ICD use in certain conditions, such as dilated cardiomyopathy.7 Last, it is important to compare the implantation activity between the various autonomous communities of Spain, and in particular, the overall implantation rate with that of other European countries. Health registries are of value in this task, as they reflect current clinical practice and are useful for patients, physicians, health care administrators, and manufacturers of cardiac arrhythmia devices.

The Spanish Implantable Cardioverter-defibrillator Registry, developed by members of the Electrophysiology and Arrhythmias Section of the Spanish Society of Cardiology (SEC, Sociedad Española de Cardiología), has been published yearly since 2005.8–20 This report presents the data on ICD implantation submitted to the Spanish Automatic Defibrillator Registry in 2017. The majority of centers performing this activity in Spain have collaborated in the registry. As in other years, this report reviews the patients’ indications and clinical characteristics, the implantation data, the device type and programming, and procedure-related complications.

METHODS

Data were compiled using a data collection form. The form was voluntarily completed by each implantation team directly either during or after the procedure, sometimes in collaboration with the device manufacturer's technical personnel. Procedures involving first-time implants as well as generator replacements were eligible for notification to the registry.

A team consisting of a technician, a SEC computer scientist, and a member of the Electrophysiology and Arrhythmia Section entered information in a database. Data cleansing was carried out by the technician and Section member. The authors of this article analyzed the data and are responsible for this publication.

The census data for the various calculations of rates per million population, both national rates and by autonomous community and province, were obtained from the Spanish National Institute of Statistics as of January 1, 2018.21 As in previous years, the data from the present registry were compared with those provided by the European Confederation of Medical Suppliers Associations (Eucomed).

When more than 1 presentation form or clinical arrhythmia was recorded on the data collection sheet of a single patient, only the most serious condition was included in the analysis. The percentage of each parameter analyzed was calculated taking into account the total number of implantations with available information on the parameter.

Statistical Analysis

Results are expressed as the mean±standard deviation or the median [interquartile range], depending on the distribution of the variable. Continuous quantitative variables were analyzed using analysis of variance or the Kruskal-Wallis test, and qualitative variables using the chi-square test. Linear regression models were used to analyze the number of implantations and implantation units per million population, and the total number of implantations and number for primary prevention in each center.

RESULTS

A total of 6273 implantation forms were received, whereas 6429 procedures were notified by Eucomed; hence, data were collected on 97.6% of implantation procedures performed in Spain. Compliance ranged from 99.7% for the field name of implantation hospital to 46.1% for the field New York Heart Association (NYHA) functional class.

Implantation Centers

In total, 181 hospitals carrying out ICD implantations reported data to the registry, which represents an increase with respect to 2016 (177) and previous years (169 in 2015, 162 in 2014, 154 in 2013, and 153 in 2012). Data from the 181 hospitals are shown in Table 1; 77 were public health centers. The total number of implantation centers, the rate per million population, and the total number of implantations per autonomous community according to the data sent to the registry are shown in Figure 1. During 2017, 100 or more devices were implanted by 22 centers, 10 or fewer devices by 86 centers, and only 1 device by 34 centers.

Table 1.

Implantations Performed by Autonomous Community, Province, and Hospital

Andalusia
AlmeríaHospital Torrecárdenas  22 
Hospital Vithas Virgen del Mar 
Hospital Comarcal La Inmaculada 
CádizClínica Nuestra Señora de la Salud 
Hospital de Jerez  40 
Hospital San Carlos 
Hospital Universitario de Puerto Real  16 
Hospital Universitario Puerta del Mar  52 
CórdobaHospital de la Cruz Roja de Córdoba 
Hospital Universitario Reina Sofía de Córdoba  51 
Granada  Hospital Universitario Virgen de las Nieves  103 
HuelvaHospital Costa de la Luz 
Hospital General Juan Ramón Jiménez  50 
Hospital Infanta Elena 
Jaén  Complejo Hospitalario de Jaén  32 
MálagaClínica de la Encarnación 
Clínica El Ángel 
Clínica Parque San Antonio  11 
Hospital Internacional Xanit 
Hospital Quirón de Málaga 
Hospital Quirónsalud Marbella 
Hospital Virgen de la Victoria  241 
SevilleClínica HLA Santa Isabel  11 
Hospital de Fátima 
Hospital Nisa Aljarafe 
Hospital Nuestra Señora de Valme  33 
Hospital Quirónsalud Sagrado Corazón 
Hospital Virgen del Rocío  101 
Hospital Virgen Macarena  60 
Aragón
ZaragozaHospital Clínico Universitario Lozano Blesa  48 
Hospital Miguel Servet  180 
Hospital Quirónsalud Zaragoza 
Principality of AsturiasHospital de Cabueñes  10 
Hospital Universitario Central de Asturias  168 
Balearic IslandsClínica Juaneda 
Clinica Quirón Palmaplanas 
Hospital Son Llàtzer  31 
Hospital Universitari Son Espases  77 
Policlínica Nuestra Señora del Rosario 
Canary Islands
Las PalmasHospital Dr. Negrín  40 
Hospital Insular de Gran Canaria  51 
Hospital Nuestra Señora del Perpetuo Socorro 
Hospital Dr. José Molina Orosa 
Clínica San Roque S.A. 
Santa Cruz de TenerifeHospital San Juan de Dios de Tenerife 
Hospital Nuestra Señora de la Candelaria  55 
Hospital Universitario de Canarias  70 
Hospiten Ramblas 
CantabriaClínica Mompía 
Hospital Universitario Marqués de Valdecilla  136 
Castile and León
Ávila  Hospital Nuestra Señora de Sonsoles  14 
Burgos  Hospital Universitario de Burgos (HUBU)  53 
LeónClínica San Francisco de León 
Hospital de León  62 
Hospital HM Nuestra Señora de Regla 
Salamanca  Complejo Hospitalario de Salamanca  75 
Segovia  Hospital General de Segovia 
ValladolidHospital Recoletas Campo Grande  10 
Hospital Clínico Universitario de Valladolid  84 
Hospital Universitario Río Hortega  35 
Castile-La Mancha
AlbaceteHospital General de Albacete  63 
Hospital Quirónsalud Albacete 
Sanatorio Santa Cristina 
Ciudad RealHospital General de Ciudad Real  60 
Quirón Ciudad Real 
Cuenca  Hospital Virgen de la Luz 
Guadalajara  Hospital General y Universitario de Guadalajara  31 
ToledoHospital Nuestra Señora del Prado  27 
Hospital Virgen de la Salud  111 
Catalonia
BarcelonaCentro Médico Teknon 
Clínica Corachan 
Clínica Delfos 
Clínica Quirónsalud Barcelona 
Clínica Sagrada Família 
Hospital Clínico de Barcelona  225 
Hospital de Bellvitge  146 
Hospital de la Santa Creu i Sant Pau  170 
Hospital de Sabadell Parc Taulí  26 
Hospital del Mar  27 
Hospital El Pilar (Quirónsalud)  14 
Hospital General de Catalunya 
Hospital Germans Trias i Pujol  54 
Hospital Sant Joan de Déu  11 
Hospital Vall d’Hebron  137 
GironaClínica Girona 
Hospital Universitario de Girona Dr. Josep Trueta  21 
Lleida  Hospital Universitario Arnau de Vilanova  28 
Tarragona  Hospital Universitario de Tarragona Joan XXIII  23 
Valencian Community
AlicanteClínica Vistahermosa 
Hospital General de Elda 
Hospital General Universitario de Alicante  169 
Hospital General Universitario de Elche 
Hospital IMED de Levante 
Hospital IMED Elche 
Hospital Mediterráneo 
Hospital Universitari Sant Joan d’Alacant  56 
CastellónConsorcio Hospitalario Provincial de Castellón 
Hospital Comarcal de Vinaròs 
Hospital General Universitari de Castelló  62 
Hospital Rey Don Jaime 
ValenciaHospital Arnau de Vilanova de Valencia 
Hospital Casa de Salud 
Hospital Clínico Universitario de Valencia  97 
Hospital de Manises  42 
Hospital General Universitario de Valencia  86 
Hospital IMED Valencia 
Hospital Nisa 9 de Octubre 
Hospital Quirónsalud Valencia 
Hospital Universitari de la Ribera  63 
Hospital Universitario Dr. Peset  28 
Hospital Universitario La Fe  160 
Extremadura
BadajozHospital Infanta Cristina de Badajoz  126 
Hospital Quirónsalud Clideba Badajoz 
Cáceres  Complejo Hospitalario de Cáceres  30 
Galicia
A CoruñaComplejo Hospitalario Universitario de A Coruña  169 
Complejo Hospitalario Universitario de Santiago  129 
Hospital HM Modelo 
Hospital Quirónsalud A Coruña 
LugoComplejo Hospitalario Xeral Calde 
Hospital Universitario Lucus Agusti  19 
Orense  Complejo Hospitalario de Ourense  13 
PontevedraComplejo Hospitalario de Pontevedra 
Hospital Álvaro Cunqueiro  86 
Hospital Montecelo 
Hospital Nuestra Señora de Fátima 
Hospital Povisa  22 
La RiojaHospital San Pedro  27 
Hospital Viamed Los Manzanos 
Community of MadridClínica La Luz 
Clínica La Milagrosa 
Clínica Moncloa  32 
Clínica Ruber, S.A. 
Fundación Hospital de Alcorcón  25 
Fundación Jiménez Díaz, Clínica Ntra. Sra. de la Concepción  58 
Grupo Hospital de Madrid  14 
Hospital 12 de Octubre  77 
Hospital Central de la Defensa  25 
Hospital Clínico San Carlos  126 
Hospital de Fuenlabrada  12 
Hospital de Torrejón 
Hospital General Universitario Gregorio Marañón  75 
Hospital General de Villalba 
Hospital Infanta Leonor  14 
Hospital Infanta Sofía 
Hospital Los Madroños 
Hospital Nisa Pardo de Aravaca 
Hospital Quirón Madrid 
Hospital Quirón San Camilo 
Hospital Ramón y Cajal  108 
Hospital Rey Juan Carlos  26 
Hospital Ruber Internacional 
Hospital San Rafael 
Hospital Severo Ochoa  20 
Hospital Universitario de Getafe  19 
Hospital Universitario Infanta Elena 
Hospital Universitario La Paz  117 
Hospital Universitario Puerta de Hierro Majadahonda  138 
Hospital Virgen de la Paloma 
Hospital Virgen del Mar 
Hospital Vithas Nuestra Señora de América 
Sanatorio San Francisco de Asís 
Region of MurciaHospital General Universitario Morales Meseguer 
Hospital General Universitario Reina Sofía (Murcia)  14 
Hospital General Universitario Santa Lucía  41 
Hospital La Vega - HLA 
Hospital Rafael Méndez  20 
Hospital Universitario Virgen de la Arrixaca  69 
Chartered Community of NavarreClínica San Miguel IMQ 
Clínica Universidad de Navarra  32 
Hospital de Navarra  61 
Basque Country
ÁlavaHospital Vithas San José 
Hospital Universitario de Araba  54 
GuipúzcoaHospital Universitario de Donostia  155 
Policlínica Gipuzkoa Quirón 
VizcayaHospital de Basurto  48 
Hospital de Cruces  57 
Hospital de Galdakao-Usansolo  15 
Hospital Quirón Vizcaya 
IMQ Zorrotzaurre 
Figure 1.

Distribution of implantation activity by autonomous community in 2017: number of implantation centers/rate per million population/total number of implantations. Mean rate, 135 implantations/million population.

(0.21MB).
Total Number of Implantations

The total number of implantations (first-time and replacements) in 2017 was 6273, a value representing an increase compared to 2016 (5673). The total number of implantations reported to the registry and those estimated by Eucomed in the last 10 years are summarized in Figure 2. These data indicate that the 2017 values actually signify a reduction in the number of ICD implantations performed in Spain relative to the previous year (6662 according to the 2016 Eucomed data).

Figure 2.

Total number of implantations notified and number estimated by Eucomed, 2008 to 2017. Eucomed, European Confederation of Medical Suppliers Associations; ICD, implantable cardioverter-defibrillator.

(0.15MB).

The overall implantation rate was 135/million population recorded in the registry and 138/million population according to Eucomed. This latter value is lower than that of the previous year (143/million population in 2016) and is much lower than the mean ICD implantation rate in Europe (311/million population in 2017). The changes occurring over the last 10 years in the implantation rates per million population according to the registry and Eucomed data are shown in Figure 3.

Figure 3.

Total number of implantations notified per million population and number estimated by Eucomed, 2008 to 2017. Eucomed, European Confederation of Medical Suppliers Associations; ICD, implantable cardioverter-defibrillator.

(0.14MB).

The name of the hospital where the procedure took place was recorded in 97.6% of notifications. The procedures notified to the registry by each participating hospital are shown in Table 1. Most implantations (5920, 94.7%) were performed in public health centers.

First Implantations Versus Replacements

This information was provided in 5193 forms sent to the SEC (83% of procedures included in the registry). There were 3710 first-time implantations; that is, 71.4% of the total (66.8% in 2016, 71.8% in 2015, 72.6% in 2014, 68.8% in 2013, and 69.4% in 2012). The rate of first-time implantations per million population was 76.5 (65.5 in 2016, 75.1 in 2015, 79.0 in 2014, 63.8 in 2013, and 64.0 in 2012).

Age and Sex

The mean (range) age of patients undergoing ICD implantation or replacement was 62.6±13.4 (6-90) years in 2017 compared with 62.7±13.4 (6-90) in 2016, 62.8±13.3 (6-89) in 2015, and 61.8±13.7 (7-94) in 2014. The mean age of patients undergoing first-time ICD implantation was 61.4±13.1 years. Men accounted for the vast majority: 82.6% of all patients and 83.6% of first-time implantations.

Underlying Heart Disease, Left Ventricular Ejection Fraction, Functional Class and Baseline Rhythm

Ischemic heart disease was the most common underlying heart disease in first-time implantations (54%), followed by dilated cardiomyopathy (25.6%), hypertrophy (6.6%), primary conduction abnormalities (Brugada syndrome and long QT syndrome) (3.1%), cardiac valve diseases (1.6%), and arrhythmogenic right ventricular cardiomyopathy (0.8%) (Figure 4).

Figure 4.

Type of heart disease prompting implantation (first-time implantations). ARVC, arrhythmogenic right ventricular cardiomyopathy. Others, patients with more than one diagnosis.

(0.22MB).

The patients’ left ventricular systolic function was provided in 68.67% of forms sent to the registry. In this overall group, left ventricular ejection fraction was> 50% in 17.4%, 50% to 41% in 8.5%, 40% to 36% in 8.3%, 35% to 31% in 20.6%, and ≤ 30% in 45.2% (Figure 5). Separate analyses in first-time ICD implantations and replacements yielded similar distributions.

Figure 5.

Left ventricular ejection fraction (LVEF) of patients in the registry (total and first-time implantations).

(0.05MB).

The NYHA functional class was recorded in 46.1% of forms. Most patients were in NYHA class II (53.4%), followed by NYHA III (28.3%), NYHA I (16.5%), and NYHA IV (1.9%). The distribution for this variable was similar between the overall group and first-time implantations (Figure 6).

Figure 6.

New York Heart Association (NYHA) functional class of patients in the registry (total and first-time implantations).

(0.04MB).

The patients’ baseline cardiac rhythm was recorded in 72.1% of notifications: sinus rhythm predominated (79%), followed by atrial fibrillation (16%) and pacemaker rhythm (4.58%). The remaining patients had other rhythms (eg, atrial flutter).

Clinical Arrhythmia Prompting Implantation, Presentation Form, and Induced Arrhythmia on Electrophysiological Study

The clinical arrhythmia that led to device implantation was reported in 67.3% of forms sent to the registry. Most patients in the first-time implantation group had no documented clinical arrhythmias (59.9%), whereas 17.0% showed sustained monomorphic ventricular tachycardia, 10.9%, nonsustained ventricular tachycardia, and 10.9% ventricular fibrillation. In the overall group, 57.4% had no documented clinical arrhythmia (Figure 7). The most common clinical presentation in both the total number of patients and in those undergoing first-time implantation (56.1% with responses provided) was an absence of symptoms, followed by syncope, sudden cardiac death, and others (Figure 8).

Figure 7.

Distribution of the arrhythmias prompting implantation (total and first-time implantations). NSVT, nonsustained ventricular tachycardia; PVT, polymorphic ventricular tachycardia; SMVT, sustained monomorphic ventricular tachycardia; VF, ventricular fibrillation.

(0.04MB).
Figure 8.

Initial presentation form in patients included in the registry (total and first-time implantations). SCD, sudden cardiac death.

(0.05MB).

Information on the electrophysiological studies performed before ICD implantation was provided in 62.6% of forms sent to the registry. These studies were carried out in 191 patients (8.2%), mainly those with ischemic heart disease and dilated cardiomyopathy. The most common induced arrhythmia was sustained monomorphic ventricular tachycardia (50.9%), followed by nonsustained ventricular tachycardia (9.9%), ventricular fibrillation (19.9%) and, to a lesser extent, other arrhythmias (6.8%). In 12.4% of the electrophysiological studies, no arrhythmia was induced.

Clinical History

Variables related to the patients’ clinical history have been recorded since 2011 so that the profile of patients receiving an ICD in Spain can be established.

Responses to these questions were provided in 62.6% of notifications from first-time implantations. The following are the most important data related to cardiovascular risk and other background: hypertension, 58%; hypercholesterolemia, 50%; smoking, 37%; diabetes mellitus, 31%; history of atrial fibrillation, 27%; family history of sudden cardiac death, 8%; renal failure, 15%; and stroke, 7%.

The QRS interval was reported in 46.3% of first-time implantations (mean, 121ms). The QRS value was> 140ms in 39%, and 88.7% of these patients were carriers of a cardiac resynchronization therapy-defibrillator (CRT-D).

Indications

The changes occurring over time (2013-2015) in first-time implantations and the form of presentation according to the type of heart disease are shown in Table 2. These data were provided in 62.6% of notifications. Ischemic heart disease was the most frequent reason for ICD implantation in Spain, accounting for 54% of first-time implantations in 2017. Among ischemic heart disease patients, the most common indication was for primary prevention (39%), although this rate is lower than those recorded in previous years (values greater than 45%). Nonetheless, in a large percentage of data collection forms, the reason prompting ICD implantation was not specified or was unclassifiable. Dilated cardiomyopathy was the second most common reason for implanting ICDs (29% of all first-time procedures). However, there was a reduction in the absolute number of first-time implantations for this reason (830 in 2017 vs 866 in 2016, 964 in 2015, and 851 in 2014). As occurred in the case of ischemic heart disease, this decrease was mainly due to a smaller number of indications for primary prevention (41% vs 64% in 2016 and 48% in 2015). In less common heart diseases, the most frequent indication was primary prevention in hypertrophic cardiomyopathy, valve diseases, congenital conditions, and Brugada syndrome. However, the most common indication in long QT syndrome was secondary prevention, which contrasts with values reported in the 2 previous years (48% in 2017 vs 30% in 2016 and 38% in 2015), but is similar to the 2014 situation (70%).

Table 2.

Number of First-time Implantations by Type of Heart Disease, Type of Clinical Arrhythmia, and Form of Presentation, 2013 to 2017

  2013  2014  2015  2016  2017 
Ischemic heart disease
Aborted SCD  135 (10.5)  141 (6.7)  200 (11.9)  135 (10.4)  101 (6.5) 
SMVT with syncope  160 (11.9)  173 (10.6)  243 (14.5)  142 (10.9)  135 (8.7) 
SMVT without syncope  179 (13.3)  108 (6.6)  121 (7.2)  226 (17.3)  212 (13.7) 
Syncope without arrhythmia  43 (3.2)  70 (4.3)  174 (10.4)  31 (2.4)  61 (3.9) 
Indication for prophylaxis  657 (48.8)  740 (45.5)  804 (48.9)  650 (49.9)  603 (39.0) 
Missing/unclassifiable  169 (12.6)  393 (24.8)  158 (9.4)  121 (9.3)  434 (28.0) 
Subtotal  1343  1625  1672  1305  1546 
Dilated cardiomyopathy
Aborted SCD  46 (6.0)  25 (6.8)  63 (6.5)  51 (5,9)  61 (7.3) 
SMVT with syncope  79 (10.4)  72 (8.5)  67 (6.9)  43 (5.0)  65 (7.8) 
SMVT without syncope  81 (10.7)  111 (13.4)  113 (11.7)  91 (10.5)  100 (12.0) 
Syncope without arrhythmia  49 (6.5)  37 (4.3)  66 (6.8)  59 (6.8)  30 (3.6) 
Indication for prophylaxis  395 (52.1)  400 (47.0)  459 (47.6)  550 (63.5)  341 (41.0) 
Missing/unclassifiable  108 (14.2)  173 (20.3)  196 (20.3)  72 (8.3)  233 (28.7) 
Subtotal  758  851  964  866  830 
Valve disease
Aborted SCD  11 (10.2)  11 (9.0)  19 (14.4)  12 (10.5)  5 (5.3) 
SMVT  41 (37.9)  38 (31.5)  33 (25.0)  28 (24.5)  22 (23.2) 
Syncope without arrhythmia  4 (3.7)  7 (5.7)  13 (9.9)  9 (7.9)  5 (5.3) 
Indication for prophylaxis  38 (35.2)  46 (37.7)  55 (41.7)  52 (45.6)  46 (48.4) 
Missing/unclassifiable  14 (12.9)  20 (16.4)  12 (9.9)  13 (11.4)  17 (17.9) 
Subtotal  108  126  132  114  95 
Hypertrophic cardiomyopathy
Secondary prevention  58 (29.9)  62 (25.8)  60 (24.3)  49 (20.3)  49 (21.5) 
Indication for prophylaxis  131 (67.5)  166 (69.2)  179 (72.5)  176 (70.3)  166 (72.8) 
Missing/unclassifiable  5 (2.8)  12 (5.0)  8 (3.2)  16 (6.6)  13 (5.7) 
Subtotal  194  240  247  241  228 
Brugada syndrome
Aborted SCD  9 (13.6)  8 (13.7)  7 (15.9)  16 (24.2)  11 (15.5) 
Prophylactic implantation in syncope  28 (42.4)  17 (29.3)  14 (31.8)  10 (15.2)  16 (22.5) 
Prophylactic implantation without syncope  18 (27.2)  22 (37.9)  12 (27.3)  35 (53.0)  38 (53.5) 
Missing/unclassifiable  11 (16.7)  11 (18.9)  11 (25.0)  5 (7.6)  6 (8.4) 
Subtotal  66  60  47  66  71 
ARVC
Aborted SCD  5 (12.2)  6 (13.3)  8 (20.5)  2 (4.3)  3 (12.5) 
SMVT  14 (34.5)  16 (35.5)  17 (41.4)  25 (54.3)  7 (29.1) 
Prophylactic implantation  14 (34.5)  16 (35.5)  14 (34.1)  18 (39.1)  10 (41.6) 
Missing/unclassifiable  8 (19.5)  7 (15.5)  2 (4.8)  1 (2.2)  4 (16.6) 
Subtotal  41  45  41  46  24 
Congenital heart disease
Aborted SCD  4 (17.4)  5 (13.9)  9 (27.3)  4 (12.1)  6 (12.0) 
SMVT  6 (26.1)  7 (19.4)  9 (27.3)  10 (30.3)  10 (20.0) 
Prophylactic implantation  10 (43.5)  15 (41.7)  12 (36.4)  12 (36.4)  29 (58.0) 
Missing/unclassifiable  3 (13.4)  9 (25.0)  3 (36.4)  7 (21.2)  5 (10.0) 
Subtotal  23  36  33  33  50 
Long QT syndrome
Aborted SCD  19 (48.7)  19 (70.4)  8 (38.1)  10 (30.3)  15 (48.4) 
Prophylactic implantation  18 (46.1)  5 (18.5)  12 (54.5)  15 (45.5)  12 (38.7) 
Missing/unclassifiable  2 (5.3)  3 (11.1)  2 (9.1)  8 (24.2)  4 (12.9) 
Subtotal  39  26  22  33  31 

ARVC, arrhythmogenic right ventricular cardiomyopathy; SCD, sudden cardiac death; SMVT, sustained monomorphic ventricular tachycardia.

Data are expressed as No. (%).

The indication for ICD implantation was identified in 62.6% of forms. Most first-time implantations were for primary prevention (62%), in a percentage identical to that recorded in 2016 and higher than the values from previous years (Table 3).

Table 3.

Changes in the Main Indications for Implantable Cardioverter-defibrillators (Percentage of First-time Implantations, 2008-2017)

Year  SCD  SMVT  Syncope  Primary prevention 
2008  9.3  21.4  12.3  57.0 
2009  9.4  20.8  13.9  55.9 
2010  10.9  20.6  11.1  57.1 
2011  10.7  15.1  14.6  59.4 
2012  12.5  10.2  19.1  58.1 
2013  13.5  11.1  22.4  53.0 
2014  13.2  17.9  10.2  58.5 
2015  11.2  13.6  16.9  58.2 
2016  11.8  17.0  9.9  62.0 
2017  12.5  15.7  9.8  62.0 

SCD, sudden cardiac death; SMVT, sustained monomorphic ventricular tachycardia

Implantation Setting and Attending Specialist

The implantation setting and specialist performing the procedure were recorded in 72.5% of the data sheets. In total, 83.1% of procedures were carried out in electrophysiology laboratories (82.1% in 2016, 83.2% in 2015, 83.4% in 2014, 79.8% in 2013, and 81.4% in 2012) and 13.8% in operating rooms. Cardiac electrophysiologists performed 80.6% of implantations (81.2% in 2016, 79.6% in 2015, 81.7% in 2014, 80.7% in 2013, and 81.0% in 2012); surgeons performed 9.2% (5.1% in 2016, 9.6% in 2015, 11% in 2014, 13.8% in 2013, and 14% in 2012), and both specialists together, 6%. Other specialists and intensivists were involved in 2.2% and 2% of procedures, respectively.

Generator Placement Site

The location of the placement site in first-time implantations was documented in 72.2% of the data forms. Placement was subcutaneous in 96.4% and subpectoral in the remaining 3.6%. In the total number of procedures carried out, the values were 95.4% and 4.6%, respectively.

Device Type

The type of device implanted is shown in Table 4. This information was recorded in 94.3% of the forms submitted to the registry. In 2017, subcutaneous defibrillator implantation was carried out in 5.3% (6.4% in 2016 and 2.4% in 2015).

Table 4.

Percent Distribution of Implanted Devices by Type

Type of device  TotalFirst-time
  2011  2012  2013  2014  2015  2016  2017  2015  2016  2017 
Subcutaneous            3.6  3.8  2.4  6.4  5.3 
Single-chamber  46.7  49.4  48.2  48.8  48.6  45.4  45.7  50.4  48.4  49.4 
Dual-chamber  18.4  18.0  18.9  17.4  14.5  13.7  15.0  13.2  13.0  14.1 
Resynchronizing  34.9  32.5  32.9  33.7  35.7  37.3  35.7  33.9  32.1  31.5 
Reasons for Device Replacement, Need for Lead Replacement, and Use of Additional Leads

In the total of 1491 replacements, information was provided for 1102 (73.9%). The most common reason for a replacement procedure was battery depletion (74.8%). Complications prompted 10.5% of replacements (8.8% in 2016, 8.6% in 2015, and 7.9% in 2014 and 2013), and a change of the indication occurred in 14.7%. In the 97 replacements with information on timing, 6.2% were performed before 6 months (9.7% in 2016, 10.2% in 2015, 9.6% in 2014, and 11.6% in 2013).

Information on the status of the leads was provided in 62.6% of replacement notifications; 8.1% (84 records) were malfunctioning, and the leads were explanted in the 17.4% of cases in which this information was submitted.

Device Programming

Data on the cardiac pacing mode was recorded in 72.2% of forms. The most common pacing mode programmed was VVI (48.2%), followed by DDD (29.6%), VVIR (9.9%), DDDR (5.4%), and others (1.9%), mainly algorithms to prevent ventricular pacing.

A ventricular fibrillation induction test was performed in 235 patients; that is, 5.3% (4.1% in 2016, 2.7% in 2015, 2.9% in 2014, 5.1% in 2013, and 6.7% in 2012) of the 4464 records providing this data. The mean number of shocks delivered was 1.1. Therefore, the threshold was not calculated in most patients; instead, the device was simply tested to verify proper functioning.

Complications

The development of complications was recorded in 70% of the data forms. Thirty-six complications were described: 10 coronary sinus dissections, 1 cardiac tamponade, 3 pneumothoraces, 4 deaths, and 18 unspecified. The mortality rate was 0.09%, which represents an increase with respect to the 3 previous years (0.02% in 2016, 0.07% in 2015, and 0.05% in 2014), although fortunately, the number remains quite low.

DISCUSSION

The results of the 2017 Spanish Implantable Cardioverter-Defibrillator Registry show the ICD implantation activity for that year. Compared with previous editions, almost all implantations performed in Spain (98%) during 2017 are represented. The results show considerable differences in the ICD implantation rate per million population between the various autonomous communities, and an overall implantation rate much lower than the European mean. The registry provides valuable information regarding the number of implant procedures performed, the type of implant, the indications for implantation, and the patients’ clinical characteristics.

Comparison With Registries From Previous Years

The Spanish Implantable Cardioverter-Defibrillator Registry was first published in 2005 with the results of 2002 to 2004. Up to 2010, there was a yearly increase in the total number of ICD procedures carried out,8–14 but in 2011 and 2012, a decrease was documented both in the registry14,15 and the Eucomed data. Starting in 2013, the number of procedures increased, and exceeded the 2010 values in that year (Figure 2 and Figure 3).17 The year 2017 witnessed the largest number of implantations recorded since the creation of the registry. However, the Eucomed data demonstrate that the number of implantations in Spain was actually lower in 2017 than in 2016. This paradox is explained by the larger number of participating centers notifying their results. In Europe there was also a slight reduction in the number of device implantations in 2017, both ICDs and CRT-Ds (311 ICDs/million population in 2017 vs 320 in 2016).22

The 2017 registry data confirm the increase in indications for primary prevention seen in 2016, with 62% of prophylactic indications (Table 3). This change has been slow and gradual, except for a sudden decrease observed in 2013. Over the last 10 years, this indication has increased by 11.3%. In other European registries, primary prevention was also the main indication for ICD implantation, with values around 80%.23,24

In 2016 and for the first time, the percentage of first- time CRT-D implantations decreased (32.1% vs 33.9% in 2015). An even greater reduction (31.1%) was observed in 2017, whereas in neighboring countries, the value was around 40%. There were no substantial changes in the percentage of first-time single-chamber or dual-chamber ICD implantations in 2017 (49% and 14%, respectively) relative to previous years. Last, first-time subcutaneous ICD implantations were performed in 5.3% in 2017, a value slightly lower than that recorded in 2016 (6.4%) and higher than the 2015 value (2.4%). Whether subcutaneous ICD use has stabilized (as the current value may suggest) or whether it will increase in the coming years, will likely depend on the results of ongoing studies that compare this type of ICD with transvenous devices.

The most common indication in 2017 continued to be ischemic heart disease (54%), followed by dilated cardiomyopathy (25.6%). There was a reduction in the percentage of dilated cardiomyopathy cases as the reason for ICD implantation (29.5% in 2016, 28.4% in 2015, 27.3% in 2014, 28.2% 2013, 27.4% in 2012, and 33.9% in 2011). This reduction was produced mainly as a result of the less extensive use of ICDs for primary prevention of sudden cardiac death. It would be difficult not to relate this smaller percentage of ICD use in dilated cardiomyopathy with the results of the DANISH trial.7 In a survey of European cardiologists, more than half the participants stated that they had changed the indication for ICD implantation as primary prevention for sudden death in dilated cardiomyopathy patients based on the results of the DANISH trial.25 However, the guidelines for the treatment of ventricular arrhythmias and prevention of sudden cardiac death published in the United States in 2017 have maintained the indication of ICD use for primary prevention in this patient population (class I, level of evidence A).1 In the opinion of the guideline authors, the data from the DANISH trial should not be applied to patients who do not have an indication for cardiac resynchronization (less than half the patients included in the study). Furthermore, the findings of 2 meta-analyses continue to show a benefit from ICD use in these patients: a 25% reduction in the relative risk of sudden cardiac death.26,27

In 2016 there was a reduction in CRT-D implantations in patients with dilated cardiomyopathy (44.3%). However, similar to the situation in the years before 2016, more than half the implants in these patients were CRT-Ds in 2017 (58.05%).16–19 In ischemic heart disease patients, the percentage of CRT-D implantations was somewhat higher than in previous years (32.0% in 2017, 26.9% in 2016, and 27.7% in 2015).19,20

With the exception of the DANISH trial, there have been no new studies in the last few years that would change the indications for ICD implantation. The indications for ICD and CRT use are well supported in the related clinical practice guidelines.1,3,28 However, the implantation rate per million population does not correspond to the expected rate based on clinical evidence, particularly in Spain.29 In 2010, the implantation rate per million population in Spain was around half that of Europe (116 vs 248); the difference progressively increased over the following years, and it is now 144 vs 320 per million population.22

In contrast to previous years, the 2017 registry provides data on 98% of the implantations reported by Eucomed. This value is clearly higher than the percentages documented from 2007 to 2016, with values around 85%. Currently, almost all hospitals performing ICD placement provide their data to the registry, even without reaching 100% of implantations. The number of implantation centers has increased relative to 2016. Two hospitals have notified more than 200 implantations, 21 hospitals more than 100 (15 in 2016, 11 in 2015, 11 in 2014), and 88 centers, most of them private, less than 10.

There were no changes relative to previous registries regarding the patients’ epidemiologic characteristics. Patients with severe ventricular dysfunction and in NYHA functional class II and III continue to predominate. Furthermore, there were no differences in the implantation setting compared with previous years: 83.1% of procedures were performed in the electrophysiology laboratory (82.1% in 2016, 83.2% in 2015, and 83.4% in 2014), and electrophysiologists carried out implantation in 80.6% (81.2% in 2016, 79.6% in 2015, and 81.7% in 2014).

Differences Between Autonomous Communities

The 2017 data continue to manifest differences between Spain's autonomous communities. The total implantation rate for 2017 in Spain was 135 per million population according to the registry and 138 according to Eucomed; both these values indicate a true reduction in ICD implantation activity in 2017 compared to 2016 (143 per million population according to Eucomed). Rates in the following autonomous communities were above the national average: Cantabria (236), Aragon (177), Principality of Asturias (172), Galicia (170), the Valencian Community (160), the Basque Country (154), Castile-La Mancha (151), Extremadura (146), the Chartered Community of Navarre (146), the Community of Madrid (142), and Castile and León (140). Those below the national average included Andalusia (124), the Region of Murcia (107), the Canary Islands (104), the Balearic Islands (103), Catalonia (120), and La Rioja (89). In 2017 there was a generalized increase in the number of implantations per million population recorded in the various autonomous communities, which, among other reasons, was likely due to the greater representativeness of the registry that year regarding the true number. Only Andalusia (102 vs 124 in 2016) and Extremadura (146 vs 166 in 2016) showed a lower rate of implantations per million population relative to 2016, whereas Asturias maintained similar values. The difference between the communities with the highest and lowest implantation rate has increased from the 2016 value (236 vs 89 in 2017 compared to 173 vs 80 in 2016).

The 2017data show that the number of implantations per million population held steady or decreased compared with the trend observed up to 2016. The persistent differences between autonomous communities and the even greater difference with respect to Europe are a particular cause for concern. A direct relationship cannot be established between the gross domestic product of each community and the number of implantations, as in some cases, communities with higher incomes show values below the average, and the opposite occurs in some of those with lower incomes. Some communities with above average activity are the least populated, as is the case of Cantabria. Nonetheless, others, such as the Community of Madrid or the Valencian Community, are exceptions to this correlation, being highly populated communities with implantation rates above the national average. Nor is there a relationship with the incidence of ischemic heart disease or heart failure in the various communities. These differences may be explained by other factors, such as the health care organization in each community, the number of arrhythmia units, and the distribution of referrals.

Comparison With Other Countries

The device implantation rate in countries participating in Eucomed was 311 per million population (320 in 2016), including both ICDs and CRT-Ds. Germany, with 510 devices per million population, remained as the country with the largest number of implantations. Spain (138 implantations/million) was the country with the smallest number. The following countries showed higher than average rates: the Czech Republic (418), Italy (412), Denmark (378), the Netherlands (362), and Poland (332). Those with rates below the average included Ireland (280), Austria (256), Sweden (256), Belgium (244), Finland (241), Norway (231), the United Kingdom (227), Switzerland (219), France (218), Portugal (201), Greece (186), and in last place, Spain (138). The difference in the implantation rate in Spain relative to the European average was maintained in 2017 (138 vs 311, compared with 144 vs 320 in 2016 and 138 vs 315 in 2015). Once again, the continuous increase in the difference between Spain and the next to last country (138 vs 186) is striking.

The CRT-D implantation rate was 124 per million population (119 in 2016, 126 in 2015, 119 in 2014, and 113 in 2013). Germany (204 implantations) remained in first place, whereas Spain (49) had the lowest rate of these implantations.

The percentage of CRT-D implantations varied with respect to the total, with values of 29% in Ireland and Denmark, 31% in Poland, and 46% in the Czech Republic. The European average was 40%. Several countries were above this average, including France, Portugal, Switzerland, Great Britain, Germany, Italy, and the Czech Republic. Ireland and Poland had a rate below 30%. The rate in Spain was 36%.

Our neighboring countries have the same regional differences24,30,31 as those seen in the Spanish registry, and there is no explanation for this fact. The number of available arrhythmia units has been suggested, but this is not a clearly related factor, at least in Spain, as certain communities with a large number of available units had smaller implantation rates. Other explanations, such as the income level, also fail to show a relationship. Countries such as Ireland, the Czech Republic, and Poland show values well above the implantation rate in Spain. The prevalence of cardiovascular diseases, the ease of access and organization of the health care system, and the degree of acceptance and adherence to clinical practice guidelines may be related to the implantation rate in Spain and its variability.

Limitations

The 2017 registry collected information from more than 97% of the implantations performed, a higher percentage than in previous years. Nonetheless, compliance with reporting on individual items was uneven. In 2018, we expect that the change in data collection through the website can be implemented, which may improve the results and clinical usefulness of the registry.

Last, we mention that the percentage of complications notified does not reflect the true situation. The data are recorded during or immediately following the implantation procedure; hence, most subacute complications are not collected.

Future Directions of the Spanish Implantable Cardioverter-defibrillator Registry

This registry is the 14th official report. The long life of this undertaking should be a source of satisfaction for the members of the SEC Electrophysiology and Arrhythmia Section that have contributed to its success. The ongoing modernization of the registry will make it possible to obtain more and better information with less effort by those involved. The quality of the data will improve with computerized collection, and notification of some items may become obligatory. This will facilitate more ambitious clinical objectives and enable inclusion of parameters such as mortality, shock delivery, and complications, to provide further important clinical information.

CONCLUSIONS

The 2017 Spanish Implantable Cardioverter-defibrillator Registry has collated

information on nearly 98% of ICD implantations carried out in Spain, which represents almost the total activity and current indications for this therapy. Following several years of growth in the number of implantations performed per million population, this rate decreased in 2017. As in previous years, the total number of implantations performed in Spain was much lower than the European mean, and the gap has continued to widen. In addition, notable differences in this activity persist between Spain's autonomous communities.

CONFLICTS OF INTERESTS

I. Fernández Lozano has participated in clinical studies sponsored by Medtronic, Abbott, Biotronik and Sorin, and has held fellowships from the SEC and the Foundation for Cardiovascular Research. J. Osca Asensi has participated in clinical studies sponsored by Abbott, Boston, and Biotronik. J. Alzueta Rodríguez has participated in communications sponsored by Boston and has held fellowships from FIMABIS.

References
[1]
S.M. Al-Khatib, W.G. Stevenson, M.J. Ackerman, et al.
2017 AHA/ACC/HRS Guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
[2]
D.P. Zipes, A.J. Camm, M. Borggrefe, ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society, et al.
Europace, 8 (2006), pp. 746-837
[3]
S.G. Priori, C. Blomström-Lundqvist, A. Mazzanti, et al.
2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.
Eur Heart J., 36 (2015), pp. 2793-2867
[4]
A.E. Epstein, J.P. Dimarco, K.A. Ellenbogen, American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices); American Association for Thoracic Surgery; Society of Thoracic Surgeons. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons, et al.
Circulation, 117 (2008), pp. e350-e408
[5]
C.M. Tracy, A.E. Epstein, D. Darbar, et al.
2012 ACCF/AHA/HRS Focused Update Incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guide.
J Am Coll Cardiol., 61 (2013), pp. e6-e75
[6]
J.J.V. McMurray, M. Packer, A.S. Desai, et al.
Angiotensin-neprilysin inhibition versus enalapril in heart failure.
N Engl J Med., 371 (2014), pp. 993-1004
[7]
L. Køber, J.J. Thune, J.C. Nielsen, et al.
Defibrillator implantation in patients with nonischemic systolic heart failure.
N Engl J Med., 375 (2016), pp. 1221-1230
[8]
R. Peinado, A. Arenal, F. Arribas, Spanish Implantable Cardioverter-Defibrillator Registry. First official report of the Spanish Society of Cardiology Working Group on Implantable Cardioverter-Defibrillators (2002-2004), et al.
Rev Esp Cardiol., 58 (2005), pp. 1435-1449
[9]
R. Peinado, E.G. Torrecilla, J. Ormaetxe, M. Alvarez, Spanish Implantable Cardioverter Defibrillators Registry. Second official report of the Spanish Society of Cardiology Working Group on Implantable Cardioverter Defibrillators (2005).
Rev Esp Cardiol., 59 (2006), pp. 1292-1302
[10]
R. Peinado, E.G. Torrecilla, J. Ormaetxe, M. Alvarez, Spanish Implantable Cardioverter Defibrillators Registry. Third Official Report of the Spanish Society of Cardiology Working Group on Implantable Cardioverter-Defibrillators (2006).
Rev Esp Cardiol., 60 (2007), pp. 1290-1301
[11]
R. Peinado Peinado, E.G. Torrecilla, J. Ormaetxe, M. Alvarez, Spanish Implantable Cardioverter-Defibrillator Registry. Fourth Official Report of the Spanish Society of Cardiology Working Group on Implantable Cardioverter-Defibrillators (2007).
Rev Esp Cardiol., 61 (2008), pp. 1191-1203
[12]
R. Peinado, E.G. Torrecilla, J. Ormaetxe, M. Alvarez, R. Cozar, J. Alzueta, Spanish implantable cardioverter defibrillator registry. 5th Official Report of the Spanish Society of Cardiology Working Group on Implantable Cardioverter-defibrillators (2008)..
Rev Esp Cardiol., 62 (2009), pp. 1435-1449
[13]
J. Alzueta, A. Linde, A. Barrera, J. Pena, R. Peinado, Spanish Implantable Cardioverter-Defibrillator Registry. Sixth official report of the Spanish Society Of Cardiology Working Group on Implantable Cardioverter-defibrillators (2009).
Rev Esp Cardiol., 63 (2010), pp. 1468-1481
[14]
J. Alzueta, J.M. Fernandez, Spanish implantable cardioverter-defibrillator registry. Seventh Official Report of the Spanish Society Of Cardiology Working Group on Implantable Cardioverter-defibrillators (2010).
Rev Esp Cardiol., 64 (2011), pp. 1023-1034
[15]
J. Alzueta, J.M. Fernandez, Spanish implantable cardioverter-defibrillator registry. Eighth Official Report of the Spanish Society of Cardiology Working Group on Implantable Cardioverter-Defibrillators (2011).
Rev Esp Cardiol., 65 (2012), pp. 1019-1029
[16]
J. Alzueta, J.M. Fernández.
Spanish Implantable Cardioverter-defibrillator Registry. Ninth Official Report of the Spanish Society of Cardiology Electrophysiology and Arrhythmias Section (2012).
Rev Esp Cardiol., 66 (2013), pp. 881-893
[17]
J. Alzueta, A. Pedrote, I. Fernandez Lozano.
Spanish Implantable Cardioverter-defibrillator Registry. Tenth Official Report of the Spanish Society of Cardiology Electrophysiology and Arrhythmias Section (2013).
Rev Esp Cardiol., 67 (2014), pp. 936-947
[18]
J. Alzueta, A. Asso, A. Quesada.
Spanish Implantable Cardioverter-defibrillator Registry. Eleventh Official Report of the Spanish Society of Cardiology Electrophysiology and Arrhythmias Section (2014).
Rev Esp Cardiol., 68 (2015), pp. 996-1007
[19]
J. Alzueta, I. Fernández-Lozano, A. Barrera.
Spanish Implantable Cardioverter-defibrillator Registry. Twelfth Official Report of the Spanish Society of Cardiology Electrophysiology and Arrhythmias Section (2015).
Rev Esp Cardiol., 69 (2016), pp. 1168-1179
[20]
J. Alzueta, I. Fernández-Lozano.
Spanish Implantable Cardioverter-defibrillator Registry. 13th Official Report of the Spanish Society of Cardiology Electrophysiology and Arrhythmias Section (2016).
Rev Esp Cardiol., 70 (2017), pp. 960-970
[21]
Instituto Nacional de Estadística. Datos poblacionales [press release 25 Jun 2018]. Available at: http://www.ine.es/prensa/cp_e2018_p.pdf. Accessed 1 Jul 2018.
[22]
MedTech Europe. Statistics for Cardiac Rhythm Management products, 2013-2017. Available at: http://www.medtecheurope.org/index.php/node/801. Accessed 20 Jun 2018.
[23]
B. Vandenberk, C. Garweg, G. Voros, et al.
Changes in implantation patterns and therapy rates of implantable cardioverter defibrillators over time in ischemic and dilated cardiomyopathy patients.
Pacing Clin Electrophysiol., 39 (2016), pp. 848-857
[24]
A. Proclemer, M. Zecchin, A. D’Onofrio, et al.
[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing — Annual report 2016].
G Ital Cardiol (Rome)., 19 (2018), pp. 119-131
[25]
K.H. Haugaa, R. Tilz, S. Boveda, et al.
Implantable cardioverter defibrillator use for primary prevention in ischaemic and non-ischaemic heart disease-indications in the post-DANISH trial era: results of the European Heart Rhythm Association survey.
Europace., 19 (2017), pp. 660-664
[26]
S.M. Al-Khatib, G.C. Fonarow, J.A. Joglar, et al.
Primary prevention implantable cardioverter defibrillators in patients with nonischemic cardiomyopathy: a meta-analysis.
JAMA Cardiol., 2 (2017), pp. 685-688
[27]
H. Golwala, N.S. Bajaj, G. Arora, P. Arora.
Implantable cardioverter-defibrillator for nonischemic cardiomyopathy: an updated meta-analysis.
Circulation., 135 (2017), pp. 201-203
[28]
SEC Working Group for the 2015 ESC Guidelines for the Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death, Expert Reviewers for the 2015 ESC Guidelines for the Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death, and the SEC Guidelines Committee. Comments on the 2015 ESC Guidelines for the Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.
Rev Esp Cardiol., 69 (2016), pp. 94-101
[29]
A. John Camm, S. Nisam.
European utilization of the implantable defibrillator: has 10 years changed the “enigma”?.
Europace., 12 (2010), pp. 1063-1069
[30]
J.V. Freeman, Y. Wang, J.P. Curtis, P.A. Heidenreich, M.A. Hlatky.
Physician procedure volume and complications of cardioverter-defibrillator implantation.
Circulation., 125 (2012), pp. 57-64
[31]
A. Lazarus, N. Biondi, J.-F. Thebaut, I. Durand-Zaleski, M. Chauvin.
Implantable cardioverter-defibrillators in France: practices and regional variability.
Europace., 13 (2011), pp. 1568-1573
Copyright © 2018. Sociedad Española de Cardiología
Idiomas
Revista Española de Cardiología (English Edition)

Subscribe to our newsletter

Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.