The current report analyzes data submitted by Spanish hospitals on cardiac pacing activity for 2024. The report includes demographic data, pacemaker types and numbers, indications, pacing modes, and the characteristics of the implanted devices. The data are compared with both those of previous years1–8 and European data provided by Eucomed (European Confederation of Medical Suppliers Association).9 Data on remote monitoring are also presented.

The registry is based on information voluntarily provided by participating centers and manufacturers after device implantation, covering both first implants and replacements. The registry is continuously compiled, updated, and maintained throughout the year by a team comprising full members of the Heart Rhythm Association of the Spanish Society of Cardiology (SEC) and by the technical team and coordinator of the Heart Rhythm Association registries of the SEC. The device manufacturing and marketing industry also collaborates by transferring relevant data. All members contributed to data cleaning and analysis and are responsible for this publication.

In accordance with Spanish Legislation (SCO/3603/2003,10 December 18, and SSI/2443/2014,11 December 17), 2 partially automated files were created: the “National pacemaker registry” and the “National implantable cardioverter-defibrillator registry”. CardioDispositivos12 is the online platform for both registries (owned by the Spanish Agency for Medicines and Health Products, Ministry of Health, Spanish Government). This platform has been managed by the SEC since 2016. Article 36 of Royal Decree 192/2023, of March 21,13 stipulates that health care centers and professionals are required to report specific data on pacemaker and defibrillator implantation (Article 18 of Regulation [EU] 2017/745 of the European Parliament)14 to the abovementioned registries. In 2024, up to the date of drafting this report, 15 223 implants have been reported via this route. This figure represents 57.6% of all implants reported to the recording platform of the Heart Rhythm Association of the SEC. Other information sources included: a) data transfer from the manufacturing and marketing industry; b) the European Pacemaker Patient Identification Card (EPPIC; 3585 pacemakers); and c) local databases submitted by implanting centers (10 524 pacemakers). The total number of units recorded by the registry was determined after cross-referencing these information sources and removing duplicates. Remote monitoring data were obtained entirely from the manufacturers.

Census data for the calculations of rates per million population, both nationally and by autonomous community and province, were obtained from the Spanish National Institute of Statistics.15 For population-based rates, implantation and remote monitoring data were derived from manufacturers’ billing records for 2024. As in previous years, the data from the present registry were compared with those provided by Eucomed.9 The percentages of each variable analyzed were calculated based on the total number of implants with available information on that parameter.

In 2024, 26 412 cardiac pacing device implants were reported to the recording platform of the Heart Rhythm Association of the SEC, which represents an 8.5% increase vs 2023. In total, 128 hospitals reported their implantation activity (16 more than in 2023 and 46 more than in 2022). Records continue to be reported to CardioDispositivos,12 after the 52% increase in 2023 vs 2022. This figure should encourage us to continue to raise awareness of the importance of reporting all implantation activity in each center. These data must be reported, not only to support a quantitative national registry, but also for the pharmacovigilance of implanted material. The recording platform of the Heart Rhythm Association of the SEC encourages the direct inclusion of implantation activity in CardioDispositivos12 or via connections from compatible platforms that facilitate their integration via automated methods. Of all of the devices implanted in Spain reported by Eucomed (47 162 devices), 56% were submitted to CardioDispositivos (a similar figure to 2023 and exceeding the 37.7% recorded in 2022), reflecting the intense efforts of the responsible technical team in the registry and the collaboration with Spanish hospitals.

By autonomous communities, Galicia, Castile and León, and Asturias once again topped the list for implants per million population, due to population aging. However, analysis of implants in patients older than 65 years revealed that the implantation rates per million population were much higher in the Community of Madrid, Balearic Islands, and Valencian Community. Spain lags behind other European countries, with 938 units/million population according to Eucomed9 (2022 data; data from 2023 were not available at the time of article preparation). This figure is well below the average (1001) and particularly behind countries such as Germany (1206), Italy (1207), and Sweden (1063).

Leadless pacemakers once again exhibited slower growth than in 2023. However, devices capable of maintaining AV synchrony comprised 41% of the total, almost twice as many as in 2023. Overall, these devices were used in the same percentage of pacemakers as in 2023 (2.2% overall), which, given the expansion of current indications,17 is likely an underprescription. The underuse of this therapy may have several explanations, such as the difference in price vs conventional pacemakers, the need to leave the device in situ during replacement, the inability to perform conduction system pacing, and the lower experience of centers with these devices.

Currently, the use of axillary vein access almost equals that of subclavian vein access due to the latter's association with pneumothorax and lead fracture during follow-up.18 Indeed, the recommended access route is axillary or cephalic according to the consensus document of the European Heart Rhythm Association endorsed by the Heart Rhythm Society, Asia Pacific Heart Rhythm Society, and Latin American Heart Rhythm Society.19

Regarding pacing modes, DDD/R is still the most commonly used mode overall (64.4%), and its use in AVB is even higher than in 2023 (75%), with limited use of the VDD/R mode (6%). In patients older than 80 years, modes favoring AV synchrony (ie, DDD mode) continued to predominate, with a very similar percentage in both sexes (in contrast to 2023, which showed a higher percentage of DDD pacing in men). The implantation of DDD pacemakers for SSS in patients with predominantly sinus rhythm slightly increased from 2023, reaching 77%, and fell to 55% in octogenarians. In addition to the decreased quality of life with age and the elevated AF burden, there may be many reasons for this reduction. AF/atrial flutter with slow or blocked ventricular response was the second most common device indication. Moreover, single-chamber VVI pacing predominated, although dual-chamber devices were used in 11% in this group. One explanation for this figure, in addition to possible classification errors, could be dual-chamber generator replacements in patients with permanent AF, in which a new dual-chamber device was implanted to avoid abandoning the atrial lead and to thereby preserve magnetic resonance imaging compatibility.

In contrast to the stabilization of previous years, cardiac resynchronization devices showed a significant 3.6% increase, which represented a 4.6% rise in CRT-D devices and a 4% uptick in CRT-P devices. Due to the consistent clinical evidence20–22 comparing conduction system pacing and biventricular pacing in patients indicated for cardiac resynchronization, the superiority of conduction system pacing has been confirmed in terms of functional class and left ventricular ejection fraction.23 However, the CardioDispositivos platform12 does not allow the reporting of lead placement in the conduction system, only in the right atrium, right ventricle, and left ventricle. In addition, there is a high level of missing data for this variable due to incompletion. This represents, as well as a bias, an added difficulty for the interpretation of the findings. Despite these major limitations, the large number of bipolar active-fixation leads implanted in the left ventricle (64%) suggests the current importance of physiological pacing in Spain.24 According to Eucomed data,9 our implantation rate per million population is half that of the European average for both CRT-P and CRT-D devices. These differences are very similar to those recorded in previous years and, even though the use of conduction system pacing for cardiac resynchronization is likely higher in Spain than in the rest of Europe,25 there may still be a low indication for this therapy in patients with heart failure symptoms and left bundle branch block.

There was another slow but gradual increase in the use of remote monitoring programs. These programs improve survival26 in patients implanted with pacemakers and defibrillators and also reduce emergency department visits and face-to-face consultations.27 However, despite current recommendations,28 the widespread use of this technology in all devices remains distant, with considerable differences in implementation percentages among the autonomous communities. This situation suggests a need to standardize the resources (both material and human) required to implement this tool in a consistent and comparable manner.

In 2024, 56% of implanted devices have been reported to the registry platform for the Heart Rhythm Association of the SEC, an 8.5% increase vs 2023. Of the total number of implanted devices, the greatest growth was seen in CRT devices (3.6%), and leadless pacemakers represented 2.2% of all pacemakers, with a highly marked increase in those capable of maintaining AV synchrony. Remote monitoring continues to grow at a slow but steady rate.

The registry is partly funded through an agreement between the Spanish Agency of Medicines and Medical Devices and the Casa del Corazón Foundation. This agreement channels a registered grant established in the 2024 Spanish budget for the management and maintenance of the national pacemaker and implantable defibrillator registries.

The present work has been conducted in accordance with international recommendations on clinical research (Declaration of Helsinki of the World Medical Association) and Organic Law 3/2018 on the Protection of Personal Data and Guarantee of Digital Rights.

No artificial intelligence was used in the preparation of this article.

R. Cózar-León, M. Molina-Lerma, and J. Navarro-Manchón performed the data collection, data analysis, and article drafting. F.J. García-Fernandez conducted the data collection, data analysis, article drafting, and final revision. D. Calvo performed the registry coordination work, data collection, integration, and analysis, critical revision, and final approval.

F.J. García Fernández has received consultancy fees from Medtronic, Boston Scientific, and Biotronik. R. Cózar-León receives consultancy fees from Medtronic. M. Molina-Lerma receives consultancy fees from Abbott, Medtronic, Boston Scientific, and Microport. The remaining authors have no conflicts of interest to declare.