The National Registry of cardiac implantable electronic devices (CIED) was set up and has been maintained by the Portuguese Association of Arrhythmology, Pacing and Electrophysiology (APAPE) since its founding in 1999. It provides an overview of national trends in the number and type of CIED implanted.

The information we publish reflects the national and regional situation and can, therefore, assist political decision-makers in adapting their actions to current circumstances, both in terms of training professionals and the economic investment required.

The registry is annual, multicenter, and voluntary, and data are collected retrospectively.

In the two years under review, a new online platform was used to make data collection and processing easier. Once fully implemented, it will give participating centers better and easier access to their own data and to the country's data.

The questionnaire available on the platform is similar to the one that was previously sent to each center. To comply with current data protection requirements, each center manager was required to verify their identity during the registration process on the platform. The data collected includes the total number of procedures categorized by the type of device implanted.

Although the sample covers the last two years, we also examined the trend in the total number of interventions, implantations, and replacements over the past decade.

The series categorizes therapies into conventional bradycardia pacemakers, cardiac resynchronization therapy with a pacemaker (CRT-P), implantable cardioverter-defibrillators (ICD), and cardiac resynchronization therapy with defibrillation (CRT-D).

The statistics for the implantation of leadless systems and subcutaneous cardio-defibrillators are also provided.

The data are presented as frequency graphs organized by year and/or implantation center.

The number of centers submitting their data was the highest since the registry began. In 2021, 49 centers participated, while in 2022, the number decreased to 48.

Over the past decade, there has been a significant increase in the number of interventions in Portugal, largely attributed to a rise in implant procedures. In 2022, a total of 16845 procedures were performed, including 13318 implantations and 3527 replacements. It is important to note that this increase in the number of implantations comes after three years (2018–2020) marked by stagnant growth and even a slight decline in numbers.

Figure 1 illustrates the annual trend over the past decade.

Figure 1.

Annual trends in the total number of interventions, including implantations and replacements.

Pacing

The total number of conventional pacing system implantations for the years 2021 and 2022 is illustrated in Figure 2.

Figure 2.

Total number of pacemaker implantations.

The total number of pacemaker implantations increased by 1.66% in 2022 compared to 2021.

Figure 3 shows the number of cases at the different centers.

Figure 3.

Total number of conventional pacemaker implants by center.

Dual-chamber pacing accounted for around two thirds of implantations, and single-chamber pacing (VVI) for approximately one third.

There was also an increase of 20% in leadless system implantations, as shown in Figure 4.

Figure 4.

Leadless pacing systems.

Cardiac resynchronization therapy with a pacemaker

Figure 5 shows that there has also been a relative increase of 8% in resynchronization systems from 2021 to 2022.

Figure 5.

CRTP systems.

Figure 6 shows the distribution of implantations by center.

Figure 6.

Total number of CRTP system implantations by center.

Implantable cardioverter-defibrillators

As shown in Figure 7, the number of ICD systems also increased 8% from 2021 to 2022.

Figure 7.

ICD systems.

Figure 8 shows the number of cases per ICD system implantation center.

Figure 8.

Total number of ICD system implants by center.

Figure 9 shows that the number of subcutaneous ICDs implanted increased by 20% between 2021 and 2022.

Figure 9.

Total number of subcutaneous ICD implants.

Cardiac resynchronisation therapy/defibrillation devices

The number of CRTD system implantations deviated from the overall upward trend, experiencing a decline of approximately 3.5%, as shown in Figure 10.

Figure 10.

CRTD system implants.

Figure 11 shows the number of cases per CRTD system implantation center.

Figure 11.

Number of cases per CRTD system implantation center.

As there were no data for 2021, in 2022, it was found that approximately one third of implanting centers performed pacing of the conduction system (either the left bundle branch or His bundle).

In 2022, we also surveyed which centers offered home monitoring. This monitoring is slightly higher for ICDs (65%) compared to conventional pacing or CRT (62%).

There was a general upward trend, both in previous years and in these two years, with an increase in the overall number of interventions in all types of devices, except for resynchronization therapy associated with defibrillation capacity (CRTD), where there was a decrease from 2021 to 2022.

When comparing Portugal's data to the European context, the number of pacemaker implants reached 974 per million inhabitants in 2022. In contrast, the median number of pacemaker implants across all member countries of the European Society of Cardiology was 607.3 per million inhabitants, with an interquartile range of 251.7 to 874.0.

In terms of cardioverter-defibrillators, a median of 121.1 ICD implants per million inhabitants was reported across ESC member countries (IQR 76.4–160.3). In contrast, Portugal's implantation rate reached 182 per million inhabitants in 2022.

In 2022, Portugal implanted 119 CRT systems (CRTP/CRTD) per million inhabitants, significantly exceeding the European median of 81.2 (IQR 30.5–116.4) CRT implants per million inhabitants in ESC member countries.

However, we need to keep in mind that this comparison with the median may be somewhat misleading, as there is a stratification based on national income levels. Compared to high-income ESC member countries,1 middle-income countries had a lower average number of procedures per million people, a difference that becomes more pronounced when considering ICD and CRT procedures.

Following a period of stagnation in the years immediately preceding those reported here, which may have been caused by the smaller number of participating centers (38 in 2018, 39 in 2019 and 2020) and possibly by the impact of the pandemic,2 there has been a significant increase in procedures in the years under review. This demonstrates the vitality of the sector in Portugal and its good position in Europe.

The centers are distributed across the country, and while the public sector remains the largest, the private sector is also clearly on the rise.

Finally, we want to emphasize the importance of this register, as it enables us to monitor the realities of Portugal and track their evolution.

This is the Portuguese National Registry on cardiac implantable electronic devices. It is a retrospective study that does not involve experiments.

The authors have no conflicts of interest to declare.