The National Registry of Cardiac Electrophysiology of the Portuguese Association of Arrhythmology, Pacing and Electrophysiology (APAPE) and the Portuguese Institute of Cardiac Rhythm (IPRC) is an observational registry that includes public and private centers that perform electrophysiological (EP) studies and ablations. It assesses the evolution of Portuguese electrophysiology since 1991.1–13 This register translates the human and technological resources of each center, as well as its casuistry, allowing us to analyze its progression over the years.

Data from this registry is also presented in documents from the European Society of Cardiology (ESC) and in the European Heart Rhythm Association (EHRA) White Book.14–16

To present the results of the national registries for 2021 and 2022, discuss Portuguese electrophysiology data and compare them with official data from different European countries.

Data were collected from all electrophysiology centers registered at APAPE, including a total of 18 public centers and eight private centers. The data were collected and entered into an online digital platform (Cardio Forms) by the coordinator of each center. The data included:

• (1)

  human and technological resources,

• (2)

  characterization of the EP studies performed, both diagnostic and ablation,

• (3)

  characterization of atrial fibrillation (AF) ablation procedures (gender, age, AF classification, ablation technique and complications), and

• (4)

  characterization of ventricular tachycardia (VT) ablation procedures (gender, age, etiology, and complications).

The National Electrophysiology Registry highlights a sustained increase in the number of EP studies, specifically ablations. This reflects the implementation and optimization of resources for differentiated treatments in our patient population.

Despite this, when compared to other European countries with a high number and high volume of centers, we realize that there is still room for improvement. According to a recent document by the ESC on the 2021 cardiovascular disease statistics, an average of 372.3 (ranging from 318.2 to 518.8) ablation procedures per million inhabitants of ESC member countries were performed for the treatment of heart rhythm disorders.17 Rates ranged from <25 procedures per million people in Bosnia and Herzegovina, Egypt, Kyrgyzstan, and Uzbekistan, to >700 procedures per million people in Belgium, Czech Republic, France, Germany, Iceland, and Switzerland; Portugal reported 395.3 ablations per million inhabitants.

The distribution of EP doctors, nurses, and cardiac physiologists in the present registry is markedly heterogeneous with regard to the allocation of resources.

The specificity and technical innovation of electrophysiology require continuous training and dedication, which means it is extremely important to maintain training programs and include dedicated nurses and cardiopulmonary technicians in the EP teams. The number of electrophysiologists is low compared to the number of active centers; this is a national phenomenon most likely related to the fact that most evolution over time in EP procedures reveals that there has been a significant increase in AF and VT ablations. In 2021–2022, there was also some relevance in cardioneuroablation and Brugada syndrome ablation.

Despite an increase in the number of VT ablations in patients with structural heart disease, this figure does not fully represent the population of patients requiring interventional treatment for VT. Several constraints could explain this, including the absence of an organized network for referral centers and logistical limitations in high-volume centers. Severely ill patients experiencing an arrhythmic storm and admitted to emergency care justify the need for a program that provides a pathway strategy, allowing for a quick approach and treatment in centers with higher expertise. In a survey conducted by the European Heart Rhythm Association in 88 centers from 12 countries performing EP studies, most centers performed <50 ablation procedures per year. There were different ablation strategies and endpoints utilized, highlighting the need for standardization in this interventional therapy.18

Cardioneuroablation gained some expressiveness in the national caseload. It has been performed in five public and three private centers, all of which are hospitals where pulmonary vein isolation procedures are carried out. Although the technique has not yet been included in the ESC recommendations, it has been shown to be useful in treating cardioinhibitory reflex syncope, especially in a younger population where there are clear benefits, despite the guidelines not specifying its use.19–21

Epicardial ablation in Brugada syndrome was performed in high-volume centers with experience in epicardial access and mapping. However, since it is a specific procedure for a very select group of patients, it is unlikely we will see a significant increase in the number of these procedures performed in the coming years.

Due to its high prevalence in the population, AF ablation plays an important role in electrophysiology laboratories. Multiple recent studies have shown that it is safer and yields better outcomes than antiarrhythmic drugs. As a result, there is expected to be a growing impact, and EP centers will need to organize themselves to optimize the interventional treatment of this common arrhythmia. The guidelines from scientific societies recommend that a minimum of 50 AF ablations be performed during an EP fellowship. They emphasize the importance of performing several AF ablation procedures each year to maintain expertise and ensure safety and success.22 Our data indicate that some centers have a low number of AF procedures annually. Despite the low rate of acute ablation complications, it is important to monitor AF recurrences and outcomes in future surveys. We should also work on developing local teams to increase activity and maintain safety and effectiveness.

We observed an increase in the referral of patients with persistent and long-standing persistent AF and elderly groups. In our data, around 30% of cases involved non-paroxysmal AF; most patients were between 60 and 69 years old, 24% were between 70 and 79 years old, and 12 patients were >80 years old.

The number of cryoballoon ablations has significantly increased, which is likely due to its “single-shot” technique, making it less time-consuming compared to radiofrequency ablation. Several studies have shown similar results between the two methods.23,24 Cryoablation procedures were performed in nine public centers and six private centers; the increase in numbers was mainly attributed to high-volume centers. The introduction of pulsed field ablation may, however, lead to a decline in the use of cryoablation.

Complications associated with AF ablation occurred in 1.2–1.5% of the procedures, a lower percentage compared to that found in the literature. The most frequent complication was related to vascular access, similarly to the findings observed in VT ablation.22 With the growing evidence of the added value of ultrasound-guided vascular puncture in terms of complications and fluoroscopy reduction, its use in daily practice is certainly expected, with a potential reduction in vascular complications.25

One limitation of this registry is that the survey is based on voluntary participation without independent monitoring. All data were entered by the EP center coordination, and not all centers provided specific diagnoses for the total number of ablations. Additionally, there was no information about the number of ablations compared to the number of patients, as some patients may receive more than one arrhythmic substrate ablation in the same procedure. Another limitation is the lack of data on the success rates of ablations performed during the period of EP activity under analysis. Future registries should address these issues to improve the quality of national data on EP diagnosis and ablations.

The field of electrophysiology is steadily growing in Portugal, both in public and private healthcare facilities. However, the rate of ablations per million inhabitants still falls below the data published by the ESC. AF is the most common arrhythmia treated with ablation, reflecting the aging population and the proven clinical benefits of this treatment. VT ablation appears to be underrepresented and is mostly conducted in high-volume centers, highlighting the need for a referral networking program. Procedures such as cardioneuroablation and Brugada syndrome ablation are gaining prominence, particularly at high-volume centers.

The authors declare that no experiments were performed on humans or animals for this study. The authors declare that they have followed the protocols of their work center on the publication of patient data. The authors declare that no patient data appear in this article.

The authors declare that they did not use artificial intelligence to prepare this article.

The authors have no conflicts of interest to declare.