Europace (2021) 00, 1–8 CLINICAL RESEARCH doi:10.1093/europace/euab011 Reduction in new cardiac electronic device implantations in Catalonia during COVID-19 Elena Arbelo 1,2,3*, Ignasi Angera4,5, Emilce Trucco6,7, Nuria Rivas-Gándara8,9, José M. Guerra10, Felipe Bisbal 3,11,12, Miguel Jáuregui-Abularach13,14, Ermengol Vallés15, Gabriel Martin16,17, Fabrizio Sbraga18, José Marı́a Tolosana1,2,3, Markus Linhart6,7, Jaume Francisco-Pascual8,9, José Montiel-Serrano10, Damià Pereferrer11,12, Diego Menéndez-Ramı́rez13,14, Jesús Jiménez15, Amin Elamrani16,17, Roger Borrás1,2, Paolo Domenico Dallaglio4,5, Eva Benito6,7, Alba Santos-Ortega8,9, Enrique Rodrı́guez-Font10, Axel Sarrias11,12, Carlos E. González-Matos13,14, Julio Martı́-Almor15, Sandra Cabrera16,17, and Lluis Mont1,2,3 1 Arrhythmia Section, Cardiology Department, Hospital Clı́nic, Universitat de Barcelona, Barcelona, Spain; 2Institut d’Investigació August Pi iSunyer (IDIBAPS), Barcelona, Spain; 3 Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; 4Arrhythmia Section, Cardiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; 5Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Spain; 6Arrhythmia Section, Cardiology Department, Hospital Universitari Doctor Josep Trueta. Girona, Spain; 7Institut d’Investigació Biomèdica de Girona (IDIBGI), Girona, Spain; 8Arrhythmia Unit, Department of Cardiology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; 9Vall d’Hebron Institut de Recerca (VHIR), Centro de investigación biomédica en red de enfermedades cardiovasculares (CIBER-CV), Barcelona, Spain; 10Arrhythmia Unit, Department of Cardiology, Hospital de la Santa Creu i Sant Pau, CIBER-CV, Universitat Autònoma de Barcelona, Barcelona, Spain; 11Arrhythmia Section, Cardiology Department, Heart Institute (iCOR), University Hospital Germans Trias i Pujol, Badalona, Spain; 12Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol (IGTP), Badalona, Spain; 13Arrhythmia Unit, Department of Cardiology, Hospital Universitari Arnau de Vilanova, Lleida, Spain; 14Institut de Recerca Biomèdica de Lleida Fundació Dr Pifarré (IRBLleida), Lleida, Spain; 15Arrhythmia Section, Cardiology Department, Hospital del Mar-IMIM. Universitat Autònoma de Barcelona, Barcelona, Spain; 16Arrhythmia Section, Cardiology Department, Hospital Joan XXIII, Universitat Rovira i Virgili, Tarragona, Spain; 17IISPV, Institut d’Investigació Sanitària Pere Virgili, Tarragona, Spain; and 18Department of Cardiac Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain Received 20 August 2020; editorial decision 1 January 2021; accepted after revision 13 January 2021 Aims During the COVID-19 pandemic, concern regarding its effect on the management of non-communicable diseases has been raised. However, there are no data on the impact on cardiac implantable electronic devices (CIED) im- plantation rates. We aimed to determine the impact of SARS-CoV2 on the monthly incidence rates and type of pacemaker (PM) and implantable cardiac defibrillator (ICD) implantations in Catalonia before and after the declara- tion of the state of alarm in Spain on 14 March 2020. ................................................................................................................................................................................................... Methods Data on new CIED implantations for 2017–20 were prospectively collected by nine hospitals in Catalonia. A mixed and results model with random intercepts corrected for time was used to estimate the change in monthly CIED implantations. Compared to the pre-COVID-19 period, an absolute decrease of 56.5% was observed (54.7% in PM and 63.7% in ICD) in CIED implantation rates. Total CIED implantations for 2017–19 and January and February 2020 was 250/month (>195 PM and >55 ICD), decreasing to 207 (161 PM and 46 ICD) in March and 131 (108 PM and 23 ICD) in April 2020. In April 2020, there was a significant fall of 185.25 CIED implantations compared to 2018 [95% confidence inter- val (CI) 129.6–240.9; P < 0.001] and of 188 CIED compared to 2019 (95% CI 132.3–243.7; P < 0.001). No significant dif- ferences in the type of PM or ICD were observed, nor in the indication for primary or secondary prevention. ................................................................................................................................................................................................... Conclusions During the first wave of the COVID-19 pandemic, a substantial decrease in CIED implantations was observed in Catalonia. Our findings call for measures to avoid long-term social impact. 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 Keywords Coronavirus • COVID-19 • SARS-CoV2 • • • Implantable cardiac defibrillator ................................................................................................................................................................................................... * Corresponding author. Tel: (þ34) 93 227 5551; fax: (þ34) 93 451 3045. E-mail address: earbelo@clinic.cat C The Author(s) 2021. For permissions, please email: journals.permissions@oup.com. Published on behalf of the European Society of Cardiology. All rights reserved. V 2 E. Arbelo et al. Dr Josep Trueta), one in Tarragona (Hospital Sant Joan de Deu), and one in What’s new? Lleida (Hospital Arnau de Vilanova), accounting for 87% of all ICD implants in the region annually.10,11 The Ethical Committee of the coordinating • Several publications have suggested a reduction of admissions centre (Hospital Clı́nic) was consulted waiving the need for approval for acute myocardial infarction and stroke during the COVID- given the nature of the data (aggregated). 19 pandemic. However, there is little evidence on its effect of the number of patients undergoing emergency and/or elective Data collection implantation of pacemakers (PMs) or cardioverter defibrillators. All of these centres prospectively collect data on PM and ICD implants • This registry is the first to provide prospectively collected data for regional accounting as well as national registries of the Spanish Society on implantation rates of new cardiac implantable electronic of Cardiology. devices (CIED) before and during the COVID-19 pandemic and For the purpose of this study, we collected data on new monthly CIED highlights the dramatic impact of the COVID-19 pandemic. implantations for the years 2017 to September 2020 to account for tem- • A decline of >50% of CIED implantations [54.7% in pacemakers poral variations/trends. March 2020 was divided into the 1st and 2nd fort- and 63.7% in implantable cardiac defibrillator (ICDs)], was nights to quantify the number of CIED implantations during the COVID- observed, not only in elective interventions but also those that 19 period, which was considered between 15 March 2020 and 30 April are normally urgent/emergency procedures (such as PM 2020. A pre-COVID-19 period between 1 February 2020 and 14 March implantations and secondary prevention ICDs), suggesting a 2020 was used for comparisons. larger and multifactorial aetiology other than the mere reorganization of hospital resources to attend COVID-19 Statistical analysis patients and suggesting the worrisome possibility of an Continuous variables are presented as counts or median [interquartile increased out-of-hospital fatality due to these treatable range (IQR)]. Categorical variables are presented as frequencies and conditions. percentages. The annual median number of implants per month was cal- culated using the total number of implantations between January and April. The median number of implantations per month in 2020 was also calculated separately for the pre-COVID-19 period using January and February. March 2020 was excluded to avoid over- or under-estimations. Introduction Standardized monthly implantation rates were calculated using the European Commission’s official dataset on number of monthly working With the spread of the coronavirus disease 2019 (COVID-19) days in Spain,12 and adjusted to the average number of working days per worldwide, there is increasing concern about the potential effect the month in Spain (21 days). overwhelming burden that this disease puts on the health care sys- Categorical variables were compared with the v2 test. A mixed model tem will have on the prevention and management of non- with random intercepts corrected for a time as a categorical variable was communicable diseases. used to estimate the change in monthly CIED implantations and to com- Since the beginning of the pandemic, major public health and car- pare CIED implantations in the pre-COVID-19 and COVID-19 periods. diac organizations have issued guidance documents recommending To assess the difference in trajectories of total cumulative CIED implanta- tions we used a time per period-interaction model. deferral of all non-emergency procedures in order to manage the in- For all tests, a two-sided P-value <0.05 was considered significant. creasing need for hospital beds and human resources, including inter- Statistical analysis was performed using R software for Windows version ventional procedures in chronic coronary syndromes and placement 3.5.3 (R Foundation for Statistical Computing, Vienna, Austria, 2019). of cardiac implantable electronic devices (CIEDs).1–5 Furthermore, There were no missing data for the variables included. to reduce the spread of the virus, governments implemented several restrictive measures such as lockdowns and social distancing, and public health authorities in several countries warned the population Results against the use of emergency services for non-urgent conditions. Several publications have suggested a decrease in the number of The total number of PM and ICD implantations for the 1st quarter patients presenting to emergency departments with acute coronary and the adjusted rate per working dates gradually increased between syndromes.6–9 However, to date there are no data on the impact of 2017 and 2019 (Figure 1, Table 1). When compared to the pre- the SARS-CoV2 pandemic on the rates of CIEDs implantation. COVID-19 period (1 February to 14 March 2020), after mandatory Therefore, the aim of this study was to determine the impact of lockdown, a significant decrease of 56.5% was observed in CIED im- SARS-CoV2 on the monthly incidence rates and type of pacemaker plantation rates (Table 2). (PM) and implantable cardiac defibrillator (ICD) implantations in The total number of CIED implantations for years 2017–19 Catalonia before and after the declaration of the state of alarm in (January to April) and 2020 (January and February) was >250 per Spain on 14 March 2020. month. In contrast, the total number of CIED implantations de- Methods creased to 207 in March and 131 in April 2020. The median monthly Study design and participating centres CIED implantation rate reported by the 9 participating centres was This observational study included all CIED implantations in nine tertiary 278 (IQR 27.5), 316 (IQR 7.25), and 312 (IQR 22.5) for the years hospitals in Catalonia: six in Barcelona (Hospital Clı́nic de Barcelona, 2017, 2018, and 2019. The median CIED implantation rate per month Hospital Vall d’Hebron, Hospital Sant Pau i Santa Creu, Hospital Bellvitge, in 2020 was 232 (IQR 74.5): 270 (IQR 12.5) in the pre-COVID-19 pe- Hospital del Mar and Hospital Germans Trias i Pujol), one in Girona (Hospital riod, decreasing to 131 implantations in April (Figure 2). Reduction in CIED implantations during COVID-19 3 Figure 1 Total number of CIED implantations adjusted per working days for the 1st quarter of years 2017 to 2020. CIED, cardiac implantable elec- tronic device; ICD, implantable cardiac defibrillator; PM, pacemaker. The model estimated a significant fall of 153 CIED 109 CIED implantations between 2019 and April 2020 (95% CI 33.8– implantations between 2017 and April 2020 [95% confidence in- 184.2; P = 01170). terval (CI) 97.3–208.7; P = 0.0037], 185.25 between 2018 and In-depth implantation counts by centre and device type, as well as April 2020 (95% CI 129.6–240.9; P < 0.001) and a decrease of 188 additional summary figures and tables are provided in the CIED implantations between 2019 and April 2020 (95% CI 132.3– Supplementary material online, Appendix 243.0.7; P < 0.001). Following the peak of the pandemic (May to September 2020), the number of monthly implantations increased to levels comparable to Pacemaker implantations The absolute number of PM implantations after lockdown was de- 2019 (Figure 3); nonetheless, the cumulative number of CIEDs clared on 14 March 2020 was 156, which represents a reduction of implanted during 2020 remains significantly lower than 2019 54.7% compared to the pre-COVID-19 period. (P < 0.0001). The total number of PM implantations for 2017–19 (January to Among the Barcelona area, the median monthly implantations dur- April) and 2020 (January and February) was >195 per month. In con- ing the 1st quarter of 2017 to 2019 was 212 (IQR 14), 232 (IQR 7.75), and 227 (IQR 10.5), respectively, decreasing to 166 (IQR 53.8) trast, the total number of PM implantations decreased to 161 in in the 1st quarter of 2020 (Supplementary material online, Table S1). March and 108 in April 2020. The median monthly PM implantation The model estimated a significant fall of 126 CIED implantations be- rate reported by the nine participating centres was 216.5 (IQR tween 2017 and April 2020 (95% CI 82.7–169.3; P < 0.0001), 139.8 27.0.0), 251 (IQR 4.75), and 246.5 (IQR 7.25) for the years 2017, between 2018 and April 2020 (95% CI 96.5–183.2; P < 0.0001) and a 2018, and 2019. The median PM implantation rate per month in 2020 decrease of 136.3 CIED implantations between 2019 and April 2020 was 178 (IQR 57.5): 213 (IQR 17.0) in the pre-COVID-19 period, de- (95% CI 93.0–179.7; P < 0.0001). Among the hospitals outside the creasing to 108 implantations in April (Figure 2). Barcelona area, the median monthly implantation rates were 66.5 The model showed a decrease of 119.0 PM implantations between (IQR 165), 84 (IQR 155), 90 (IQR 7.5), and 65 (19.2) for the 1st quar- 2017 and April 2020 (95% CI 67.3–170.7; P ¼ 0.0119), 142.8 between ter of 2017 to 2020, respectively (Supplementary material online, 2018 and April 2020 (95% CI 91.06–194.5; P = 0.0035) and a de- Table S1). Despite the decrease in absolute numbers, the model did crease of 140.2 PM implantations between 2019 and April 2020 (95% not estimate a significant fall between any of the comparisons: de- CI 88.5–191.9; P ¼ 0.004). crease of 83 CIED implantations between 2017 and April 2020 (95% No significant differences in the type of PM implanted were ob- CI 7.8–158.2; P = 0.3201), 98.3 CIED implantations between 2018 served when comparing the pre-COVID-19 to the COVID-19 pe- and April 2020 (95% CI 23.1–173.5; P ¼ 0.1804) and a decrease of riod (P = 0.345). 4 E. Arbelo et al. Table 1 Total number of implants by device type. A. Pacemaker implantations during the first quarter (2017–20) ...................................................................................................................................................................................................................... 2017 January February March April Total Single-chamber PM 96 (97a) 91 (96a) 137 (126a) 107 (127a) 431 (446a) Dual-chamber PM 93 (94a) 108 (114a) 127 (117a) 109 (130a) 437 (455a) a a a a CRT PM 11 (11 ) 12 (13 ) 11 (10 ) 6 (7 ) 40 (41a) Total 200 (202a) 211 (223a) 275 (253a) 222 (264a) 908 (942a) 2018 January February March April Total Single-chamber PM 107 (102a) 108 (114a) 110 (114a) 115 (118a) 440 (448a) Dual-chamber PM 138 (132a) 104 (110a) 127 (132a) 129 (133a) 498 (507a) CRT PM 8 (8a) 12 (13a) 12 (12a) 10 (10a) 42 (43a) a a a a Total 253 (242 ) 224 (237 ) 249 (258 ) 254 (261 ) 980 (998a) 2019 January February March April Total Single-chamber PM 104 (104a) 105 (111a) 106 (107a) 98 (109a) 413 (425a) Dual-chamber PM 130 (130a) 140 (148a) 117 (118a) 138 (149a) 525 (542a) CRT PM 13 (13a) 18 (19a) 14 (14a) 10 (20a) 55 (57a) a a a a Total 247 (247 ) 263 (278 ) 237 (238 ) 246 (278 ) 993 (1024 a) 2020 January February 1st to 15th March 16th to 31st March April Total Single-chamber PM 72 (72a) 90 (95a) 48 (46 a) 29 (28a) 41 (43a) 277 (284a) a a a a a Dual-chamber PM 110 (110 ) 124 (131 ) 58 (55 ) 18 (17 ) 62 (66 ) 375 (379a) CRT PM 14 (14a) 16 (17a) 7 (7a) 1 (1a) 5 (5a) 42 (44a) TOTAL 196 (196a) 230 (243a) 113 (108a) 48 (46a) 108 (115a) 694 (708a) B. Implantable cardiac defibrillators during the first quarter (2017–2020). ...................................................................................................................................................................................................................... 2017 January February March April Total Single-chamber ICD 20 (20a) 35 (37a) 29 (27a) 29 (34a) 113 (118a) Dual-chamber ICD 8 (8a) 3 (3a) 8 (7a) 4 (5a) 23 (23a) CRT ICD 20 (20a) 16 (17a) 16 (15a) 21 (25a) 73 (77a) a a a a S-ICD 4 (4 ) 7 (7 ) 1 (1 ) 7 (8 ) 19 (20a) Total 52 (52a) 61 (64a) 54 (50a) 61 (72a) 228 (238a) 2018 January February March April Total Single-chamber ICD 36 (34a) 37 (39a) 34 (35a) 41 (42a) 148 (151a) Dual-chamber ICD 4 (4a) 4 (4a) 5 (5a) 3 (3a) 16 (16a) CRT ICD 21 (20a) 20 (21a) 19 (20a) 20 (21a) 80 (81a) a a a a S-ICD 6 (6 ) 5 (5 ) 5 (5 ) 2 (2 ) 18 (18a) Total 67 (64a) 66 (69a) 63 (65a) 66 (68a) 261 (266a) 2019 January February March April Total Single-chamber ICD 40 (40a) 50 (53a) 35 (35a) 31 (33a) 156 (161a) Dual-chamber ICD 7 (7a) 5 (5a) 5 (5a) 4 (4a) 21 (21a) CRT ICD 18 (18a) 22 (23a) 21 (21a) 21 (22a) 82 (84a) a a a a S-ICD 8 (8 ) 8 (8 ) 5 (5 ) 3 (3 ) 24 (24a) Total 73 (73a) 85 (89a) 66 (66a) 59 (62a) 283 (290) 2020 January February 1st to 15th March 16th to 31st March April Total a a a Single-chamber ICD 31 (31 ) 32 (34 ) 20 (19 ) 5 (5a) 9 (10a) 97 (98a) Dual-chamber ICD 6 (6a) 6 (6a) 1 (1a) 0 (0a) 1 (1a) 14 (14a) CRT ICD 18 (18a) 15 (16a) 11 (11a) 4 (4a) 13 (14 a) 61 (62a) a a a a a S-ICD 5 (5 ) 2 (2 ) 4 (4 ) 1 (1 ) 0 (0 ) 12 (12a) Total 60 (60a) 55 (58a) 36 (35a) 10 (10a) 23 (25a) 184 (186a) CRT, cardiac resynchronization therapy; ICD, implantable cardiac defibrillator; PM, pacemaker; S-ICD, subcutaneous implantable cardiac defibrillator. a Monthly rates adjusted per working days in Spain.12 Reduction in CIED implantations during COVID-19 5 Table 2 Comparison of total number of implantations before and after mandatory lockdown in Spain Pre-COVID-19 period COVID-19 period (16th Decrease % (1st February 2020 to March 2020 to 30th 15th March 2020) April 2020) .................................................................................................................................................................................................................... PM total 343 156 #54.5% <0.001 PM single-chamber 138 (40.2%) 70 (44.9%) # 49.3% PM dual-chamber 182 (53.1%) 80 (51.3%) #56.0% PM CRT 23 (6.7%) 6 (3.8%) #73.9% ICD total 91 33 #63.7% <0.001 ICD single-chamber 52 (57.1%) 14 (42.4%) #73.1% ICD dual-chamber 7 (7.7%) 1 (3.0%) #85.7% ICD CRT 26 (28.6%) 17 (51.5%) #34.6% ICD S-ICD 6 (6.6%) 1 (3.0%) #83.3% Primary prevention 48 (52.7%) 16 (48.5%) #66.7% ICD single-chamber 25 4 ICD dual-chamber 3 0 ICD CRT 16 12 S-ICD 4 0 Secondary prevention 43 (47.3%) 17 (51.5%) #60.5% ICD single-chamber 27 10 ICD dual-chamber 4 1 ICD CRT 10 5 S-ICD 2 1 Overall 434 189 #56.5% <0.001 CRT, cardiac resynchronization therapy; ICD, implantable cardiac defibrillator; S-ICD, subcutaneous implantable cardiac defibrillator; PM, pacemaker. Implantable cardiac defibrillator for primary prevention] in the pre-COVID-19 period vs. 51.55% 12/ implantations 17 for primary prevention) in the COVID-19 period]. Furthermore, there were also no differences in the indication of ICD implantation: The absolute number of ICD implantations after lockdown was de- 48 out of 91 (52.7%) ICD implantations were primary prevention in clared on 14th March 2020 was 33, representing a 63.0.7% decrease the pre-COVID-19 period compared to 16 out 33 (48.5%) ICD compared to the pre-COVID-19 period (66.7% in primary preven- implantations in the COVID-19 period (P = 0.829). tion and 60.5% in secondary prevention). The total number of ICD implantations for 2017–19 (January to April) and 2020 (January and February) was >55 per month. In con- trast, the total number of ICD implantations decreased to 46 in Discussion March and 23 in April 2020. The median monthly ICD implantation rate reported by the 9 participating centres was 57.5 (IQR 7.5), 66 Concern regarding the impact that COVID-19 is having on cardiovas- (IQR 1.0) and 69.5 (IQR 11.75) for the years 2017, 2018, and 2019. cular care has been raised. Although available data are mainly focused The median CIED implantation rate per month in 2020 was 51.5 on the reduction of admissions for acute myocardial infarction (MI) (IQR 16.0): 57.5 (IQR 2.5) in the pre-COVID-19 period, decreasing and stroke in emergency departments,7–9,13–15 some reports also to 23 implantations in April (Figure 2). show a fall in urgent admissions for cardiac arrhythmias.15–17 Our The model showed a decrease of 34.0 ICD implantations between analysis of CIED implantation activity in nine tertiary hospitals in 2017 and April 2020 (95% CI 17.12–50.88; P ¼ 0.0268), 42.5 between Catalonia, Spain, which accounts for almost 90% of ICD implanta- 2018 and April 2020 (95% CI 25.6–59.4; P = 0.0067) and a decrease tions in the Catalonian region, showed a dramatic reduction (>50%) of 47.75 ICD implantations between 2019 and April 2020 (95% CI in CIED placements following the COVID-19 pandemic. Two recent 30.9–64.6; P = 0.0030). small retrospective studies in Italy suggested a fall in PM place- When compared to the pre-COVID-19 period, there was no sig- ments.17,18 In Germany, a retrospective analysis of claims data nificant difference in the type of ICD implanted in the COVID-19 pe- showed a significant decrease in emergency hospitalizations for heart riod (P = 0.0566), although no subcutaneous ICD (S-ICD) was placed rhythm disorders (including bradycardia) and a reduction of cardiac following lockdown in any centre and there was a higher proportion rhythm management procedures (composite of PM and ICDs).16 To of cardiac resynchronization therapy-ICD placement [28.6% (16/26 further support the prior findings, in our study, we provide 6 E. Arbelo et al. Figure 2 Median CIED implantation rate per month for years 2017–20. (A) Pacemakers. (B) Implantable cardiac defibrillators. CIED, cardiac im- plantable electronic device; ICD, implantable cardiac defibrillator; PM, pacemaker. Figure 3 Number of monthly and cumulative CIED implantations adjusted per working days for years 2019 and 2020. CIED, cardiac implantable electronic device. Reduction in CIED implantations during COVID-19 7 prospectively collected data for the past 4 years to account for tem- COVID-19 and non-COVID-19 patient pathways (to reduce risk and poral variations/trends detailed analysis type of device. the fear of contagion in the healthcare facility). Unfortunately, The description of the underlying causes leading to the marked de- evidence-based evaluation of these policies in the current pandemic cline in CIED implantation rates is beyond the scope of this study, but is lacking yet. they are likely to be multifactorial. First, following the outbreak of the SARS-CoV2 infection, many governments took extraordinary meas- Limitations ures including mandatory confinement and recommended avoidance This multicentre prospective study has several limitations. First, due of non-urgent hospital visits to preserve hospital beds and prepare to the limitation in human resources during the COVID-19 pan- for a possible shortage of human resources. These measures may demic, we have not been able to collect extensive data on relevant have discouraged patients from consulting emergency departments variables such as patient sociodemographic data, indication for CIED or primary care practices. Second, with the purpose of protecting implantation, and clinical presentation, among other data. For the hospital resources, elective procedures and non-critical visits were same reason, we were only able to analyse CIED implantations by postponed, leading to the cancellation of elective CIED implantations. weeks from February to September 2020. Finally, and foremostly, the This global trend was further enhanced by the recommendations of observational nature of the study did not allow any conclusion to be several cardiac societies to avoid non-urgent electrophysiological drawn in relation to the underlying causes for the significant decrease procedures including ICDs for primary prevention.1–5 Third, although in CIED implantations during the COVID-19 pandemic. Over- speculative, it is possible that the fear of contagion also discouraged treatment in the pre-COVID-19 period may be raised as a potential patients from accessing emergency medical services. The fact that the concern; however, the long life-expectancy in Spain,34,35 together COVID-19 fatality rate is higher with advanced age has been widely with data from the Spanish and European Societies of Cardiology, reported in the media, and therefore, patient reluctance to present suggest otherwise.10,11,19–31,36 Questions may be raised whether to the hospital would not be unexpected. Finally, it is possible that these patients were treated outside Catalonia; however, the lock- emergency departments were more focused on managing the pan- down measures during the alarm state, travel restrictions between demic, leading to reduced awareness of other clinical conditions or communities thereafter, and, most importantly, the structured deferral of less urgent cases. This has been suggested as a possible healthcare system provision in Spain (divided by regions), reduce the cause for the significant decrease in non-ST-elevation myocardial in- likelihood to a minimum. farction hospitalizations compared to ST-elevation events.6,9 These alarming data suggest the possibility of increased morbidity and mortality due to the unintended consequences of more than half Conclusion of patients remaining in need of PM or ICD because of the implemen- tation of public health policies during the current pandemic. In conclusion, during the COVID-19 pandemic, a worrying decrease Furthermore, data from the Spanish Society Cardiology of in CIED implantations was observed in Catalonia. Further investiga- Cardiology have shown that, since 2005, there have been consistently tions should assess the possible underlying causes and the possible lower ICD implantation rates per million population in Spain com- resulting adverse outcomes, such as an increase in morbidity and pared with the rest of Europe (overall implantation rate per million mortality. population was 152 in 2018 in Spain compared to 306 in Europe), Our findings call for measures to avoid long-term social impact. with large geographical disparities and Catalonia always below the na- Data availability tional average.10,11,19–31 Our data show the gradual increase in the All data collected for the study will be made available as supplemen- number of CIED implantations between 2017 and 2019 in Catalonia, tary material to anyone who wishes access it for any purpose. Data which has been suddenly stopped by COVID-19. The effect of the will include detailed counts of cardiac implantable electronic device current pandemic may increase the existing inequalities if this reduc- placement from 2017 to April 2020, by type and centre. The data will tion in ICD is experienced differently across regions. be accessible immediately following publication with no end date. The fact that the reduction in ICD implantation rates affected both primary and secondary prevention indications equally is particularly Conflict of interest: E.A., MD, PhD, MSc: Institutional support for intriguing, considering that the recommendation of international soci- fellowship programs from Abbott, Biotronik, Boston Scientific and eties of avoiding non-urgent/elective procedures only included ICD Medtronic; Lluis Mont, MD, PhD: Speaking and consulting honorar- implantation for primary prevention.1–5 Several studies have sug- ium from Abbott, Biotronik, Boston Scientific and Medtronic; gested an increased incidence in out-of-hospital cardiac arrest fatality Institutional support for fellowship programs from Abbott, Biotronik, rates, which may underlie the marked reduction in ICD implantations Boston Scientific and Medtronic; J.M.T., MD, PhD: Consulting hono- for secondary prevention. Nonetheless, further studies are needed rarium from Abbott, Biotronik, Boston Scientific and Medtronic; to evaluate this hypothesis.32,33 Institutional support for fellowship programs from Abbott, Biotronik, To reduce the risk of a major decline in new CIED implantations in Boston Scientific and Medtronic; R.B., MSc: Institutional support for the event of a resurgence of the pandemic, several health policy fellowship programs from Abbott, Biotronik, Boston Scientific and measures could be considered, including awareness campaigns for Medtronic; N.R.-G., MD, PhD, MSc: Speaking honorarium from the general population (how to recognize cardiac symptoms and Abbott; J.F.-P., MD: Speaking honorarium from Abbott; Alba Santos- how to proceed), appropriate healthcare resource distribution Ortega MD: Speaking honorarium from Abbott; J.M.G., MD, PhD: (avoiding cancellation of all non-emergent procedures and ensuring Speaking and consulting honorarium from Abbott, Biotronik, Boston adequate response of emergency medical systems), and dedicated Scientific and Medtronic; E.R.-F., MD, PhD: Speaking and consulting 8 E. Arbelo et al. honorarium from Abbott, Biotronik, Boston Scientific and Medtronic. 18. Migliore F, Zorzi A, Gregori D, Monte AD, Falzone PV, Verlato R, et al. on behalf of The Padua School of Cardiology Network. Urgent pacemaker implantation Other authors declare no conflict of interests. rates in the Veneto Region of Italy after the COVID-19 outbreak. Circ: Arrhythmia Electrophysiol 2020;13:e008722. References 19. Peinado R, Arenal A, Arribas F, Torrecilla E, Alvarez M, Ormaetxe JM et al. 1. The European Society for Cardiology. ESC Guidance for the Diagnosis and Spanish implantable cardioverter-defibrillator registry. First official report of the Management of CV Disease during the COVID-19 Pandemic. https://www.escar spanish society of cardiology working group on implantable cardioverter- dio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance (21 defibrillators (2002-2004). Rev Esp Cardiol 2005;58:1435–49. April 2020, date last accessed). 20. 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