The National Registry of Cardiac Electrophysiology was last published in 2016. This kind of data should be available at least every two years since it is a crucial means to divulge the work that is being done in the field. It is the only way to improve our behavior and results, through timely and thorough data analysis.

The main issue with the lack of data from trustworthy sources such as that presented by Sousa et al. in this issue of the Journal1 is the need to fill the void with imprecise data of doubtful origin.

From my standpoint, this registry should not be called the National Registry of Cardiac Electrophysiology but rather the National Ablation Registry, considering that traditionally in Portugal, the former comprised data on both ablations and implantable cardioverter-defibrillators and cardiac resynchronization therapy devices.

The aim of the Portuguese Association for Arrhythmology, Pacing and Electrophysiology (APAPE)’s registry, I believe, should not be to make comparisons between centers, nor should it be used to assess which centers fulfill the requirements for recognition as a training center. This function is fulfilled by the European Society of Cardiology (ESC) and the European Heart Rhythm Association (EHRA), which provide an application form to be filled out and signed by the physician responsible for the center.2 I also disagree with the authors when they state that this registry should be used to update the national health authorities concerning the productivity of the different centers. Government bodies have their own channels dedicated to assessing the performance of public health care services.

In fact, I am in favor of anonymizing the data. With the European General Data Protection Regulation, the disclosure of identified data is more and more undesirable and should be discouraged. The registry should reflect the overall Portuguese numbers in the field of electrophysiology to be included in the European Framework for Action on Integrated Health Services Delivery. As such, it could be used for data collection by European organizations so that Portugal can be accurately represented in European registries such as the EHRA White Book3 and the ESC Cardiovascular Disease Statistics 2017 atlas.4 The main purpose of a national registry should be to present anonymous results that show the differences and asymmetries between centers, providing information that can be used for institutional introspection and improvement. Furthermore, the registry should include not only the type and number of procedures but also acute and long-term success rates, as well as number and type of procedure-related complications, including periprocedural death. It is time to take steps towards assessment of quality of care and good medical practice, as an important part of health care.

When commenting on the results presented in this paper, it should be borne in mind that these numbers do not reflect the situation in Portuguese hospitals in 2020. The total number of ablations performed in Portugal in 2016, 297 per million population, although not as low as presented in the ESC Cardiovascular Disease Statistics 20174 (184 per million population), is still below the mean number of ablations in the high-income countries in which Portugal is included (341 per million population). In recent years atrial fibrillation (AF) has become the most frequent arrhythmia ablated. In Portugal this shift occurred in 2016 and has continued since. By comparison, in Spain this paradigm change occurred only one year later, in 2017,5 while in 2016 AF already accounted for about half the total number of ablations in Germany, 41% in France and 33% in Italy.3

The Portuguese National Registry of Cardiac Electrophysiology for 2015 and 2016 reports the number of ventricular tachycardia (VT) ablations, but does not specify the percentage of patients who underwent ablation of true VT as opposed to premature ventricular contractions (PVCs). Thus, the numbers presented probably overestimate the rate of VT ablation. Regarding VT ablation, Portugal is a long way behind other high-income European countries. The numbers for VT/PVC ablation were stable for the previous four years, representing less than 7% of all ablations. This is surely an indication of the need for efforts to improve the treatment of patients with structural heart disease and defibrillator devices, to prevent recurrent shocks and arrhythmic storms. As the authors pointed out, the minimum number of VT ablations required by EHRA to recognize an electrophysiology center as an EHRA training center is 20. In 2016 only three centers performed over 20 cases of VT ablation, of which the real number of sustained VT cases is unknown.

Finally, regarding the number of centers, it should be emphasized that in 2015, eight centers performed fewer than 20 ablations per year and one center did not perform any ablations at all. The German Updated Survey on Interventional Electrophysiology only considers data from centers performing more than 30 ablations a year.6 If centers performing fewer than 20 ablations per year are excluded, there were seventeen centers (1.7 per million population) in 2015 and eighteen in 2016 (1.8 per million population) in Portugal, which is lower than the mean number of centers performing ablations in high-income countries: 1.9 per million population, according to the 2017 ESC Cardiovascular Disease Statistics.4

Next February we will have access to APAPE's ablation registry for 2019 and hopefully the numbers will be different. It is important to publish updated, anonymized, unbiased and complete data. Nevertheless, the coordinators of the registry and the authors of this paper are to be thanked for their work in publishing the data, because better late than never.