Parallel import and pacemakers: who pays the ferryman?

Fifty years after its introduction in clinical cardiology, artificial pacing for patients with bradyarrhythmias has made a huge leap forward.1 The development from bulky, simple fixed-rate pacemakers to small, complex, multi-programmable devices paralleled the vast technological achievements of the second half of the 20th century. In the late 1990s hope emerged even for patients with severe heart failure, with the introduction of biventricular pacing which resulted in an additional class I indication according to the recent guideline of the European Society of Cardiology.2 Consequently, the number of implantations has steadily increased, resulting in more than 10,000 implantations (both first implants and replacements) in the Netherlands in 2007.