The correct rate of implantation for implantable cardioverter defibrillator (ICD) and CRT-D devices is not known, but practice surveys suggest persistent under-utilization of these treatments on both sides of the Atlantic. Although recent clinical trial results and the implementation of current guidelines appear to have encouraged a growth of the rate of implantation in most countries, there remains a remarkable trans-Atlantic difference which has not changed much for more than 10 years. For every European ICD implant, there are four implants in the USA after adjustment for the size of the populations. Since very large variations in the implantation rates also occur between and within European Countries, an opportunity is afforded to explore the possible cause of these differences. It seems very unlikely to be explained simply by guideline discrepancies, financial constraints, or differences in disease prevalence. Instead, it is more likely to be attributable to a relative paucity of electrophysiologists, and their associated resources. In turn, the failure to establish effective educational programmes, screening, and referral pathways contributes to far fewer patients. It seems unlikely that adequate equity of access to this potentially lifesaving treatment will be provided until adequate registries, audits, and gap analyses are undertaken throughout Europe.