AVNRT ablation continued to be the third most commonly treated ablation target, after AF and CTI. A total of 3898 procedures were performed, representing a 24.5% increase vs 2021. Together with CTI ablation, AVNRT was once again the ablation target treated in the highest number of centers (n = 102). The reported success rate was 99% and the complication rate was 0.5%, which included 10 AVBs (0.3%), 5 vascular complications, 4 pericardial effusions, and 1 embolism. Radiofrequency was the most commonly used energy source, and cryoablation was applied in just 2.6% of procedures. Nonfluoroscopic navigation systems were used in 42.4% of procedures, most without fluoroscopy (78% of procedures with a mapping system).

AP ablation was once again the fourth most frequently treated ablation target, with 8.1% of all ablations performed in 2022 and a 14.7% increase in the total number of procedures vs 2021 (1888 vs 1645 in 2021). AP ablation was reported by 98 of the 103 participating centers, with a success rate of 94% and complication rate of 1%. These complications included 11 vascular complications, 1 pericardial effusion, 1 pulmonary embolism, 1 AVB, and 1 intraprocedural vasospasm. In addition, 46.1% of the APs showed bidirectional conduction, 11.2% had exclusively anterograde conduction, and 42.7% had exclusively retrograde conduction. Left APs continued to be the most frequent location (50% of procedures), with a 97.6% ablation success rate, followed by inferoseptal pathways (27.5%; 96.9% reported success rate), right free wall pathways (12.4%; 89.6% success rate), and Para-Hisian/anteroseptal pathways (10.1%; 91% success rate). Epicardial ablation was necessary in 30 procedures, whereas, for the first time, transseptal access was used more than retroaortic access for ablation of the left pathways (58.7% vs 41.3%). The use of navigation systems predominated (65%), with a slight decrease from 2021 (70%), and 25.2% of procedures were performed without fluoroscopy.

IVT ablation was maintained at 4.3% of all procedures, similar to previous years. In absolute numbers (1011 procedures), a considerable increase of 42.6% was found vs 2021. After a drop in the number of centers treating this ablation target in 2021 (75 centers), the 88 centers of 2020 was once again reached, with an average of 10.3 procedures per center (range, 1-94). Regarding the locations of the tachycardias, 49% were in the right ventricular outflow tract, 18% were in the left ventricular outflow tract, 12.7% were in the aortic root, 7.4% were fascicular tachycardias, 4% were epicardial tachycardias, and 0.6% had an origin in the pulmonary artery. Finally, 8.4% were in other locations (in order of frequency): papillary muscles, mitral annulus, right ventricular free wall, tricuspid annulus, and moderator band. The reported success rate was 85% (between 70% for epicardial/coronary sinus and 91% for right ventricular outflow tract).

A navigation system was used in 88.1% of procedures and 14% were fluoroscopy free. The use of ablation catheters with an irrigated tip and contact forcesensing technology predominated for this ablation target (82%). Other energy sources were rarely used: alcohol ablation (1 procedure), cryoablation (3 procedures), and electroporation (1 procedure). Eight stereotactic radioablation procedures were reported between 2 centers. There were 29 complications (2.9%): 3 AVBs, 9 vascular complications, 14 pericardial effusions, and 1 aortic leaflet perforation.

ICM-VT ablation comprised 2.4% of all ablations performed, with 567 procedures in 539 patients. This represents an increase in both procedures (114 more) and centers (70 centers; 5 more than in 2021). The mean number of procedures was 5.5±6.3 (range, 1-27). Navigation systems were used in most procedures (91.5%) and just 14 (2.4%) were fluoroscopy free. The success rate was 86% and the most commonly used ablation catheters had an irrigated tip and contact forcesensing technology (94.5% of procedures). Two procedures were performed with stereotactic radioablation, as well as 2 with cryoablation and 1 with electroporation. An increase was detected in the use of transseptal access, reaching 66% of procedures. The combined endocardial/epicardial approach was adopted in 9% of procedures while exclusively epicardial access was used in 2.8%. The predominant strategy was ablation of the substrate (78.1% of procedures),while conventional activation mapping was applied in 21.7%. The complication rate reached 7.9%, a number similar to that of previous years: 15 vascular complications, 3 AVBs, 9 pericardial effusions, 4 embolisms, and 11 heart failure decompensations. A total of 2 deaths associated with this procedure were reported (1 electromechanical dissociation and 1 cardiogenic shock; 0.4% mortality).

After a fall in procedures and centers in 2021 (199 procedures in 45 centers), the data from 2022 showed an increase in both variables (313 procedures in 65 centers), exceeding the numbers recorded in previous years. The mean number of procedures per center was 6.8±4 (range, 1-17) and the success rate was 78%. A nonfluoroscopic navigation system was used in most procedures (91%). The substrates treated included the following: nonischemic dilated cardiomyopathy, 168 (73.2% success rate); arrhythmogenic cardiomyopathy, 65 (95% success rate); hypertrophic cardiomyopathy, 11 (90.9% success rate); congenital heart disease, 27 (96.3% success rate); bundle-branch tachycardia, 8 (87.5% success rate); and miscellaneous conditions, which included Chagas disease, sarcoidosis, myocarditis, and valvular heart disease (96.3% successful).

The use of ablation catheters with an irrigated tip and contact forcesensing technology was standard (92.9%), whereas the other energy sources were rarely used: 5 alcohol ablations and 1 radioablation. A transseptal approach was used in 36.4% of procedures and retroaortic in 33.8%. The combined endocardial-epicardial approach was used in 22.3% of procedures while the exclusively epicardial approach was used in 11.5%.

The reported success rate was 6.7%: 3 vascular complications, 5 pericardial effusions, 1 embolism, 2 acute myocardial infarctions, 6 heart failure decompensations, 1 pneumothorax, 1 mediastinal puncture, and 1 oropharyngeal hemorrhage. No deaths were associated with the procedure.

A total of 525 ablations were reported in pediatric patients, which represents a 30% increase vs 2021 and indicates a progressive rise in the number of procedures in recent years. Pediatric ablations remained at 2.4% of all procedures (2.2% in 2021 and 1.6% in 2020) (figure 7). Ablations in pediatric patients were reported by 44 centers, an increase vs previous years, with considerable variation in procedures per center. The most frequently treated ablation target continued to be APs (61.5% of procedures, 323 procedures, 44 centers; range, 1-70), followed by AVNRT (24.8%, 130 procedures, 32 centers; range, 1-40) and FAT (5.3%, 28 procedures, 12 centers; range, 1-9). Other ablation targets were much less frequent in this population, such as IVT (2.7%, 14 procedures, 6 centers; range, 1-6), ICT (2.5%, 13 procedures, 4 centers; range, 1-9), MAT (1.5%, 8 procedures, 3 centers; range, 1-6), AF (0.9%, 5 procedures, only 1 center), and NICM-VT (0.8%, 4 procedures, 1 in each center). Figure 7 shows the distribution of pediatric procedures by ablation target and as a proportion of the total number of procedures.

Figure 7.

Distribution of pediatric procedures by ablation target and as a proportion of the total number of procedures. AP, accessory pathway; AVNRT, atrioventricular nodal reentrant tachycardia; CTI, cavotricuspid isthmus; FAT, focal atrial tachycardia; IVT, idiopathic ventricular tachycardia; MAT, macroreentrant atrial tachycardia.

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In 2022, a total of 862 procedures were performed for this ablation target (considerably more than the 749 procedures performed in 2021). This represented 3.7% of the total number of ablations in the registry. There was a notable increase in the acute efficacy of the procedure, from 79% in 2021 to 88% in 2022, probably related to refinement of the mapping and ablation techniques. In total, 21 complications were recorded (2.4% vs 3% in 2021): 4 vascular complications, 6 pericardial effusions, 1 embolism, and 3 others. One death was linked to the procedure, recorded as a consequence of an atrioesophageal fistula.

AF ablation continued its constant growth and remained the most commonly treated ablation target. It represented 35% of all ablations (vs 33% in 2022), with a total of 8185, a huge increase from the 5848 procedures in 2021 (even though there were fewer centers participating in the registry). Of the 103 participating centers, 90 reported AF ablation (87%). Of all AF ablations, 60.5% were in patients with paroxysmal AF, 36% in patients with persistent AF, and 3.5% in patients with long-standing persistent AF; these percentages are similar to those of previous years. Overall, 97% of the ablations were considered successful. Most of the ablations (n=7966, 85%) had pulmonary vein isolation as sole objective. Other objectives included electrogram reduction at the pulmonary vein antrum (n=472; 5%), lines in the left atrium (n=509; 5%), and ablation of the superior vena cava (1%). Notably, this percentage (85%) (ie, a pulmonary vein-specific ablation strategy) was clearly lower than in 2021 (92%), which suggests that the treatment increased of ablation targets other than the pulmonary veins.

Point-by-point ablation with a radiofrequency catheter continued to slightly predominate over single-shot ablation with cryoballoons (55% and 41%, respectively), and an irrigated catheter with contact forcesensing technology was used in almost 95% of point-by-point procedures (figure 8). In addition, the first electroporation (pulse-field) ablation procedures were recorded, with a total of 244 procedures (3% of the total). Laser ablation dropped from 83 procedures in 2021 to none in 2022 and, once again, no use was recorded of the circular multielectrode catheter. In total, 280 AF ablation procedures were performed without fluoroscopy (5.7%).

Figure 8.

Changes over time in ablation techniques for atrial fibrillation via the point-by-point and cryoablation techniques from 2013.

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In 2022, 230 complications were associated with AF ablation, 2.8% of all procedures, a notable decrease from the 3.5% in 2021. The most frequent complications were vascular (n=67) and pericardial effusion (n=63). Six deaths were reported (0.07%): 2 related to atrioesophageal fistula, 1 due to massive stroke, 1 after cardiac tamponade, 1 due to cardiogenic shock in a patient with severe left ventricular dysfunction, and 1 due to sudden cardiac death in a patient with dilated cardiomyopathy and severe left ventricular dysfunction several days after the procedure.

In 2022, 4640 CTI ablations were performed; once again, it was the second most commonly treated ablation target (19.9% of all ablations). Notably, ablation with a mapping system now predominates, increasing from 46% to 52%; in addition, 27% of CTI ablations were performed without fluoroscopy.

The procedure was successful in 98% of cases, a similar percentage to 2021, and a complication rate of 0.5% (23 procedures) was recorded, with 1 death after cardiac tamponade that required surgical drainage. Other complications included 11 vascular complications, 3 pericardial effusions, 2 AVBs, and 1 acute myocardial infarction.

In 2022, 1293 AVN ablations were performed, and it was once again the fifth most commonly treated ablation target. The success rate was 99% while the complication rate was 0.6% (n=8). As in previous years, the most frequent complications were related to vascular access (n=6). The other complications were pericardial effusion (n=1) and embolism (n=1). Just 51 of the 1293 ablations were performed with a mapping system and only 19 without fluoroscopy.

In 2022, 592 FAT ablations were reported (2.5% of all ablations). The vast majority of FAT ablations (490 of 592 ablations; 83%) were performed with a mapping system and 25% without fluoroscopy.

The procedure was successful in 89% of cases, similar to 2021. Five complications (0.8%) were reported; the more frequent were those related to the vascular access (n=3), as well as 1 pericardial effusion and 1 myocardial infarction. Notably, the absence of AVB during the ablation was reported in 2022, except for 1 transient AVB.

The percentage of ablation procedures performed with nonfluoroscopic navigation systems grew once again, from 52% in 2021 to 55% in 2022 (12 858 procedures). The use of a mapping system dominated for MAT (94% of procedures), FAT (83%), and VT (88% of idiopathic VTs, 92% of postinfarction VTs, and 91% of nonischemic cardiomyopathy-related VTs). More intermediate percentages were reported for AVNRT (42%), AP (61%), and ICT (52%). Mapping systems were rarely used for AVN ablation (4%).

The number of procedures performed without fluoroscopy increased to 3676 and was maintained at 16% overall. The ablation targets most commonly treated without fluoroscopy were AVNRT, CTI, and FAT (33%, 27%, and 25%, respectively), with a gradual increase in AP ablation procedures (23%). Fluoroscopy-free procedures were rare for the remaining ablation targets.

Despite the inclusion of cardioneuroablation in the registry, no information was provided on the use of mapping systems and fluoroscopy-free procedures.