Once again, AF ablation remained the most commonly treated ablation target and even increased, with a total of 9942 procedures (1757 more than in 2022). This ablation target was treated in 89% of the centers participating in the registry (2 percentage points higher than in 2022). Regarding clinical presentation, 60.3% of cases were paroxysmal AF, 35.7% were persistent AF, and 4% were long-standing persistent AF. These percentages are similar to those of previous years. The overwhelming majority of ablation procedures involved electrical isolation of the pulmonary veins (n=9240), followed by electrogram reduction at the pulmonary vein antrum (n=957) and lines in the left atrium (n=633). Other ablation targets included superior vena cava isolation (n=83), fibrotic area ablation (n=122), and vein of Marshall ethanol infusion (n=174). Reported success rates were 97% for pulmonary vein isolation and 99% for superior vena cava isolation.

Defining single-shot as the only other single-shot ablation strategy besides point-by-point ablation, a combined single-shot plus point-by-point strategy was used in 89 patients, out of a total of 9942 AF ablation procedures. For the first time in the registry, the single-shot technique (50.1% of AF ablations) exceeded the point-by-point approach (49.9%) (figure 7). The point-by-point techniques included irrigated-tip catheters with contact forcesensing technology in 4775 procedures, standard irrigated catheters in 352 procedures, and other types in 56 procedures. Among the single-shot techniques, cryoablation continued to predominate (n=3954 procedures), although there was a highly significant increase in PFA (n=1038 procedures), which sharply increased from 3% of all AF ablation procedures in 2022 to 10.3% in 2023. Mapping systems were used in 5078 procedures (51%), and zero-fluoroscopy procedures comprised 530 (5.3%). As auxiliary instruments for ablation, steerable sheaths were used in 2683 procedures, intracardiac echocardiography in 1057, and general anesthesia in 4511.

Figure 7.

Variations in point-by-point vs single-shot AF ablation techniques from 2014 to 2023.

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In 2023, a total of 245 complications were recorded. This figure corresponded to 2.5% and is slightly lower than the 2.8% recorded in 2022. The most common complications were vascular (29%), followed by pericardial effusion (27%) and phrenic nerve palsy (24%). Less frequent complications included peripheral embolism (7.6%) and heart failure/shock (2.8%). Three deaths were reported (6 in 2022): 2 due to massive stroke and 1 due to cardiogenic shock. No cases of AF ablation-related atrioesophageal fistula were reported in 2023.

A total of 5067 CTI ablations were recorded in 2023 (427 more than in 2022). As a result, CTI was the second most commonly treated ablation target after AF (19.5% of all ablations). The trend continued toward an increased number of procedures performed with a mapping system (14% increase from 2022) and without fluoroscopy (7% increase from 2022) (table 3).

The success rate was 98% (similar to 2022), with a similar percentage of complications vs the previous year (0.5% in 2022 and 0.4% in 2023). Most complications were vascular (n=16) and 1 patient developed atrioventricular block (AVB). The most commonly used catheters were irrigated-tip catheters with contact forcesensing technology (41%), followed by standard irrigated catheters (31%) and 8- and 4-mm catheters (23% and 5%, respectively).

AVNRT ablation continued to be the third most commonly treated ablation target (16%), after AF and CTI. Although the percentage relative to other ablation targets has gradually decreased in recent years, the absolute number of procedures has progressively increased (4213 procedures, representing an 8% increase vs 2022). The reported success rate was 99%, with a complication rate of 0.4%, which included 9 AVBs (0.2%) and 7 vascular complications. Both the energy source used (radiofrequency was the most frequently used approach, while cryoablation was used in only 2.2% of procedures) and the use of mapping systems (48%) remained at figures similar to those of previous years.

AP ablation was once again the fourth most frequently treated ablation target, accounting for 8% of all ablations performed and showing a 6.2% increase in the total number of procedures vs 2022 (2005 vs 1888 in 2022). The success rate was 95% while the complication rate was 0.8%, which included 6 pericardial effusions, 5 vascular complications, 3 embolisms, and 2 AVBs. In addition, 46% of the APs showed bidirectional conduction, 19% had exclusively anterograde conduction, and 35% had exclusively retrograde conduction. Left APs continued to be the most frequent location (52.5% of procedures, with a 98% ablation success rate), followed by inferoseptal pathways (26.5%; 97% success rate), para-Hisian/anteroseptal pathways (10.6%; 80% success rate), and right free wall pathways (10.5%; 93% success rate). Epicardial ablation was necessary in 28 procedures. Transseptal access was used more frequently than retroaortic access for ablation of the left pathways (61% vs 39%). Mapping systems were used in more than half of all procedures and almost a fifth were fluoroscopy-free.

A total of 1263 AVN ablations were performed in 2023 (30 fewer than in 2022). A success rate of 98% was recorded, as well as a complication rate of 0.3% (all vascular). The most commonly used catheters were 4-mm catheters (47%), followed by standard irrigated catheters (28%) and 8-mm and irrigated contact forcesensing catheters (19% and 6%, respectively). Mapping systems and zero-fluoroscopy strategies were used in less than 5% of all procedures for this ablation target.

In 2023, 897 procedures were performed for this ablation target (35 more than in 2022). This figure represented 3.5% of all ablations in the registry. Overall effectiveness remained similar to that of 2022 (88% in 2022 and 89% in 2023) for both right atrial ablation targets (88%) and left atrial targets (91%). Most catheters (89%) were contact forcesensing catheters. There was a notable increase in the use of electroporation (n=5) and vein of Marshall ethanol infusion (n=18), although the number of procedures is still very low.

All procedures were performed using a mapping system, and 90 were performed without fluoroscopy. Of the 21 complications reported, the most frequent were vascular (n=11), followed by pericardial effusions requiring drainage (n=6) and embolic phenomena (n=3). As for AF ablation, no atrioesophageal fistula was reported after MAT ablation in 2023.

In 2023, 639 FAT ablations were performed (47 more than in 2022), representing 2.5% of all reported ablations. Of these, 65% were in the right atrium and 35% in the left atrium, with acute success rates of 95% and 89%, respectively (similar to 2022). Five complications were recorded: 2 AVBs requiring pacemaker implantation, 2 vascular complications, and 1 pericardial effusion. All procedures were performed using a mapping system, while 124 were conducted without fluoroscopy.

IVT ablation procedures in 2023 remained consistent with 2022, both as a percentage (4.2%) and in absolute numbers (1095 vs 1011 procedures in 2022). The number of centers performing these procedures was also stable, at 85, with a median of 8.5 [12] procedures per center. Regarding the locations of the tachycardias, 47% originated in the right ventricular outflow tract, 20% in the left ventricular outflow tract, and 13% in the aortic root. In addition, 6.4% were fascicular tachycardias, 3% were epicardial tachycardias, and 0.1% originated in the pulmonary artery. In 10% of procedures, the origin was located elsewhere (from most to least frequent): papillary muscle, mitral annulus, tricuspid annulus, and moderator band. The reported success rate was 87% (72% in the left ventricular outflow tract and 91% in the right ventricular outflow tract).

Mapping systems were used in 90% of procedures. The use of irrigated-tip catheters with contact forcesensing technology was standard for this ablation target (89%). The use of energy sources other than radiofrequency was rare (alcohol ablation in 3 cases and cryoablation in 2). Overall, 23 complications were recorded (2.1%), including 10 vascular complications, 7 pericardial effusions, 2 embolisms, 1 acute infarction, and 1 aortic leaflet perforation. One death occurred, caused by electromechanical dissociation in the context of arterial ethanol ablation.

Although there were no major changes in the number of centers performing ICM-VT ablations (n=70) or the percentage of procedures (2% of the total number of ablations performed), there was an absolute increase of 6.7% in the number of procedures (n=605). The median number of procedures was 5 [8]. Mapping systems were used in most procedures, and zero-fluoroscopy procedures were rare (table 3). The acute success rate was 86% and the most commonly used ablation catheters were irrigated-tip catheters with contact forcesensing technology (97%). Six centers performed stereotactic radioablation (18 procedures). The access routes were similar to those used in 2022, with transseptal access being the common (66% of procedures). A combined endocardial/epicardial approach was used in 9% of procedures, while exclusively epicardial access was used in 2.6%. The predominant strategy was substrate ablation (68%), with conventional activation mapping applied in 18%. The complication rate was 6.3%, which is similar to that of previous years, and included 12 vascular complications, 7 AVBs, 11 pericardial effusions, 2 embolisms, and 5 cases of heart failure decompensation. Three deaths were associated with the procedure (1 electromechanical dissociation, 1 stroke, and 1 cardiogenic shock; 0.5% mortality).

The number of centers (n=59) and total number of procedures (n=339) in 2023 were similar to those in 2022. The median number of procedures per center was 2 [19] and the success rate was 85%. An electroanatomic mapping system was used in most procedures (87%). The main ablation targets were nonischemic dilated cardiomyopathy in 183 procedures (54%; 79% success), arrhythmogenic cardiomyopathy in 59 procedures (17%; 76% success), hypertrophic cardiomyopathy in 14 procedures (4.1%; 100% success), congenital heart disease in 30 procedures (8.8%, 93.3% success), and bundle-branch tachycardia in 9 procedures (2.6%; 87.5% success).

The use of irrigated-tip catheters with contact forcesensing technology was standard (95.5%), while the use of other energy sources was rare, with 9 radioablations and 1 alcohol ablation. The transseptal approach was used in 37% of procedures. A combined endocardial-epicardial approach was used in 22% of procedures while exclusively epicardial access was used in 13%.

The reported complication rate was 4.4%: 5 pericardial effusions, 4 heart failure decompensations, 3 vascular complications, and 1 pleural effusion. No deaths were associated with the procedure.

A total of 466 ablations were reported in pediatric patients, representing 3.3% of the total figure, without counting AF or VT ablations (including these ablation targets, the percentage of the total was 1.8%) (figure 8). The most frequently treated ablation target continued to be APs (67% of procedures, 313 procedures, 41 centers), followed by AVNRT (23%, 109 procedures, 29 centers) and FAT (3.4%, 16 procedures, 12 centers). Other ablation targets were much less frequently treated in this population: IVT (3.4%), ICT (1.5%), MAT (1%), NICM-VT (2 procedures), and AF (1 procedure). Thus far, no complications have been associated with ablations performed in the pediatric population.

Figure 8.

Relative proportion of each ablation target in pediatric patients (younger than 15 years) vs the total number of procedures in 2023. AP, accessory pathway; AVNRT, atrioventricular nodal re-entrant tachycardia; CTI, cavotricuspid isthmus; FAT, focal atrial tachycardia; IVT, idiopathic ventricular tachycardia; MAT, macrore-entrant atrial tachycardia.

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The percentage of ablation procedures performed with electroanatomic mapping systems was similar to that of 2022 (55% in 2022 and 54% in 2023). Notably, the use of mapping systems predominated in less complex ablation targets (CTI, AVNRT, and APs), which once again showed an increase in zero-fluoroscopy procedures (table 3). AVN ablation continued to be a less complex target that rarely involved mapping systems and zero-fluoroscopy strategies. The use of mapping systems is practically standard in MAT and VT ablations. For these targets, zero-fluoroscopy procedures are rare, although 18% of IVT ablations adopted a zero-fluoroscopy strategy. Finally, 20% of FAT ablations were performed without a mapping system.

In 2023, there was a significant increase in the number of centers performing cardioneuroablation, rising from 25 centers in 2022 to 41 in 2023. However, the increase in the total number of procedures for this ablation target was more modest (111 in 2022 to 142 in 2023). This indicates that the technique is becoming more established, although the indication for this type of ablation remains limited, likely due to strict patient selection.