Why atrial fibrillation ablation remains underused in EuroAsia Task Force countries: insights from the ESC-EHRA Atlas and a regional survey

BACKGROUND: The prevalence of atrial fibrillation (AF) is increasing worldwide, yet access to catheter ablation remains uneven across regions. This study aimed to compare access to AF ablation across seven EuroAsia Task Force countries and identify barriers and potential strategies for improving service provision. METHODS: This cross-sectional study combined a secondary analysis of the 2025 European Society of Cardiology - European Heart Rhythm Association (ESC-EHRA) Atlas on Heart Rhythm Disorders with a structured regional survey. Procedural activity, infrastructure, and workforce indicators were compared with ESC reference medians and expressed per million population. Missing data for Turkmenistan were obtained from the national representative (2023). Exploratory correlations between ablation rates and healthcare expenditure indicators were assessed, including current health expenditure as a percentage of gross domestic product, out-of-pocket expenditure, domestic general government health expenditure, and current health expenditure per capita. RESULTS: AF ablation volume ranged from 2 to 190 procedures per million population, with six of seven countries below the European median (151 per million). Hospitals performing ablation ranged from 0.1 to 1.9 per million, with only one country exceeding the ESC median. No country met benchmarks for high-volume ablation centers or operator density. Fellowship density was low (0.1-1.3 per million). Financial barriers were identified as the main obstacle by five of six country representatives. CONCLUSIONS: Access to AF ablation in EuroAsia Task Force countries is low and heterogeneous. Healthcare financing structure and per-capita health spending may be more important determinants of access than overall expenditure relative to gross domestic product.