Cardioneuroablation for vasovagal syncope and atrioventricular block: A step‐by‐step guide

Abstract

Catheter-based cardioneuroablation is increasingly being utilized to improve outcomes in patients with vasovagal syncope and atrioventricular block due to vagal hyperactivity.There is now increasing convergence among enthusiasts on its various aspects, including patient selection, technical steps, and procedural end-points. This pragmatic review aims to take the reader through a step-by-step approach to cardioneuroablation: we begin with a brief overview of the anatomy of intrinsic cardiac autonomic nervous system, before focusing on the indications, preprocedure and postprocedure management, necessary equipment, and its potential limitations.

Clinical impact of aging on outcomes of cardioneuroablation for reflex syncope or functional bradycardia: Results from the cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs—The ELEGANCE multicenter study

“…Anatomical map of the LA was acquired using CARTO 3 (Biosense Webster, Diamond Bar, CA) or NavX (Abbott, USA) and fused with CT images. Areas where GPs are usually located 8 were searched for fragmented EGM (fEGMs) (i.e., showing 4 deflections) but ablated based on anatomical landmarks independently from the presence of fragmentation. As from June 2022, epicardial fat pads near the area of anticipated GPs with attenuation -190 to -30 Hounsfield Units (HU) were segmented, exported using ADAS3D software (Galgo Inc.), and integrated in electro-anatomical maps for real-time guidance of GP ablation (Figure 1).…”

“…The ablation end-point for each GP was defined as abolition of RF-induced vagal response for LSGP, MTGP and LIGP increase in basal HR 25% for the SPSGP, RIGP and Ao-SVC GPs, and shortening of at least 25% of AH interval for the IPSGP 8,16 .…”

“…Cardioneuroablation (CNA) is a new approach for treating vasovagal syncope (VVS) [1][2][3][4] , carotid sinus syndrome (CSS) 5 , symptomatic sinus bradycardia 6 , and atrioventricular (AV) blocks 7,8 caused by autonomic imbalance. Evidence suggests that autonomic control in younger individuals is characterized by the predominance of vagal activity, while in older individuals, sympathetic tone is more prominent 9 .…”

Arrhythmic syncope: From diagnosis to management

“…Finally, in recent years it has been demonstrated that cardiac denervation of parasympathetic ganglia can be highly effective in reducing cardioinhibitory reflex syncope, a technique known as cardioneuroablation[ 43 ]. Tilt test might play a crucial role in detecting suitable patients for this promising procedure[ 44 ].…”

Author’s Reply—Atropine: Hero or villain in cardioneuroablation?

“…“Abandonment” of high-frequency stimulation has not been prevalent, less so at the time of this procedure early in 2021, and labs that exclude high-frequency stimulation generally do so in favor of an electrogram-only approach, rather than replacing it with extracardiac vagal stimulation, as implied. 1 , 2 , 3 We are interested in the potential of extracardiac vagal stimulation to optimize denervation assessment; however, its incorporation in mainstream CNA workflows has been, as Drs Pachon cite, quite limited.…”