The future of cardioneuroablation in cardiovascular medicine

ABSTRACT

Introduction

Cardioneuroablation is increasingly being utilized to improve outcomes in patients with vagally mediated bradyarrhythmias. However, there are still controversial issues in the field including patient selection, safety and efficacy, and procedural end-points.

Areas covered

In this review, the current role of cardioneuroablation is summarized, and controversial issues related to the modality are discussed.

Expert opinion

According to small open-label cohort studies, overall freedom from syncope recurrence was higher than 90% after cardioneuroablation in patients with vasovagal syncope (VVS). Use of the electrogram-based strategy or high-frequency stimulation demonstrate similar success rate except in procedures limited to the right atrium. Based on a recently published randomized controlled trial and metanalysis, it may be possible now to make a strong recommendation for cardioneuroablation in patients <40 years of age, and those with the cardioinhibitory or mixed type of VVS who continue to experience frequent and/or burdensome syncope recurrences. Considering patients with VVS are prone to significant placebo/expectation effect, sham-controlled trials may help to quantify the placebo effect. In well-selected patients with functional atrioventricular block and sinus bradycardia, may result in encouraging medium-term outcomes. However, functional bradycardia is identified in a minority of patients presenting with high-grade atrioventricular block or sinus node dysfunction.

KEYWORDS:

• Ablation
• atrioventricular block
• bradycardia
• ganglionated plexus
• pacemaker
• syncope

Article highlights

• Cardiac parasympathetic nervous system consists of extrinsic (the vagus nerve) and intrinsic parts (ganglionated plexi-GPs) which are usually clustered in the following five major and one minor atrial locations.

• Increased parasympathetic activity is one of the main reasons of VVS and some form of clinical bradyarrhythmias.

• Ablation of GPs may cause parasympathetic denervation and might be used to treat VVS with dominant cardioinhibitory response and vagally-mediated atrioventricular block and sinus node dysfunction.

• Head-up tilt table test and implantable loop recorders can be used to select suitable candidates for cardioneuroablation.

• Cardioneuroablation appears to be a safe procedure during short and medium-term follow-up.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.