Right atrial cardioneuroablation of asystolic reflex syncope

BACKGROUND Cardioneuroablation (CNA) should focus on the vagal ganglia located in the right atrium close to the sinoatrial and the atrioventricular nodes. OBJECTIVE The study aimed to evaluate the efficacy and safety of right atrial CNA. METHODS Patients with severe, asystolic reflex syncope identified by implantable loop recorder (ILR) or tilt testing underwent right atrial CNA and were subsequently monitored using ILR. RESULTS The population included 28 patients with a mean age of 40.5 6 13.4 years, of whom 71% were men. Over a median follow-up period of 12.5 months, 8 patients experienced 44 episodes of asystole lasting longer than 3 seconds, as recorded by an ILR. The burden of asystolic episodes significantly reduced from 0.89 episodes per month before CNA (145 over 163 patient-months) to 0.11 episodes per month after CNA (44 over 397 patient-months), with a relative risk reduction of 0.12, P = .0001. Similarly, the burden of syncopal episodes decreased from 0.23 episodes per month before CNA to 0.06 episodes per month after CNA, resulting in an relative risk reduction of 0.24, P = .0001. Median heart rate increased from 75 bpm (interquartile range: 72-79) before ablation to 83 bpm (interquartile range: 78-85) after ablation, lasting up to 9 months post-procedure. No patients experienced complications during the procedure. During follow-up, 2 patients received pacemakers, 1 underwent a redo procedure, and 4 experienced mild transient symptoms: 3 had palpitations and 1 had dyspnea, none requiring therapy. CONCLUSION Right atrial CNA reduced asystolic episodes by 88% and syncopal episodes by 76% during the mid-term followup. Adverse events were infrequent and mild.