A Tailored Approach to Cardioneuroablation for Reflex Syncope and Functional Bradycardia. Results from the ELEGANCE multicenter study

Figures

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  Figure 1. Study flowchart. Study flowchart and CNA strategies. A total of 123 patients underwent preprocedural MDCT with LA and RA extraction, LA wall thickness measurement, and GP segmentation. Sixty-nine patients were treated with the standard protocol, consisting of a biatrial, non-selective ablation of all GPs (LSGP, MTGP, LIGP, AO-SVC GP, SPSGP, and IPSGP). Fifty-four patients were treated with a tailored protocol, beginning with a pathophysiology-guided LA approach (SPSGP for fSND, IPSGP for fAVB, or both if dual), followed by RA ablation if no LA response, and additional GP targeting if still non-responsive. AO-SVC GP, aorto–superior vena cava ganglionated plexus; CNA, cardioneuroablation; fAVB, functional atrioventricular block; fSND, functional sinus node dysfunction; GP, ganglionated plexus; IPSGP, inferior paraseptal ganglionated plexus; LA, left atrium; LAWT, left atrial wall thickness; LIGP, left inferior ganglionated plexus; LSGP, left superior ganglionated plexus; MDCT, multidetector computed tomography; MTGP, mitral ganglionated plexus; RA, right atrium; SPSGP, superior paraseptal ganglionated plexus.

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  Figure 2. Distribution of HUTT responses before and after CNA in standard and tailored groups. The bar plot illustrates the proportional distribution of HUTT responses before and after CNA in Standard and Tailored groups. Post-CNA, both groups showed a significant increase in negative response.

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  Figure 3. Heart rate at serial holter ECG extended serial holter monitoring demonstrated sustained HR changes across all follow-up timepoints. Both the tailored and standard CNA approaches produced comparable HR increases, with no significant differences between groups in median HR (P = 0.67), minimum HR (P = 0.22), or maximum HR (P = 0.36). HUTT, head-up tilt test.

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  Figure 4. Kaplan–meier analysis of syncope-free survival: standard vs. tailored approaches. The Kaplan–Meier survival analysis compares syncope-free survival rates between patients treated with the standard approach and those treated with a tailored approach over a follow-up period. The analysis indicates no statistically significant difference between the two groups, as evidenced by a log-rank P-value of 0.96. Additionally, the hazard ratio of 1.0 (95% CI: 0.1–15.9) highlights equivalent outcomes between the standard and tailored approaches in preventing syncope recurrence. HR, hazard ratio.