Electroanatomic versus CT-guided cardioneuroablation: different pathways, same outcome

Background Cardioneuroablation (CNA) is an emerging therapy for cardioinhibitory (CNI) vasovagal (VVS) syncope (1). Electroanatomic (EGM-based) and CT-guided strategies are commonly used approaches yet have not been directly compared (2,3). Objectives To compare the procedural and clinical outcomes of EGM-based and CT-guided CNA. Methods Patients with documented CNI VVS syncope underwent CNA at our University Hospital between July 2023 and May 2025. An EGM-based approach was used from July 2023 to June 2024, and a CT-guided approach from June 2024 to May 2025. Biatrial ablation targeted primarily the superior paraseptal ganglionated plexus (SPGP) and the inferior paraseptal GP (IPGP). The Wenckebach point and sinus rhythm cycle length were measured at baseline under general anesthesia to ensure the same sympathetic tone within the procedure, then after ablation of all the GP, and within 2-3 minutes after atropine injection. At the end of the procedure, the residual vagal tone was assessed as a percentage of difference between the maximum sinus rate and the shortest Wenckebach point before and after the atropine injection. All patients were monitored with an implantable loop recorder and had at least 6 months of follow up. Results Thirty-eight patients underwent 39 CNA procedures: 15 (38%) using the EGM-based approach and 24 (62%) the CT-guided approach. Freedom from CNI syncope at 6 months was 93% and 96%, respectively (p = 1.0). Mean follow-up was longer in the EGM-based cohort (21 ± 4 vs. 11 ± 3 months, p < 0.001). The residual atropine effect on sinus rate (3 ± 7% vs. 7 ± 9%, p = 0.17) and Wenckebach point (3 ± 7% vs. 7 ± 9%, p = 0.18) did not differ significantly. The CT-guided approach involved more ablation points (41 ± 8 vs. 32 ± 5, p < 0.001) and tended to have longer ablation duration (764 ± 177 vs. 654 ± 179 s, p = 0.067). Mean procedural duration was similar (66 ± 15 vs. 67 ± 16 min, p = 0.849). Conclusion EGM-based and CT-guided CNA are distinct procedural strategies yielding comparable electrophysiological and clinical outcomes.