Impact of adjunctive cardioneuroablation on heart rate and clinical outcomes in atrial fibrillation ablation: a retrospective study

Background Cardioneuroablation (CNA) is an emerging technique designed to modulate cardiac vagal innervation. Its role as an adjunct to atrial fibrillation (AF) ablation, particularly in patients with bradycardia or a vagal predominance, remains to be clarified. Purpose The primary objective was to assess the impact of CNA on heart rate (HR) and maintenance of sinus rhythm. Secondary endpoints included heart rate variability (HRV), arrhythmia recurrence, reintervention, complications, and symptom improvement. Methods We conducted a single-centre retrospective observational study including consecutive patients who underwent AF ablation between November 2022 and December 2024. Standardised clinical, electrocardiographic, and procedural data were collected. Patients were divided into CNA and non-CNA groups according to whether adjunctive right atrial CNA was performed. Results Seventy-four patients underwent AF ablation, of whom 15 received adjunctive CNA. Baseline bradycardia was more frequent in the CNA group (80% vs 32%, p = 0.001). In the CNA group, HR on standard ECG increased significantly from a median of 52 [45–60] bpm pre-procedure to 69.9 ± 15.0 bpm at 3 months (p = 0.008), with a trend maintained at 1 year (64.2 ± 15.1 bpm, p = 0.066). The mean change in HR at 3 months was greater with CNA compared with controls (13.5 [8–18.5] vs 5 [-1–14] bpm, p = 0.024). Among bradycardic patients treated with CNA, HR rose significantly at 3 months (p = 0.023) and 1 year (p = 0.028) versus baseline, while no significant change was observed in bradycardic patients without CNA (p > 0.1). No significant differences were found between groups in AF recurrence (20% vs 32%, p = 0.529), adverse events (13% vs 8%, p = 0.624), HRV parameters, or procedural duration (162 [136–206] min vs 162 [137–192] min, p = 0.375). Conclusion CNA performed in addition to AF ablation appears to be a safe and promising approach to modulate vagal tone in bradycardic or vagally mediated patients. Its favourable and sustained effect on HR, particularly in bradycardic patients, supports its potential physiological benefit. Prospective randomised studies are warranted to confirm these findings and to define its long-term impact.