Key result
Electrogram-guided stepwise cardioneuroablation linked to 0% recurrence of refractory vasovagal syncope at one year.
Why the study?
While biatrial cardioneuroablation approaches are common for refractory vasovagal syncope, the efficacy of a stepwise strategy beginning right-sided and progressing to the left atrium only if necessary remained incompletely defined.
Does a stepwise, electrogram-guided cardioneuroablation strategy prevent syncope recurrence in patients with refractory cardioinhibitory or mixed vasovagal syncope?
Observational (n=57)
Does a stepwise, electrogram-guided cardioneuroablation strategy prevent syncope recurrence in patients with refractory cardioinhibitory or mixed vasovagal syncope?
A stepwise cardioneuroablation strategy starting with right-sided ablation is highly effective for refractory vasovagal syncope, eliminating syncope recurrence at 1 year while avoiding left atrial access in over half of patients.
Supports stepwise cardioneuroablation in refractory vasovagal syncope; leaves open need for randomized confirmation before practice change.
Cardioneuroablation (CNA) is an emerging treatment for refractory vasovagal syncope (VVS). While biatrial approaches are common, the efficacy of a stepwise strategy-beginning with right-sided ablation and progressing to the left atrium only if necessary-remains incompletely defined. We conducted an observational, retrospective registry (2024-2025) of 57 patients (mean age 34.5 ± 16.8 years) with highly refractory cardioinhibitory (Vasovagal Syncope International Study 2A/2B, 77.2%) or mixed (Vasovagal Syncope International Study 1, 22.8%) VVS. All patients had normal intrinsic conduction verified by electrophysiological study and a positive atropine challenge. A fragmented electrogram-guided stepwise CNA was performed. Left-sided ablation was performed exclusively if right-sided ablation failed to meet predefined end points (fragmented electrogram elimination, heart rate [HR] increase >25%, and postablation atropine response <10%). Acute procedural success was achieved in 96.5% of cases. Right-sided ablation alone met denervation criteria in 30 patients (52.6%), while 27 (47.4%) required a subsequent biatrial approach. The requirement for a biatrial approach was not significantly predicted by the predominant rhythm disturbance (sinus slowing vs AV block). At a mean follow-up of 12.5 ± 6.0 months, there were 0% syncope recurrences. Significant improvements were observed at 6 months in mean HR (59.7 ± 9.9 to 79.6 ± 7.8 beat/min; p < 0.001) and in all time- and frequency-domain HR variability parameters, confirming sustained parasympathetic withdrawal. A stepwise, electrogram-guided CNA is a highly safe and effective therapy for carefully selected patients with functional VVS. Initial right-sided ablation is sufficient in over half of the cases, safely optimizing procedure time and avoiding unnecessary left atrial access without compromising clinical outcomes.
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Robledo-Nolasco et al. (2026) conducted an observational in Refractory vasovagal syncope (n=57). Fragmented electrogram-guided stepwise cardioneuroablation was evaluated on Syncope recurrences. Stepwise, electrogram-guided cardioneuroablation achieved 96.5% acute procedural success and 0% syncope recurrences at 12.5 months in patients with refractory vasovagal syncope.
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