Cardioneuroablation for Reflex Syncope and Functional Bradyarrhythmias: A State-of-the-Art Review

Figures

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  Figure 1. Anatomical targets in cardioneuroablation: the seven ganglionated plexus framework. Reproduced with permission from Gigante C et al. Europace. 2026;28(1):euaf320 [17]. Three-dimensional electroanatomical reconstruction showing the principal GP regions targeted during CNA, including the superior paraseptal GP (SPSGP), inferior paraseptal GP (IPSGP), right inferior GP (RIGP), left superior GP (LSGP), Marshall tract GP (MTGP), and aorto-superior vena cava GP (Ao-SVC GP). L, left; R, right.

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  Figure 2. Diagnostic pathway for identification of the cardioinhibitory phenotype and candidate selection for cardioneuroablation. CNA, cardioneuroablation; CSS, carotid sinus syndrome; DC, deceleration capacity; HR, heart rate; ILR, implantable loop recorder; VASIS, Vasovagal Syncope International Study.

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  Figure 3. Multimodal integration of GP localization strategies: convergence of empirical anatomical reference, CT-segmented epicardial fat pads (ADAS 3D), and peak-frequency analysis (OTNF ≥ 450 Hz) on an electroanatomic map (EnSite X).

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  Figure 4. Practical algorithm for patient selection and procedural strategy in cardioneuroablation. The workflow proceeds from clinical suspicion (recurrent reflex syncope or functional bradyarrhythmia despite conservative therapy) through phenotypic confirmation (head-up tilt testing, implantable loop recorder or telemetry, carotid sinus massage, supported by a positive atropine test and elevated deceleration capacity) and explicit exclusion of poor candidates (predominant vasodepressor response, structural heart disease, intrinsic conduction system disease, blunted atropine response), to phenotype-guided target selection (sinoatrial, atrioventricular, or combined phenotype), ganglionated plexus localization strategy, ablation with confirmation of acute procedural endpoints, and post-procedural follow-up. Localization yields most when several methods converge, and the procedural goal is calibrated parasympathetic denervation rather than maximal denervation.