Extracardiac vagal nerve stimulation–guided cardioneuroablation in patients with interrupted superior vena cava and brachiocephalic vein drainage: Tips, tricks, and insights from 500 consecutive cases including 5 complex procedures—Insights from the Polish Cardioneuroablation and Cardioneuromodulation registry

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Vagally mediated bradyarrhythmias referred for ECVS-guided cardioneuroablation (n=500). Intervention: Extracardiac vagal nerve stimulation (ECVS)-guided cardioneuroablation (CNA) using standard or alternative vascular access. Primary outcome: Successful baseline unilateral ECVS cannulation via standard SVC and brachiocephalic vein access and incidence of venous drainage anomalies requiring alternative access.

Q: What does this research mean for the field?

Alternative vascular access routes enable successful extracardiac vagal nerve stimulation-guided cardioneuroablation in patients with interrupted superior vena cava or brachiocephalic vein drainage. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Sebastian M. Stec; Antoni Wileczek; Hasso Uuetoa; Marta Kornaszewska; Magdalena Zagrodzka; Jakub Batko; Karolina Barańska-Pawełczak

doi:10.1016/j.hrcr.2026.01.010

January 28, 2026HeartRhythm Case ReportsOpen Access

Extracardiac vagal nerve stimulation–guided cardioneuroablation in patients with interrupted superior vena cava and brachiocephalic vein drainage: Tips, tricks, and insights from 500 consecutive cases including 5 complex procedures—Insights from the Polish Cardioneuroablation and Cardioneuromodulation registry

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Key result

Alternative vascular access enables successful ECVS-guided cardioneuroablation in ~1% of patients with anomalous venous drainage.

n=500

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Why the study?

Rare anomalies in superior vena cava and brachiocephalic vein drainage hinder standard retrograde internal jugular vein cannulation required for extracardiac vagal nerve stimulation-guided cardioneuroablation.

Can alternative vascular access routes and multimodality imaging enable successful extracardiac vagal nerve stimulation-guided cardioneuroablation in patients with vagally mediated bradyarrhythmias and interrupted superior vena cava or brachiocephalic vein drainage?

Key Points

Describe alternative vascular access routes, imaging techniques, and procedural strategies for performing extracardiac vagal nerve stimulation–guided cardioneuroablation in patients with interrupted superior vena cava or brachiocephalic vein drainage.
Identified 5 complex procedures with venous drainage interruption from 500 consecutive cases in the Polish Cardioneuroablation and Cardioneuromodulation registry.
Used preprocedural multimodality imaging including computed tomography, magnetic resonance imaging, and transesophageal echocardiography alongside targeted venography to map venous anatomy.
Utilized alternative vascular access pathways including subclavian veins, persistent left superior vena cava, the azygos vein, and ultrasound-guided retrograde internal jugular vein puncture.
Alternative vascular access routes successfully enabled bilateral or unilateral internal jugular vein cannulation across all 5 complex procedural cases.
Retrograde access via atypical pathways such as a persistent left superior vena cava or ultrasound guidance facilitated effective vagus nerve capture and cardioneuroablation despite thoracic venous obstruction.

Study Design

Type

Observational (n=500)

Multicenter

Yes

Structured PICO

Can alternative vascular access routes and multimodality imaging enable successful extracardiac vagal nerve stimulation-guided cardioneuroablation in patients with vagally mediated bradyarrhythmias and interrupted superior vena cava or brachiocephalic vein drainage?

P

Population

500 consecutive patients with vagally mediated bradyarrhythmias referred for ECVS-guided cardioneuroablation across 7 European countries, including 5 complex cases (1.0%) with interrupted superior vena cava or brachiocephalic vein drainage.

I

Intervention

Extracardiac vagal nerve stimulation (ECVS)-guided cardioneuroablation (CNA) utilizing multimodality imaging (CT, MRI, TEE, ultrasound, venography) and alternative vascular access routes (unilateral/bilateral subclavian veins, persistent left SVC via coronary sinus, azygos vein, or direct ultrasound-guided retrograde internal jugular vein cannulation) in cases of interrupted SVC or brachiocephalic venous drainage.

O

Outcome

Feasibility and procedural success of internal jugular vein cannulation for ECVS (confirming complete binodal/bilateral parasympathetic denervation by absence of ECVS-induced sinus arrest and AVB) and incidence of SVC/brachiocephalic venous interruptionsurrogate

Limitations

Absence of additional electrophysiological or clinical signs of vagal nerve capture during postprocedural ECVS
Difficulty in achieving timely and successful cannulation of the left internal jugular vein
Inability to visualize the vagus nerve and requirement for continuous fluoroscopy during standard fluoroscopy-guided electrode positioning
Postprocedural ECVS lacks additional electrophysiological or clinical signs of vagal nerve capture
Standard fluoroscopy-guided ECVS cannot visualize the vagus nerve and requires continuous fluoroscopy

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Implication

This series establishes that preprocedural multimodality imaging and alternative vascular access routes (such as via a persistent left SVC, subclavian vein, or direct retrograde internal jugular puncture) enable successful ECVS-guided cardioneuroablation in the 1% of patients with congenital or lead-related SVC/brachiocephalic venous interruption.

Abstract

Key Teaching Points1. Patients with vagally mediated bradyarrhythmias (VMB) referred for n (ECVS)-guided cardioneuroablation (CNA) typically require retrograde and bilateral cannulation of the internal jugular veins (IJV) via the superior vena cava (SVC).However, rare anomalies in SVC and brachiocephalic vein drainage can hinder the implementation of ECVS for CNA guidance, necessitating alternative vascular access for ECVS, preferably bilateral but at minimum unilateral.2. Preprocedural multimodality imaging (CT, MRI, TEE), complemented by targeted venography, is crucial for identifying SVC and brachiocephalic venous interruptions enabling individualized ECVS-guided CNA strategies and coordinated Heart Team planning.3.This case series describes the incidence of these anomalies, explores alternative vascular access routes, and provides technical tips, procedural strategies, and imaging guidance for successful IJV cannulation in patients with VMB and interrupted SVC drainage into the right atrium (RA) referred for complex ECVS-guided CNA.Access via unilateral or bilateral subclavian veins, a persistent left SVC, the azygos vein, or retrograde puncture with ultrasonography-guided IJV cannulation can facilitate ECVS-guided CNA in patients with complex upper thoracic venous anatomy due to adult congenital heart disease or iatrogenic interruption of SVC-RA drainage.

Discussion

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Cite This Study

Stec et al. (2026) conducted an observational in Vagally mediated bradyarrhythmias referred for ECVS-guided cardioneuroablation (n=500). Extracardiac vagal nerve stimulation (ECVS)-guided cardioneuroablation (CNA) using standard or alternative vascular access was evaluated on Successful baseline unilateral ECVS cannulation via standard SVC and brachiocephalic vein access and incidence of venous drainage anomalies requiring alternative access. Alternative vascular access routes enabled successful ECVS-guided cardioneuroablation in the 1.0% (5/500) of bradyarrhythmia patients with interrupted SVC or brachiocephalic vein drainage.

synapsesocial.com/papers/6a81c710c61ccf7f9ed81f7e https://doi.org/10.1016/j.hrcr.2026.01.010

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Key Points

Study Design

Structured PICO

Limitations

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Implication

Abstract

Discussion

Cite This Study

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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