Cardioneuroablation for treating functional bradyarrhythmias. How much is enough?

Cardioneuroablation is an endocardial atrial catheter ablation technique proposed in the 1990s, to obtain enough vagal denervation to treat functional bradyarrhythmias without a pacemaker [1]. The distinguished Indian Pacing and Electrophysiology Journal presents us this interesting study of Mesquita D et al. “Anatomic guided ablation of the atrial right ganglionated plexi is enough for cardiac autonomic modulation in patients with significant bradyarrhythmias” [2]. It is another notable contribution to this highly promising new technique. Publications that reproduce the original technique adding new methods are extremely valuable to prove reproducibility and feasibility. Several authors have been trying to simplify the CNA [3,4]. Unfortunately, it is not easy. Some aspects deserve to be carefully analyzed. The high complexity of cardiac innervation restrains these efforts and may cause frustration. The main concerns to some publications may be the diversity of mapping techniques, the absence of direct denervation control in many articles, the lack of a solid endpoint, the possible placebo effect, the short follow-up, the question of the learning curve. Significant challenges of this method were already apparent in the first series of patients and deserve to be shortly commented.