Right atrial cardioneuroablation of asystolic reflex syncope

Background: Cardioneuroablation (CNA) should focus on the vagal ganglia located in the right atrium close to the sinoatrial and the atrioventricular nodes. Objective: The study aimed to evaluate the efficacy and safety of right atrial CNA. Methods: Patients with severe, asystolic reflex syncope identified by implantable loop recorder (ILR) or tilt testing underwent right atrial CNA and were subsequently monitored using ILR. Results: The population included 28 patients with a mean age of 40.5 ± 13.4 years, of whom 71% were men. Over a median follow-up period of 12.5 months, 8 patients experienced 44 episodes of asystole lasting longer than 3 seconds, as recorded by an ILR. The burden of asystolic episodes significantly reduced from 0.89 episodes per month before CNA (145 over 163 patient-months) to 0.11 episodes per month after CNA (44 over 397 patient-months), with a relative risk reduction of 0.12, P = .0001. Similarly, the burden of syncopal episodes decreased from 0.23 episodes per month before CNA to 0.06 episodes per month after CNA, resulting in an relative risk reduction of 0.24, P = .0001. Median heart rate increased from 75 bpm (interquartile range: 72–79) before ablation to 83 bpm (interquartile range: 78–85) after ablation, lasting up to 9 months post-procedure. No patients experienced complications during the procedure. During follow-up, 2 patients received pacemakers, 1 underwent a redo procedure, and 4 experienced mild transient symptoms: 3 had palpitations and 1 had dyspnea, none requiring therapy. Conclusion: Right atrial CNA reduced asystolic episodes by 88% and syncopal episodes by 76% during the mid-term follow-up. Adverse events were infrequent and mild.