Cardioneuroblation for Functional Bradycardia and Vasovagal Syncope Outcomes from the US Multicenter CNA Registry (JCEP August 2025)-Article: Cardioneuroblation for Functional Bradycardia and Vasovagal Syncope Outcomes from the US Multicenter CNA Registry

Article: Cardioneuroblation for Functional Bradycardia and Vasovagal Syncope Outcomes from the US Multicenter CNA Registry

Back to course

Pdf Summary

This study reports outcomes from the first-ever large multicenter U.S. registry evaluating cardioneural ablation (CNA) as treatment for functional bradycardia and vasovagal syncope (VVS), conditions characterized by excessive parasympathetic tone causing symptomatic bradycardia or syncope. CNA involves catheter-based radiofrequency ablation targeting ganglionated plexus (GP) regions in the atria to reduce maladaptive autonomic reflexes.<br /><br />Between 2018 and 2024, 205 patients (mean age 47±17 years; 49% female) underwent 210 CNA procedures across 15 U.S. centers for recurrent VVS or symptomatic functional sinus bradycardia (SB) or atrioventricular block (AVB) refractory to medical/behavioral therapy. Most patients (66%) had syncope as indication, primarily VVS (62%) and some AVB-related syncope; others had SB or AVB without syncope. An anatomical approach targeting typical GP sites in both atria was used in 77% of cases, with high-frequency stimulation aiding localization in 47%. The mean radiofrequency ablation time was 697±515 seconds.<br /><br />Procedurally, vagal responses (heart rate decrease ≥5 bpm) were observed in 52% and sympathetic responses (heart rate increase ≥5 bpm) in 73%. Post-ablation, mean heart rate increased by 20±15 bpm acutely, and electrophysiology parameters showed improved conduction. Complications occurred in 4.7%, including respiratory failure, sinus node dysfunction, hemopericardium, and one death unrelated directly to CNA.<br /><br />At average 14 months follow-up, 78% of patients with syncope remained free from recurrence, with syncope episodes dropping from a median of 7 to zero. Ninety-seven percent avoided permanent pacemaker implantation, highlighting CNA’s potential to reduce device dependence. The study underscores CNA’s feasibility, reasonable safety profile, and significant clinical efficacy in reducing syncope and functional bradycardia burden.<br /><br />Limitations include lack of control group, heterogeneous ablation techniques, and limited long-term data. However, these observational findings represent a major advance paving the way for randomized controlled trials to define CNA’s role beyond compassionate use in refractory patients. Standardization of procedural endpoints and careful patient selection remain priorities for optimizing safety and outcomes in this novel autonomic neuromodulation therapy.

Keywords

cardioneural ablation

functional bradycardia

vasovagal syncope

ganglionated plexus

radiofrequency ablation

syncope recurrence

autonomic neuromodulation

sinus bradycardia

atrioventricular block

pacemaker avoidance