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Brain & Heart Cardioneuroablation for VMB

CNA techniques and has paved the way for more refined right superior GP and targeting all left atrial GPs. Further
and patient-specific procedures. Aksu et al. 13,18,22,24,26,34,40,46,47 research is required to determine whether focusing solely
employed a streamlined approach targeting primary GPs on the right superior GP provides long-term benefits and
in the atria, which yielded positive outcomes. Conversely, to further elucidate the complex regulation of GPs. CNA is
Zhao et al. and Qin et al. conducted anatomical GP a novel surgical technique that currently lacks long-term
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ablations in both atria to manage symptomatic sinus clinical follow-up data extending beyond a decade. While
bradycardia. Debruyne et al. 19,25 adopted a unifocal the growing body of short-term evidence is promising,
approach on the right side to address neurally mediated long-term studies are essential to evaluate the durability
syncope and sinus node issues. In the two case reports of its outcomes. Moreover, its prolonged effects remain to
presented in this study, we demonstrate that CNA can be determined. The long-term success of this procedure
achieve favorable outcomes whether the approach is from can be undermined by incomplete ablation, potentially
the RA or LA. This efficacy is likely due to the anatomical resulting in reinnervation due to the presence of remaining
position of the RAGP, which is located between the LA intramural parasympathetic post-ganglionic neurons. To
and RA, allowing access to this GP site from either atrium address this issue, future approaches could involve multiple
(Figure 7). ablations using both endocardial and epicardial pathways
to improve long-term outcomes.
The interaction among GPs necessitates careful selection
of targeted GPs for ablation to minimize potential adverse In clinical practice, we encounter two primary patient
effects. Chiou et al. identified a fat pad near the right populations. The first group includes those with VMB who
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pulmonary artery as a critical relay point in the cardiac may avoid the need for pacemaker implantation through
autonomic network, which Debruyne et al. 19,25 targeted CNA. The second group consists of a significant cohort
during their procedures. By systematically selecting which of patients who had previously received a pacemaker due
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GPs to target based on patient-specific anatomical and to VMB. For these patients, CNA has the potential to
functional markers, the risk of unnecessary complications render both the pacemaker and its implanted electrodes,
can be reduced, and outcomes can be optimized. Our which may degrade over time, unnecessary. The broader
prior research on CNA in patients with vasovagal syncope clinical implications of this procedure include reducing
demonstrated that sequentially targeting specific GPs, dependency on long-term device management, which
starting from the left superior GP to the RAGP, resulted could potentially ease the burden on healthcare systems
in immediate and sustained heart rate increases during while improving patients’ quality of life. This paradigm
ablation of the RAGP, with other GPs primarily eliciting shift could reshape how clinicians manage VMB patients
vagal responses. 21,49 This suggests that the RAGP plays a in the coming years.
significant role in CNA outcomes. Despite these findings, Our analysis included studies with relatively small
there is a direct comparison between ablating only the sample sizes or retrospective designs. Future investigations
should aim to include extensive, prospective, multicenter
studies that are double-blinded and randomized to further
validate our conclusions. A recent search of the https://
clinicaltrials.gov/website revealed numerous prospective
clinical trials designed to evaluate the effects of CNA
on VMB. 50,51 In addition, randomized controlled trials
have been performed to compare the outcomes of CNA
with pacemaker implantation. We look forward to the
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forthcoming results of these studies with great interest.
These investigations are expected to address existing gaps
in knowledge, providing the robust evidence required to
establish clinical practice guidelines.
Despite its promising outlook, several challenges
remain to be addressed. First, the complexity of the
cardiac autonomic nervous system necessitates a nuanced
Figure 7. The three-dimensional endocardial surface of the left atrium understanding of GP interactions and precise techniques to
and right atrium and locations of the right anterior ganglionated plexus. ensure successful outcomes. The lack of universal protocols
The right anterior ganglionated plexus (within the red dashed circle) is
located between the left and right atria, allowing access to it from either for GP targeting leads to variability in procedural efficacy. In
atrium. addition, cost considerations and the availability of trained

Volume 3 Issue 1 (2025) 7 doi: 10.36922/bh.4824