Background
Background
Cardioneuroablation represents a novel approach for treating functional
bradyarrhythmias and/or atrial fibrillation, including neurocardiogenic
syncope1, utilizing endocardial catheter
radiofrequency ablation(RF) of vagal innervation within the atrial
walls, obviating the need for pacemaker implantation2.
It was created in the nineties being the first series published in
20053.
RF ablation attenuates the vagal innervation in the atrial walls and in
the epicardial ganglion plexuses (GPs) leading to the abolition or
substantial attenuation of the cardioinhibitory
reflex.3,4,5 ,
allowing many patients to be treated without the need for pacemaker
implantation6,7,.
Despite widespread use worldwide, demonstrating good
reproducibility,5,8,9continuous refinement of the technique remains imperative. In this
sense, it is essential to have a hard endpoint that can be used as a
standard in all services, allowing an objective and rational comparison
of results, regardless of the denervation technique used.
To establish a standardized endpoint and ensure procedural rationality,
we introduced the extracardiac vagal stimulation in
2015.10. This tool allows for the assessment of the
effectiveness of vagal denervation and determines whether further
ablation is necessary to achieve complete acute elimination of the vagal
effect, thereby serving for validating vagal denervation, which is
considered the gold-standard endpoint of the procedure.
Some aspects deserve to be considered:
1. Safe methods for visualizing GPs remain elusive and are inferred
through indirect means3,11;
2. A significant proportion of vagal innervation extends beyond the main
GPs12;
3. Individual variability in innervation levels introduces
unpredictability in the anatomical approach12;
4. High-frequency endocardial stimulation identifies only distal
innervation sites and does not assess global vagal innervation, which is
the primary driver of the cardioinhibitory reflex13;
5. Vagal reinnervation occurs to varying degrees in all
cases14,15 underscoring the
importance of comprehensive denervation during the initial procedure to
minimize the risk of recurrence.
In this study, we aimed to investigate whether Cardioneuroablation,
coupled with the elimination of the vagal effect induced by extracardiac
vagal stimulation (ECVS), can enhance long-term outcomes.