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.