Clin Res Cardiol (2022).

Cardioneuroablation for vagally-mediated arrhythmias: initial single-centre experience
S. Raffa1, M. Frommhold1, G. Borisov1, K. Issa1, A. Fink1, O. Alothman1, J. C. Geller1
1Rhythmologie und invasive Elektrophysiologie, Zentralklinik Bad Berka GmbH, Bad Berka;
Background: The influence of the autonomic nervous system on the complex pathophysiologic mechanisms of different cardiac arrhythmias has gained increasing interest in recent years. Catheter ablation of ganglionated plexi (GP) localised at the epicardial surface of both atria (so called cardioneuroablation [CNA]) represents an emerging therapy for a number of vagally-mediated cardiac arrhythmias. Aim of this study is to present our intial experience with CNA.
Methods: Data from all patients undergoing CNA at our institution were prospectively  included in this study. 
Results: Between July 2020 and November 2021, a total of 9 patients (median age 62 [IQR 58-71] years, 4 women) with vagally-mediated arrhythmias underwent CNA either alone or in combination with pulmonary vein isolation (PVI). The majority had advanced AV-block (n=8), either isolated (n=4) or combined with other conditions [atrial fibrillation (AF n=2), sinus bradycardia and AF (n=1), or syncope (n=1)]. One patient presented with sinus bradycardia and paroxysmal AF. During the ablation procedure (performed under deep sedation with propofol and fentanyl), a detailed biatrial activation- and voltage-map was acquired using the Ensite Precision 3D-mapping system and a multipolar catheter (HD-Grid). Ablation was performed in the anatomical areas where GP are usually located, using a contact-force-sensing catheter (TactiCath) and trying to achieve a lesion index (LSI) of at least 5. In case of vagal response or increase in heart rate during ablation, energy application was continued based on LSI and repeated until no vagal effect was elicited anymore. In the 3 patients suffering from AF, PVI was performed as well. The main procedure data is shown in the table.

   Procedure Duration (min) Ablation Time (s)   X-ray Time (min) X-ray Dose (cGy/cmq) 
 Median and IQR 170 (160, 200)  2002 (1541, 2286) 1.7 (0.5, 2.0)  18 (13, 32) 

No relevant procedure- or sedation-related complications (groin hematoma n=1) occurred. All but 2 patients had complete acute success with evidence of cardiac denervation and resumption of normal heart rhythm. The 2 patients showed isolated persistent functional AV-block, and normal AV-node conduction recovered at 2 weeks-follow-up in both. At a median flow-up of 3 (IQR 1-6) months, no symptom/arrhythmia recurrence and no hospitalisation for any cardiac arrhythmia or pacemaker implantation occurred. 

Conclusions: In this single centre initial experience of CNA, excellent short-term clinical results could be achieved. Even in a relatively old but well selected population suffering from vagally-mediated arrhythmias, modification of the intrinsic cardiac autonomic system was able to correct vagal hyperactivity and restored normal heart rhythm. Further studies with longer follow-up will clarify whether short-term results persist over time.