Cardioneuroablation for Cardioinhibitory Vasovagal Syncope

Abstract

The autonomic nervous system (ANS) plays a key role in cardiovascular regulation, optimizing cardiac performance to match the metabolic needs of the body. The various elements of the cardiac neuraxis, their physiologic functioning, and pathologic alterations in various cardiac disorders are increasingly being understood and have contributed to an greater interest in identifying neuromodulatory strategies for treating arrhythmic, and in particular reflex syncope, disorders.

The role of the ANS in vasovagal syncope (VVS) is well established, albeit incompletely understood. While a number of strategies (e.g., drugs, pacing, physical maneuvers) have attempted to favorably alter different components of the reflex arc involved in VVS, their therapeutic benefits have been limited. Cardioneuroablation, targeting the epicardial cardiac ganglia components of the intrinsic cardiac nervous system, is a promising new strategy, which to date has principally focused on management of patients with severe forms of cardioinhibitory forms of VVS refractory to medical therapy. Several groups have reported favorable outcomes with significant reductions in recurrence of syncopal episodes. However, current evidence is derived from case reports, case series, and small cohort studies which temper enthusiasm for the positive results reported. Well-designed randomized control studies are required before this potentially exciting therapeutic strategy can be considered for wider application in the clinical management of patients with VVS. In this chapter we review the anatomic basis of the cardiac neural network, and briefly discuss current neuromodulatory efforts in various cardiac disorders before reviewing current evidence for cardioneuroablation in VVS.