Cardioneuroablation for swallowing-induced syncope: To pace or to ablate, that is the question

Selective cardioneuroablation of the posteromedial left ganglionated plexus for drug-resistant swallow syncope with functional atrioventricular block

“…During a mean follow-up period of 9.2 months, all patients experienced symptom relief. 5 Thereafter, cardioneuroablation has been performed not only for NMS and bradyarrhythmias 5 , 6 , 7 , 8 , 9 but also for atrial fibrillation. 10 In addition to the 3 GP sites in the right atrium, 5 GP sites in the left atrium have been targeted.…”

“… 10 Also, HFS and/or simple anatomical approach has been proposed to identify the locations of GPs instead of spectral mapping. 6 , 7 , 8 , 9 , 10 Recently, a first randomized controlled trial evaluating the efficacy of cardioneuroablation for cardioinhibitory NMS was reported. 7 Cardioneuroablation was superior to conventional nonpharmacologic therapy (education and lifestyle modification) in terms of lower rate of recurrent syncope during 25 months of follow-up (8% vs 54%, P = .0004).…”

“…However, selective ablation of the posteromedial left GP seems sufficient for a functional AV block with a maintained sinus rate. This minimal ablation strategy can avoid the risk of inappropriate sinus tachycardia 6 , 9 and may reduce the potential risk of procedural complications. At the same time, it may be associated with accelerated junctional beats surpassing the sinus rhythm, which can be symptomatic in sensitive patients.…”

“… 5 , 6 , 7 To date, however, there have been only a limited number of case reports on cardioneuroablation for swallow syncope. 8 , 9 Here, we present a case of drug-resistant swallow syncope with transient advanced AV block, successfully treated by selective ablation of the posteromedial left ganglionated plexus (GP).…”

Advantages and pitfalls of selective cardioneuroablation targeting the atrioventricular node

“…The authors are to be commended for a highly educational case report that is important not only in demonstrating again the utility of CNA instead of pacemaker implant to treat recurrent swallowing syncope but also in showing that selective AV nodal denervation can be performed in the case of a dominant AV nodal phenotype and thereby avoid excessive SR acceleration, like in the recently published case report. 5 In our practice, we use a similar principle in selected patients with functional bradyarrhythmias and a dominant AV nodal phenotype, in whom we perform complete denervation of the AV node followed by gentle ablation of the SRGP so that this main vagal entry is partially modified with moderate SR acceleration. Such a strategy is especially appropriate for patients with a high resting SR and/or considerable SR acceleration after atropine administration.…”