Multimodal, device-based therapeutic targeting of the cardiovascular autonomic nervous system

The miniaturization of implantable sensors and actuators, combined with advances in interactive modelling and high-resolution imaging, is propelling the use of medical devices for counteracting impaired neural control of the cardiovascular system. In this Review, we discuss the current effectiveness of this technology for modulating autonomic activity in numerous cardiovascular conditions, including high blood pressure, heart failure and cardiac arrhythmias. We advocate for smarter closed-loop bionic devices fitted with feedback from multiple sensors to allow adaptive, state-dependent control, and discuss how the adoption of artificial intelligence technology would facilitate auto-personalization to meet the needs of patients. We also describe how transcriptomics of autonomic circuits can guide device-based approaches. Finally, the use of stem cell therapies to target sympathetic circuits more precisely will help to optimize the therapeutic effects of autonomic modulation for the treatment of arrhythmia. For bioelectronic medicine to achieve clinical utility in neurocardiology, these innovations must demonstrate improved efficacy beyond that offered by contemporary interventions.