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A tailored approach to cardioneuroablation for reflex syncope and functional bradycardia: results from the ELEGANCE
Carlo Gigante1,2, Diego Penela3, Daniel Viveros1,2
1Arrhythmia Department, Heart Institute, Teknon Medical Center, c. Villana, 12, Barcelona 08022, Spain.
Insights
A tailored cardioneuroablation (CNA) approach, targeting specific ganglionated plexi (GPs) based on patient symptoms, proved as effective as the standard method. This personalized strategy significantly reduced procedure time and radiofrequency energy use.
Area of Science:
- Cardiology
- Autonomic Nervous System Research
- Electrophysiology
Background:
- Cardioneuroablation (CNA) modulates the cardiac autonomic nervous system by targeting ganglionated plexi (GPs).
- Current CNA approaches often involve targeting all accessible GPs.
- The efficacy of a selective GP targeting strategy based on clinical phenotype remains to be fully elucidated.
Purpose of the Study:
- To compare a tailored CNA strategy, selectively targeting GPs based on clinical phenotype, against the standard approach of targeting all GPs.
- To assess procedural efficiency and clinical outcomes between the two strategies.
Main Methods:
- A prospective, multicenter European study (ELEGANCE) included 123 patients undergoing CNA.
- Patients were divided into a tailored group (n=54), targeting specific GPs (SPSGP for sinus node dysfunction, IPSGP for AV block), and a standard group (n=69).
- Procedural data and clinical outcomes, including syncope recurrence and heart rate changes, were compared.
Main Results:
- The tailored group demonstrated significantly shorter procedure times (63 vs. 85 minutes) and reduced radiofrequency (RF) time (5.4 vs. 10.4 minutes) compared to the standard group.
- Acute procedural success rates (93% vs. 90%) and heart rate increases (40% vs. 40%) were similar between groups.
- At a median follow-up of 15.9 months, syncope recurrence rates were comparable, with no significant difference in inappropriate sinus tachycardia incidence.
Conclusions:
- An individualized CNA strategy, targeting specific GPs based on patient pathophysiology, yields outcomes equivalent to the standard approach.
- This tailored method enhances procedural efficiency by reducing RF delivery, shortening procedure duration, and limiting the extent of ablation.
- Selective GP targeting offers a more efficient and potentially less invasive alternative for managing reflex syncope and functional bradyarrhythmias.
Aims:
Cardioneuroablation (CNA) is a catheter-based intervention for reflex syncope and functional bradyarrhythmias that consists in the modulation of the parasympathetic cardiac autonomic nervous by targeting ganglionated plexi (GPs).To compare an ablation strategy of selective GP targeting based on clinical phenotype (tailored approach) vs. the standard approach of targeting all GPs (standard approach).
Methods And Results:
This is a prospective, multicentre European study (ELEGANCE study), including 123 patients who underwent CNA (73 men; median age 50 years). Among them 54 (44%) were treated with a tailored approach, targeting the superior paraseptal ganglionated plexus (SPSGP) for sinus node dysfunction and the inferior paraseptal ganglionated plexus (IPSGP) for AV block. Procedural data and clinical outcomes were compared with the remaining 69 patients treated using a standard approach.Clinical phenotypes included isolated functional sinus node dysfunction (43.1%), isolated functional AV block (9.8%), and dual presentations (47.2%). In the tailored group 1.6 ± 0.7 GPs were targeted per patient. Compared to the standard approach, the tailored group had significantly shorter procedure times (63 vs. 85 min, P = 0.005) and reduced RF time (5.4 vs. 10.4 min, P < 0.001). Acute procedural success (tailored: 93% vs. standard: 90%, P = 0.98) and the increase in heart rate (tailored: 40 ± 30.7% vs. standard: 40 ± 31.4%, P = 0.96) were similar between groups. During a median 15.9 months [IQR: 9.8, 24.6] follow-up, there were no differences in syncope recurrence rate (log-rank P = 0.96). Inappropriate sinus tachycardia occurred in 8.1% of patients, (tailored 8.6% vs. standard 7.4%; P = 0.79).
Conclusion:
An individualized CNA strategy, simplified by targeting specific GPs according to patient's pathophysiology, achieved outcomes equivalent to the standard approach while improving procedural efficiency through reduced RF delivery, shorter procedure duration, and limited ablation extent.
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