A functional-anatomic mapping protocol for cardioneuroablation: A mechanistic case series
Esteban W R Rivarola1, Victor Kormann1, Francisco Darrieux1
1Unidade Clinica de Arritmias Cardiacas, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de SaoPaulo, Sao Paulo, Brazil.
Heart Rhythm O2
|May 25, 2026
Summary
This study introduces a new functional-anatomic mapping method for cardioneuroablation (CNA) in functional bradycardia. The approach personalizes ablation strategies, leading to successful outcomes without symptom recurrence in all patients.
Area of Science:
- Cardiology
- Electrophysiology
- Autonomic Nervous System
Background:
- Radiofrequency catheter ablation of ganglionated plexi (cardioneuroablation, CNA) is an alternative to pacemakers for functional bradycardia.
- Optimal CNA strategy, including target identification and unilateral vs. biatrial ablation, remains debated.
- Current practice often involves biatrial ablation, but single-atrial approaches may suffice in select patients.
Purpose of the Study:
- To develop and evaluate a functional-anatomic mapping approach for CNA.
- To combine extracardiac vagal stimulation (EVS) and endocardial high-frequency stimulation (EHFS) to identify critical vagal pathways.
- To enable individualized procedural strategies for CNA.
Main Methods:
- Prospective mechanistic study of 5 patients with cardioinhibitory vasovagal syncope.
- Application of a functional-anatomic protocol using EVS and EHFS throughout the procedure.
- Assessment of dynamic changes in autonomic responses post-lesion delivery to infer vagal connections.
Main Results:
- Identified 5 distinct functional profiles, guiding individualized ablation strategies (right atrial-only, left atrial-only, or biatrial).
- All patients achieved the heart rate increment endpoint (>15%) and significant heart rate variability attenuation.
- No symptom recurrence observed during a mean follow-up of 13.4 months.
- Functional mapping revealed asymmetrical vagal innervation and interganglionated plexus connectivity.
Conclusions:
- The functional-anatomic methodology allows for precise definition of ablation extent and laterality.
- This approach provides a framework for standardizing cardioneuroablation procedures.
- Individualized CNA strategies based on functional mapping are effective and safe for managing functional bradycardia.
