Cardioneuroablation for Reflex Syncope and Functional Bradyarrhythmias: A State-of-the-Art Review

Cardioneuroablation (CNA), defined as endocardial catheter ablation of atrial ganglionated plexi within the intrinsic cardiac autonomic nervous system, has emerged as a mechanism-directed therapy for cardioinhibitory reflex syncope and functional bradyarrhythmias. By attenuating postganglionic parasympathetic input to the sinoatrial and atrioventricular nodes, CNA targets the autonomic substrate of cardioinhibition rather than merely treating its bradycardic consequence. Over the past two decades, the evidence base has progressed from pioneering single-center experiences to multicenter registries, systematic reviews, meta-analyses, and randomized clinical trials, with reported freedom from recurrent syncope of approximately 80-94% in carefully selected patients at medium-term follow-up. This state-of-the-art narrative review summarizes the rationale, anatomy, patient-selection principles, mapping and ablation strategies, procedural endpoints, clinical outcomes, safety profile, and emerging applications of CNA. Particular emphasis is placed on the unresolved questions that will define the future of the field: the absence, to date, of adequately powered sham-controlled efficacy data; the lack of a universally validated intraprocedural endpoint; the biological and clinical significance of vagal reinnervation; and the gap between expert-center and broader real-world outcomes. Current evidence supports CNA as a promising, anatomically grounded neuromodulatory therapy, but its transition from expert-center innovation to guideline-endorsed treatment will depend on rigorous patient selection, standardized procedural endpoints, and the results of ongoing randomized trials.