[Cardioneuroablation for vasovagal syncope: rationale, evidence, and limitations of an emerging therapy]

Cardioneuroablation (CNA) is an emerging catheter-based neuromodulation strategy aimed at reducing vagal influence on the sinoatrial and atrioventricular nodes through ablation of atrial ganglionated plexi. Its rationale is particularly strong in forms with a predominant cardioinhibitory component, especially asystolic forms, whereas it appears weak in purely vasodepressor forms. Available evidence suggests a reduction in syncope recurrence and disease burden in selected patients, but derives largely from observational, often single-center studies, with heterogeneous selection criteria, procedural techniques, endpoints, and follow-up duration. Relevant issues remain unresolved, including placebo effect, reinnervation, post-procedural sinus tachycardia, long-term safety, and comparison with pacemaker therapy. Pending the results of ongoing randomized trials, CNA remains a promising but non-standardized therapy, to be reserved for selected patients with severe cardioinhibitory vasovagal syncope, in qualified centers and within structured pathways for systematic outcome collection.