Skip to main content

Advertisement

SpringerLink
Log in

Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life

  • Global Cardiovascular Health (L Sperling and D Gaita, Section Editors)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Vasovagal syncope (VVS) is a common entity causing transient loss of consciousness and affecting quality of life. Guideline-recommended therapy involves conservative measures and pacing in selected patients. Cardioneuroablation (CNA) targeting the ganglionated plexi in the heart has been shown to reduce excessive vagal excitation, which plays a major role in the pathophysiology of VVS and functional bradycardia.

Recent Findings

The introduction of CNA has fueled research into its value for the treatment of VVS. Multiple observational studies and one randomized trial have demonstrated the safety and efficacy of CNA and the positive impact on quality of life. This review describes the rationale and CNA procedural techniques and outcomes. Patient selection and future directions have also been described.

Summary

Cardioneuroablation is a promising treatment for patients with recurrent VVS and functional bradycardia. Further large-scale randomized studies are needed to further verify the safety and efficacy of this approach.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Serletis A, Rose S, Sheldon AG, Sheldon RS. Vasovagal syncope in medical students and their first-degree relatives. Eur Heart J. 2006;27(16):1965–70.

    PubMed  Google Scholar 

  2. Torabi P, Rivasi G, Hamrefors V, Ungar A, Sutton R, Brignole M, et al. Early and late-onset syncope: insight into mechanisms. Eur Heart J. 2022;43(22):2116–23.

    PubMed  PubMed Central  Google Scholar 

  3. Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883–948.

    PubMed  Google Scholar 

  4. Rose MS, Koshman ML, Spreng S, Sheldon R. The relationship between health-related quality of life and frequency of spells in patients with syncope. J Clin Epidemiol. 2000;53(12):1209–16.

    CAS  PubMed  Google Scholar 

  5. • Sheldon RS, Grubb BP II, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015;12(6):e41-63. A consensus paper introducing the most recent nomenclature of ganglionated plexi.

    PubMed  PubMed Central  Google Scholar 

  6. Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, et al. 2021 ESC Guidelines on cardiac pacing and resynchronization therapy. Eur Heart J. 2021;42(35):3427–520.

    PubMed  Google Scholar 

  7. Pachon JC, Pachon EI, Pachon JC, Lobo TJ, Pachon MZ, Vargas RN, et al. “Cardioneuroablation”—new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF-ablation. Europace. 2005;7(1):1–13.

    PubMed  Google Scholar 

  8. Aksu T, Golcuk E, Yalin K, Guler TE, Erden I. Simplified cardioneuroablation in the treatment of reflex syncope, functional AV block, and sinus node dysfunction. Pacing Clin Electrophysiol. 2016;39(1):42–53.

    PubMed  Google Scholar 

  9. •• Piotrowski R, Baran J, Sikorska A, Krynski T, Kulakowski P. Cardioneuroablation for reflex syncope: efficacy and effects on autonomic cardiac regulation—a prospective randomized trial. JACC Clin Electrophysiol. 2023;9(1):85–95. The only randomized controlled trial in the field.

  10. Mosqueda-Garcia R, Furlan R, Tank J, Fernandez-Violante R. The elusive pathophysiology of neurally mediated syncope. Circulation. 2000;102(23):2898–906.

    CAS  PubMed  Google Scholar 

  11. Brignole M, Menozzi C, Del Rosso A, Costa S, Gaggioli G, Bottoni N, et al. New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification. Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope International Study. Europace. 2000;2(1):66–76.

    CAS  PubMed  Google Scholar 

  12. Pachon JC, Pachon EI, Aksu T, Gopinathannair R, Kautzner J, Yao Y, et al. Cardioneuroablation: Where are we at? Heart Rhythm O2. 2023;4(6):401–13.

    PubMed  PubMed Central  Google Scholar 

  13. Pauza DH, Rysevaite-Kyguoliene K, Vismantaite J, Brack KE, Inokaitis H, Pauza AG, et al. A combined acetylcholinesterase and immunohistochemical method for precise anatomical analysis of intrinsic cardiac neural structures. Ann Anat. 2014;196(6):430–40.

    PubMed  Google Scholar 

  14. Pauza DH, Skripka V, Pauziene N, Stropus R. Morphology, distribution, and variability of the epicardiac neural ganglionated subplexuses in the human heart. Anat Rec. 2000;259(4):353–82.

    CAS  PubMed  Google Scholar 

  15. Armour JA, Murphy DA, Yuan BX, Macdonald S, Hopkins DA. Gross and microscopic anatomy of the human intrinsic cardiac nervous system. Anat Rec. 1997;247(2):289–98.

    CAS  PubMed  Google Scholar 

  16. Hou Y, Scherlag BJ, Lin J, Zhang Y, Lu Z, Truong K, et al. Ganglionated plexi modulate extrinsic cardiac autonomic nerve input: effects on sinus rate, atrioventricular conduction, refractoriness, and inducibility of atrial fibrillation. J Am Coll Cardiol. 2007;50(1):61–8.

    PubMed  Google Scholar 

  17. Brignole M, Aksu T, Calò L, Debruyne P, Deharo JC, Fanciulli A, et al. Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope. Europace. 2023;25(5):euad033.

    PubMed  PubMed Central  Google Scholar 

  18. Pachon JC, Pachon EI, Cunha Pachon MZ, Lobo TJ, Pachon JC, Santillana TG. Catheter ablation of severe neurally meditated reflex (neurocardiogenic or vasovagal) syncope: cardioneuroablation long-term results. Europace. 2011;13(9):1231–42.

    PubMed  Google Scholar 

  19. Pachon ME, Pachon-Mateos JC, Higuti C, Santillana PT, Lobo T, Pachon C, et al. Relation of fractionated atrial potentials with the vagal innervation evaluated by extracardiac vagal stimulation during cardioneuroablation. Circ Arrhythm Electrophysiol. 2020;13(4):e007900.

    PubMed  Google Scholar 

  20. Scanavacca M, Hachul D, Pisani C, Sosa E. Selective vagal denervation of the sinus and atrioventricular nodes, guided by vagal reflexes induced by high frequency stimulation, to treat refractory neurally mediated syncope. J Cardiovasc Electrophysiol. 2009;20(5):558–63.

    PubMed  Google Scholar 

  21. Yao Y, Shi R, Wong T, Zheng L, Chen W, Yang L, et al. Endocardial autonomic denervation of the left atrium to treat vasovagal syncope: an early experience in humans. Circ Arrhythm Electrophysiol. 2012;5(2):279–86.

    PubMed  Google Scholar 

  22. Hu F, Zheng L, Liang E, Ding L, Wu L, Chen G, et al. Right anterior ganglionated plexus: the primary target of cardioneuroablation? Heart Rhythm. 2019;16(10):1545–51.

    PubMed  Google Scholar 

  23. Aksu T, Guler TE, Mutluer FO, Bozyel S, Golcuk SE, Yalin K. Electroanatomic-mapping-guided cardioneuroablation versus combined approach for vasovagal syncope: a cross-sectional observational study. J Interv Card Electrophysiol. 2019;54(2):177–88.

    PubMed  Google Scholar 

  24. Debruyne P, Rossenbacker T, Collienne C, Roosen J, Ector B, Janssens L, et al. Unifocal right-sided ablation treatment for neurally mediated syncope and functional sinus node dysfunction under computed tomographic guidance. Circ Arrhythm Electrophysiol. 2018;11(9):e006604.

    PubMed  Google Scholar 

  25. Francia P, Viveros D, Falasconi G, Soto-Iglesias D, Fernández-Armenta J, Penela D, et al. Computed tomography-based identification of ganglionated plexi to guide cardioneuroablation for vasovagal syncope. Europace. 2023;25(6).

  26. • Francia P, Viveros D, Falasconi G, Penela D, Soto-Iglesias D, Martí-Almor J, et al. Clinical impact of aging on outcomes of cardioneuroablation for reflex syncope or functional bradycardia: results from the cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs-The ELEGANCE multicenter study. Heart Rhythm. 2023;20(9):1279–86. A recent study demonstrating the outcomes of cardioneuroablation among different age groups.

    PubMed  Google Scholar 

  27. Debruyne P, Rossenbacker T, Janssens L, Collienne C, Ector J, Haemers P, et al. Durable physiological changes and decreased syncope burden 12 months after unifocal right-sided ablation under computed tomographic guidance in patients with neurally mediated syncope or functional sinus node dysfunction. Circ Arrhythm Electrophysiol. 2021;14(6):e009747.

    PubMed  PubMed Central  Google Scholar 

  28. Rivarola EW, Hachul D, Wu T, Pisani C, Hardy C, Raimundi F, et al. Targets and end points in cardiac autonomic denervation procedures. Circ Arrhythm Electrophysiol. 2017;10(2):e004638.

    PubMed  Google Scholar 

  29. Lellouche N, Buch E, Celigoj A, Siegerman C, Cesario D, De Diego C, et al. Functional characterization of atrial electrograms in sinus rhythm delineates sites of parasympathetic innervation in patients with paroxysmal atrial fibrillation. J Am Coll Cardiol. 2007;50(14):1324–31.

    PubMed  Google Scholar 

  30. Aksu T, Padmanabhan D, Shenthar J, Yalin K, Gautam S, Valappil SP, et al. The benefit of cardioneuroablation to reduce syncope recurrence in vasovagal syncope patients: a case-control study. J Interv Card Electrophysiol. 2022;63(1):77–86.

    PubMed  Google Scholar 

  31. Aksu T, Yalin K, Gopinathannair R. Fractionation mapping software to map ganglionated plexus sites during sinus rhythm. J Cardiovasc Electrophysiol. 2020;31(12):3326–9.

    PubMed  Google Scholar 

  32. •• Vandenberk B, Lei LY, Ballantyne B, Vickers D, Liang Z, Sheldon RS, et al. Cardioneuroablation for vasovagal syncope: a systematic review and meta-analysis. Heart Rhythm. 2022;S1547–5271(22):02088–94. A meta-analysis of observational studies.

    Google Scholar 

  33. Lin J, Liu Q, Jiang R, Chen S, Yu L, Jiang C. Selective anatomical catheter ablation of left atrial ganglionated plexus for vasovagal syncope: left superior and right anterior ganglionated plexus ablation. Pacing Clin Electrophysiol. 2023;46(8):1010–8.

    PubMed  Google Scholar 

  34. Sun W, Zheng L, Qiao Y, Shi R, Hou B, Wu L, et al. Catheter ablation as a treatment for vasovagal syncope: long-term outcome of endocardial autonomic modification of the left atrium. J Am Heart Assoc. 2016;5(7).

  35. Pachon MJ, Pachon ME, Santillana PT, Lobo TJ, Pachon CTC, Pachon MJ, et al. Simplified method for vagal effect evaluation in cardiac ablation and electrophysiological procedures. JACC Clin Electrophysiol. 2015;1(5):451–60.

    PubMed  Google Scholar 

  36. Piotrowski R, Zuk A, Baran J, Sikorska A, Krynski T, Kulakowski P. Ultrasound-guided extracardiac vagal stimulation—new approach for visualization of the vagus nerve during cardioneuroablation. Heart Rhythm. 2022;19(8):1247–52.

    PubMed  Google Scholar 

  37. Rose MS, Koshman ML, Ritchie D, Sheldon R. The development and preliminary validation of a scale measuring the impact of syncope on quality of life. Europace. 2009;11(10):1369–74.

    PubMed  Google Scholar 

  38. Ng J, Sheldon RS, Ritchie D, Raj V, Raj SR. Reduced quality of life and greater psychological distress in vasovagal syncope patients compared to healthy individuals. Pacing Clin Electrophysiol. 2019;42(2):180–8.

    PubMed  Google Scholar 

  39. de Barros ESRLA, Volich RM, de Barros ESPGM, da Costa Darrieux FC, Scanavacca MI, Hachul DT. Effect of psychotherapy on recurrence of events and quality of life in patients with vasovagal syncope. Sci Rep. 2022;12(1):5745.

    Google Scholar 

  40. Baysal E, Mutluer FO, Dagsali AE, Kumrulu UC, Huang HD, Aksu T. Improved health-related quality of life after cardioneuroablation in patients with vasovagal syncope. J Interv Card Electrophysiol. 2022.

  41. Brignole M, Arabia F, Ammirati F, Tomaino M, Quartieri F, Rafanelli M, et al. Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study. Europace. 2016;18(9):1427–33.

    PubMed  Google Scholar 

  42. Brignole M, Donateo P, Tomaino M, Massa R, Iori M, Beiras X, et al. Benefit of pacemaker therapy in patients with presumed neurally mediated syncope and documented asystole is greater when tilt test is negative: an analysis from the third International Study on Syncope of Uncertain Etiology (ISSUE-3). Circ Arrhythm Electrophysiol. 2014;7(1):10–6.

    PubMed  Google Scholar 

  43. Mandel WJ, Hayakawa H, Allen HN, Danzig R, Kermaier AI. Assessment of sinus node function in patients with the sick sinus syndrome. Circulation. 1972;46(4):761–9.

    CAS  PubMed  Google Scholar 

  44. Aksu T, Erdem GT. Cardioneuroablation in the management of vasovagal syncope, sinus node dysfunction and functional atrioventricular block: patient selection based on supporting evidence. J Atr Fibrillation. 2020;13(1):2396.

    PubMed  PubMed Central  Google Scholar 

  45. Xhyheri B, Manfrini O, Mazzolini M, Pizzi C, Bugiardini R. Heart rate variability today. Prog Cardiovasc Dis. 2012;55(3):321–31.

    PubMed  Google Scholar 

  46. Pachon MJ, Pachon ME, Pachon CTC, Santillana PT, Lobo TJ, Pachon MJ, et al. Long-term evaluation of the vagal denervation by cardioneuroablation using holter and heart rate variability. Circ Arrhythm Electrophysiol. 2020;13(12):e008703.

    PubMed  Google Scholar 

  47. Bauer A, Kantelhardt JW, Barthel P, Schneider R, Mäkikallio T, Ulm K, et al. Deceleration capacity of heart rate as a predictor of mortality after myocardial infarction: cohort study. Lancet. 2006;367(9523):1674–81.

    PubMed  Google Scholar 

  48. Zheng L, Sun W, Liu S, Liang E, Du Z, Guo J, et al. The diagnostic value of cardiac deceleration capacity in vasovagal syncope. Circ Arrhythm Electrophysiol. 2020;13(12):e008659.

    CAS  PubMed  Google Scholar 

  49. Aksu T, Mandrola J, Raj SR. Permanent pacing for recurrent vasovagal syncope: new answers or just more questions? J Electrocardiol. 2021;65:88–90.

    PubMed  Google Scholar 

  50. Chung WH, Masuyama K, Challita R, Hayase J, Mori S, Cha S, et al. Ischemia-induced ventricular proarrhythmia and cardiovascular autonomic dysreflexia after cardioneuroablation. Heart Rhythm. 2023;S1547–5271(23):02557–62.

    Google Scholar 

  51. Aksu T, Turagam M, Gautam S, Futyma P, Akella K, Baysal E, et al. Effects of permanent cardiac pacing on ventricular repolarization when compared to cardioneuroablation. J Electrocardiol. 2021;67:13–8.

    PubMed  Google Scholar 

  52. Aksu T, Guler TE, Bozyel S, Golcuk SE, Yalin K, Lakkireddy D, et al. Medium-term results of cardioneuroablation for clinical bradyarrhythmias and vasovagal syncope: effects on QT interval and heart rate. J Interv Card Electrophysiol. 2021;60(1):57–68.

    PubMed  Google Scholar 

  53. Sakamoto S, Schuessler RB, Lee AM, Aziz A, Lall SC, Damiano RJ Jr. Vagal denervation and reinnervation after ablation of ganglionated plexi. J Thorac Cardiovasc Surg. 2010;139(2):444–52.

    PubMed  Google Scholar 

  54. Thurber CJ, Sneider DR, Sauer WH, Kapur S. Recurrent vasovagal syncope following successful cardioneuroablation. Heart Rhythm Case Rep. 2022;8(7):465–8.

    Google Scholar 

  55. Aksu T, Guler TE, Bozyel S, Yalin K, Gopinathannair R. Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation. Europace. 2020;22(9):1320–7.

    PubMed  Google Scholar 

  56. Rivarola EWR, Hachul D, Wu TC, Pisani C, Scarioti VD, Hardy C, et al. Long-term outcome of cardiac denervation procedures: the anatomically guided septal approach. JACC Clin Electrophysiol. 2023;9(8 Pt 1):1344–53.

    PubMed  Google Scholar 

  57. Scanavacca M, Rivarola EWR, Torres RVA, Hardy C, Wu TC, Darrieux F, et al. Sinus node artery occlusion during cardiac denervation procedures. JACC Case Rep. 2022;4(18):1169–75.

    PubMed  PubMed Central  Google Scholar 

  58. Aksu T, Guler TE, Bozyel S, Yalin K. Vagal responses during cardioneuroablation on different ganglionated plexi: is there any role of ablation strategy? Int J Cardiol. 2020;304:50–5.

    PubMed  Google Scholar 

  59. Huang X, Chen Y, Huang Y, Zhao H, He L, Tan Z, et al. Comparative effects of intensive ganglionated plexus ablation in treating paroxysmal atrial fibrillation and vasovagal syncope. Clin Cardiol. 2020;43(11):1326–33.

    PubMed  PubMed Central  Google Scholar 

  60. Hu F, Zheng L, Liu S, Shen L, Liang E, Liu L, et al. The impacts of the ganglionated plexus ablation sequence on the vagal response, heart rate, and blood pressure during cardioneuroablation. Auton Neurosci. 2021;233:102812.

    PubMed  Google Scholar 

  61. Calo L, Rebecchi M, Sette A, Sciarra L, Borrelli A, Scara A, et al. Catheter ablation of right atrial ganglionated plexi to treat cardioinhibitory neurocardiogenic syncope: a long-term follow-up prospective study. J Interv Card Electrophysiol. 2021;61(3):499–510.

    PubMed  Google Scholar 

  62. Candemir B, Baskovski E, Beton O, Shanableh N, Akbulut İM, Kozluca V, et al. Procedural characteristics, safety, and follow-up of modified right-sided approach for cardioneuroablation. Anatol J Cardiol. 2022;26(8):629–36.

    CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Invasive Electrophysiology, Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, 1407 N. Vaptzarov blvd 51B, Sofia, Bulgaria

    Vassil Traykov

  2. Department of Electrophysiology, Clinic of Cardiology, National Heart Hospital, Sofia, Bulgaria

    Tchavdar Shalganov

Authors
  1. Vassil Traykov
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tchavdar Shalganov
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

VT and TS worked on the contents. VT drafted the manuscript while TS proofread the manuscript.

Corresponding author

Correspondence to Vassil Traykov.

Ethics declarations

Conflict of Interest

Vassil Traykov reports the following: personal fees from Boehringer Ingelheim, Berlin Menarini, Abbott, Novartis, Bayer, Merck, and Biotronik. In addition, they also report other from AstraZeneca and Pfizer. Tchavdar Shalganov reports the following: other from AstraZeneca and Teva, and personal fees from Bayer.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Traykov, V., Shalganov, T. Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life. Curr Cardiol Rep 25, 1839–1849 (2023). https://doi.org/10.1007/s11886-023-01997-1

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11886-023-01997-1

Keywords

Search

Navigation