481 Real-world outcomes of cardioneural ablation for refractory vasovagal syncope: 10-year UK tertiary centre experience

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Background Cardioneural ablation (CNA) targets ganglionated plexi to abolish vagal inputs causing bradycardia in refractory vasovagal syncope (VVS). Long term real-world data on procedural methodology, safety, and long-term outcomes remain limited. Methods We conducted a retrospective single-center study of 25 patients with refractory VVS undergoing CNA at a UK tertiary syncope center (2013-2023). Patients had recurrent syncope despite lifestyle modifications and pharmacotherapy, with documented bradycardia via implantable loop recorder or head-up tilt testing. Procedures involved electroanatomical mapping, high-frequency stimulation of ganglionated plexi, and extracardiac vagal stimulation (ECVS) via bilateral internal jugular catheters to confirm abolition of vagal responses. Primary outcomes included syncope recurrence and quality-of-life measures. Results Mean age was 32±12 years (56% female), with baseline syncope frequency of 19±21 episodes/year. All procedures were technically successful, with mean procedure time 194±44 minutes and 18.3±8.3 radiofrequency lesions delivered. Superior and inferior paraseptal ganglia were targeted in 84% and 92% of cases, respectively. ECVS abolished atrioventricular block in 91% and sinus arrest in 86%. At 12-month follow-up, syncope frequency decreased to 0.6±1.3 episodes/year (p<0.001), and to 0.0±0.2 at mean 34.4-month follow-up. Quality-of-life scores improved significantly (EQ-5D: 0.78→0.92, p<0.001; VAS: 59→83, p<0.001). Midodrine was discontinued in all patients. One patient required permanent pacemaker implantation for procedural sinus arrest. Syncope recurred in 24%; repeat ablation was required in 12%. Conclusions CNA demonstrates sustained efficacy and safety for refractory VVS with significant quality-of-life improvements in this real-world cohort.

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