# A tailored approach to cardioneuroablation for reflex syncope and functional bradycardia: results from the ELEGANCE multicentre study

## TL;DR

A new tailored approach to a heart procedure called cardioneuroablation was tested and found to be as effective as the standard method but faster and more efficient.

## Contribution

The study introduces a tailored cardioneuroablation strategy that targets specific ganglionated plexi based on patient-specific clinical phenotypes.

## Key findings

- The tailored approach reduced procedure and radiofrequency times without compromising clinical outcomes.
- Both tailored and standard approaches had similar acute procedural success and heart rate increases.
- Syncope recurrence rates were comparable between the two groups during follow-up.

## Abstract

Cardioneuroablation (CNA) is a catheter-based intervention for reflex syncope and functional bradyarrhythmias that consists in the modulation of the parasympathetic cardiac autonomic nervous by targeting ganglionated plexi (GPs).

To compare an ablation strategy of selective GP targeting based on clinical phenotype (tailored approach) vs. the standard approach of targeting all GPs (standard approach).

This is a prospective, multicentre European study (ELEGANCE study), including 123 patients who underwent CNA (73 men; median age 50 years). Among them 54 (44%) were treated with a tailored approach, targeting the superior paraseptal ganglionated plexus (SPSGP) for sinus node dysfunction and the inferior paraseptal ganglionated plexus (IPSGP) for AV block. Procedural data and clinical outcomes were compared with the remaining 69 patients treated using a standard approach.

Clinical phenotypes included isolated functional sinus node dysfunction (43.1%), isolated functional AV block (9.8%), and dual presentations (47.2%). In the tailored group 1.6 ± 0.7 GPs were targeted per patient. Compared to the standard approach, the tailored group had significantly shorter procedure times (63 vs. 85 min, P = 0.005) and reduced RF time (5.4 vs. 10.4 min, P < 0.001). Acute procedural success (tailored: 93% vs. standard: 90%, P = 0.98) and the increase in heart rate (tailored: 40 ± 30.7% vs. standard: 40 ± 31.4%, P = 0.96) were similar between groups. During a median 15.9 months [IQR: 9.8, 24.6] follow-up, there were no differences in syncope recurrence rate (log-rank P = 0.96). Inappropriate sinus tachycardia occurred in 8.1% of patients, (tailored 8.6% vs. standard 7.4%; P = 0.79).

An individualized CNA strategy, simplified by targeting specific GPs according to patient’s pathophysiology, achieved outcomes equivalent to the standard approach while improving procedural efficiency through reduced RF delivery, shorter procedure duration, and limited ablation extent.

Graphical AbstractPatients with recurrent syncope or bradyarrhythmia symptoms underwent non-invasive evaluation (Holter ECG, HUTT, TTE), electrophysiologic testing (CSM, atropine), and MDCT for LA wall thickness and GP segmentation. Standard CNA targeted all GPs biatrially, while the tailored protocol ablated SPSGP for fSND and IPSGP for fAVB, with RA ablation if no LA response. Tailored CNA achieved similar outcomes with shorter procedure and RF times. CNA, cardioneuroablation; CSM, carotid sinus massage; ECG, electrocardiogram; fAVB, functional atrioventricular block; fSND, functional sinus node dysfunction; GP, ganglionated plexus; GPs, ganglionated plexi; HUTT, head-up tilt test; IPSGP, inferior paraseptal ganglionated plexus; LA, left atrium; MDCT, multidetector computed tomography; RA, right atrium; RF, radiofrequency; SPSGP, superior paraseptal ganglionated plexus; TTE, transthoracic echocardiography.

Patients with recurrent syncope or bradyarrhythmia symptoms underwent non-invasive evaluation (Holter ECG, HUTT, TTE), electrophysiologic testing (CSM, atropine), and MDCT for LA wall thickness and GP segmentation. Standard CNA targeted all GPs biatrially, while the tailored protocol ablated SPSGP for fSND and IPSGP for fAVB, with RA ablation if no LA response. Tailored CNA achieved similar outcomes with shorter procedure and RF times. CNA, cardioneuroablation; CSM, carotid sinus massage; ECG, electrocardiogram; fAVB, functional atrioventricular block; fSND, functional sinus node dysfunction; GP, ganglionated plexus; GPs, ganglionated plexi; HUTT, head-up tilt test; IPSGP, inferior paraseptal ganglionated plexus; LA, left atrium; MDCT, multidetector computed tomography; RA, right atrium; RF, radiofrequency; SPSGP, superior paraseptal ganglionated plexus; TTE, transthoracic echocardiography.