Empirical Anatomical Versus HAFE-Guided Cardioneuroablation for Vasovagal Syncope: Long-Term Efficacy and Safety Outcomes.

BACKGROUND AND AIMS: Vasovagal syncope (VVS) poses challenges despite therapy, and optimal cardioneuroablation (CNA) targeting ganglionated plexi (GPs) remains debated. This study compared long-term efficacy and safety between empirical anatomical-guided CNA (EAGC) and high-amplitude fractionated electrogram (HAFE)-guided CNA in patients with refractory VVS.

METHODS

This single-center retrospective analysis (July 2018 to July 2023) included 109 patients with refractory VVS undergoing CNA. Patients were divided into the EAGC group (n = 70; empirical GP ablation at common anatomical sites) or the HAFE group (n = 39; HAFE mapping-guided GP ablation). The primary endpoint was 24-month syncope-free survival; secondary endpoints included procedural metrics, quality of life (QoL, via syncope dysfunction score [SDS]), and procedure-related complications.

RESULTS

No significant difference in 24-month syncope-free survival was observed between groups (HR = 1.648, 95% CI 0.648-4.194; log-rank p = 0.285), with rates of 85.6% in the EAGC group and 77.2% in the HAFE group. The HAFE group demonstrated shorter procedure time (median 66.00 min [IQR 52.00-87.50] vs. 90.00 min [IQR 71.75-101.50]; p < 0.001) and reduced radiation exposure (X-ray dose: 6.00 [IQR 4.17-10.75] mGy vs. 12.00 [IQR 6.48-20.00] mGy; p = 0.002) and fluoroscopy time (2.53 [IQR 1.92-4.06] min vs. 4.38 [IQR 2.47-7.05] min; p < 0.001) compared to those in the EAGC group. Both groups exhibited significant reductions in syncope dysfunction score (SDS; p < 0.001), however, the intergroup difference in score reduction failed to reach statistical significance (ΔSDS; p = 0.487). Complication rates were comparable between two groups.

CONCLUSIONS

EAGC and HAFE-guided CNA demonstrated comparable 24‑month syncope‑free survival with no significant difference in recurrence risk, while HAFE-guided CNA improved procedural efficiency.