Cardioneuromodulation for Recurrent Malignant Neurocardiogenic Syncope in Pediatric Patients: Results from a Tertiary Center.

Malignant neurocardiogenic syncope (MNS) is defined as recurrent syncope with minimal prodromes associated with significant prolonged asystole during head-up tilt test (HUTT). Although cardioneuromodulation (CNM) is an emerging therapy for cardioinhibitory reflex syncope and other functional bradyarrhythmias and is increasingly considered an alternative to cardiac pacing in selected adult patients, evidence for its use in children remains limited. This study aims to describe the procedural characteristics and clinical outcomes of CNM in pediatric patients with MNS and to identify the clinical profile of those most likely to benefit from CNM. This is a prospective observational single-arm cohort. All pediatric patients with recurrent traumatic syncope and HUTT-documented asystole (≥ 15 seconds) undergoing CNM were enrolled. Baseline clinical features, HUTT findings, procedural data, acute endpoints, complications, and follow-up outcomes were collected. All patients underwent CNM using a right atrial-only approach, targeting right-sided ganglionated plexi using anatomical and electrogram guidance. Eight patients (50% female; mean age 13 ± 2.5 years) with a high burden of traumatic reflex syncope were enrolled in this study. All procedures were completed without major complications. After ablation, an implantable loop recorder (ILR) was inserted in all patients for continuous rhythm surveillance. During a short-term follow-up (6 ± 3 months), all patients experienced marked reduction in syncope burden with no further traumatic recurrences (from a mean of 2 episodes/month to 0 episodes at 6 ± 3 months); ILR monitoring showed no prolonged asystole. In this small pediatric cohort, CNM was safe, feasible, and associated with favorable short-term clinical and rhythm outcomes. Larger pediatric studies with standardized selection criteria and longer follow-up are needed to define efficacy and durability.