Endocardial gaglionated plexi ablation in different vagally-mediated clinical settings: From cardioneuroablation to cardio-neuromodulation

Cardioneuroablation (CNA) is now recognized as a safe and effective method in patients with cardioinhibitory neurocardiogenic syncope (CNCS), especially in young patients in order to avoid or prolong, as much as possible, the timing of definitive cardiac pacing. Several investigations have shown beneficial and very satisfactory results with a standard non-extensive endocardial ablation, aimed at identifying high-amplitude fragmented signals in the right and left atria. Despite this, the current scientific debate is focused about a proposal on an ablative method, even more individualized than CNA (at least as a first approach), considering that a standardized approach, especially in the left atrium, could expose CNCS patients with a good prognosis to an excessive risk of complications. These findings, moving from the concept of CNA to a new concept of ‘cardioneuromodulation’, opened a new era, aimed at a non-extensive and individualized treatment of different clinical CNCS scenarios or vagally-mediated atrioventricular block or sinus-atrial node dysfunction.