Cardioneuroablation for vasovagal syncope: A systematic review and meta-analysis

BACKGROUND Cardioneuroablation (CNA) has emerged as prom-ising therapy for patients with refractory vasovagal syncope (VVS). OBJECTIVE The purpose of this study was to provide a freedom from syncope estimate for CNA, including subgroup analysis by method and target of ablation.METHODS A systematic search was performed in MEDLINE and EM -BASE according to the PRISMA guidelines until February 14, 2022. Observational studies and clinical trials reporting freedom from syn-cope were included. Meta-analysis was performed with a random -effects model.RESULTS A total of 465 patients were included across 14 studies (mean age 39.8 +/- 4.0 year; 53.5% female). Different techniques were used to guide CNA: 50 patients (10.8%) by mapping fraction-ated electrograms, 73 (15.7%) with the spectral method, 210 (45.2%) with high-frequency stimulation, 73 (15.7%) with a purely anatomically guided method, and 59 (12.6%) with a combination. The target was biatrial in 168 patients (36.1%), left atrium only in 259 (55.7%), and right atrium only in 38 (8.2%). The freedom from syncope was 91.9% (95% confidence interval [CI] 88.1%- 94.6%; I2 = 6.9%; P = .376). CNA limited to right atrial ablation was associated with a significant lower freedom from syncope (81.5%; 95% CI 51.9%-94.7%; P <.0001) vs left atrial ablation only (94.0%; 95% CI 88.6%--6.9%) and biatrial ablation (92.7%; 95% CI 86.8%-96.1%). Subgroup analysis according to the tech-nique used to identify ganglionated plexi did not show any signif-icant difference in freedom from syncope (P = .206). CONCLUSION This meta-analysis suggests a high freedom from syncope after CNA in VVS. Well-designed, double-blind, multicenter, sham-controlled randomized clinical trials are needed to provide ev-idence for future guidelines.