Cardioneuroablation: Catheter Vagal Denervation as a New Therapy for Cardioinhibitory Syncope


  • José Carlos Pachon Mateos
  • Enrique I Pachón Mateos
  • Christian Higuti
  • Tomas Guilhermo Santillana Peña
  • Tasso Julio Lobo
  • Carlos Thiene Cunha Pachón
  • Juán Carlos Pachón Mateos
  • Juán Carlos Zerpa Acosta
  • Felipe Ortencio
  • Ricardo Amarante


The vasovagal syncope is the most frequent cause of transient loss of consciousness, especially in young people without significant heart disease. The malignant cardioinhibitory form is caused by abrupt and intense vagal reflex with or without defined triggers. Refractory cases to preventive measures and pharmacological handling has been treated with definitive pacemaker implantation. Besides showing questionable results, pacemaker implantation is highly rejected by young patients. In the late 1990s, we proposed specific vagal denervation by catheter ablation and spectral mapping, for paroxysmal AF, functional bradyarrhythmias and severe cases of malignant cardioinhibitory syncope giving rise to cardioneuroablation. Recently, many authors worldwide have been reproducing the cardioneuroablation results where elimination or significant reduction of the vagal response were observed, which abolished symptoms in more than 75% of patients followed up to 14 years, without complications. Therefore, cardioneuroablation has shown to be a real therapeutic option in malignant syncope cardioinhibitory and in any exclusive vagal mediated bradyarrhythmia without the need for pacemaker implantation.


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Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 2015 Heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015;12(6):e41-63. hrthm.2015.03.029

Moya A, Sutton R, Ammirati F, Blanc J-J, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009;30(21):2631-71.

Brignole M, Menozzi C, Moya A, Andresen D, Blanc J-J, Krahn AD, et al. Pacemaker therapy in patients with neutrally mediated syncope and documented asystole. Third International Study on Syncope of Uncertain Etiology (ISSUE 3). A randomized trial. Circulation. 2012;125(21):2566-71.

Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, et a. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: Executive summary – A report of theAmerican College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008;117:2820-40.

Pachon MJC, Pachon MEI, Pachon MJC, Lobo TJ, Pachon MZ, Vargas RN, et al. “Cardioneuroablation” – new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF-ablation. Europace. 2005;7(1):1-13.

Morillo CA, Eckberg DL, Ellenbogen KA, Beightol LA, Hoag JB, Tahvanainen KU, et al. Vagal and sympathetic mechanisms in patients with orthostatic vasovagal syncope. Circulation. 1997;96(8):2509-13. https://doi. org/10.1161/01.cir.96.8.2509

Armour JA. Potential clinical relevance of the ‘little brain’ on the mammalian heart. Exp Physiol. 2008;93(2):165- 76.

Pachón MJC, Pachón MEI, Pachón MZC, Lobo TJ, Pachón MJC, Santillana PTG. Catheter ablation of severe neutrally meditated reflex (neurocardiogenic or vasovagal) syncope: cardioneuroablation long-term results. Europace. 2011;13(9):1231-42. europace/eur163

Taylor EW, Jordan D, Coote JH. Central control of the cardiovascular and respiratory systems and their interactions in vertebrates. Physiol Rev. 1999;79(3):855- 916.

Santini M, Ammirati F, Colivicchi F, Gentilucci G, Guido V. The effect of atropine in vasovagal syncope induced by head-up tilt testing. Eur Heart J. 1999;20(23):1745-51.

Gallego JC, Cubero JS, Pulpón LA, Rodríguez MA, Salas C, Ortiz-Berrocal J. Angina pectoris in the heart transplant recipient: evidence of reinnervation. Rev Esp Cardiol. 2001;54(6):799-802.

Murphy DA, Thompson GW, Ardell JL, McCraty R, Stevenson RS, Sangalang VE, et al. The heart reinnervates after transplantation. Ann Thorac Surg. 2000;69(6):1769-81.

Coyer BH, Pryor R, Kirsch WM, Blount Júnior SG. Left stellectomy in the long QT syndrome. Chest. 1978;74(5):584-6. chest.74.5.584

Pappone C, Santinelli V, Manguso F, Vicedomini G, Gugliotta F, Augello G, et al. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation. Circulation. 2004;109(3):327-34.

Po SS, Nakagawa H, Jackman WM. Localization of left atrial ganglionated plexi in patients with atrial fibrillation. J Cardiovasc Electrophysiol. 2009;20(10):1186-9. https://

Driessen AH, Berger WR, Krul SP, van den Berg NW, Neefs J, Piersma FR, et al. Ganglion plexus ablation in advanced atrial fibrillation: The AFACT study. J Am Coll Cardiol. 2016;68(11):1155-65. jacc.2016.06.036

Aksu T, Baysal E, Guler TE, Yalin K. Selective right atrial cardioneuroablation in functional atrioventricular block. Europace. 2016;19(2):333.

Aksu T, Golcuk E, Yalin K, Guler TE, Erden I. Simplified cardioneuroablation in the treatment of reflex syncope, functional AV block, and sinus node dysfunction. Pacing Clin Electrophysiol. 2016;39(1):42-53.

Rivarola E, Hardy C, Sosa E, Hachul D, Furlan V, Raimundi F, et al. Selective atrial vagal denervation guided by spectral mapping to treat advanced atrioventricular block. Europace. 2016;18(3):445-9. https://doi. org/10.1093/europace/euv142

Klank-Szafran M, Stec S, Sledz J, Janion M. Radiofrequency ablation and cardioneuroablation for AVNRT and atrioventricular block. Kardiol Pol. 2010;68(6):720-4.

Yao Y, Shi R, Wong T, Zheng L, Chen W, Yang L, et al. Endocardial autonomic denervation of the left atrium to treat vasovagal syncope: an early experience in humans. Circ Arrhythm Electrophysiol. 2012;5(2):279-86. https://

Liang Z, Jiayou Z, Zonggui W, Dening L. Selective atrial vagal denervation guided by evoked vagal reflex to treat refractory vasovagal syncope. Pacing Clin Electrophysiol. 2012;35(7):e214-8.

Scanavacca M, Hachul D, Pisani C, Sosa E. Selective vagal denervation of the sinus and atrioventricular nodes, guided by vagal reflexes induced by high-frequency stimulation, to treat refractory neurally mediated syncope. J Cardiovasc Electrophysiol. 2009;20(5):558-63.

Stavrakis S, Scherlag BJ, Po SS. Autonomic modulation: an emerging paradigm for the treatment of cardiovascular diseases. Circ Arrhythm Electrophysiol. 2012;5(2):247-8. CIRCEP.112.972307

Fukunaga M, Wichterle D, Peichl P, Aldhoon B, Cihák R, Kautzner J. Differential effect of ganglionic plexi ablation in a patient with neutrally mediated syncope and intermittent atrioventricular block. Europace. 2016;19(1):119-26.

Pachón MJC, Pachón MEI, Pachón MJC, Lobo TJ, Pachón MZ, Vargas RNA, et al. A new treatment for atrial fibrillation based on spectral analysis to guide the catheter RF-ablation. Europace. 2004;6(6):590-601.

Chang HY, Lo LW, Lin YJ, Lee SH, Chiou CW, Chen SA. Relationship between intrinsic cardiac autonomic ganglionated plexi and the atrial fibrillation nest. Circ J. 2014;78(4):922-8. 1053

Singhal R, Lo LW, Lin YJ, Chang SL, Hu YF, Chao TF, et al. Intrinsic cardiac autonomic ganglionated plexi within epicardial fats modulate the atrial substrate remodeling: experiences with atrial fibrillation patients receiving catheter ablation. Acta Cardiol Sin. 2016;32(2):174-84.

Oh S, Kong HJ, Choi EK, Kim HC, Choi YS. Complex fractionated electrograms and AF nests in vagally mediated atrial fibrillation. Pacing Clin Electrophysiol. 2010;33(12):1497-503.

Pachon M JC, Arruda M. Spectral mapping identifies critical atrial myocardial sites prone to “electrical resonance”: could it be the missing puzzle piece in the physiopathology of AF maintenance? J Cardiovasc Electrophysiol. 2012;23(11):1163-4.

Mateos JCP, Mateos EIP, Lobo TJ, Pachón MZC, Mateos JCP, Pachón DQ, et al. Radiofrequency catheter ablationof atrial fibrillation guided by spectral mapping of atrial fibrillation nests in sinus rhythm. Arq Bras Cardiol. 2007;89(3):124-34/140-50.

Arruda M, Natale A. Ablation of permanent AF:adjunctive strategies to pulmonary veins isolation: targeting AF NEST in sinus rhythm and CFAE in AF. J Interv Card Electrophysiol. 2008;23(1):51-7.

Pachon MJC, Pachon MEI, Santillana PTG, Lobo TJ, Pachon CTC, Pachon MJC, et al. Simplified method for vagal effect evaluation in cardiac ablation and electrophysiological procedures. JACC Clin Electrophysiol. 2015;1(5):451-60.

Pauza DH, Skripka V, Pauziene N, Stropus R. Anatomical study of the neural ganglionated plexus in the canine right atrium: implications for selective denervation and electrophysiology of the sinoatrial node in dog. Anat Rec. 1999;255(3):271-94.;2-2

Pachon MJC, Pachon MEI, Lobo TJ, Pachon MJC, Pachon MZ, Vargas RN, et al. Syncopal high-degree AV block treated with catheter RF ablation without pacemaker implantation. Pacing Clin Electrophysiol. 2006;29(3):318-22.

Pauza DH, Skripka V, Pauziene N, Stropus R. Morphology, distribution, and variability of the epicardiac neural ganglionated subplexuses in the human heart. Anat Rec. 2000;259(4):353 82 (20000801) 259:4% 3C353 :: AIDAR10%3E3.0.CO;2-R

Chiou C-W, Eble JN, Zipes DP. Efferent Vagal Innervation of the Canine Atria and Sinus and Atrioventricular Nodes- The Third Fat Pad. Circulation. 1997;95(11):2573-84.

Lellouche N, Buch E, Celigoj A, Siegerman C, Cesario D, Diego C. et al. Functional characterization of atrial electrograms in sinus rhythm delineates sites of parasympathetic innervation in patients with paroxysmal atrial fibrillation. J Am Coll Cardiol. 2007;50(14):1324-31.

Hachul D. Does non-pharmacological treatment affect outcomes in dysautonomic syndromes? Cardiol J. 2014;21(6):611-5.

Mateos JCP, Mateos EIP, Peña TG, Lobo TJ, Mateos JCP, Vargas RN, et al. Simplified method for esophagus protection during radiofrequency catheter ablation of atrial fibrillation--prospective study of 704 cases. Ver Bras Cir Cardiovasc. 2015;30(2):139-47.

Olshansky B, Sullivan RM. Syncope in Patients with Organic Heart Disease. Cardiol Clin. 2015;33(3):449-63.

Pauza DH, Skripka V, Pauziene N. Morphology of the intrinsic cardiac nervous system in the dog: a whole-mount study employing histochemical staining with acetylcholinesterase. Cells Tissues Organs. 2002;172(4):297-320.



How to Cite

Pachon Mateos, J. C. ., Mateos, E. I. P. ., Higuti, C., Peña, T. G. S. ., Lobo, T. J. ., Pachón, C. T. C., Mateos, J. C. P., Acosta, J. C. Z. ., Ortencio, F. ., & Amarante, R. . (2020). Cardioneuroablation: Catheter Vagal Denervation as a New Therapy for Cardioinhibitory Syncope. JOURNAL OF CARDIAC ARRHYTHMIAS, 32(3), 182–196. Retrieved from