Ganglionated plexi ablation in right atrium to treat cardioinhibitory neurocardiogenic syncope.

Cardioinhibitory neurocardiogenic syncope (CNS) is caused by inappropriately trigger-activated cardiac reflex which finally precipitates asystole, sinus bradycardia, or atrioventricular (AV) block. Despite young patients affected by CNS have an excellent prognosis when electro-structural heart diseases are excluded, their quality of life may be seriously affected by recurrent episodes. Cardiac pacing might help to control symptoms and therefore is considered in patients aged more than 40 years old with recurrent episodes and docu- mented cardioinhibitory response. In young individuals, the role of cardiac pacing is dubious due to predicted frequent device substitutions and adverse ventricular remodeling over time. Recently, radiofrequency (RF) biatrial ablation of gan- glionated plexi (GP) has showed promising results in the short- and long-term treatment of reflex syncope, functional atrioven- tricular block, or sinus node dysfunction. We report the case of two patients with frequent episodes of CNS with marked cardioinhibitory response at head-up tilt test (HUT) who remained highly symptomatic despite common therapeutic measures. Given the young age of the patients, we decided to attempt, on the basis of previous models of atrial denervation, a transcatheter ablation at anatomical sites of the right atrial GP, to evaluate if vagal denervation was effec- tive to prevent or to reduce syncope episodes, delaying as long as possible the timing for pacemaker implantation.