Po-05-233 cardioneuroablation in patients with a prior pacemaker implant

Cardioneuroablation (CNA) is an alternative therapeutic method for patients with functional bradyarrhythmias who are otherwise candidates for permanent pacing. In a specific clinical scenario, CNA can also be a treatment option for patients with previously implanted pacemakers. We investigated whether CNA could substitute permanent pacing in selected patients with a pacemaker associated with complications, technical failures, or decreased quality of life. Among 198 patients who underwent CNA by radiofrequency energy between 2014 and 2022, there were 13 patients (7%) with a pacemaker in whom CNA was indicated as a "substitute" treatment. The reasons were as follows: lead failure (n = 6), low-grade infection in the device pocket (n = 1), infective endocarditis (n = 1), recurrent syncope even after pacemaker implantation (n = 1), and discomfort associated with the implanted device (n = 4). In 4 patients, the pacemaker was explanted shortly before CNA because of serious complications. Biatrial CNA was guided anatomically using a 3D mapping system and intracardiac echocardiography. Empirical sites of ganglionated plexi were targeted. The procedural endpoint was the unresponsiveness of sinus and AV nodes to extracardiac vagal nerve stimulation. Patients (n = 13, 77% male, age: 41 ± 12 years) had a pacemaker implanted 11 ± 7 years ago. They responded to atropine (2 mg IV) administration by accelerating the sinus rhythm by 55 ± 33%. CNA was technically successful and uncomplicated in all of them. During the follow-up of 40 ± 16 months (range 16 - 66 months), two patients (15%) had a recurrence of syncope. In both, the syncope was reproduced by tilt testing and classified as a pure vasodepressor event. In the remaining patients, the follow-up was uneventful. Elective explantation of the pacing system has so far been performed in 5 of 9 patients and is planned in 4 remaining patients after reaching a sufficient length of post-procedural follow-up. CNA is an effective and safe method, which is not only an alternative to the pacemaker implant but can also be used in patients with functional bradyarrhythmias, and previously implanted pacemakers who experience significant adverse events associated with the pacing system.