CONGRESS ABSTRACT

A 43-year-old male presented with syncope episodes dating back to adolescence, sometimes preceded by prodromal symptoms. Initially, some of these syncopal episodes were attributed to epilepsy, leading to the initiation of medical therapy. However, due to the persistence of syncope and an increase in episodes, a loop recorder (ILR) was implanted. The ILR monitoring revealed numerous episodes of sinus arrest occurring at least monthly, with prolonged sinus arrest associated with symptomatic syncope. The patient underwent a tilt test, which was positive for vasodepressor vasovagal syncope. Considering the patient's refusal to the pacemaker implantation and the predominantly vagal nature of his clinical presentation despite the absence of cardioinhibitory syncope during the tilt test we decided to attempt cardiac neuroablation (CNA). The echocardiogram was normal. The invasive electrophysiological study excluded intrinsic disturbances of the cardiac conduction system. We initially decided to ablate the superior and inferior paraseptal parasympathetic ganglia using a right-sided approach only. Post-procedural telemetric monitoring showed no significant arrhythmic events. However, 23 days later, the patient experienced a new syncopal episode, with the ILR recording a 20-second sinus arrest. In agreement with the patient, we proceeded to complete the procedure by targeting the superior and inferior paraseptal parasympathetic ganglia using a left-sided approach. The patient underwent a second CNA procedure. Telemetric monitoring during the subsequent 24 hours revealed a brief episode of asymptomatic non-sustained ventricular tachycardia (VT). Since the procedure, the patient's average heart rate has increased by 24 bpm, and no further episodes of VT have been observed. We remain in the early stages of follow-up and are closely monitoring the patient’s clinical progress. This clinical case highlights the complexities of real-world scenarios, especially when addressing the underlying mechanisms of syncope and were documented asystole. This issue is particularly significant in young patients. Once the clinical indication for CNA is determined, deciding which parasympathetic ganglia to ablate and how to perform the ablation remains a complex challenge.