Background Cardioneuroablation (CNA) is a novel therapeutic approach for functional bradyarrhythmias, specifically neurocardiogenic syncope or atrial fibrillation, achieved through endocardial radiofrequency catheter ablation of vagal innervation, obviating the need for pacemaker implantation. Originating in the nineties, the first series of CNA procedures was published in 2005. Extra-cardiac vagal stimulation (ECVS) is employed as a direct method for stepwise denervation control during CNA. Objective This study aimed to compare the long-term follow-up outcomes of patients with severe cardioinhibitory syncope undergoing CNA with and without denervation confirmation via ECVS. Method A cohort of 48 patients, predominantly female (56.3%), suffering from recurrent syncope (5.1±2.5 episodes annually) that remained unresponsive to clinical and pharmacological interventions, underwent CNA, divided into two groups: ECVS and NoECVS, consisting of 34 and 14 cases, respectively. ECVS procedures were conducted with and without atrial pacing. Results Demographic characteristics, left atrial size, and ejection fraction displayed no statistically significant differences between the groups. Follow-up duration was comparable, with 29.1 ± 15 months for the ECVS group and 31.9±20 months for the NoECVS group (p=0.24). Notably, syncope recurrence was significantly lower in the ECVS group (2 cases vs. 4 cases, Log Rank p=0.04). Moreover, the Hazard ratio revealed a five-fold higher risk of syncope recurrence in the NoECVS group. Conclusion This study demonstrates that concluding CNA with denervation confirmation via ECVS yields a higher success rate and a substantially reduced risk of syncope recurrence compared to procedures without ECVS confirmation.

Introduction: Left atrial posterior wall isolation (LAPWI) is often performed in addition to pulmonary vein isolation (PVI) to improve outcome in patients with persistent atrial fibrillation (AF). In this setting, LAPWI + PVI using cryoballoon ablation had comparable results with radiofrequency ablation (RFA). The aim of the study is to evaluate the feasibility and safety of a new cryoballoon ablation system in PVI + LAPWI isolation, comparing it with the historical platform. Methods: The study was a prospective, non-randomized, single center study. Forty consecutive patients, undergoing PVI + LAPWI with the novel POLARx™, were compared to 40 consecutive patients who underwent the same procedure with the established Arctic Front Advance PRO™. Results: Acute isolation was achieved in all PVs in both groups and LAPWI was achieved in 38 patients (95%) in the POLARx group and in 36 patients (90%) in Arctic Front group. Procedural outcomes were similar between the two groups, except for lower temperatures during cryoapplications in the POLARx group, for both PVI and LAPWI. The complication rate was low and similar between groups. Conclusion: LAPWI+PVI with the novel POLARx™ Cryoballoon is feasible and safe; the results are comparable with the Arctic Front Advance PRO™ system.

Introduction: As the pulmonary vein isolation (PVI) is the cornerstone of the atrial fibrillation (AF) ablation procedure, esophagus overheating has become a subject of great concern. Objectives: To assess whether the mechanical displacement of the esophagus (MDE), performed by a regular transesophageal echocardiogram probe (TEEP) may prevent esophagus overheating during the procedure. Methods: A 55 patient prospective-controlled study with paroxysmal or persistent AF in which RF delivery was stopped, whenever a sinusoidal probe with multiple thermocouples detected a luminal esophageal temperature (LET) elevation ≥0.5°C. A LET elevation <0.5°C during RF delivery was considered the successful endpoint after performed the MDE. In some patients, diluted barium was instilled to highlight the esophagus boundaries. Esophagogastroduodenoscopy (EGD) was performed if there were any sign or symptom of esophagus injury after the procedure. Results: The MDE was necessary in 47 of the 55 subjects enrolled to correct LET elevation (≥0.5°C). After the MDE, 41 of those 47 patients had a LET elevation <0.5°C, and none of them, had a LET elevation ≥38.5°C. The average basal LET was 35.71 ± 0.12°C. Immediately before the MDE, the average LET was 37.03 ± 0.06°C and post-displacement was 35.83 ± 0.08°C. The displacement range average was 2.25± 1.19cm (maximum: 6.17cm). After displacement, 100% of the esophagus remained in the same position. Of the total 14 patients who underwent EGD, 6 were normal, erosion was detected in 1 and superficial hematoma in 7. Conclusion: the MDE was effective and safe in preventing its overheating during RF catheter AF ablation.