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We read with great interest the recent paper by Piotrowski et al. [1]. In this well-written article, the authors aimed to present their initial experience related to cardioneuroablation (CNA) strategy in patients with reflex syncope (RS). Although RS is the most common type of syncope, there is still no well-defined and effective strategy for the management of cardioinhibitory-type RS in patients under the age of 40 years [2]. CNA is a relatively new strategy; nevertheless, previous studies demonstrated its promising results [2, 3]. In the present article, the authors performed a stepwise and empirical anatomical ablation in the previously determined ganglionated plexi (GP). Four strategies have been used to map the GP and identify the ablation targets: high-frequency stimulation, purely anatomical localisation, atrial electrogram characteristics, and different combinations of these strategies [4]. In the anatomical approach, empirical ablation is performed in previously defined sites, on the basis of animal studies and human autopsy specimens. However, the anatomical location and number of GP identified during an electrophysiological study (EPS) may vary significantly among patients [5]. This may explain the variety of approaches used by authors, such as: ablation exclusively in the left or right atrium, ablation in both atria, or ablation only in the interatrial septum. The strategy applied in the present cases, i.e. empirical anatomical ablation from the right or left atrial side, was previously used by some groups [5]. Although no need for additional equipment such as a stimulator with high-frequency stimulation feature or a software programme to convert local electrograms to spectral potentials seems to be the most important advantage of anatomical-based ablation, it was found to be related to higher RS recurrence rates in our recently published meta-analysis [4]. Also, an anatomical-based approach may increase the number of ablation points due to empirical ablation in the presumed sites. Thus, to perform a more specific and restricted ablation without compromising the success, one would need a method taking into account these anatomical variations during EPS. With this aim, we used the electroanatomic mapping-guided CNA strategy and compared this technique with a hybrid approach in which a combination of high-frequency stimulation, spectral analysis, and additional anatomical ablation was used [3]. Median event-free survival was comparable between the groups. There was no new syncopal episode in any patient at the end of six-month follow-up. The main advantage of our new technique is the opportunity to localise GP without using any additional equipment during EPS. Secondly, in the paper by Piotrowski et al. [1], only an increase in heart rate or a decrease in the degree of atrioventricular (AV) block was used as a procedural endpoint [1]. Defining reasonable procedural endpoints seems to be the Achilles’ heel of CNA strategy because we still do not know how to detect complete vagolysis and whether an incomplete

kardiologia polska

There are still debates on cardioneuroablation strategy despite increasing evidence. Commentary to the article: “Cardioneuroablation using an anatomical approach: a new and promising method for the treatment of cardioinhibitory neurocardiogenic syncope”