Radiofrequency cardioneuroablation versus conventional management for recurrent vasovagal syncope: a 50-pair propensity-score matched cohort study

Cardioneuroablation (CNA) is a catheter-based strategy that targets atrial ganglionated plexi to attenuate excessive cardiac parasympathetic activity in selected patients with recurrent vasovagal syncope (VVS). Comparative long-term data remain limited, and observational findings require careful control for treatment-selection bias. We conducted a retrospective, single-centre cohort study of patients aged 18–65 years with recurrent VVS, positive head-up tilt testing (HUTT), and no structural heart disease. Consecutive patients treated with anatomically guided radiofrequency CNA between January 2016 and December 2019 were compared with a source cohort of conventionally managed patients treated during the same period ( n = 128). Propensity scores were estimated from demographic, clinical, HUTT, haemodynamic and echocardiographic variables, and 50 CNA patients were matched 1:1 to 50 controls. The primary endpoint was time to first recurrent syncope through 60 months. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using a Cox proportional hazards model with robust variance clustered by matched pair. After matching, baseline covariates were balanced (all standardized mean differences < 0.10). Recurrent syncope occurred in 6 of 50 patients (12.0%) after CNA and 22 of 50 controls (44.0%) during 60 months. Five-year freedom from recurrent syncope was 88.0% versus 56.0% (log-rank P = 0.0003). In the matched Cox model, CNA was associated with a lower hazard of recurrent syncope (HR = 0.24, 95% CI 0.10–0.57; P = 0.001). CNA was also associated with lower annualized syncope burden, fewer emergency visits, and more frequent negative or non-diagnostic repeat HUTT at 12 months. Mean heart rate increased early after CNA, whereas SDNN and RMSSD decreased, with partial recovery over 36–60 months. No death, stroke, cardiac tamponade or permanent phrenic nerve injury occurred. In this propensity-score matched cohort, radiofrequency CNA was associated with lower 5-year recurrent syncope and measurable autonomic remodeling compared with conventional management. Because the study was observational, single-centre and modest in size, these findings should be interpreted as supportive rather than definitive evidence and require confirmation in larger prospective studies with standardized autonomic and procedural endpoints.