Omnipolar Technology Near Field Versus Fragmentation Signals Mapping at Anatomically Defined Ganglionated Plexi Sites During Cardioneuroablation

BACKGROUND: Cardioneuroablation (CNA) is an established catheter-based therapy for refractory vasovagal syncope (VVS), targeting atrial ganglionated plexi (GPs) by radiofrequency ablation. Omnipolar Technology Near Field (OTNF) is a novel automated spectral mapping algorithm integrated within the EnSite X system; its systematic comparison with fragmentation mapping during CNA has not previously been reported. OBJECTIVES: To evaluate the feasibility, safety, and efficacy of a streamlined, imaging-free anatomically guided CNA approach and to compare real-time OTNF mapping at three spectral thresholds with fractionation analysis in detecting GPs at anatomically consistent locations. METHODS: Twenty-six consecutive patients (mean age 43.9 ± 16.4 years; 69% female; ≥ 3 VVS episodes/year) were enrolled prospectively at two French centres. All procedures used an HD Grid catheter for bilateral OTNF and fractionation mapping, followed by sequential ablation of five GP sites. Acute success was defined as heart rate increase > 50% from baseline and blunted atropine response (< 25% increment). Directional discordance between fractionation and OTNF map was assessed by McNemar's exact test. RESULTS: Acute procedural success was achieved in 22 out of 26 patients (84.6%), with no complications. Mean procedure time was 95.2 ± 20.5 min. CNA produced significant vagal denervation: heart rate increased from 60.2 ± 12.9 to 88.1 ± 18.2 bpm (p < 0.003), AH interval shortened from 97.6 ± 22.9 to 78.2 ± 21.7 ms (p = 0.007), Wenckebach cycle length decreased from 441.5 ± 118.9 to 330.0 ms (p < 0.003) and SNRT decreased from 1235.0 ± 273.7 to 1028.4 ± 235.1 ms (p = 0.003). At 400 Hz, OTNF showed significantly higher signal positivity than fractionation mapping at the LSGP (concordance 57.7%) and RIGP (concordance 65.4%). At 500 and 600 Hz, no directional asymmetry was detected while concordance remained below 70% at these sites. At a median follow-up of 20.2 ± 7.6 months, 81% of patients were free from syncope. CONCLUSIONS: A simplified, anatomical CNA approach is safe, feasible, and effective. OTNF and fragmentation signals mapping shows modest concordance at five anatomically consistent GP locations, confirming that those strategies capture partially non-overlapping electrophysiological information.