In this session chaired by Richard Schilling (London, UK), Roderick Tung (University of Arizona College of Medicine, Phoenix, US) presents a live cardioneural ablation case in a 30-year-old woman with recurrent syncope and tilt-induced bradycardia. After failed midodrine and beta-blockers, the team perform a detailed EP study, assessing sinus node recovery time, AV nodal Wenckebach and dual AV nodal physiology before proceeding. Using intracardiac echo, 3D mapping and prior CT, they target left-sided and then right anterior ganglionated plexi around the LSPV roof, Marshall ridge, SVC–RA junction and CS ostium with radiofrequency ablation at 30–50 W under light propofol sedation.
Panel experts Devi Nair (Jonesboro, US), Tolga Aksu (Istanbul, TR) and Luis Carlos Saenz Morales (Bogota, CO) discuss case selection, emphasising symptom–rhythm correlation, tilt testing, implantable loop recorders and reserving this off-label, compassionate therapy for highly symptomatic younger patients. They review mapping strategies based on fractionated electrograms, epicardial fat pads and ICE-guided anatomical landmarks, debate atropine testing and potential PFA roles, and highlight key endpoints including heart rate increase, shortened corrected SNRT, improved AV nodal conduction and reduced syncope burden. The group stress avoiding pacemaker implantation in young patients, given limited trial benefit of anti-bradycardia pacing in reflex syncope.
