Cardioneuroablation for Ictal Asystole: A Multicenter Case Series

Background: Cardioneuroablation (CNA) is an emerging therapy for vagally mediated bradyarrhythmias. Its role in ictal asystole, a rare but severe manifestation of epilepsy, remains poorly defined. Objectives: This study sought to summarize procedural characteristics and clinical outcomes of CNA performed for ictal asystole. Methods: We conducted a retrospective multicenter study across 6 international centers, identifying adult patients who underwent CNA for ictal asystole (≥4 s) from 2017 to 2025. Results: A total of 12 patients (aged 39 ± 9 years, 50% female) were included; 9/12 had focal impaired-awareness seizures. All patients exhibited sinus arrest during the events, with a mean asystole of 16 ± 8 s, and a median number of 7 syncopal events. Biatrial CNA (75% under conscious sedation) was facilitated by 3-dimensional electroanatomic mapping. Ganglionated plexi (GPs) were identified using anatomical landmarks and fractionated electrograms. Right superior (12 of 12), right inferior (10 of 12), and left inferior (9 of 12) GPs were most frequently ablated. After CNA, the sinus rate increased by ≥25% in 10 of 12 patients, and 9 of 12 demonstrated a blunted atropine response. No procedural complications occurred. Over a median follow-up of 20.5 months, 8 of 12 patients remained free from ictal asystole. Four patients experienced recurrent syncope at 2 to 15 months and underwent repeated CNA, with one of them achieving durable freedom from syncope. Two patients ultimately required a pacemaker implant. Conclusions: In patients with ictal asystole, biatrial CNA appears to be safe and may substantially reduce syncope burden, although repeated ablation or permanent pacing may be required. Prospective studies are needed to better define efficacy and long-term outcomes.