Cardioneuroablation versus cardiac pacemaker in the management of dominant cardioinhibitory vasovagal syncope: a retrospective cohort study

Background: Refractory dominant cardioinhibitory vasovagal syncope (VVS) remains a therapeutic challenge in patients older than 40 years. Dual-chamber pacemakers with closed-loop stimulation (CLS-PM) are guideline-supported, while cardioneuroablation (CNA), targeting ganglionated plexus, has emerged as a device-free alternative. Direct comparative data between these strategies are limited. Methods: We conducted a retrospective, comparative cohort study including patients > 40 years with refractory cardioinhibitory VVS treated between 2018 and 2024. Patients underwent either CNA with extracardiac vagal stimulation validation (CNA-ECVS) or CLS-PM implantation. The primary outcome was recurrence of the first syncope episode. Secondary outcomes included syncope-free survival, syncope burden (≥ 50% reduction), and safety. Kaplan–Meier analysis and Cox proportional hazards models were applied. Results: Eighty patients were included (37 CNA-ECVS, 43 CLS-PM; mean age 58.0 ± 14.6 years). Patients in the CNA group were younger than those in the CLS-PM group (49.9 ± 10.3 vs. 65.0 ± 14.1 years; p < 0.001). During a mean follow-up of 3.8 years, syncope-free rates were 89.2% in the CNA group and 79.1% in the CLS-PM group (p = 0.363). Syncope-free survival did not differ significantly (log-rank p = 0.168), and recurrence risk was similar between strategies (HR 0.45; 95% CI 0.14–1.46; p = 0.182). Post-procedural syncope burden was numerically lower after CNA (10.8% vs. 20.9%) but without statistical significance. No major adverse events were observed in either group. Conclusions: In patients older than 40 years with refractory cardioinhibitory NCS, CNA with physiological validation and CLS-PM therapy demonstrated comparable efficacy and safety. Both strategies represent viable therapeutic options, warranting confirmation in randomized clinical trials.