Cardioneuroablation has emerged as a potential alternative to cardiac pacing in selected cases with vasovagal reflex syncope, extrinsic vagally induced sinus bradycardia-arrest or atrioventricular block. The technique was first introduced decades ago, and its use has risen over the past decade. However, as with any intervention, proper patient selection and technique are a prerequisite for a safe and effective use of cardioneuroablation therapy. This document aims to review and interpret available scientific evidence and provide a summary position on the topic.

Background—: Transesophageal echocardiography (TEE) is the gold standard for the exclusion of thrombi in the left atrial appendage (LAA) before ablation for atrial fibrillation. Intracardiac echocardiography (ICE) is used to assist atrial fibrillation ablation; however, it can also be used for LAA imaging. The aim of our study was to determine whether ICE could replace TEE and to identify the optimal ICE placement for LAA visualization. Methods and Results—: Seventy-six consecutive patients (56 men; mean age, 55±9.6 years) scheduled for atrial fibrillation ablation underwent TEE before the procedure and LAA assessment by ICE. An 8F AcuNav probe was introduced into right atrium, pulmonary artery, and coronary sinus. LAA structure was analyzed by the echocardiographer and electrophysiologist who were blinded to the results of TEE. ICE probe was positioned in the right atrium in all patients, in the pulmonary artery in 64 of 74 (86%) patients, and in the coronary sinus in 49 of 74 (66%) patients. The LAA was properly visualized in 56 of 64 (87.5%) patients from the pulmonary artery versus 13 of 49 (26%) patients from the coronary sinus ( P <0.001). From the right atrium, the whole LAA cavity could not be seen in any patient. In those patients in whom LAA was visualized properly by ICE, a perfect agreement between ICE and TEE was obtained (both techniques detected LAA thrombus in 2 patients and excluded LAA thrombus in the remaining patients). Conclusions—: ICE can be used safely and effectively for the evaluation of LAA in patients undergoing atrial fibrillation ablation. ICE imaging from pulmonary artery is accurate for LAA visualization. Clinical Trial Registration—: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01371279.

Observational studies and a recent randomized controlled trial have provided some evidence that cardioneuroablation (CNA) may prevent syncope recurrence in patients affected by cardioinhibitory reflex syncope during the first 2 years following the procedure. Nevertheless, many issues concerning clinical indications, methodology, and long-term results remain unresolved. These issues constitute the background of this manuscript in which pioneers in CNA and experts in syncope debated critical aspects aimed at finding agreement or, if not possible, that highlighting the controversies could be addressed in future studies.

Aims Electrocardiographic diagnosis of wide QRS complex tachycardia (WCT) continues to be challenging as none one of the available methods is specific for ventricular tachycardia (VT) diagnosis. We aimed to construct a method for WCT differentiation based on a scoring system, in which ECGs are graded according to the number of VT-specific features. This novel method was validated and compared with Brugada algorithm and other methods. Methods and results A total of 786 WCTs (512 VTs) from 587 consecutive patients with a proven diagnosis were analysed by two blinded observers. The VT score method was based on seven ECG features: initial R wave in V1, initial r > 40 ms in V1/V2, notched S in V1, initial R in aVR, lead II R wave peak time ≥50 ms, no RS in V1-V6, and atrioventricular dissociation. Atrioventricular dissociation was assigned two points, and each of the other features was assigned one point. The overall accuracy of VT score ≥1 for VT diagnosis (83%) was higher than that of the aVR (72%, P = 0.001) and Brugada (81%) algorithms. Ventricular tachycardia score ≥3 was present in 66% of VTs and was more specific (99.6%) than any other algorithm/criterion for VT diagnosis. Ventricular tachycardia score ≥4 was present in 33% of VTs and was 100% specific for VT. Conclusion The new ECG-based method provides a certain diagnosis of VT in the majority of patients with VT, identifies unequivocal ECGs, and has superior overall diagnostic accuracy to other ECG methods.