Biatrial cardioneuroablation guided by robotic magnetic navigation and artificial intelligence-based mapping in vagal bradyarrhythmias: A controlled observational study.

PURPOSE: Reflex bradyarrhythmias and syncope related to excessive vagal tone may be refractory to conservative therapy and significantly impair quality of life. Cardioneuroablation (CNA) has emerged as a device-sparing alternative, but real-world outcome data remain limited. METHODS: We retrospectively evaluated 12 consecutive patients (aged 23-55 years) with drug-refractory, vagally mediated bradyarrhythmias confirmed by tilt-table testing. All underwent biatrial CNA guided by ultra-high-density electroanatomical mapping with automated fragmented-electrogram detection and robotic magnetic navigation. A contemporaneous cohort of medically managed patients with comparable clinical profiles (n = 10) served as a control group. The primary outcome was freedom from syncope or clinically significant bradyarrhythmia without pacemaker implantation. Secondary outcomes included procedural metrics, heart-rate changes, and recurrence during follow-up. RESULTS: All CNA procedures were completed without acute complications and with minimal fluoroscopy exposure. Resting sinus rate increased substantially after ablation. Over a mean follow-up of approximately 12 months, most CNA-treated patients remained free of symptomatic bradyarrhythmia or syncope without requiring pacemaker implantation, whereas recurrence and pacemaker placement were less frequent compared with controls. No delayed complications were observed. CONCLUSIONS: In this small, retrospective real-world cohort, biatrial CNA guided by automated electrogram analysis and robotic navigation was feasible, safe, and associated with short-term autonomic modulation and symptomatic improvement over approximately 12 months of follow-up in selected patients with vagally mediated bradyarrhythmias. These findings are exploratory and warrant confirmation in larger, prospective studies with longer follow-up to assess durability and reinnervation risk.