Yoo, Jeanwoo

Abstract Background Vagally mediated syncope and functional bradyarrhythmias can cause recurrent symptoms, injury and a need for permanent pacing, yet standard therapies do not address the underlying autonomic reflex. Cardioneuroablation (CNA) targets this mechanism, but adoption has been limited by uncertainty about patient selection, procedural endpoints and durable outcomes. Methods We studied 95 consecutive patients with vagally mediated syncope (n=78) or functional bradyarrhythmia (n=17) who underwent CNA at a single center by a single lead operator under a uniform, prospectively maintained protocol. Extracardiac vagal stimulation (ECVS) was performed before and after ablation to confirm vagally mediated sinus or atrioventricular (AV) nodal responses and to verify their attenuation. Outcomes through 1 year included clinical recurrence, quality of life, pacing burden and pacemaker extraction. Results Before ablation, ECVS provoked sinus pauses in 95.8% of patients and AV block in 91.6%; after ablation, sinus pauses were abolished in every patient and residual AV block was present in 4.2%. One-year freedom from recurrent syncope and from bradyarrhythmia-related events was 93.8% and 94.1%. Syncope burden fell from a median of 2.7 episodes per year to none, and disease-specific quality of life improved substantially (P<0.001). Among patients with pre-existing devices, atrial pacing burden fell from a median of 22% to 0%. There were no strokes, deaths or myocardial infarctions. Conclusions In this single-center cohort, physiology-guided CNA was associated with durable symptom control, improved quality of life and reduced pacing across vagally mediated bradyarrhythmia syndromes. Multicenter controlled studies are needed to confirm these findings.

Background: Subaortic membrane (SAM) is a fibromuscular ridge beneath the aortic valve that causes fixed left ventricular outflow tract (LVOT) obstruction. Surgical resection is the standard treatment for symptomatic patients or those with high gradients; however, recurrence occurs in up to 14% of adults within 5 years. While radiofrequency ablation (RFA) is well-established in arrhythmia management, its role in treating SAM has not been previously described. Case Information: 53-year-old man with HTN, BMI 51.7, and well-controlled OSA presented with worsening exertional dyspnea and fatigue in April 2024. He had prior surgical SAM resection in 2018, complicated by third-degree AV block requiring pacemaker implantation. Follow-up echocardiography revealed SAM recurrence with peak LVOT gradient of 52 mmHg. Given elevated surgical risk, a novel catheter-based RFA approach was pursued. In July 2024, the patient underwent catheter-based RFA under general anesthesia. A ThermoCool SmartTouch SF catheter was advanced retroaortically across the aortic valve toward the subaortic ridge, guided by CARTO 3 with CartoSound. A semi-circular lesion set was delivered to the septum inferior to the membrane. Two steam pops occurred during ablation in this area. Serial transthoracic echocardiograms at 3 and 8 months demonstrated sustained LVOT gradient reduction, from 52 mmHg pre-ablation to 49 mmHg and 38 mmHg, respectively. Left ventricular ejection fraction (EF) remained stable at 61%, with no new wall motion abnormalities or pericardial effusion. The patient reported marked improvement in symptoms and normalization of daily activity tolerance. No procedural complications or hospital readmissions occurred. Decision-Making: Given the patient’s high surgical risk and recurrent symptoms, the multidisciplinary team determined that repeat sternotomy carried elevated morbidity. RFA offered a targeted, minimally invasive solution that leveraged electrophysiology tools and preserved structural integrity while maximizing safety. Conclusions: This first-in-human case illustrates the feasibility of intracardiac RFA for recurrent SAM. The patient experienced sustained LVOT gradient reduction, preserved EF, and marked symptomatic improvement. This novel approach may offer a viable option for select patients with recurrent subaortic obstruction and prior sternotomy, warranting further investigation to define lesion durability, depth of tissue effect, and conduction system safety.

ABSTRACT Background Pulmonary vein isolation is a standard therapy for paroxysmal atrial fibrillation (AF). Pulsed field ablation (PFA) has emerged as a novel approach aiming to improve efficacy and safety over conventional thermal ablation (CTA) (radiofrequency and cryoballoon). This meta‐analysis evaluated outcomes of PFA versus thermal ablation in paroxysmal AF. Methods Electronic databases were searched through May 2025 for randomized controlled trials (RCTs) and observational studies that compared the efficacy and safety of PFA versus CTA. The primary outcome was AF recurrence. Summary estimates were conducted using random effects. Results A total of six studies, involving 1928 patients, were included. The incidence of AF recurrence was significantly lower among patients treated with PFA (risk ratio [RR] 0.67; 95% confidence interval [CI] 0.53–0.85). PFA was associated with a lower incidence of any atrial arrhythmia recurrence (RR 0.78, 95% CI: 0.61–0.99). The total procedure duration was significantly shorter with PFA (mean difference −21.46 min (95% CI: −26.04 to −16.88)), but there was no difference in fluoroscopy time. The rates of esophageal injury and phrenic nerve palsy were lower with PFA. However, the data were limited for these two outcomes, and a meta‐analysis was not conducted for them. There was no difference between the two groups in the incidence of stroke or pericardial tamponade. Conclusion Among patients with paroxysmal AF undergoing catheter ablation, PFA is associated with favorable outcomes, including lower recurrence and shorter procedure time compared to conventional ablation modalities.