Could Cardioneuroablation Replace Permanent Pacemakers?

A permanent pacemaker helps control a slower heart rate and long-term arrhythmias. However, the surgical procedure of implanting a pacemaker comes with several risks at the site of implantation, including infection, swelling, bruising or bleeding, blood clotting, damage to blood vessels or nerves as well as a collapsed lung. On the other hand, CNA is a simple, 30-minute procedure performed using radiofrequency catheter ablation with fewer complications. The newly transplanted heart has functional nerve connections of its own. Interestingly, in this case study, the nerves in the newly transplanted heart were getting activated autonomously causing the heart rate to slow down. The exact mechanism behind this phenomenon is unclear, according to Valderrabano. However, this study indicates that the nerves in the heart can get activated by themselves which is a novel finding and adds insight into how the nerves in the heart function. Created in the 1990s, the patented technique of CNA has been utilized to improve patient outcomes in cases of slower heart rates. Valderrabano has used CNA to prevent episodes of fainting in patients where this is disruptive. In this case study, however, Valderrabano cautiously explored the avenue of cauterizing nerves in a newly transplanted heart.

According to Valderrabano, “Orthotopic heart transplant results in transection of the vagal nerve and the post-ganglionic sympathetic fibers from extrinsic sympathetic ganglia, causing complete disconnection of the graft from central connections with the central nervous system. Axonal degeneration follows, resulting in the disappearance of nerve terminals within transplanted tissue. Over time, 40% to 70% of orthotopic heart transplant recipients will reinnervate, with sympathetic reinnervation occurring five to six months postoperatively and parasympathetic reinnervation requiring one to three years. Given the perceived high risk of sudden death from bradyarrhythmia, the patient underwent dual-chamber pacemaker implantation. We suspected a neurally mediated mechanism of his paroxysmal atrioventricular block because of the absence of graft dysfunction. If high-frequency stimulation of the intrinsic cardiac nerve could replicate the atrioventricular block, we reasoned that cardioneuroablation would be therapeutic”. This interesting study underscores the possibility that CNAs may replace permanent pacemakers while offering improved outcomes for OHT recipients with heart blocks. A prospective clinical trial, albeit with a smaller sample size, may shed light on the probabilities of success that can be expected with CNA, which may aid OHT patients to make more informed decisions. More studies along these lines will help us better understand the future implications of CNA in cardiovascular medicine.