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 mid-term symptomatic improvement 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.