Arrhythmia recurrence following PVI with cardioneuromodulation: insights from a cohort of patients with both bradycardia and paroxysmal atrial fibrillation

Introduction

Cardiac neuromodulation (CNM) aims to rebalance cardiac autonomic tone by targeting atrial ganglionated plexi. Predictors of atrial fibrillation (AF) recurrence and the durability of autonomic response after CNM combined with pulmonary vein isolation remain uncertain.

Purpose

To identify predictors of AF recurrence and to test the hypothesis that an immediate stable heart-rate (HR) rise after CNM is associated with lower recurrence in patients with paroxysmal AF and profound resting sinus bradycardia.

Methods

We conducted a retrospective study of 33 consecutive patients who underwent combined CNM + pulmonary veins isolation for AF (2019–2025). Baseline comorbidities, medications and symptoms were recorded. Primary endpoint was AF recurrence documented by ECG or ambulatory monitoring. Immediate autonomic response was predefined as a stable HR rise >10 bpm between the last pre-ablation and first post-ablation measurements. Comparisons used t-tests or Fisher’s exact test, as appropriate. Missing data were analysed as observed without imputation.

Results

Mean age was 59.8 ± 12.5 years and 51.5% were male. Hypertension 63.6%, dyslipidaemia 51.5%, diabetes 12.1%. Palpitations were present in 88%. The mean number of ablated plexi at first procedure was 2.44 ± 1.22. Patients with recurrence were younger (52.8 ± 15.2 vs 61.6 ± 10.8 years; one-sided p = 0.047, Figure 1). No major complications occurred during the procedures.

An immediate HR rise ≥ 10 bpm occurred in 22/33 (66.7%) and was associated with a lower AF recurrence rate (27% vs 55%; p = 0.03, Figure 2). Neither classic left atrium high-rate stimulation, vagal extracardiac stimulation, nor targeting ≥3 versus ≤2 plexuses were associated with AF recurrence on univariate testing (all p > 0.10). No major procedural complications occurred.

Conclusion(s)

In this study, CNM was safe and produced measurable autonomic modulation in 2/3 of patients, captured by an immediate stable HR rise >10 bpm. AF recurrence was not linked to most baseline or procedural variables, but younger age and the absence of acute HR rise emerged as marker of higher recurrence risk. Validation in larger, prospective cohorts with systematic HR variability acquisition and predefined procedural endpoints are needed to refine candidate selection and optimise CNM durability.AF_CNA_1AF_CNA_2