By attenuating the vagal inputs to the heart, cardioneuroablation can expand therapy options in seizure management, particularly where cardiac inhibition is of concern.

Radiofrequency cardiac ablation, well-established since the 1990’s, is routinely used to treat various tachyarrhythmias. Cardioneuroablation (CNA), which uses the same technology, can be used to treat disorders mediated by high vagal tone, such as cardioinhibitory syncope. We present a case where this modality was used to expand therapy options in a patient with ictal bradycardia and atrioventricular block. 

The patient is a 12-year-old female with a history of focal seizures since infancy who presented to the Epilepsy Monitoring Unit for increasing seizure burden despite escalation of anti-seizure medications. She was therefore being considered for vagal nerve stimulator (VNS) therapy, known to sometimes result in the implantation of cardiac pacemakers due to profound bradycardia and asystole. During seizures, bedside monitoring showed multiple runs of ictal heart block (ventricular rates in the 20’s) and two episodes of high-grade block, resulting in 7-10 seconds of asystole. To attenuate her cardiac vagal response and allow for more therapy options, she underwent cardioneuroablation therapy. During the procedure, she had easily induced asystole, greater than 10 seconds, with vagal stimulation. Two areas of vagal input to the heart were successfully ablated. Post ablation, vagal stimulation resulted in only mild sinus slowing (90 bpm down to 80 bpm). The longest inducible pause was one second.  She was observed overnight in the epilepsy unit and discharged home the following day. VNS therapy could now be considered in her with less concern for profound bradycardia and cardiac asystole from such therapy.

Cardioneuroablation is currently primary used to treat difficult to manage cardio-inhibitory syncope.    It can be used to treat ictal bradyarrhythmias and expand seizure management options.