A case report of sinus node-sparing hybrid ablation for refractory sinus tachycardia following cardioneuroablation for sinus node dysfunction.

BACKGROUND: Cardioneuroablation (CNA) is increasingly used worldwide in the treatment of functional bradyarrhythmia mediated by excessive vagal tone. However, a potential early or long-term complication is the development of postprocedural inappropriate sinus tachycardia (IST), which remains difficult to manage. Recent data suggest that sinus node (SN)-sparing hybrid ablation may offer promising long-term outcomes in patients with IST and postural orthostatic tachycardia syndrome (POTS). We present what is, to our knowledge, the first documented case of such a procedure performed for IST/POTS following an uncomplicated CNA for symptomatic vagally mediated sinus bradycardia (SB). The comprehensive treatment strategy included on-site cardiac rehabilitation, a home-based telerehabilitation program, and evaluation using cardiovascular autonomic functional testing (CAFT) and the Malmö POTS scoring system. We present a 33-year-old woman with a 6-month history of dizziness, palpitations, exercise and orthostatic intolerance, dyspnea, presyncope, and one syncope episode. Symptoms of IST (130-170 bpm) appeared within 1 week after CNA for symptomatic SB. Despite the diagnosis of IST, CAFT have confirmed POTS. Other causes of sinus tachycardia (ST) were excluded according to guidelines. Nonpharmacological and pharmacological treatment proved ineffective. Following shared decision-making, the patient was referred for SN-sparing hybrid ablation with right-sided video-assisted thoracoscopic surgery (VATS). The patient subsequently participated in hybrid cardiac rehabilitation. At the 3-month follow-up, she was drug free and maintained a normal sinus rhythm. No evidence of bradycardia, IST/POTS, or vasovagal syncope (VVS), including CAFT, was documented during the follow-up. The serial MALMO POTS scoring system before and 3, 6, 9, 12 and 18 months after SN-sparing hybrid ablation demonstrated consistent and significant improvement, with scores decreasing from 46 to 13, 10, 6 and 12 points, respectively, values comparable to those observed in the healthy population. CONCLUSIONS: This is the first reported case of SN-sparing hybrid ablation for IST/POTS that developed after primary, uncomplicated CNA. Although not yet included in guidelines, the implementation of both procedures for cardiovascular autonomic dysfunction (CVAD) requires comprehensive and multidisciplinary heart team management. The MALMO POTS scoring system might be a useful tool for assessing CVAD before and after cardioneuromodulation procedures and further comprehensive evaluation.