Empirical anatomic ablation
This strategy can be used in 2 different ways: adjunctive to electrogram analysis or HFS (44) or both; or as a true stand-alone strategy, via isolated right atrial or left atrial approaches (48, 62). Sun et al (48) compared HFS-guided and empirically defined ablation approaches in 57 VVS cases. No statistical differences were found between HFS-guided and anatomical-guided ablation groups in either freedom from syncope or recurrent prodromes.
Future implications
The optimal approach to modulate the intrinsic cardiac ANS, the number of sGPs to be targeted and the long-term consequences of these therapies remain unclear. It is important to note that intrinsic cardiac ANS modulation can be associated with procedural risks, either in terms of procedural complications or the potential for off target effects like enhanced susceptibility to ventricular arrhythmias (66). Given the very complicated and variable distribution of epicardial ganglia and sGPs in humans, further characterization of the hierarchy of sGPs and specific atrial sGPs that ought to be targeted for arrhythmia therapy will be crucial. Until we get more data from prospective randomized studies, it is reasonable to proceed with caution in ablating these structures.