Peak Frequency–Guided Cardioneuroablation and Pulmonary Vein Isolation in Sinus Node Dysfunction and Atrial Fibrillation

Background: Sinus node dysfunction (SND) commonly coexists with atrial fibrillation (AF), leading to bradycardia, syncope, and pacemaker implantation. Effective therapies addressing both arrhythmic triggers and autonomic factors remain limited. Case Summary: A 49-year-old woman with paroxysmal AF, symptomatic sinus bradycardia, and frequent sinus pauses showed prolonged sinus node recovery time. High-resolution electroanatomic mapping with peak frequency analysis identified fractionated, high-frequency atrial potentials in the anterior right superior pulmonary vein. Selective cardioneuroablation and pulmonary vein isolation normalized heart rate, improved recovery time, and maintained sinus rhythm without pacemaker implantation over 12 months. Discussion: This case illustrates that mapping-guided autonomic modulation can restore sinus node function in AF with SND. Take-Home Messages: Dual ablation with cardioneuroablation and pulmonary vein isolation can treat AF with SND while avoiding pacemaker implantation. Combining high-resolution fractionation mapping with peak frequency analysis enables precise localization of autonomic targets to optimize outcomes.