BACKGROUND: Cardioneuroablation (CNA) targets the ganglionated plexus (GP) to treat neurally mediated syncope, yet a standardized GP identification method is lacking. Postprocessing of cardiac computed tomography (CT) data identifies epicardial fat, thus allowing fat pad identification. Whereas the feasibility of CT-guided CNA is documented, data about GP anatomy and comprehensive evaluations of GP targeting methods remain scarce. OBJECTIVE: This study sought to describe GP anatomy using CT fat pad segmentation and to evaluate the accuracy of different approaches in locating these GPs. METHODS: The study included 26 CNA or atrial fibrillation ablation patients. GPs were identified through CT-based fat segmentation. CT-derived atrial meshes were merged with corresponding meshes from electroanatomic mapping. Spatial correlation was studied between atrial fractionated electrograms (FEGMs) and epicardial fat pads. Several target areas from the different ablation approaches (FEGM, anatomic, CT-based fat pad identification, and target line) were spatially compared. RESULTS: Correlation between epicardial fat pads and signal fragmentation was weak in the left atrium (ρ = 0.01 ± 0.13 [P = .73]
ϕ = -0.00 ± 0.10 [P = .94]) and even negative in the right atrium (ρ = 0.11 ± 0.09 [P <
.001]
ϕ = -0.10 ± 0.08 [P <
.001]). The FEGM approach was associated with a more extensive ablation area (3.74% vs 17.0% [P <
.001] for the anatomic and the FEGM approach for the left atrium and 3.45% vs 9.53% [P <
.001] for the anatomic and the FEGM approach for the right atrium). CONCLUSION: CT-based fat pad segmentation reveals significant interpatient variability in GP anatomy. GPs show low colocalization with signal fragmentation, causing inaccurate localization based on fragmentation alone. An anatomy-focused approach offers a more targeted ablation strategy.