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Background Cardioinhibitory syncope in young patients with structurally normal hearts poses a therapeutic challenge. Cardioneuroablation (CNA) targeting atrial ganglionated plexi has emerged as a potential alternative to permanent pacing. Leadless pacemakers are increasingly considered the gold standard for young patients requiring pacing. We report and compare outcomes of CNA and leadless pacemaker implantation in patients with cardioinhibitory syncope, who were offered a shared decision-making approach.Methods Seven patients with recurrent syncope and documented prolonged sinus pauses, normal echocardiography, and no intrinsic conduction disease were analysed. Four patients (3 male, mean age 36 years) underwent CNA using anatomically guided and fractionation-based ablation of left and right atrial ganglionated plexi, with adjunctive atropine testing and vagal stimulation. Three female patients (mean age 29 years) underwent implantation of an Abbott Aveir single-chamber leadless atrial pacemaker. Patients selected treatment based on informed preference. Follow-up ranged from 6 months to 2 years.Results In the CNA group, baseline pauses ranged from 15 to 40 seconds. Acute procedural heart rate increase or attenuation of vagal response was observed in three cases. There were no acute procedural complications related to CNA; however, one patient required dual-chamber pacemaker implantation due to presumed sinus node artery injury, with subsequent spontaneous recovery of sinus rhythm and no further pauses. During follow-up, three of four CNA patients remained free from recurrent syncope; one experienced a single prodromal syncopal episode with a 4-second pause at one year.In the leadless pacemaker group, baseline pauses ranged from 11 to 60 seconds. Implantation was uncomplicated in all cases, with minimal ventricular pacing burden. One patient experienced a presyncopal episode during follow-up; no recurrent syncope was documented.Conclusion In selected patients with cardioinhibitory syncope and structurally normal hearts, CNA demonstrated favourable medium-term outcomes comparable to leadless pacing, while avoiding lifelong device therapy. Leadless pacemakers remain a reliable gold-standard option, particularly in patients with very prolonged or frequent pauses. Larger prospective studies are required to define optimal patient selection and long-term efficacy of CNA.