Background <p>Cardioneuroablation is increasingly being adopted as a treatment for vasovagal syncope (VVS). Identification of the cardiac ganglionated plexus (GP) is a critical factor influencing the outcome of the procedure. This study sought to compare the efficacy of tentative anatomical ablation (TAA) and high-frequency electrical stimulation (HFS) in locating the GP.</p> Methods <p>A total of 58 patients diagnosed with VVS were consecutively enrolled, including 46 patients with the cardioinhibitory type and 12 patients with the mixed type who exhibited a significant decrease in heart rate (HR). The first 19 enrolled patients simultaneously underwent HFS- and TAA-guided GP localization. All patients underwent anatomical GP ablation.</p> Results <p>The number of GP sites with a positive response to TAA was significantly greater than those from HFS (15 ± 4 per person vs. 12 ± 4 per person; <i>p</i> &lt; 0.001). Following anatomical ablation, the patients exhibited an increase in HR (69 ± 13&#xa0;bpm vs. 91 ± 13&#xa0;bpm, <i>p</i> &lt; 0.001), a reduction in sinus node recovery time (1155 ± 169 ms vs. 934 ± 162 ms, <i>p</i> &lt; 0.001), an enhancement of atrioventricular conduction (Wenckebach point: 418 ± 87 ms vs. 338 ± 41 ms; effective refractory period of atrioventricular node: 334 ± 84 ms vs. 254 ± 54 ms, all <i>p</i> &lt; 0.001), and a reduction in heart rate variability (HRV) (HRV_SDNN: 146 ± 64 ms vs. 67 ± 29 ms; high frequency: 309.18 ± 99.42 vs. 24.21 ± 12.73, all <i>p</i> &lt; 0.001). During a median follow-up of 18 months, the rate of freedom from syncope recurrent was 94.8%, with no statistically significant differences observed in age, gender, or type of head-up tilt test.</p> Conclusions <p>In GP localization, TAA-guided responses demonstrated greater precision and wider distribution compared to HFS-guided approaches. Anatomical GP ablation can significantly decrease autonomic tone and prevent syncope in patients with VVS.</p> Clinical trial number <p>Not applicable.</p>