Efficacy of implantable loop recorders in establishing symptom-rhythm correlation in young patients with syncope and palpitations

Insertable loop recorder use for detection of intermittent arrhythmias

The advent of prolonged monitoring with the implanted loop recorders has revolutionized the quest for detection of elusive infrequent arrhythmias in patients with unexplained syncope. The capability of prolonged monitoring has permitted us to obtain symptom rhythm correlation in the majority of patients suspected to have underlying infrequent arrhythmia. The implanted loop recorder is easily implanted in the left pectoral region with a minimally invasive procedure, providing at least 14 months of continuous monitoring that is both patient and automatically activated. Several recent studies suggest that it plays a major role in patients with infrequent symptoms and suspected arrhythmia, including patients with syncope and conduction disturbances, mild to moderate underlying heart disease, and atypical epilepsy. In a randomized trial, the device was found to be cost-effective and improved diagnostic yield compared to conventional tilt and electrophysiological testing. Wider application of prolonged monitoring is ongoing, including assessment of ventricular arrhythmias, atrial fibrillation, and conduction disturbances. The implantable loop recorder is most useful in patients with infrequent unexplained syncope when noninvasive testing is negative.

Fainting freshmen and sinking sophomores: cardiovascular issues of the adolescent

PURPOSE OF REVIEW

Syncope is a common symptom in adolescents. The vast majority of cases are the result of benign neurocardiogenic syncope, without associated risk of sudden death. This paper reviews the mainstays of diagnosis and treatment for syncopal episodes, differentiation of syncope from life-threatening arrhythmia and aborted sudden cardiac death, and the patient populations at highest risk for cardiac symptoms and cardiac disease.

RECENT FINDINGS

A detailed history (including past medical history and family history that focus on cardiac disease) combined with dynamic physical examination and electrocardiogram identifies the vast majority of adolescents with significant heart disease. Further diagnostic modalities have limited utility. Reassurance and supportive measures remain the treatment of choice, although drug therapy can sometimes be helpful, even if data are limited. Divergent approaches to the screening of the young competitive athlete exist. Particular attention is required in adolescents and young adults with exercise-associated syncope, eating disorders, chronic fatigue syndrome, or history of congenital heart disease. Their symptoms may be either more serious or challenging to manage.

SUMMARY

Syncope in the adolescent patient is very common; true cardiac disease is not. The traditional diagnostic screen of history and physical combined with an electrocardiogram will identify the overwhelming majority of patients with significant disease. Patients with abnormalities on this initial office evaluation, history of cardiac disease, or complicating medical illness may benefit from referral to a cardiologist. Even within this patient subset, many will prove to have benign disease.

Feasibility of the Inframammary Location for Insertable Loop Recorders in Young Women and Girls

The parasternal location for the insertable loop recorder (ILR) has potential for erosion in small patients, and can be aesthetically unappealing, especially for young women. We assessed the feasibility of the inframammary location in nine patients, utilizing a 2 cm transverse incision at the inferior and medial border of the left or right breast. Signal quality was adequate with clearly discernable atrial and ventricular electrograms. No complications involving the surgical site were observed. Cosmetically, placement of the scar in the natural breast crease has been favorably accepted. Inframammary implantation of the ILR is feasible, and is the preferred method in young women and girls at our center.