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Abstract
Catheter-based neuromodulation of intrinsic cardiac autonomic nervous system is increasingly being used to improve outcomes in patients with vasovagal syncope and bradyarrhythmias caused by vagal overactivity. However, there is still no consensus for patient selection, technical steps, and procedural end points. This review takes the reader on a practical exploration of neuromodulation for bradyarrhythmias, concentrating on the critical aspects of proper patient selection, evidence-based insights, and anatomic intricacies within the intrinsic cardiac autonomic nervous system. Also discussed are different mapping techniques and outcome measures. Future directions to optimize the utilization of this technique in clinical practice are highlighted.
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Affiliation(s)
- Asad Khan
- Division of Cardiology, Rush University Medical Center, 1717 West Congress Parkway, Chicago, IL 60612, USA
| | - Henry D Huang
- Division of Cardiology, Rush University Medical Center, 1717 West Congress Parkway, Chicago, IL 60612, USA
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul 34100, Turkey.
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2
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Penela D, Berruezo A, Roten L, Futyma P, Richter S, Falasconi G, Providencia R, Chun J. Cardioneuroablation for vasovagal syncope: insights on patients' selection, centre settings, procedural workflow and endpoints-results from an European Heart Rhythm Association survey. Europace 2024; 26:euae106. [PMID: 38781099 PMCID: PMC11114473 DOI: 10.1093/europace/euae106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/18/2024] [Indexed: 05/25/2024] Open
Abstract
AIMS Cardioneuroablation (CNA) is a catheter-based intervention for recurrent vasovagal syncope (VVS) that consists in the modulation of the parasympathetic cardiac autonomic nervous system. This survey aims to provide a comprehensive overview of current CNA utilization in Europe. METHODS AND RESULTS A total of 202 participants from 40 different countries replied to the survey. Half of the respondents have performed a CNA during the last 12 months, reflecting that it is considered a treatment option of a subset of patients. Seventy-one per cent of respondents adopt an approach targeting ganglionated plexuses (GPs) systematically in both the right atrium (RA) and left atrium (LA). The second most common strategy (16%) involves LA GP ablation only after no response following RA ablation. The procedural endpoint is frequently an increase in heart rate. Ganglionated plexus localization predominantly relies on an anatomical approach (90%) and electrogram analysis (59%). Less utilized methods include pre-procedural imaging (20%), high-frequency stimulation (17%), and spectral analysis (10%). Post-CNA, anticoagulation or antiplatelet therapy is prescribed, with only 11% of the respondents discharging patients without such medication. Cardioneuroablation is perceived as effective (80% of respondents) and safe (71% estimated <1% rate of procedure-related complications). Half view CNA emerging as a first-line therapy in the near future. CONCLUSION This survey offers a snapshot of the current implementation of CNA in Europe. The results show high expectations for the future of CNA, but important heterogeneity exists regarding indications, procedural workflow, and endpoints of CNA. Ongoing efforts are essential to standardize procedural protocols and peri-procedural patient management.
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Affiliation(s)
- Diego Penela
- Humanitas Research Center, Milano, Italy
- Heart Institute, Teknon Medical Center Barcelona, Spain
| | | | - Laurent Roten
- Department of Cardiology, Inselspital-Bern University Hospital, University of Bern, Bern, Switzerland
| | - Piotr Futyma
- St. Joseph’s Heart Rhythm Center Rzeszow and Medical College, University of Rzeszow, Rzeszow, Poland
| | - Sergio Richter
- Heart Center Dresden, University Hospital, Technical University Dresden, Dresden, Germany
| | - Giulio Falasconi
- Humanitas Research Center, Milano, Italy
- Heart Institute, Teknon Medical Center Barcelona, Spain
| | - Rui Providencia
- St Bartholomew’s Hospital, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Julian Chun
- Cardioangiologisches Centrum Bethanien, Agaplesion Bethanien Krankenhaus, Frankfurt, Germany
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3
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Aksu T, Chung MK. Cardioneuroablation for Cardioinhibitory Vasovagal Syncope: Rationale, Approaches, and Its Role in Long-Term Management. CURRENT CARDIOVASCULAR RISK REPORTS 2024; 18:55-64. [PMID: 38707611 PMCID: PMC11064987 DOI: 10.1007/s12170-024-00736-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/07/2024]
Abstract
Purpose of Review Cardioneuroablation (CNA) has emerged as a potential alternative to pacemaker therapy in well-selected cases with vasovagal syncope (VVS). In recent years, the number of CNA procedures performed by electrophysiologists has considerably risen. However, some important questions, including proper patient selection and long-term results, remain unanswered. The present article aims to critically review and interpret latest scientific evidence for clinical indications and how to approach long-term management. Recent Findings CNA is a new approach that has been supported mainly by retrospective or observational data for its use in syncope. Overall, in mixed population studies treated with CNA, 83.3 to 100% have been reported to be free of syncope over follow-up periods of 6 to 52.1 months. For studies including patients who underwent CNA with pure VVS, 73.2 to 100% have been reported to be syncope-free over follow-up periods of 4 to 45.1 months. One large meta-analysis showed 91.9% freedom from syncope after CAN. To date, only one randomized controlled trial with small case number has been performed of CNA compared to non-pharmacological treatment in VVS. In this study of 48 patients with an average of 10 ± 9 spontaneous syncopal episodes prior to study enrollment and 3 ± 2 episodes in the year prior to CNA. After CNA, 92% were free of syncope compared with 46% treated with optimal non-pharmacological treatment to prevent new syncope episodes (P = 0.0004). To date, most studies have included younger patients (< 60 years of age). There are only limited data in patients older than 60, and some studies suggest less of an effect in relatively older patients. Summary Cardioneuroablation can be performed to decrease syncope recurrence in adult patients aged < 60 years, with severe or recurrent cardioinhibitory syncope without prodromal symptoms, after proven failure of conventional therapies. Due to a paucity of data supporting efficacy in older individuals or for vasodepressor components, CNA in adult patients aged > 60 years or in the presence of a dominant vasodepressor should be considered investigational in severely symptomatic patients after proven failure of pharmacological and non-pharmacological therapies.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Faculty of Medicine, Yeditepe University Hospital, Istanbul 34742, Turkey
| | - Mina K. Chung
- Heart, Vascular, and Thoracic Institute, and Lerner Research Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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Kautzner J. Do we have a clear end-point for cardioneuroablation? J Cardiovasc Electrophysiol 2024; 35:651-653. [PMID: 38556798 DOI: 10.1111/jce.16265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/17/2024] [Indexed: 04/02/2024]
Affiliation(s)
- Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Chakraborty P, Chen PS, Gollob MH, Olshansky B, Po SS. Potential consequences of cardioneuroablation for vasovagal syncope: A call for appropriately designed, sham-controlled clinical trials. Heart Rhythm 2024; 21:464-470. [PMID: 38104955 DOI: 10.1016/j.hrthm.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
Cardioneuroablation (CNA) is being increasingly used to treat patients with vasovagal syncope (VVS). Bradycardia, in the cardioinhibitory subtype of VVS, results from transient parasympathetic overactivity leading to sinus bradycardia and/or atrioventricular block. By mitigating parasympathetic overactivity, CNA has been shown to improve VVS symptoms in clinical studies with relatively small sample sizes and short follow-up periods (<5 years) at selected centers. However, CNA may potentially tip the autonomic balance to a state of sympathovagal imbalance with attenuation of cardiac parasympathetic activity. A higher heart rate is associated with adverse cardiovascular events and increased mortality in healthy populations without cardiovascular diseases. Chronic sympathovagal imbalance may also affect the pathophysiology of spectra of cardiovascular disorders including atrial and ventricular arrhythmias. This review addresses potential long-term pathophysiological consequences of CNA for VVS.
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Affiliation(s)
- Praloy Chakraborty
- Heart Rhythm Institute, Section of Cardiovascular Diseases, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Peter Munk Cardiac Centre, Toronto General Hospital and University Health Network, Toronto, Ontario, Canada
| | - Peng-Sheng Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael H Gollob
- Peter Munk Cardiac Centre, Toronto General Hospital and University Health Network, Toronto, Ontario, Canada
| | - Brian Olshansky
- Department of Internal Medicine - Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Sunny S Po
- Heart Rhythm Institute, Section of Cardiovascular Diseases, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
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Aksu T, Tung R, De Potter T, Markman TM, Santangeli P, du Fay de Lavallaz J, Winterfield JR, Baykaner T, Alyesh D, Joza JE, Gopinathannair R, Badertscher P, Do DH, Hussein A, Osorio J, Dewland T, Perino A, Rodgers AJ, DeSimone C, Alfie A, Atwater BD, Singh D, Kumar K, Salcedo J, Bradfield JS, Upadhyay G, Sood N, Sharma PS, Gautam S, Kumar V, Forno ARJD, Woods CE, Rav-Acha M, Valeriano C, Kapur S, Enriquez A, Sundaram S, Glikson M, Gerstenfeld E, Piccini J, Tzou WS, Sauer W, d'Avila A, Shivkumar K, Huang HD. Cardioneuroablation for the management of patients with recurrent vasovagal syncope and symptomatic bradyarrhythmias: the CNA-FWRD Registry. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01789-9. [PMID: 38499825 DOI: 10.1007/s10840-024-01789-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/13/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Cardioneuroablation has been emerging as a potential treatment alternative in appropriately selected patients with cardioinhibitory vasovagal syncope (VVS) and functional AV block (AVB). However the majority of available evidence has been derived from retrospective cohort studies performed by experienced operators. METHODS The Cardioneuroablation for the Management of Patients with Recurrent Vasovagal Syncope and Symptomatic Bradyarrhythmias (CNA-FWRD) Registry is a multicenter prospective registry with cross-over design evaluating acute and long-term outcomes of VVS and AVB patients treated by conservative therapy and CNA. RESULTS The study is a prospective observational registry with cross-over design for analysis of outcomes between a control group (i.e., behavioral and medical therapy only) and intervention group (Cardioneuroablation). Primary and secondary outcomes will only be assessed after enrollment in the registry. The follow-up period will be 3 years after enrollment. CONCLUSIONS There remains a lack of prospective multicentered data for long-term outcomes comparing conservative therapy to radiofrequency CNA procedures particularly for key outcomes including recurrence of syncope, AV block, durable impact of disruption of the autonomic nervous system, and long-term complications after CNA. The CNA-FWRD registry has the potential to help fill this information gap.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, 34100, Istanbul, Turkey
| | - Roderick Tung
- The University of Arizona College of Medicine, Banner-University Medical Center, 755 E McDowell Road, Phoenix, AZ, 85006, USA
| | - Tom De Potter
- Department of Cardiology, OLV Hospital, Aalst, Belgium
| | - Timothy M Markman
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | - Tina Baykaner
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Daniel Alyesh
- South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80120, USA
| | | | | | | | - Duc H Do
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Ayman Hussein
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jose Osorio
- Arrhythmia Institute at Grandview, Birmingham, AL, USA
- Heart Rhythm Clinical Research Solutions, Birmingham, AL, USA
| | - Thomas Dewland
- Electrophysiology Section, Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Alexander Perino
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Albert J Rodgers
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | | | - Alberto Alfie
- Electrophysiology Section, Cardiology Division, Hospital Nacional Profesor Alejandro Posadas, Av. Illia y Marconi S/N 1684, El Palomar, Moron, Province of Buenos Aires, Argentina
| | | | - David Singh
- The Queens Medical Center, Honolulu, HI, USA
| | | | | | - Jason S Bradfield
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Gaurav Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC 9024, Chicago, IL, 60637, USA
| | - Nitesh Sood
- Arrhythmia Services, Southcoast Health, Fall River, MA, USA
| | - Parikshit S Sharma
- Department of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Sandeep Gautam
- Department of Cardiac Electrophysiology, University of Missouri-Columbia, Columbia, MO, USA
| | - Vineet Kumar
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Christopher E Woods
- Department of Cardiology, California Pacific Medical Center, San Francisco, CA, USA
| | - Moshe Rav-Acha
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, 9112102, Jerusalem, Israel
| | | | - Sunil Kapur
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andres Enriquez
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Sri Sundaram
- South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80120, USA
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, 9112102, Jerusalem, Israel
| | - Edward Gerstenfeld
- Electrophysiology Section, Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jonathan Piccini
- Duke Clinical Research Institute, Duke University Hospital, Durham, USA
| | - Wendy S Tzou
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Henry D Huang
- Department of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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Sikiric I, Jurisic Z, Breskovic T, Juric-Paic M, Berovic N, Kedzo J, Pletikosic I, Aksu T, Anic A. Focal pulsed field ablation for guiding and assessing the acute effect of cardioneuroablation. J Interv Card Electrophysiol 2024:10.1007/s10840-023-01716-4. [PMID: 38285282 DOI: 10.1007/s10840-023-01716-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/03/2023] [Indexed: 01/30/2024]
Affiliation(s)
- Ivan Sikiric
- Department of Cardiology, University Hospital Centre Split, Split, Croatia.
| | - Zrinka Jurisic
- Department of Cardiology, University Hospital Centre Split, Split, Croatia
| | - Toni Breskovic
- Department of Cardiology, University Hospital Centre Split, Split, Croatia
| | - Marina Juric-Paic
- Department of Cardiology, University Hospital Centre Split, Split, Croatia
| | - Nina Berovic
- Department of Cardiology, University Hospital Centre Split, Split, Croatia
| | - Josip Kedzo
- Department of Cardiology, University Hospital Centre Split, Split, Croatia
| | - Ivan Pletikosic
- Department of Cardiology, University Hospital Centre Split, Split, Croatia
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Ante Anic
- Department of Cardiology, University Hospital Centre Split, Split, Croatia
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Traykov V, Shalganov T. Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life. Curr Cardiol Rep 2023; 25:1839-1849. [PMID: 37982935 DOI: 10.1007/s11886-023-01997-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE OF REVIEW Vasovagal syncope (VVS) is a common entity causing transient loss of consciousness and affecting quality of life. Guideline-recommended therapy involves conservative measures and pacing in selected patients. Cardioneuroablation (CNA) targeting the ganglionated plexi in the heart has been shown to reduce excessive vagal excitation, which plays a major role in the pathophysiology of VVS and functional bradycardia. RECENT FINDINGS The introduction of CNA has fueled research into its value for the treatment of VVS. Multiple observational studies and one randomized trial have demonstrated the safety and efficacy of CNA and the positive impact on quality of life. This review describes the rationale and CNA procedural techniques and outcomes. Patient selection and future directions have also been described. Cardioneuroablation is a promising treatment for patients with recurrent VVS and functional bradycardia. Further large-scale randomized studies are needed to further verify the safety and efficacy of this approach.
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Affiliation(s)
- Vassil Traykov
- Department of Invasive Electrophysiology, Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, 1407 N. Vaptzarov blvd 51B, Sofia, Bulgaria.
| | - Tchavdar Shalganov
- Department of Electrophysiology, Clinic of Cardiology, National Heart Hospital, Sofia, Bulgaria
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Xu X, He S, Liu Q, Liu R, Zhang L, Chen W, Yin Y, Lu T. Cardioneuroablation for successful treatment of symptomatic bradycardia in a 12-year-old child after a 6-month follow-up. Front Cardiovasc Med 2023; 10:1290482. [PMID: 38099231 PMCID: PMC10720979 DOI: 10.3389/fcvm.2023.1290482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/07/2023] [Indexed: 12/17/2023] Open
Abstract
Background Cardioneuroablation (CNA) is recognized as a promising therapeutic option for adults with severe symptomatic bradycardia caused by excessive vagal tone. However, no pediatric cases have been reported to date. Therefore, the aim of this study is to evaluate the feasibility and efficacy of CNA in children. Methods A 12-year-old male patient was hospitalized with symptoms of fatigue, palpitations, and syncope for more than 2 months, and was definitively diagnosed with functional sinoatrial node dysfunction by using a 12-lead electrocardiogram, 24-h Holter monitoring, loading dose of atropine test (0.04 mg/kg), and treadmill exercise test. Simultaneously, whole-exome sequencing was performed on the child and his core family members. After completing the preoperative examination and signing the informed consent form, the child underwent CNA therapy. Results First, the electroanatomic structures of both atria were mapped out by using the Carto 3 system, according to the protocol of purely anatomy-guided and local fractionated intracardiac electrogram-guided CNA methods. Then, the local fractionated intracardiac electrograms of each cardiac ganglionated plexus (GP), including the GP between the aortic root and the medial wall of the superior vena cava, the GP between the posterior wall of the coronary sinus ostium and the left atrium, the GP between the anterior antrum of the right superior pulmonary vein and the superior vena cava, the GP in the superolateral area around the root of the left superior pulmonary vein, the GP around the root of the right inferior pulmonary vein, and the GP around the root of the left inferior pulmonary vein, were used as targets for ablation at a power of 30 W with an ablation index of 350-400. At a 6-month follow-up, the child's heart rhythm saw a complete restoration to sinus rhythm and clinical symptoms disappeared. Conclusion The first application of CNA in a child with symptomatic sinus bradycardia was achieved with better clinical outcomes. CNA can be carried out cautiously in children under suitable indications.
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Affiliation(s)
- Xin Xu
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Shuang He
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Qian Liu
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ruixi Liu
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Lei Zhang
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Weijie Chen
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tiewei Lu
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Letsas KP, Saplaouras A, Mililis P, Dragasis S, Patsiotis IG, Kariki O, Kadda O, Katsa G, Bazoukis G, Efremidis M. Cardioneuroablation for neurally-mediated syncope: Initial experience. Hellenic J Cardiol 2023; 74:87-89. [PMID: 37647986 DOI: 10.1016/j.hjc.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/14/2023] [Accepted: 08/24/2023] [Indexed: 09/01/2023] Open
Abstract
Cardioneuroablation is an emerging alternative therapeutic modality for young patients with severe neurally-mediated syncope. We present two images of cardioneuroablation performed in young patients who suffered from recurrent neurally-mediated syncope with asystole and functional atrioventricular block. The patients remain syncope-free during follow-ups.
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Affiliation(s)
- Konstantinos P Letsas
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece. https://twitter.com/K_Letsas
| | | | - Panagiotis Mililis
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stylianos Dragasis
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Ilias G Patsiotis
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Ourania Kariki
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Olga Kadda
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Georgia Katsa
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - George Bazoukis
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Michael Efremidis
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
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Olshansky B, Ricci F, Fedorowski A. Importance of resting heart rate. Trends Cardiovasc Med 2023; 33:502-515. [PMID: 35623552 DOI: 10.1016/j.tcm.2022.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022]
Abstract
Resting heart rate is a determinant of cardiac output and physiological homeostasis. Although a simple, but critical, parameter, this vital sign predicts adverse outcomes, including mortality, and development of diseases in otherwise normal and healthy individuals. Temporal changes in heart rate can have valuable predictive capabilities. Heart rate can reflect disease severity in patients with various medical conditions. While heart rate represents a compilation of physiological inputs, including sympathetic and parasympathetic tone, aside from the underlying intrinsic sinus rate, how resting heart rate affects outcomes is uncertain. Mechanisms relating resting heart rate to outcomes may be disease-dependent but why resting heart rate in otherwise healthy, normal individuals affects outcomes remains obscure. For specific conditions, physiologically appropriate heart rate reductions may improve outcomes. However, to date, in the normal population, evidence that interventions aimed at reducing heart rate improves outcomes remains undefined. Emerging data suggest that reduction in heart rate via vagal activation and/or sympathetic inhibition is propitious.
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Affiliation(s)
- Brian Olshansky
- Division of Cardiology, Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA.
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, Via dei Vestini, 33, Chieti 66100, Italy; Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden; Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, 171 76 Stockholm, Sweden
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Yarkoni M, Rehman WU, Bajwa A, Yarkoni A, Rehman AU. Ganglionated Plexus Ablation Procedures to Treat Vasovagal Syncope. Int J Mol Sci 2023; 24:13264. [PMID: 37686062 PMCID: PMC10487499 DOI: 10.3390/ijms241713264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Vasovagal syncope (VVS) refers to a heterogeneous group of conditions whereby the cardiovascular reflexes normally controlling the circulation are interrupted irregularly in response to a trigger, resulting in vasodilation, bradycardia, or both. VVS affects one-third of the population at least once in their lifetime or by the age of 60, reduces the quality of life, and may cause disability affecting certain routines. It poses a considerable economic burden on society, and, despite its prevalence, there is currently no proven pharmacological treatment for preventing VVS. The novel procedure of ganglionated plexus (GP) ablation has emerged rapidly in the past two decades, and has been proven successful in treating syncope. Several parameters influence the success rate of GP ablation, including specific ablation sites, localization and surgical techniques, method of access, and the integration of other interventions. This review aims to provide an overview of the existing literature on the physiological aspects and clinical effectiveness of GP ablation in the treatment of VVS. Specifically, we explore the association between GPs and VVS and examine the impact of GP ablation procedures as reported in human clinical trials. Our objective is to shed light on the therapeutic significance of GP ablation in eliminating VVS and restoring normal sinus rhythm, particularly among young adults affected by this condition.
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Affiliation(s)
- Merav Yarkoni
- Heart and Vascular Institute, United Health Services, Johnson City, NY 13790, USA; (W.u.R.); (A.B.); (A.Y.); (A.u.R.)
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Li L, Po S, Yao Y. Cardioneuroablation for Treating Vasovagal Syncope: Current Status and Future Directions. Arrhythm Electrophysiol Rev 2023; 12:e18. [PMID: 37457436 PMCID: PMC10345939 DOI: 10.15420/aer.2023.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/05/2023] [Indexed: 07/18/2023] Open
Abstract
Syncope is defined by transient and spontaneous loss of consciousness with rapid recovery. Vasovagal syncope (VVS) is the most common form of syncope and is strongly associated with hypervagotonia. There is, however, a lack of effective therapies for VVS. Cardioneuroablation (CNA) is an emerging and promising intervention for VVS with favourable outcomes. CNA has been shown to suppress excessive excitation of vagal activity through ablating the cardiac ganglionated plexi. CNA in the management of VVS requires more structured and comprehensive studies and several issues concerning patient selection, selection of ablation targets, ablation endpoints and the long-term effect of CNA are yet to be determined. This review describes its clinical applications and future directions based on current research data and the authors' own experiences.
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Affiliation(s)
- Le Li
- Cardiac Arrhythmia Center, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Sunny Po
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, US
| | - Yan Yao
- Cardiac Arrhythmia Center, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
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Brignole M, Aksu T, Calò L, Debruyne P, Deharo JC, Fanciulli A, Fedorowski A, Kulakowski P, Morillo C, Moya A, Olshansky B, Piotrowski R, Stec S, Wichterle D. Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope. Europace 2023; 25:euad033. [PMID: 37021351 PMCID: PMC10227654 DOI: 10.1093/europace/euad033] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 04/07/2023] Open
Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Piazzale Brescia 2, 20149 Milano, Italy
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, 34755 Ataşehir/İstanbul, Turkey
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, 00169 Roma, Italy
| | | | - Jean Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, France and Aix Marseille Université, C2VN, 13005 Marseille, France
| | - Alessandra Fanciulli
- Department of Neurology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine, Karolinska Institute, 17177 Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 20502 Malmö, Sweden
| | - Piotr Kulakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Carlos Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, T2N 1N4 Calgary, AB, Canada
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, 08028 Barcelona, Spain
| | - Brian Olshansky
- Division of Cardiology, University of Iowa Hospitals, 52242 Iowa City, IA, USA
| | - Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Sebastian Stec
- Division of Electrophysiology, Cardioneuroablation, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), 11336 Prague, Czechia
- Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, 11336 Prague, Czechia
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15
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Soni B, Gupta D, Gopinathannair R. Quality of life improvement following cardioneuroablation for vasovagal syncope: expected or too early to say? J Interv Card Electrophysiol 2023:10.1007/s10840-023-01489-w. [PMID: 36705871 DOI: 10.1007/s10840-023-01489-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/17/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Bosky Soni
- Department of Medicine, University of Pittsburgh School of Medicine, Harrisburg, PA, USA
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
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Piotrowski R, Baran J, Sikorska A, Krynski T, Kulakowski P. Cardioneuroablation for Reflex Syncope: Efficacy and Effects on Autonomic Cardiac Regulation-A Prospective Randomized Trial. JACC Clin Electrophysiol 2023; 9:85-95. [PMID: 36114133 DOI: 10.1016/j.jacep.2022.08.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/05/2022] [Accepted: 08/15/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Treatment of cardioinhibitory vasovagal syncope (VVS) is difficult. Recently, cardioneuroablation (CNA) has emerged as a new therapeutic option. OBJECTIVES This study sought to assess the effects of CNA on syncope recurrences in patients with VVS. METHODS This study was a prospective, open, randomized, controlled, investigator-initiated trial comparing CNA versus optimal nonpharmacologic therapy in patients with cardioinhibitory VVS. Patients were included if they had documented symptomatic cardioinhibitory or mixed VVS and positive atropine test. CNA was performed using radiofrequency ablation of the ganglionated plexi from the left and right atria. Follow-up lasted 2 years. Primary endpoint was time to first syncope recurrence. Secondary endpoints included changes in sinus rhythm and heart rate variability measured in Holter electrocardiography at baseline and 3, 12, and 24 months after CNA, as well as changes in quality of life at baseline and after completion of follow-up. RESULTS A total of 48 patients (17 male, mean age 38 ± 10 years, 24 in CNA group, 24 in control group) entered the study. The primary endpoint occurred in 2 patients (8%) from the CNA group versus 13 control patients (54%) (P = 0.0004). After CNA the mean sinus rhythm at 24-hour Holter electrocardiography was significantly faster and heart rate variability parameters significantly changed toward parasympathetic withdrawal compared with baseline values. Quality of life significantly improved in the CNA group (30 ± 10 points vs 10 ± 7 points; P = 0.0001), whereas it remained stable in control patients (31 ± 10 points vs 30 ± 10 points; P = 0.5501). CONCLUSIONS This is the first randomized study documenting efficacy of CNA in patients with cardioinhibitory VVS. Larger studies are needed to confirm these findings. (Cardioneuroablation for Reflex Syncope [ROMAN]; NCT03903744).
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Affiliation(s)
- Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland.
| | - Jakub Baran
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Agnieszka Sikorska
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Tomasz Krynski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Piotr Kulakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
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Aksu T, Skeete JR, Huang HH. Ganglionic Plexus Ablation: A Step-by-step Guide for Electrophysiologists and Review of Modalities for Neuromodulation for the Management of Atrial Fibrillation. Arrhythm Electrophysiol Rev 2023; 12:e02. [PMID: 36845167 PMCID: PMC9945432 DOI: 10.15420/aer.2022.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/29/2022] [Indexed: 02/01/2023] Open
Abstract
As the most common sustained arrhythmia, AF is a complex clinical entity which remains a difficult condition to durably treat in the majority of patients. Over the past few decades, the management of AF has focused mainly on pulmonary vein triggers for its initiation and perpetuation. It is well known that the autonomic nervous system (ANS) has a significant role in the milieu predisposing to the triggers, perpetuators and substrate for AF. Neuromodulation of ANS - ganglionated plexus ablation, vein of Marshall ethanol infusion, transcutaneous tragal stimulation, renal nerve denervation, stellate ganglion block and baroreceptor stimulation - constitute an emerging therapeutic approach for AF. The purpose of this review is to summarise and critically appraise the currently available evidence for neuromodulation modalities in AF.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | | | - Henry H Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, US
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Gopinathannair R, Olshansky B, Turagam MK, Gautam S, Futyma P, Akella K, Tanboga HI, Bozyel S, Yalin K, Padmanabhan D, Shenthar J, Lakkireddy D, Aksu T. Permanent pacing versus cardioneuroablation for cardioinhibitory vasovagal syncope. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01456-x. [PMID: 36562915 DOI: 10.1007/s10840-022-01456-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND We compared the efficacy and safety of cardioneuroablation (CNA) vs. permanent pacing (PM) for recurrent cardioinhibitory vasovagal syncope (CI-VVS). METHODS One hundred sixty-two patients (CNA = 61, PM = 101), age 36 + 11 years) with syncope frequency of 6.7 ± 3.9/year were included in this multicenter study. All patients with CNA were provided by a single center, while patients with PM were provided by 4 other centers. In the CNA arm, an electroanatomic mapping guided approach was used to detect and ablate ganglionated plexus sites. Dual chamber rate drop response (RDR) or close loop stimulation (CLS) transvenous and leadless pacemakers were implanted using standard technique. The primary endpoint was freedom from syncope. RESULTS Of 101 patients in the PM group, 39 received dual-chamber pacemaker implants with the CLS algorithm, 38 received dual-chamber pacemakers with the RDR algorithm, and 24 received a leadless pacemaker. At 1-year follow-up, 97% and 89% in the CNA and PM group met the primary endpoint (adjusted HR = 0.27, 95% CI 0.06-1.24, p = 0.09). No significant differences in adverse events were noted between groups. There was no significant association between age (HR:1.01, 95% CI 0.96-1.06, p = 0.655), sex (HR:1.15, 95% CI 0.38-3.51, p = 0.809), and syncope frequency in the past year (HR:1.10, 95% CI 0.97-1.25, p = 0.122) and the primary outcome in univariable analyses. CONCLUSIONS After adjustment for patient characteristics, the medium-term syncope recurrence risk of CI-VVS patients who underwent CNA was similar to that of a population of patients undergoing pacemaker implantation with a similar safety profile.
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Affiliation(s)
- Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute and Research Foundation, 5100 W 110Th St, Ste 200, Overland Park, KS, 66211, USA.
| | - Brian Olshansky
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mohit K Turagam
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sandeep Gautam
- Division of Cardiovascular Medicine, University of Missouri-Columbia, Columbia, MO, USA
| | - Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszow, Poland
| | | | - Halil Ibrahim Tanboga
- Department of Cardiology, Nisantasi University & Hisar Intercontinental Hospital, Istanbul, Turkey
| | - Serdar Bozyel
- University of Health Sciences, Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey
| | - Kivanc Yalin
- Department of Cardiology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Deepak Padmanabhan
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Jayaprakash Shenthar
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, 5100 W 110Th St, Ste 200, Overland Park, KS, 66211, USA
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Vandenberk B, Lei LY, Ballantyne B, Vickers D, Liang Z, Sheldon RS, Chew DS, Aksu T, Raj SR, Morillo CA. Cardioneuroablation for vasovagal syncope: A systematic review and meta-analysis. Heart Rhythm 2022; 19:1804-1812. [PMID: 35716859 DOI: 10.1016/j.hrthm.2022.06.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/09/2022] [Accepted: 06/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cardioneuroablation (CNA) has emerged as promising therapy for patients with refractory vasovagal syncope (VVS). OBJECTIVE The purpose of this study was to provide a freedom from syncope estimate for CNA, including subgroup analysis by method and target of ablation. METHODS A systematic search was performed in MEDLINE and EMBASE according to the PRISMA guidelines until February 14, 2022. Observational studies and clinical trials reporting freedom from syncope were included. Meta-analysis was performed with a random-effects model. RESULTS A total of 465 patients were included across 14 studies (mean age 39.8 ± 4.0 year; 53.5% female). Different techniques were used to guide CNA: 50 patients (10.8%) by mapping fractionated electrograms, 73 (15.7%) with the spectral method, 210 (45.2%) with high-frequency stimulation, 73 (15.7%) with a purely anatomically guided method, and 59 (12.6%) with a combination. The target was biatrial in 168 patients (36.1%), left atrium only in 259 (55.7%), and right atrium only in 38 (8.2%). The freedom from syncope was 91.9% (95% confidence interval [CI] 88.1%-94.6%; I2 = 6.9%; P = .376). CNA limited to right atrial ablation was associated with a significant lower freedom from syncope (81.5%; 95% CI 51.9%-94.7%; P <.0001) vs left atrial ablation only (94.0%; 95% CI 88.6%--6.9%) and biatrial ablation (92.7%; 95% CI 86.8%-96.1%). Subgroup analysis according to the technique used to identify ganglionated plexi did not show any significant difference in freedom from syncope (P = .206). CONCLUSION This meta-analysis suggests a high freedom from syncope after CNA in VVS. Well-designed, double-blind, multicenter, sham-controlled randomized clinical trials are needed to provide evidence for future guidelines.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
| | - Lucy Y Lei
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brennan Ballantyne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David Vickers
- Mozell Core Analysis Lab, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zhiying Liang
- Mozell Core Analysis Lab, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Tolga Aksu
- Yeditepe University Hospital, Department of Cardiology, Istanbul, Turkey
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
INTRODUCTION Cardioneuroablation is increasingly being utilized to improve outcomes in patients with vagally mediated bradyarrhythmias. However, there are still controversial issues in the field including patient selection, safety and efficacy, and procedural end-points. AREAS COVERED In this review, the current role of cardioneuroablation is summarized, and controversial issues related to the modality are discussed. EXPERT OPINION According to small open-label cohort studies, overall freedom from syncope recurrence was higher than 90% after cardioneuroablation in patients with vasovagal syncope (VVS). Use of the electrogram-based strategy or high-frequency stimulation demonstrate similar success rate except in procedures limited to the right atrium. Based on a recently published randomized controlled trial and metanalysis, it may be possible now to make a strong recommendation for cardioneuroablation in patients <40 years of age, and those with the cardioinhibitory or mixed type of VVS who continue to experience frequent and/or burdensome syncope recurrences. Considering patients with VVS are prone to significant placebo/expectation effect, sham-controlled trials may help to quantify the placebo effect. In well-selected patients with functional atrioventricular block and sinus bradycardia, may result in encouraging medium-term outcomes. However, functional bradycardia is identified in a minority of patients presenting with high-grade atrioventricular block or sinus node dysfunction.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Asad Khan
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Henry Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
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Aksu T, Mutluer FO, Tanboga HI, Gupta D. Pericarditis following left atrial ablation. J Cardiovasc Electrophysiol 2022; 33:2394-2397. [PMID: 36073138 DOI: 10.1111/jce.15672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/02/2022] [Accepted: 09/01/2022] [Indexed: 11/28/2022]
Abstract
We aimed to evaluate the incidence of acute pericarditis following cardioneuroablation (CNA) and to compare this with patients undergoing left atrial (LA) radiofrequency ablation for atrial fibrillation (AF). This is a single-center prospective study. During the study period, CNA for vasovagal syncope was performed in 42 patients, pulmonary vein isolation (PVI) for paroxysmal AF in 46 patients, and posterior wall isolation (PWI) in addition to PVI for persistent AF in 22 patients. Pericarditis was reported by 18 (16.4%) patients overall: 1 (2.4%) patient in CNA group, 8 (17.4%) patients in PVI group, and 9 (40.9%) patients in PWI (p<0.001). On univariable logistic regression analysis, CNA was associated with a lower risk of pericarditis (odds ratio 0.11, 95% CI 0.01-0.97), while ablation of PWI plus PVI was associated with a higher risk of pericarditis compared with PVI (odds ratio 3.29, 95% CI 1.05-10.3). This study shows that pericarditis is extremely uncommon following CNA and is significantly less frequent than following AF ablation. This difference is likely related to the much lower amount of LA ablation necessary in this group. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Ferit Onur Mutluer
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Halil Ibrahim Tanboga
- Department of Cardiology, Faculty of Medicine, Nisantası University, Istanbul, Turkey
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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22
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Chen W, Liu Z, Xiao P, Xu Y, Li D, Xiong Q, Zou L, Qin F, Tao X, Chen J, Lan X, Du H, Yin Y, Ling Z. Extracardiac Vagal Stimulation-Assisted Cardioneuroablation: Dynamically Evaluating the Impact of Sequential Ganglionated Plexus Ablation on Vagal Control of SAN and AVN in Patients with Sinoatrial Node Dysfunction. J Cardiovasc Dev Dis 2022; 9:jcdd9060188. [PMID: 35735817 PMCID: PMC9225033 DOI: 10.3390/jcdd9060188] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/05/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022] Open
Abstract
Cardioneuroablation (CNA) is proposed as a promising therapy for patients with sinoatrial node dysfunction (SND) that is mediated by excessive vagal tone. However, a series of urgent questions about CNA remain unanswered. From December 2020 to March 2022, six patients with symptomatic SND who underwent CNA were summarized in this report. Sequential CNA targeting Ao-SVC GP, PMLGP, RAGP, and LSGP was performed in patients, guided by fractionated intracardiac electrograms and dynamically evaluated by extracardiac vagal stimulation (ECVS). The results showed that Ao-SVC GP ablation led to a significant increase in heart rate (HR) and the elimination of sinus arrest evoked by ECVS, while the vagal responses of atrial ventricular block were eliminated by the ablation of PMLGP and LSGP. Post-procedure HR increased up to 64-86% of the maximum HR of an atropine test at baseline. The median HR from Holter monitoring increased from 52.8 ± 2.1 bpm at baseline to 73.0 ± 10.4 bpm after the procedure (p = 0.012) and to 71.3 ± 10.1 bpm at the six-month follow-up (p = 0.011). Bradycardia-related symptoms disappeared in all patients at the six-month follow-up. This case series reveals the feasibility of using the ECVS-assisted sequential CNA technique and indicates the critical role of ECVS in dynamically evaluating the impact of sequential CNA on the vagal control of SAN and AVN.
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23
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Cardioneuroablation for vagally mediated bradyarrhythmias: Are we there yet? Heart Rhythm 2022; 19:1253-1254. [PMID: 35597424 DOI: 10.1016/j.hrthm.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/24/2022]
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24
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Linz D, Stavrakis S. Cardioneuroablation for vasovagal syncope: How to move beyond "learning by burning"? J Interv Card Electrophysiol 2022:10.1007/s10840-022-01232-x. [PMID: 35486301 DOI: 10.1007/s10840-022-01232-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, 6202 AZ, Maastricht, The Netherlands.
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, USA
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