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Joza J, Gustavo Bravosi da Rosa L, Alturki A, Anglesio V, Sanchez-Somonte P, Poletaev V, Bernier M, Verma A, Essebag V. Cardioneuroablation as a strategy to prevent pacemaker implantation in young patients with vasovagal syncope. IJC HEART & VASCULATURE 2024; 51:101360. [PMID: 38379634 PMCID: PMC10877404 DOI: 10.1016/j.ijcha.2024.101360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
Background Cardioneuroablation (CNA) is an ablation technique that targets epicardial ganglionic plexi to reduce syncope burden and avoid pacemaker implantation in patients with cardioinhibitory vasovagal syncope (VVS). This study aims to demonstrate feasibility and safety of CNA in high-risk refractory VVS patients using continuous monitoring with an implantable loop recorder (ILR). Methods Data was collected prospectively for patients undergoing CNA. Patients were required to have recurrent syncope with documented asystole, refractory to conservative measures. Ganglionic plexi (GPs) were identified by fragmented signals and high frequency stimulation (HFS). Ablation was performed until loss of positive response to HFS, Wenckebach cycle shortening was achieved, or an increase in sinus rate of > 20 bpm. Follow-up was performed through remote and clinic follow-up of their ILRs. Results Between December 2020 and July 2023 six patients (mean age 29 ± 3, 67 % female)underwent CNA. The baseline heart rate and Wenckebach cycle length was 63.2 ± 15 bpm and 582 ms before and 91 ± 5 bpm and 358 ms after ablation respectively. During a median follow-up of 13.4 months, 3/5 patients had no further syncopal episodes, 1 had a recurrence, underwent repeat CNA with no further episodes at 1 year, and 1 had 5 syncopal events, which was a dramatic reduction from nearly daily episodes pre-CNA. There were no procedure related complications. Conclusions A dramatic reduction in documented pauses and syncope burden was noted post CNA. Appropriate patient selection with rigorous objective follow-up in an experienced center is necessary. Larger studies are required to confirm these findings.
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Affiliation(s)
| | | | - Ahmed Alturki
- McGill University Health Center, Montreal, Quebec, Canada
| | | | | | | | - Martin Bernier
- McGill University Health Center, Montreal, Quebec, Canada
| | - Atul Verma
- McGill University Health Center, Montreal, Quebec, Canada
| | - Vidal Essebag
- McGill University Health Center, Montreal, Quebec, Canada
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
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Aksu T, Po SS. How to perform cardioneuroablation for vasovagal syncope and functional bradycardia. Heart Rhythm 2024; 21:100-105. [PMID: 37776935 DOI: 10.1016/j.hrthm.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/21/2023] [Accepted: 09/21/2023] [Indexed: 10/02/2023]
Affiliation(s)
- Tolga Aksu
- Faculty of Medicine, Yeditepe University, Istanbul, Turkey.
| | - Sunny S Po
- University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
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3
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Cai S, Zheng L, Yao Y. Cardioneuroablation for vasovagal syncope alters head-up tilt test response and reduces cardiac deceleration capacity. HeartRhythm Case Rep 2023; 9:773-778. [PMID: 38047189 PMCID: PMC10691945 DOI: 10.1016/j.hrcr.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Simin Cai
- Center of Arrhythmia, Huazhong Fuwai Hospital, Heart Center, Henan Provincial People’s Hospital, The People’s Hospital of Zhengzhou University, Henan, China
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihui Zheng
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Stec S, Wileczek A, Reichert A, Śledź J, Kosior J, Jagielski D, Polewczyk A, Zając M, Kutarski A, Karbarz D, Zyśko D, Nowarski Ł, Stodółkiewicz-Nowarska E. Shared Decision Making and Cardioneuroablation Allow Discontinuation of Permanent Pacing in Patients with Vagally Mediated Bradycardia. J Cardiovasc Dev Dis 2023; 10:392. [PMID: 37754821 PMCID: PMC10532162 DOI: 10.3390/jcdd10090392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Safe discontinuation of pacemaker therapy for vagally mediated bradycardia is a dilemma. The aim of the study was to present the outcomes of a proposed diagnostic and therapeutic process aimed at discontinuing or not restoring pacemaker therapy (PPM) in patients with vagally mediated bradycardia. METHODS The study group consisted of two subgroups of patients with suspected vagally mediated bradycardia who were considered to have PPM discontinued or not to restore their PPM if cardioneuroablation (CNA) would successfully treat their bradycardia. A group of 3 patients had just their pacemaker explanted but reimplantation was suggested, and 17 patients had preexisting pacemakers implanted. An invasive electrophysiology study was performed. If EPS was negative, extracardiac vagal nerve stimulation (ECVS) was performed. Then, patients with positive ECVS received CNA. Patients with an implanted pacemaker had it programmed to pace at the lowest possible rate. After the observational period and control EPS including ECVS, redo-CNA was performed if pauses were induced. The decision to explant the pacemaker was obtained based on shared decision making (SDM). RESULTS After initial clinical and electrophysiological evaluation, 17 patients were deemed eligible for CNA (which was then performed). During the observational period after the initial CNA, all 17 patients were clinically asymptomatic. The subsequent invasive evaluation with ECVS resulted in pause induction in seven (41%) patients, and these patients underwent redo-CNA. Then, SDM resulted in the discontinuation of pacemaker therapy or a decision to not perform pacemaker reimplantation in all the patients after CAN. The pacemaker was explanted in 12 patients post-CNA, while in 2 patients explantation was postponed. During a median follow-up of 18 (IQR: 8-22) months, recurrent syncope did not occur in the CNA recipients. CONCLUSIONS Pacemaker therapy in patients with vagally mediated bradycardia could be discontinued safely after CNA.
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Affiliation(s)
- Sebastian Stec
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Antoni Wileczek
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Agnieszka Reichert
- Department of Invasive Cardiology, County Specialistic Hospital, 37-450 Stalowa Wola, Poland
| | - Janusz Śledź
- El-Medica, EP-NETWORK, 26-110 Skarzysko-Kamienna, Poland
| | - Jarosław Kosior
- Department of Cardiology, Masovian Specialist Hospital, 26-617 Radom, Poland
| | - Dariusz Jagielski
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, 50-981 Wroclaw, Poland
- Faculty of Medicine, Wrocław University of Science and Technology, 50-370 Wroclaw, Poland
| | - Anna Polewczyk
- Department of Physiology, Pathophysiology and Clinical Immunology, Institute of Medical Sciences, Jan Kochanowski University, 25-369 Kielce, Poland
- Department of Cardiac Surgery, Świętokrzyskie Center of Cardiology, 25-736 Kielce, Poland
| | - Magdalena Zając
- Department of Special Pedagogy and Speech Therapy, Kazimierz Wielki University, 85-064 Bydgoszcz, Poland
| | - Andrzej Kutarski
- Department of Cardiology, Medical University, 20-059 Lublin, Poland
| | | | - Dorota Zyśko
- Department of Emergency Medicine, Wrocław Medical University, 50-367 Wroclaw, Poland
| | - Łukasz Nowarski
- Vascular Surgery Department, The Brothers of Saint John of God Hospital, 31-061 Krakow, Poland
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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: 27] [Impact Index Per Article: 27.0] [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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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: 43] [Impact Index Per Article: 43.0] [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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7
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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: 36] [Impact Index Per Article: 18.0] [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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Minguito-Carazo C, Martínez-Sande JL, González-Melchor L, González-Ferrero T, González-Juanatey JR, Rodríguez-Mañero M. Changes in autonomic response during cardioneuroablation in an elderly patient with carotid sinus syndrome. HeartRhythm Case Rep 2022; 8:781-785. [PMID: 36618591 PMCID: PMC9811009 DOI: 10.1016/j.hrcr.2022.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Carlos Minguito-Carazo
- Arrhythmia Unit, Cardiology Department, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain,Address reprint requests and correspondence: Dr Carlos Minguito Carazo, University Hospital of Santiago de Compostela, A Choupana St, Santiago de Compostela, 15706, A Coruña, Spain.
| | - José Luis Martínez-Sande
- Arrhythmia Unit, Cardiology Department, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain,Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Laila González-Melchor
- Arrhythmia Unit, Cardiology Department, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Teba González-Ferrero
- Arrhythmia Unit, Cardiology Department, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Jose Ramón González-Juanatey
- Arrhythmia Unit, Cardiology Department, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain,Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Moisés Rodríguez-Mañero
- Arrhythmia Unit, Cardiology Department, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain,Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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Lisboa da Silva RMF, Oliveira PML, Tonelli HAF, Alves Meira ZM, Mota CDCC. Neurally Mediated Syncope in Children and Adolescents: An Updated Narrative Review. Open Cardiovasc Med J 2022. [DOI: 10.2174/18741924-v16-e2205110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Syncope presents a proportion of up to 25% among children and adolescents and accounts for 0.9% of emergency room visits. Its most frequent aetiology is neurally mediated syncope, which includes vasovagal syncope and orthostatic hypotension. Up to 70% of the paediatric population with reflex syncope is female. There are usually precipitating factors and prodromes. This mini-review will discuss the particularities of the clinical presentation, diagnosis, modified Calgary score, indications and accuracy of the head-up tilt test, classification, and pathophysiology in four sequential phases. Prognostic data and the non-pharmacological and pharmacological approaches will also be reviewed and differences regarding reflex syncope in adults will be discussed.
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10
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Ultrasound-guided extra-cardiac vagal stimulation – new approach for visualization of vagus nerve during cardioneuroablation. Heart Rhythm 2022; 19:1247-1252. [DOI: 10.1016/j.hrthm.2022.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/31/2022] [Accepted: 04/16/2022] [Indexed: 11/21/2022]
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