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Lemery R. Historical Perspective of the Cardiac Autonomic Nervous System. Card Electrophysiol Clin 2024; 16:219-227. [PMID: 39084715 DOI: 10.1016/j.ccep.2024.01.001] [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] [Indexed: 08/02/2024]
Abstract
The contemporary history of the cardiac autonomic nervous system includes early descriptions of neuroanatomy in the 19th century, followed by an understanding of the physiologic determinants of neurocardiology in the 20th century. Neurology and cardiology preceded the arrival of clinical cardiac electrophysiology, a specialized field in medicine devoted to the diagnosis and treatment of cardiac arrhythmias. The rapid growth in pharmacology, ablation, pacing and defibrillation, associated with significant technological breakthroughs, have resulted in new opportunities for neuromodulation in the 21st century. Small changes in autonomic tone can potentially provide important therapeutic benefits for patients with cardiac and arrhythmia disorders.
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Affiliation(s)
- Robert Lemery
- Cardiology and Medical History, 835 René-Lévesque E, Montréal, Québec, Canada, H2L 4V5.
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2
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Alyesh D, Palmeri N, Jones B, Hanslip S, Choe W, Sundaram S. Cardioneural ablation-the first case series without the use of fluoroscopy. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01881-0. [PMID: 39090327 DOI: 10.1007/s10840-024-01881-0] [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: 05/09/2024] [Accepted: 07/16/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Cardioneural ablation (CNA) and fluoroless ablation (FA) are emerging procedures and movements in contemporary in electrophysiology. Ablation of ganglionated plexus (GP) inputs in the atrium has been successfully targeted as a treatment for symptomatic bradyarrhythmias due to increased parasympathetic tone. As most of these patients are young, avoidance of ionizing radiation is of critical importance to limit potential long term deleterious effects. With widespread use of 3D electroanatomic mapping systems and advanced intracardiac echo (ICE) imaging, fluoroless ablation has become more widely adopted. However, fluoroless CNA has not been widely performed. The objective of this study is to demonstrate that CNA can be done safely and effectively without fluoroscopy. METHODS At a single-center, consecutive patients undergoing CNA with a fluoroless approach are described. GP mapping and ablation were performed in both atria. From the right atrium (RA), the right atrium-superior vena cava (RA-SVC GP), the posteromedial ganglionated plexus (PMLGP), which can be accessed from the right atrium-coronary sinus ostium, and the Vein of Marshall GP (VOM-GP) were evaluated. From the left atrium (LA), the superior left atrial ganglionated plexus (LSGP), the left inferior ganglionated plexus (LIGP), the right anterior ganglionated plexus (RAGP), and the right inferior ganglionated plexus (RIGP) were targeted. RESULTS Over the study period, beginning on January 31, 2021, 30 consecutive subjects (15 females/15 males) aged 42.9 ± 13.6 years underwent GP ablation. The average subject had 9.5 (± 9.2) episodes of syncope prior to ablation. The average CHADS2-VA2SC score was zero. The average LVEF was 64.8% (± 4.9). Two of the subjects had concomitant ablations, six failed prior medical therapy, and one had a prior pacemaker placed. All of the procedures were done without fluoroscopy. The average follow-up was 604 (± 366) days. There were 8 patients that did not improve symptomatically postfirst ablation. Four of the eight underwent repeat ablation and have subsequently improved. 26/30 patients symptomatically improved after the 1st or 2nd ablation. There were no complications noted. CONCLUSION In comparison to the traditional CNA with fluoroscopy, this proof of concept study reveals fluoroless GP ablation can be performed safely. In addition, the durability and success rate are comparable to other studies of CNA. Given the young age of the cohort and the longitudinal risks of ionizing radiation, fluoroless CNA is a feasible procedure for this patient population.
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Affiliation(s)
- Daniel Alyesh
- Cardiac Electrophysiology, South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80111, USA
| | - Nicholas Palmeri
- Cardiac Electrophysiology, South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80111, USA
| | - Benjamin Jones
- Abbott Laboratories, 100 Abbott Park Road, Abbott Park, North Chicago, IL, 60064, USA
| | - Samantha Hanslip
- Abbott Laboratories, 100 Abbott Park Road, Abbott Park, North Chicago, IL, 60064, USA
| | - William Choe
- Cardiac Electrophysiology, South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80111, USA
| | - Sri Sundaram
- Cardiac Electrophysiology, South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80111, USA.
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Marrese A, Persico R, Parlato E, Faccenda D, Salucci A, Comparone G, Pergola V, Ammirati G, Addeo L, Fonderico C, Cocchiara L, Volpe A, Visconti P, Rapacciuolo A, Strisciuglio T. Cardioneuroablation: the known and the unknown. Front Cardiovasc Med 2024; 11:1412195. [PMID: 39131701 PMCID: PMC11310060 DOI: 10.3389/fcvm.2024.1412195] [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: 04/04/2024] [Accepted: 06/28/2024] [Indexed: 08/13/2024] Open
Abstract
Cardioneuroablation (CNA) is a novel interventional procedure for the treatment of recurrent vasovagal syncope (VVS) and advanced atrioventricular block secondary to hyperactivation of vagal tone in young patients. By damaging the cardiac parasympathetic ganglia, CNA seems to be able to mitigate and/or abolish the excessive vagal activity and improve patients' outcome. This review is intended to give a detailed and comprehensive overview of the current evidences regarding (1) the clinical applications of CNA (2) the identification of ablation targets and procedural endpoints (3) the medium-long term effect of the procedure and its future perspectives. However, clinical data are still limited, and expert consensus or recommendations in the guidelines regarding this technique are still lacking.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - T. Strisciuglio
- Department of Cardiology, University of Naples Federico II, Naples, Italy
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Önder ŞE, Güler TE, Bozyel S, Dalgıç N, Şipal A, Çağdaş M, Kılıç E, Huang H, Aksu T. Step-by-step application of a new ganglionated plexus mapping method in a patient with vasovagal syncope. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01885-w. [PMID: 39046609 DOI: 10.1007/s10840-024-01885-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: 06/16/2024] [Accepted: 07/17/2024] [Indexed: 07/25/2024]
Affiliation(s)
- Şükriye Ebru Önder
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Tümer Erdem Güler
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Serdar Bozyel
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Nur Dalgıç
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Abdülcebbar Şipal
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Metin Çağdaş
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Emre Kılıç
- Bioritim Sağlık Hizmetleri, Bursa, Turkey
| | - Henry Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Tolga Aksu
- Faculty of Medicine, Yeditepe University, Istanbul, Turkey.
- Department of Cardiology, Yeditepe University Hospital, 34742, Istanbul, Turkey.
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Aksu T, Piotrowski R, Tung R, De Potter T, Markman TM, du Fay de Lavallaz J, Rekvava R, Alyesh D, Joza JE, Badertscher P, Do DH, Bradfield JS, Upadhyay G, Sood N, Sharma PS, Guler TE, Gul EE, Kumar V, Koektuerk B, Dal Forno ARJ, Woods CE, Rav-Acha M, Valeriano C, Enriquez A, Sundaram S, Glikson M, d’Avila A, Shivkumar K, Kulakowski P, Huang HD. Procedural and Intermediate-term Results of the Electroanatomical-guided Cardioneuroablation for the Treatment of Supra-Hisian Second- or Advanced-degree Atrioventricular Block: the PIRECNA multicentre registry. Europace 2024; 26:euae164. [PMID: 38954426 PMCID: PMC11218561 DOI: 10.1093/europace/euae164] [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: 02/28/2024] [Accepted: 04/18/2024] [Indexed: 07/04/2024] Open
Abstract
AIMS Prior case series showed promising results for cardioneuroablation in patients with vagally induced atrioventricular blocks (VAVBs). We aimed to examine the acute procedural characteristics and intermediate-term outcomes of electroanatomical-guided cardioneuroablation (EACNA) in patients with VAVB. METHODS AND RESULTS This international multicentre retrospective registry included data collected from 20 centres. Patients presenting with symptomatic paroxysmal or persistent VAVB were included in the study. All patients underwent EACNA. Procedural success was defined by the acute reversal of atrioventricular blocks (AVBs) and complete abolition of atropine response. The primary outcome was occurrence of syncope and daytime second- or advanced-degree AVB on serial prolonged electrocardiogram monitoring during follow-up. A total of 130 patients underwent EACNA. Acute procedural success was achieved in 96.2% of the cases. During a median follow-up of 300 days (150, 496), the primary outcome occurred in 17/125 (14%) cases with acute procedural success (recurrence of AVB in 9 and new syncope in 8 cases). Operator experience and use of extracardiac vagal stimulation were similar for patients with and without primary outcomes. A history of atrial fibrillation, hypertension, and coronary artery disease was associated with a higher primary outcome occurrence. Only four patients with primary outcome required pacemaker placement during follow-up. CONCLUSION This is the largest multicentre study demonstrating the feasibility of EACNA with encouraging intermediate-term outcomes in selected patients with VAVB. Studies investigating the effect on burden of daytime symptoms caused by the AVB are required to confirm these findings.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Icerenkoy Mah. Hastahane Sok. 4, 34752, Istanbul, Turkey
| | - Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 01-809, Warsaw, Poland
| | - Roderick Tung
- The University of Arizona College of Medicine-Phoenix, Department of Cardiology, Banner University Medical Center, Phoenix, AZ 85004, USA
| | - Tom De Potter
- Cardiovascular Center, OLV Hospital, Aalst, 9300, Belgium
| | - Timothy M Markman
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Roin Rekvava
- Department of Rhythm Management and Electrophysiology, American Hospital Tbilisi, Tbilisi 01102, Georgia
| | - Daniel Alyesh
- South Denver Cardiology Associates, Littleton, CO 80120, USA
| | - Jacqueline E Joza
- Department of Cardiology, McGill University, Montreal, QC, H3A 0G4, Canada
| | - Patrick Badertscher
- Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Duc H Do
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Gaurav Upadhyay
- Section of Cardiology, Center for Arrhythmia Care, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Nitesh Sood
- Department of Cardiology, Southcoast Health, Fall River, MA 02720, USA
| | - Parikshit S Sharma
- Division of Cardiology, Rush University Medical Center, 1717 West Congress Parkway, Chicago, IL 60612, USA
| | - Tumer Erdem Guler
- Division of Cardiology, Kocaeli State Hospital, Kocaeli, 41060, Turkey
| | - Enes Elvin Gul
- Division of Cardiology, Atlas University, Medicine Hospital, Istanbul, 34203, Turkey
| | - Vineet Kumar
- Inova Medical Group, Arrhythmia 8081 Innovation Park Dr 602, Fairfax, VA 22031, USA
| | - Buelent Koektuerk
- Department of Cardiology, Witten/Herdecke University, Witten, D-58455, Germany
- Department of Cardiology and Electrophysiology, Sana Clinics Düsseldorf, Düsseldorf, 40625, Germany
| | | | - Christopher E Woods
- Department of Cardiology, California Pacific Medical Center, San Francisco, CA 94110, USA
| | - Moshe Rav-Acha
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, PO Box 3235, Jerusalem 9103102, Israel
| | | | - Andres Enriquez
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Queen’s University, Kingston, ON K7l 3N6, Canada
| | - Sri Sundaram
- South Denver Cardiology Associates, Littleton, CO 80120, USA
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, PO Box 3235, Jerusalem 9103102, Israel
| | - Andre d’Avila
- Beth Israel Deaconess Medical Center, Harvard Thorndike Electrophysiology Institute, Boston, MA 02215, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Piotr Kulakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 01-809, Warsaw, Poland
| | - Henry D Huang
- Division of Cardiology, Rush University Medical Center, 1717 West Congress Parkway, Chicago, IL 60612, USA
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Deharo JC, Fedorowski A, Brignole M. Cardioneuroablation for treatment of atrioventricular block: to cure the patient or the electrocardiogram? Europace 2024; 26:euae156. [PMID: 38954425 PMCID: PMC11218559 DOI: 10.1093/europace/euae156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024] Open
Affiliation(s)
- Jean-Claude Deharo
- Assistance Publique—Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, France and Aix Marseille Université, C2VN, Cardiologie—Hôpital La Timone, Boulevard Jean Moulin, 13005 Marseille, France
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, 171 64 Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Michele Brignole
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
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7
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Francisco-Pascual J, Lal-Trehan Estrada N. Syncope. Med Clin (Barc) 2024; 162:606-612. [PMID: 38388319 DOI: 10.1016/j.medcli.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 02/24/2024]
Affiliation(s)
- Jaume Francisco-Pascual
- Unitat d'Arrítmies, Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, España; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, España.
| | - Nisha Lal-Trehan Estrada
- Unitat d'Arrítmies, Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, España
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8
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Kaza N, Sorbini M, Liu Z, Johal M, Porter B, Nowbar A, Levy S, Dani M, Taraborelli P, Eardley P, Zuhair M, Arnold A, Howard J, Whinnett ZI, Francis DP, Shun-Shin MJ, Lim PB, Keene D. Therapeutic options for neurocardiogenic syncope: a meta-analysis of randomised trials with and without blinding. Open Heart 2024; 11:e002669. [PMID: 38890128 PMCID: PMC11191821 DOI: 10.1136/openhrt-2024-002669] [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: 03/06/2024] [Accepted: 05/15/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Neurocardiogenic syncope is a common condition with significant associated psychological and physical morbidity. The effectiveness of therapeutic options for neurocardiogenic syncope beyond placebo remains uncertain. METHODS The primary endpoint was the risk ratio (RR) of spontaneously recurring syncope following any therapeutic intervention. We also examined the effect of blinding on treatment efficacy. We identified all randomised trials which evaluated the effect of any pharmacological, device-based or supportive intervention on patients with a history of syncope. A systematic search was conducted on Medline, Embase, PubMed databases and Cochrane Central Register for Controlled Trials from 1950 to 25 April 2023. Event rates, their RRs and 95% CIs were calculated, and a random-effects meta-analysis was conducted for each intervention. Data analysis was performed in R using RStudio. RESULTS We identified 47 eligible trials randomising 3518 patients. Blinded trials assessing syncope recurrence were neutral for beta blockers, fludrocortisone and conventional dual-chamber pacing but were favourable for selective serotonin reuptake inhibitors (SSRIs) (RR 0.40, 95% CI 0.26 to 0.63, p<0.001), midodrine (RR 0.70, 95% CI 0.53 to 0.94, p=0.016) and closed-loop stimulation (CLS) pacing (RR 0.15, 95% CI 0.07 to 0.35, p<0.001). Unblinded trials reported significant benefits for all therapy categories other than beta blockers and consistently showed larger benefits than blinded trials. CONCLUSIONS Under blinded conditions, SSRIs, midodrine and CLS pacing significantly reduced syncope recurrence. Future trials for syncope should be blinded to avoid overestimating treatment effects. PROSPERO REGISTRATION NUMBER CRD42022330148.
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Affiliation(s)
| | | | | | | | | | | | - Shuli Levy
- Imperial College Healthcare NHS Trust, London, UK
| | - Melanie Dani
- Imperial College Healthcare NHS Trust, London, UK
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Fedorowski A, Fanciulli A, Raj SR, Sheldon R, Shibao CA, Sutton R. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat Rev Cardiol 2024; 21:379-395. [PMID: 38163814 DOI: 10.1038/s41569-023-00962-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London, UK
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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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11
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Valenti N, Di Monaco A, Romanazzi I, Vitulano N, Troisi F, Quadrini F, Grimaldi M. A case report of cardiac neuromodulation in a young patient with a third-degree atrioventricular block. Front Cardiovasc Med 2024; 11:1370522. [PMID: 38633841 PMCID: PMC11021669 DOI: 10.3389/fcvm.2024.1370522] [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: 01/14/2024] [Accepted: 03/13/2024] [Indexed: 04/19/2024] Open
Abstract
Background There are some functional bradyarrhythmias that are caused by a dysregulation of the autonomic nervous system, for which a therapeutic strategy of cardioneuroablation (CNA) is conceivable. Case summary In this study, we report the case of a 19-year-old woman with a non-congenital third-degree atrioventricular block (AVB), symptomatic for lipothymia and dyspnea caused by mild exertion. She had a structurally normal heart and no other comorbidities. The atropine test and the exercise stress test documented a sinus tachycardia at 190 bpm with a 2:1 AVB, a narrow QRS, and an atrioventricular conduction of 1:1 until reaching a sinus rhythm rate of 90 bpm. She underwent the CNA procedure, which targeted the inferior paraseptal ganglion plexus, with a gradual change in the ECG levels recorded during the radiofrequency delivery from a third-degree AVB to a first-degree AVB. After the procedure, we observed a complete regression of the third-degree AVB, with evidence of only a first-degree AVB and a complete regression of symptoms until the 6-month follow-up. Conclusions Although not yet included in current guidelines, the CNA procedure could be used to treat AV node dysfunction in young subjects, as it could represent an alternative to pacemaker implantation. However, more randomized studies are needed to assess the long-term efficacy of this promising technique.
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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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Herweg B, Patel RS, Noujaim S, Spano J, Mencer N, Vijayaraman P. Cryoballoon cardioneuroablation: New electrophysiological insights. Heart Rhythm O2 2024; 5:209-216. [PMID: 38690146 PMCID: PMC11056456 DOI: 10.1016/j.hroo.2024.03.004] [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] [Indexed: 05/02/2024] Open
Abstract
Background Cardioneuroablation (CNA) targeting ganglionated plexi has shown promise in treating vasovagal syncope. Only radiofrequency ablation has been used to achieve this goal thus far. Objective The purpose of this study was to investigate the utility of cryoballoon ablation (CBA) of the pulmonary veins (PVs) as a potential simplified approach to CNA. Methods We report our observations of autonomic modulation in a series of 17 patients undergoing CBA for atrial fibrillation and our early experience using CBA of the PVs in 3 patients with malignant vagal syncope. In 17 patients undergoing CBA of AF, sinus cycle length was recorded intraprocedurally after ablation of individual PVs. Results The most pronounced shortening of the sinus cycle length was observed after isolation of the right upper PV, which was ablated last. Reduced sinus node recovery time and atrioventricular (AV) nodal effective refractory period were observed after CBA. Resting heart rate was elevated by 6-7 bpm after CBA and persisted during 12-month follow-up. CBA of the PVs was performed in 3 patients with recurrent vagal syncope mediated by sinus arrest (n = 2) and AV block (n = 1). In all patients, isolation of the right upper PV resulted in marked shortening of sinus cycle length. During follow-up of 178 ± 43 days (134-219 days), CNA resulted in abolition of pauses, bradycardia-related symptoms, and syncope in all patients. Conclusion CBA of the PVs (particularly the right upper PV) may be a predictable anatomic CNA approach in patients with refractory vagal syncope due to sinus arrest and/or AV block and may warrant systematic investigation as a tool to perform CNA.
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Affiliation(s)
- Bengt Herweg
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Ritesh S. Patel
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Sami Noujaim
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | | | - Nicholas Mencer
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
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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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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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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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Brignole M, Rivasi G, Fedorowski A. Mechanism-based therapy of non-cardiac syncope: a practical guide. Europace 2024; 26:euae073. [PMID: 38529800 PMCID: PMC10988836 DOI: 10.1093/europace/euae073] [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: 02/20/2024] [Accepted: 03/08/2024] [Indexed: 03/27/2024] Open
Abstract
The term non-cardiac syncope includes all forms of syncope, in which primary intrinsic cardiac mechanism and non-syncopal transient loss of consciousness can be ruled out. Reflex syncope and orthostatic hypotension are the most frequent aetiologies of non-cardiac syncope. As no specific therapy is effective for all types of non-cardiac syncope, identifying the underlying haemodynamic mechanism is the essential prerequisite for an effective personalized therapy and prevention of syncope recurrences. Indeed, choice of appropriate therapy and its efficacy are largely determined by the syncope mechanism rather than its aetiology and clinical presentation. The two main haemodynamic phenomena leading to non-cardiac syncope include either profound hypotension or extrinsic asystole/pronounced bradycardia, corresponding to two different haemodynamic syncope phenotypes, the hypotensive and bradycardic phenotypes. The choice of therapy-aimed at counteracting hypotension or bradycardia-depends on the given phenotype. Discontinuation of blood pressure-lowering drugs, elastic garments, and blood pressure-elevating agents such as fludrocortisone and midodrine are the most effective therapies in patients with hypotensive phenotype. Cardiac pacing, cardioneuroablation, and drugs preventing bradycardia such as theophylline are the most effective therapies in patients with bradycardic phenotype of extrinsic cause.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Department of Cardiology, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
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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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Han Y, Shao M, Yang H, Sun H, Sang W, Wang L, Wang L, Yang S, Jian Y, Tang B, Li Y. Safety and efficacy of cardioneuroablation for vagal bradycardia in a single arm prospective study. Sci Rep 2024; 14:5926. [PMID: 38467744 PMCID: PMC10928196 DOI: 10.1038/s41598-024-56651-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 03/08/2024] [Indexed: 03/13/2024] Open
Abstract
Cardioneuroablation (CNA) is currently considered as a promising treatment option for patients with symptomatic bradycardia caused by vagotonia. This study aims to further investigate its safety and efficacy in patients suffering from vagal bradycardia. A total of 60 patients with vagal bradycardia who underwent CNA in the First Affiliated Hospital of Xinjiang Medical University from November 2019 to June 2022. Preoperative atropine tests revealed abnormal vagal tone elevation in all patients. First, the electroanatomic structures of the left atrium was mapped out by using the Carto 3 system, according to the protocol of purely anatomy-guided and local fractionated intracardiac electrogram-guided CNA methods. The upper limit of ablation power of superior left ganglion (SLGP) and right anterior ganglion (RAGP) was not more than 45W with an ablation index of 450.Postoperative transesophageal cardiac electrophysiological examination was performed 1 to 3 months after surgery. The atropine test was conducted when appropriate. Twelve-lead electrocardiogram, Holter electrocardiogram, and skin sympathetic nerve activity were reviewed at 1, 3, 6 and 12 months after operation. Adverse events such as pacemaker implantation and other complications were also recorded to analyze the safety and efficacy of CNA in the treatment of vagus bradycardia. Sixty patients were enrolled in the study (38 males, mean age 36.67 ± 9.44, ranging from 18 to 50 years old). None of the patients had a vascular injury, thromboembolism, pericardial effusion, or other surgical complications. The mean heart rate, minimum heart rate, low frequency, low/high frequency, acceleration capacity of rate, and skin sympathetic nerve activity increased significantly after CNA. Conversely, SDNN, PNN50, rMSSD, high frequency, and deceleration capacity of rate values decreased after CNA (all P < 0.05). At 3 months after ablation, the average heart rate, maximum heart rate, and acceleration capacity of heart rate remained higher than those before ablation, and the deceleration capacity of heart rate remained lower than those before ablation and the above results continued to follow up for 12 months after ablation (all P < 0.05). There was no significant difference in other indicators compared with those before ablation (all P > 0.05). The remaining 81.67% (49/60) of the patients had good clinical results, with no episodes of arrhythmia during follow-up. CNA may be a safe and effective treatment for vagal-induced bradycardia, subject to confirmation by larger multicenter trials.
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Affiliation(s)
- Yafan Han
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Medical Science and Technology Innovation Center, College of Laboratory Animals (Provincial Laboratory Animal Center), Shandong First Medical University, Affiliated Provincial Hospital, Jinan, 250117, China
| | - Mingliang Shao
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Cardiovascular Department, The People's Hospital of Xuancheng City, Anhui, 242000, China
| | - Hang Yang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Huaxin Sun
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Department of Cardiology, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu Cardiovascular Disease Research Institute, Chengdu, 610014, Sichuan, China
| | - Wanyue Sang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Lu Wang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Liang Wang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Suxia Yang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Yi Jian
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Baopeng Tang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China.
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China.
| | - Yaodong Li
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China.
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China.
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20
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Kulakowski P, Baran J, Sikorska A, Krynski T, Niedzwiedz M, Soszynska M, Piotrowski R. Cardioneuroablation for reflex asystolic syncope: Mid-term safety, efficacy, and patient's acceptance. Heart Rhythm 2024; 21:282-291. [PMID: 38036236 DOI: 10.1016/j.hrthm.2023.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/19/2023] [Accepted: 11/25/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Cardioneuroablation (CNA) is a promising therapy for reflex asystolic syncope; however, convincing data on the mid-term safety and efficacy of this procedure are lacking. OBJECTIVE The purpose of this study was to assess the mid-term safety, efficacy, and patient acceptance of CNA. METHODS This prospective observational single-center study included 115 consecutive patients (mean age 39 ± 13 years; 58% female) treated between 2016 and 2022 who completed at least 1-year follow-up. RESULTS No significant procedure-related acute complications occurred. During median follow-up of 28 months (range 12-75), 95 (83%) remained free from syncope. Of the 20 patients (17%) with syncope recurrence, syncope burden decreased from a mean 17 (median 6.5) to 3.75 (median 2.5) episodes (P = .015). In 9 of 10 patients, pacing system removal was possible. Repeated CNA was needed in 3 patients (3%), whereas pacemaker implantation was performed in 5 (4%). The most frequent mid-term complication of CNA was sinus rhythm acceleration (from 60 ± 14 bpm to 90 ± 16 bpm; P <.0001), which was symptomatic in 31 patients (27%); 8 patients (7%) required chronic beta-blocker and/or ivabradine. Sinus node modification was necessary in 1 patient. Other complaints included dyspnea, chronic chest pain, and decreased exercise capacity, which were mild and reported by 16 patients (14%). Patient acceptance of CNA was very high: 96% stated that it was worth undergoing the procedure. CONCLUSIONS Mid-term efficacy of CNA exceeds 80%, and acute complications are absent. The most frequent mid-term chronic complication is inappropriate sinus tachycardia, which in 7% required chronic treatment. The procedure is well accepted by patients.
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Affiliation(s)
- Piotr Kulakowski
- 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
| | - Michal Niedzwiedz
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Malgorzata Soszynska
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland.
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Giannino G, Braia V, Griffith Brookles C, Giacobbe F, D'Ascenzo F, Angelini F, Saglietto A, De Ferrari GM, Dusi V. The Intrinsic Cardiac Nervous System: From Pathophysiology to Therapeutic Implications. BIOLOGY 2024; 13:105. [PMID: 38392323 PMCID: PMC10887082 DOI: 10.3390/biology13020105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024]
Abstract
The cardiac autonomic nervous system (CANS) plays a pivotal role in cardiac homeostasis as well as in cardiac pathology. The first level of cardiac autonomic control, the intrinsic cardiac nervous system (ICNS), is located within the epicardial fat pads and is physically organized in ganglionated plexi (GPs). The ICNS system does not only contain parasympathetic cardiac efferent neurons, as long believed, but also afferent neurons and local circuit neurons. Thanks to its high degree of connectivity, combined with neuronal plasticity and memory capacity, the ICNS allows for a beat-to-beat control of all cardiac functions and responses as well as integration with extracardiac and higher centers for longer-term cardiovascular reflexes. The present review provides a detailed overview of the current knowledge of the bidirectional connection between the ICNS and the most studied cardiac pathologies/conditions (myocardial infarction, heart failure, arrhythmias and heart transplant) and the potential therapeutic implications. Indeed, GP modulation with efferent activity inhibition, differently achieved, has been studied for atrial fibrillation and functional bradyarrhythmias, while GP modulation with efferent activity stimulation has been evaluated for myocardial infarction, heart failure and ventricular arrhythmias. Electrical therapy has the unique potential to allow for both kinds of ICNS modulation while preserving the anatomical integrity of the system.
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Affiliation(s)
- Giuseppe Giannino
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Valentina Braia
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Carola Griffith Brookles
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Federico Giacobbe
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Fabrizio D'Ascenzo
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Gaetano Maria De Ferrari
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Veronica Dusi
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
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Piotrowski R, Baran J, Sikorska A, Niedzwiedz M, Krynski T, Kulakowski P. Cardioneuroablation: comparison of acute effects of the right vs. left atrial approach in patients with reflex syncope: the ROMAN2 study. Europace 2024; 26:euae042. [PMID: 38315895 PMCID: PMC10873699 DOI: 10.1093/europace/euae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/25/2023] [Accepted: 01/24/2024] [Indexed: 02/07/2024] Open
Affiliation(s)
- Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Jakub Baran
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Agnieszka Sikorska
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Michał Niedzwiedz
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Tomasz Krynski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Piotr Kulakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
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23
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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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24
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Cui CP, Xiong X, Zhao JX, Fu DH, Zhang Y, Ma PB, Wu D, Li BY. Piezo1 channel activation facilitates baroreflex afferent neurotransmission with subsequent blood pressure reduction in control and hypertension rats. Acta Pharmacol Sin 2024; 45:76-86. [PMID: 37670136 PMCID: PMC10770313 DOI: 10.1038/s41401-023-01154-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/12/2023] [Indexed: 09/07/2023] Open
Abstract
Mechanosensitive cation channels such as Piezo1 and Piezo2 are activated by mechanical force like a starched wall of the aorta while blood pressure (BP) rising, which helps to elucidate the underlying mechanism of mechanotransduction of baroreceptor endings. In this study we investigated how Piezo1 channel activation-mediated gender- and afferent-specific BP regulation in rats. We established high-fat diet and fructose drink-induced hypertension model rats (HFD-HTN) and deoxycorticosterone (DOCA)-sensitive hypertension model rats. We showed that the expression levels of Piezo1 and Piezo2 were significantly up-regulated in left ventricle of HFD and DOCA hypertensive rats, whereas the down-regulation of Piezo1 was likely to be compensated by Piezo2 up-regulation in the aorta. Likewise, down-regulated Piezo1 was observed in the nodose ganglion (NG), while up-regulated Piezo2 was found in the nucleus tractus solitarius (NTS), which might synergistically reduce the excitatory neurotransmitter release from the presynaptic membrane. Notably, microinjection of Yoda1 (0.025-2.5 mg/ml) into the NG concentration-dependently reduced BP in both hypertensive rat models as well as in control rats with similar EC50; the effect of Yoda1 was abolished by microinjection of a Piezo1 antagonist GsMTx4 (1.0 μM). Functional analysis in an in vitro aortic arch preparation showed that instantaneous firing frequency of single Ah-fiber of aortic depressor nerve was dramatically increased by Yoda1 (0.03-1.0 μM) and blocked by GsMTx4 (1.0 μM). Moreover, spontaneous synaptic currents recorded from identified 2nd-order Ah-type baroreceptive neurons in the NTS was also facilitated over 100% by Yoda1 (1.0 μM) and completely blocked by GsMTx4 (3.0 μM). These results demonstrate that Piezo1 expressed on Ah-type baroreceptor and baroreceptive neurons in the NG and NTS plays a key role in a sexual-dimorphic BP regulation under physiological and hypertensive condition through facilitation of baroreflex afferent neurotransmission, which is presumably collaborated by Piezo2 expression at different level of baroreflex afferent pathway via compensatory and synergistic mechanisms.
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Affiliation(s)
- Chang-Peng Cui
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, 150081, China
| | - Xue Xiong
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, 150081, China
| | - Jia-Xin Zhao
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, 150081, China
| | - Dong-Hong Fu
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, 150081, China
| | - Yan Zhang
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, 150081, China
| | - Peng-Bo Ma
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, 150081, China
| | - Di Wu
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, 150081, China
- Department of Pharmacy, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116023, China
| | - Bai-Yan Li
- Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, 150081, China.
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25
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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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26
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Kulakowski P. Reflex syncope: assessment and management. Heart 2023; 109:1785-1792. [PMID: 37137676 DOI: 10.1136/heartjnl-2022-322031] [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] [Indexed: 05/05/2023] Open
Affiliation(s)
- Piotr Kulakowski
- Department of Cardiology, Grochowski Hospital, Centre for Postgraduate Medical Education, Warszawa, Poland
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27
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Chung WH, Masuyama K, Challita R, Hayase J, Mori S, Cha S, Bradfield JS, Ardell JL, Shivkumar K, Ajijola OA. Ischemia-induced ventricular proarrhythmia and cardiovascular autonomic dysreflexia after cardioneuroablation. Heart Rhythm 2023; 20:1534-1545. [PMID: 37562487 DOI: 10.1016/j.hrthm.2023.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Cardioneuroablation (CNA) is an attractive treatment of vasovagal syncope. Its long-term efficacy and safety remain unknown. OBJECTIVE The purpose of this study was to develop a chronic porcine model of CNA to examine the susceptibility to ventricular tachyarrhythmia (ventricular tachycardia/ventricular fibrillation [VT/VF]) and cardiac autonomic function after CNA. METHODS A percutaneous CNA model was developed by ablation of left- and right-sided ganglionated plexi (n = 5), confirmed by histology. Reproducible bilateral vagal denervation was confirmed after CNA by extracardiac vagal nerve stimulation (VNS) and histology. Chronic studies included 16 pigs randomized to CNA (n = 8) and sham ablation (n = 8, Control). After 6 weeks, animals underwent hemodynamic studies, assessment of cardiac sympathetic and parasympathetic function using sympathetic chain stimulation and direct VNS, respectively, and proarrhythmic potential after left anterior descending (LAD) coronary artery ligation. RESULTS After CNA, extracardiac VNS responses remained abolished for 6 weeks despite ganglia remaining in ablated ganglionated plexi. In the CNA group, direct VNS resulted in paradoxical increases in blood pressure, but not in sham-ablated animals (CNA group vs sham group: 8.36% ± 7.0% vs -4.83% ± 8.7%, respectively; P = .009). Left sympathetic chain stimulation (8 Hz) induced significant corrected QT interval prolongation in the CNA group vs the sham group (11.23% ± 4.0% vs 1.49% ± 4.0%, respectively; P < .001). VT/VF after LAD ligation was more prevalent and occurred earlier in the CNA group than in the control group (61.44 ± 73.7 seconds vs 245.11 ± 104.0 seconds, respectively; P = .002). CONCLUSION Cardiac vagal denervation is maintained long-term after CNA in a porcine model. However, chronic CNA was associated with cardiovascular dysreflexia, diminished cardioprotective effects of cardiac vagal tone, and increased susceptibility to VT/VF in ischemia. These potential long-term negative effects of CNA suggest the need for rigorous clinical studies on CNA.
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Affiliation(s)
- Wei-Hsin Chung
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California; China Medical University Hospital, Taichung, Taiwan
| | - Kiyoshi Masuyama
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Ronald Challita
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Steven Cha
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jeffery L Ardell
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California.
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28
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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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29
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Almeida S. Cardioneuroablation: A game-changer for vasovagal syncope. Rev Port Cardiol 2023; 42:831-833. [PMID: 37263497 DOI: 10.1016/j.repc.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
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30
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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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31
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Santos Silva G, Fonseca P, Cardoso F, Almeida J, Ribeiro S, Oliveira M, Sanfins V, Gonçalves H, Pachon M JC, Barra S, Primo J, Lourenço A, Fontes-Carvalho R. Cardioneuroablation for severe neurocardiogenic syncope. Rev Port Cardiol 2023; 42:821-829. [PMID: 37268266 DOI: 10.1016/j.repc.2023.02.012] [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: 09/30/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 06/04/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Cardioneuroablation (CNA), a technique based on radiofrequency ablation of cardiac vagal ganglia, was developed to treat recurrent vasovagal syncope (VVS) with a predominant cardioinhibitory component, as an alternative to pacemaker implantation. The aim of our study was to evaluate the safety and success rate of CNA guided by extracardiac vagal stimulation in patients with highly symptomatic cardioinhibitory VVS. METHODS Prospective study of patients who underwent anatomically guided CNA at two cardiology centers. All patients had a history of recurrent syncope with a predominant cardioinhibitory component and refractory to conventional measures. Acute success was determined by the absence or significant reduction of cardiac parasympathetic response to extracardiac vagal stimulation. The primary endpoint was the recurrence of syncope during follow-up. RESULTS In total, 19 patients (13 males; mean age 37.8±12.9 years) were included. Ablation was acutely successful in all patients. One patient had a convulsive episode after the procedure, which was deemed unrelated to the ablation, requiring admission to intensive care but without sequelae. No other complications occurred. At a mean follow-up of 21.0±13.2 months (range 3-42 months), 17 patients remained free of syncope. The remaining two patients had recurrence of syncope and, despite undergoing a new ablation procedure, required pacemaker implantation during follow-up. CONCLUSION Cardioneuroablation, confirmed by extracardiac vagal stimulation, appears to be an effective and safe treatment option for highly symptomatic patients with refractory VVS with a predominant cardioinhibitory component, providing a new potential approach as an alternative to pacemaker implantation.
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Affiliation(s)
- Gualter Santos Silva
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - Paulo Fonseca
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - Filipa Cardoso
- Hospital Senhora da Oliveira, Cardiology Department, Guimarães, Portugal
| | - João Almeida
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - Sílvia Ribeiro
- Hospital Senhora da Oliveira, Cardiology Department, Guimarães, Portugal
| | - Marco Oliveira
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - Víctor Sanfins
- Hospital Senhora da Oliveira, Cardiology Department, Guimarães, Portugal
| | - Helena Gonçalves
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | | | - Sérgio Barra
- Hospital da Luz Arrábida, Cardiology Department, V. N. Gaia, Portugal.
| | - João Primo
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - António Lourenço
- Hospital Senhora da Oliveira, Cardiology Department, Guimarães, Portugal
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32
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Haghjoo M. Is cardioneuroablation ready for prime time? Heart Rhythm 2023; 20:1287-1288. [PMID: 37379939 DOI: 10.1016/j.hrthm.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Majid Haghjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Institute, Tehran, Iran; Department of Electrophysiology, Rajaie Cardiovascular Medical and Research Institute, Tehran, Iran.
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33
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Francia P, Viveros D, Falasconi G, Penela D, Soto-Iglesias D, Martí-Almor J, Alderete J, Saglietto A, Bellido AF, Franco-Ocaña P, Zaraket F, Matiello M, Fernández-Armenta J, San Antonio R, Berruezo A. Clinical impact of aging on outcomes of cardioneuroablation for reflex syncope or functional bradycardia: Results from the cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs-The ELEGANCE multicenter study. Heart Rhythm 2023; 20:1279-1286. [PMID: 37329936 DOI: 10.1016/j.hrthm.2023.06.007] [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: 04/20/2023] [Revised: 05/27/2023] [Accepted: 06/09/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Cardioneuroablation (CNA) is a novel treatment for reflex syncope. The effect of aging on CNA efficacy is not fully understood. OBJECTIVE The purpose of this study was to assess the impact of aging on candidacy and efficacy of CNA for treating vasovagal syncope (VVS), carotid sinus syndrome (CSS), and functional bradyarrhythmia. METHODS The ELEGANCE (cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs) multicenter study assessed CNA in patients with reflex syncope or severe functional bradyarrhythmia. Patients underwent pre-CNA Holter electrocardiography (ECG), head-up tilt testing (HUT), and electrophysiological study. CNA candidacy and efficacy was assessed in 14 young (18-40 years), 26 middle-aged (41-60 years), and 20 older (>60 years) patients. RESULTS Sixty patients (37 men; mean age 51 ± 16 years) underwent CNA. The majority (80%) had VVS, 8% had CSS, and 12% had functional bradycardia/atrioventricular block. Pre-CNA Holter ECG, HUT, and electrophysiological findings did not differ across age groups. Acute CNA success was 93%, without differences between age groups (P = .42). Post-CNA HUT response was negative in 53%, vasodepressor in 38%, cardioinhibitory in 7%, and mixed in 2%, without differences across age groups (P = .59). At follow-up (8 months, interquartile range 4-15), 53 patients (88%) were free of symptoms. Kaplan-Meier curves did not show differences in event-free survival between age groups (P = .29). The negative predictive value of a negative HUT was 91.7%. CONCLUSION CNA is a viable treatment for reflex syncope and functional bradyarrhythmia in all ages, and is highly effective in mixed VVS. HUT is a key step in postablation clinical assessment.
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Affiliation(s)
- Pietro Francia
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain; Cardiology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Daniel Viveros
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Giulio Falasconi
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Diego Penela
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - David Soto-Iglesias
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Julio Martí-Almor
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - José Alderete
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Andrea Saglietto
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | | | - Paula Franco-Ocaña
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Fatima Zaraket
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain; Clínica del Pilar, Barcelona, Spain
| | | | | | - Rodolfo San Antonio
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain; Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Antonio Berruezo
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain.
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Fedorowski A, Kulakowski P, Brignole M, de Lange FJ, Kenny RA, Moya A, Rivasi G, Sheldon R, Van Dijk G, Sutton R, Deharo JC. Twenty-five years of research on syncope. Europace 2023; 25:euad163. [PMID: 37622579 PMCID: PMC10450792 DOI: 10.1093/europace/euad163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 08/26/2023] Open
Abstract
Over the last 25 years, the Europace journal has greatly contributed to dissemination of research and knowledge in the field of syncope. More than 400 manuscripts have been published in the journal. They undoubtedly improved our understanding of syncope. This symptom is now clearly differentiated from other forms of transient loss of consciousness. The critical role of vasodepression and/or cardioinhibition as final mechanisms of reflex syncope is emphasized. Current diagnostic approach sharply separates between cardiac and autonomic pathways. Physiologic insights have been translated, through rigorously designed clinical trials, into non-pharmacological or pharmacological interventions and interventional therapies. The following manuscript is intended to give the reader the current state of the art of knowledge of syncope by highlighting landmark contributions of the Europace journal.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Eugeniavägen 3, 171 76 Solna, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Piotr Kulakowski
- Department of Cardiology, Medical Centre for Postgraduate Education, Grochowski Hospital, Ul. Grenadierow 51/59, 04-073 Warsaw, Poland
| | - Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Piazzale Brescia 20, 20149 Milan, Italy
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, 152-160 Pearse St, Dublin, Ireland
- Mercer Institute for Successful Ageing, St. James Hospital, James St, Dublin 8, D08 NHY1Ireland
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, Carrer de Sabino Arana 5-19, 08028 Barcelona, Spain
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Robert Sheldon
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute, 3310 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Gert Van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, Du Cane Road, London, W12 0HS, United Kingdom
| | - Jean-Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France and Aix Marseille Université, C2VN, 264 Rue Saint-Pierre, 13005 Marseille, France
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Chestaro Feliz J, Duran Luciano P, Guevara N, Zaremski L, Baghdadi S, Marazzato J, Di Biase L. Pseudo-pacemaker syndrome with prolonged PR interval: A narrative review. Pacing Clin Electrophysiol 2023; 46:904-912. [PMID: 37486858 DOI: 10.1111/pace.14790] [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: 05/04/2023] [Revised: 06/25/2023] [Accepted: 07/06/2023] [Indexed: 07/26/2023]
Abstract
Pseudo-pacemaker syndrome (PPMS) is a rare complication of first-degree atrio-ventricular (AV) block in which a very prolonged PR interval causes AV dyssynchrony and subsequent symptoms of hemodynamic instability in the absence of an implanted pacemaker. The aim of this manuscript was to describe a unique case of PPMS and to provide a comprehensive review of the topic to help clinicians in the diagnosis and management of this condition. Through systematic research on PubMed, Google Scholar, EBSCO, and Ovid MEDLINE and using the search strings "pseudo-pacemaker syndrome" and "symptomatic first-degree AV block," we identified 14 articles accounting for 17 cases of PPMS, including our case report. The most common age group for PPMS was middle-aged and young adults, with an average age of 47 years. Palpitations were the most common presenting symptom and four main etiologies of PPMS were identified, as follows: (1) Idiopathic PPMS with evidence of impaired conduction over the AV node (20% of cases), (2) PPMS associated with reversable inflammatory causes (13%) or (3) associated with iatrogenic surgical or interventional procedures leading to the permanent damage of the normal AV conduction system (20%), and, finally, (4) PPM related to dual AV nodal physiology (DAVNP) as a primary finding (27%) or occurring after fast or slow pathway ablation for treatment of AV nodal re-entrant tachycardia (AVNRT) (20%). Treatment should be patient-tailored and based on the specific etiology once identified. However, the treatment of PPMS due to DAVNP without AVNRT presentation is yet to be clarified.
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Affiliation(s)
| | | | - Nehemias Guevara
- Department of Internal Medicine, SBH Health Systems, Bronx, New York, USA
| | - Lynn Zaremski
- Department of Cardiology, SBH Health Systems, Bronx, New York, USA
| | - Salim Baghdadi
- Department of Cardiology, SBH Health Systems, Bronx, New York, USA
| | - Jacopo Marazzato
- Department of Electrophysiology, Albert Einstein College of Medicine at Montefiore Hospital, Bronx, New York, USA
| | - Luigi Di Biase
- Department of Electrophysiology, Albert Einstein College of Medicine at Montefiore Hospital, Bronx, New York, USA
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Yoneda F, Shizuta S, Makiyama T, Masunaga N, Hoshida S, Kimura T. Selective cardioneuroablation of the posteromedial left ganglionated plexus for drug-resistant swallow syncope with functional atrioventricular block. HeartRhythm Case Rep 2023; 9:513-517. [PMID: 37614381 PMCID: PMC10444546 DOI: 10.1016/j.hrcr.2023.04.022] [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: 08/25/2023] Open
Affiliation(s)
- Fumiya Yoneda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nobutaka Masunaga
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Shiro Hoshida
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Prakash A, Sutton R. Prospective randomized study comparing permanent pacing with rate drop response and closed loop stimulation in patients with vasovagal syncope where permanent pacing is indicated and selected as the appropriate treatment option. J Cardiovasc Electrophysiol 2023; 34:1744-1749. [PMID: 37393604 DOI: 10.1111/jce.15991] [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: 03/20/2023] [Revised: 06/10/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Pacing for vasovagal syncope is established. Two pacing algorithms are available. The rate-drop-response (RDR-Medtronic) is triggered by falling heart rate acting with modified rate-hysteresis. The closed loop stimulation or system (CLS-Biotronik) is triggered by impedance changes in the right ventricle reflecting falling volume and rising contractility. These are very different physiologically. Both algorithms carry favorable reports in clinical use. METHODS A randomized-controlled superiority trial is proposed to compare the two algorithms for the control of vasovagal syncope in patients for whom pacing is indicated by current guidelines in North America and Europe. Available recent evidence may be seen as supporting superiority of CLS. No comparison between the two algorithms has been made. In this trial, patients will be centrally randomized to one or other algorithm on a 1:1 basis. Two-hundred-seventy-six patients in each group will be recruited. Sample size is determined using a confidence interval of 95%, a power of 90%, and a drop-out rate of 10% to detect an 11% difference between CLS and RDR. Recurrent symptom comparison will be made by an independent committee. The Co-primary endpoints will be recurrent syncope burden compared with that in 24-months preimplant, and occurrence of syncope in 24-months follow-up. Each outcome will be compared between the two algorithms. Secondary endpoints will be program and drug therapy changes over 24-months follow-up and quality of life by questionnaire at baseline,1 and 2 years. RESULTS AND CONCLUSIONS These are anticipated to clarify the device algorithm choice and, therefore, to improve patient care.
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Affiliation(s)
- Atul Prakash
- Rutgers Medical School, Newark, New Jersey, USA
- Prime Health Care, Newark, New Jersey, USA
- St Mary's General Hospital, Passaic, New Jersey, USA
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital Campus of National Heart & Lung Institute, Imperial College, London, UK
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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: 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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Rebecchi M, De Ruvo E, Borrelli A, Sette A, Sgueglia M, Grieco D, Canestrelli S, Politano A, Panattoni G, Licciardello C, Latorre M, Panuccio M, Mattatelli A, Calò L. Ganglionated plexi ablation in the right atrium for the treatment of cardioinhibitory syncope. Eur Heart J Suppl 2023; 25:C261-C264. [PMID: 37125307 PMCID: PMC10132630 DOI: 10.1093/eurheartjsupp/suad002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Neurocardiogenic syncope, also called vasovagal syncope, represents one of the clinical manifestations of neurally mediated syncopal syndrome. Generally, the prognosis of the cardioinhibitory form of neurocardiogenic syncope is good, but quality of life is seriously compromised in patients who experience severe forms. Drug therapy has not achieved good clinical results and very heterogeneous data come from studies regarding permanent cardiac pacing. In this scenario, the ganglionated plexi ablation has been proposed as an effective and safe method in patients with cardioinhibitory neurocardiogenic syncope, especially in young patients in order to avoid or prolong, as much as possible, the timing of definitive cardiac pacing. Certainly, making this procedure less extensive and limiting the ablation in the right atrium (avoiding the potential complications of a left atrial approach) and at level of anatomical regions of the most important ganglionated plexy, considered 'gateway' of the sino-atrial and atrio-ventricular node function (through the recognition of specific endocardial potentials), could be very advantageous in this clinical scenario. Finally, randomized, multicentre, clinical trials on a large population are needed to better understand which is the best ablation treatment (right-only or bi-atrial) and provide evidence for syncope guidelines.
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Affiliation(s)
- Marco Rebecchi
- Corresponding author. Tel: +39 0623188406, Fax: +39 0623188410, ;
| | - Ermenegildo De Ruvo
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Alessio Borrelli
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Antonella Sette
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Marianna Sgueglia
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Domenico Grieco
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Stefano Canestrelli
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Alessandro Politano
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Germana Panattoni
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Claudio Licciardello
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Maria Latorre
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Marco Panuccio
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Antonella Mattatelli
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, 00100 Rome, Italy
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Francisco Pascual J, Jordan Marchite P, Rodríguez Silva J, Rivas Gándara N. Arrhythmic syncope: From diagnosis to management. World J Cardiol 2023; 15:119-141. [PMID: 37124975 PMCID: PMC10130893 DOI: 10.4330/wjc.v15.i4.119] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/02/2023] [Accepted: 04/10/2023] [Indexed: 04/20/2023] Open
Abstract
Syncope is a concerning symptom that affects a large proportion of patients. It can be related to a heterogeneous group of pathologies ranging from trivial causes to diseases with a high risk of sudden death. However, benign causes are the most frequent, and identifying high-risk patients with potentially severe etiologies is crucial to establish an accurate diagnosis, initiate effective therapy, and alter the prognosis. The term cardiac syncope refers to those episodes where the cause of the cerebral hypoperfusion is directly related to a cardiac disorder, while arrhythmic syncope is cardiac syncope specifically due to rhythm disorders. Indeed, arrhythmias are the most common cause of cardiac syncope. Both bradyarrhythmia and tachyarrhythmia can cause a sudden decrease in cardiac output and produce syncope. In this review, we summarized the main guidelines in the management of patients with syncope of presumed arrhythmic origin. Therefore, we presented a thorough approach to syncope work-up through different tests depending on the clinical characteristics of the patients, risk stratification, and the management of syncope in different scenarios such as structural heart disease and channelopathies.
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Affiliation(s)
- Jaume Francisco Pascual
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- Grup de Recerca Cardiovascular, Vall d’Hebron Institut de Recerca, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Pablo Jordan Marchite
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Jesús Rodríguez Silva
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Nuria Rivas Gándara
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
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San Antonio R. Time for a paradigm shift: from pacing to ablation in reflex syncope. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01521-z. [PMID: 37052860 DOI: 10.1007/s10840-023-01521-z] [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: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Rodolfo San Antonio
- Heart Disease Institute, Bellvitge Institute for Biomedical Research (IDIBELL), Bellvitge University Hospital, Feixa Llarga st., L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
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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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Pawłowski R, Zalewski P, Newton J, Piątkowska A, Koźluk E, Opolski G, Buszko K. An assessment of heart rate and blood pressure asymmetry in the diagnosis of vasovagal syncope in females. Front Physiol 2023; 13:1087837. [PMID: 36699671 PMCID: PMC9868761 DOI: 10.3389/fphys.2022.1087837] [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: 11/02/2022] [Accepted: 12/20/2022] [Indexed: 01/10/2023] Open
Abstract
Introduction: Heart Rate Asymmetry (HRA) describes a phenomenon of differences between accelerations and decelerations in human heart rate. Methods used for HRA assessment can be further implemented in the evaluation of asymmetry in blood pressure variations (Blood Pressure Asymmetry-BPA). Methods: We have analyzed retrospectively the series of heartbeat intervals extracted from ECG and beat-to-beat blood pressure signals from 16 vasovagal patients (age: 32.1 ± 13.3; BMI: 21.6 ± 3.8; all female) and 19 healthy subjects (age: 34.6 ± 7.6; BMI: 22.1 ± 3.4; all female) who have undergone tilt test (70°). Asymmetry was evaluated with Poincaré plot-based methods for 5 min recordings from supine and tilt stages of the test. The analyzed biosignals were heart rate (RR), diastolic (dBP) and systolic Blood Pressure (sBP) and Pulse Pressure (PP). In the paper we explored the differences between healthy and vasovagal women. Results: The changes of HRA indicators between supine and tilt were observed only in the control group (Porta Index p = 0.026 and Guzik Index p = 0.005). No significant differences in beat-to-beat variability (i.e. spread of points across the line of identity in Poincaré plot-SD1) of dBP was noted between supine and tilt in the vasovagal group (p = 0.433 in comparison to p = 0.014 in healthy females). Moreover, in vasovagal patients the PP was significantly different (supine: 41.47; tilt: 39.27 mmHg) comparing to healthy subjects (supine: 35.87; tilt: 33.50 mmHg) in supine (p = 0.019) and in tilt (p = 0.014). Discussion: Analysis of HRA and BPA represents a promising method for the evaluation of cardiovascular response to orthostatic stressors, however currently it is difficult to determine a subject's underlying health condition based only on these parameters.
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Affiliation(s)
- Rafał Pawłowski
- Department of Biostatistics and Biomedical Systems Theory, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland,*Correspondence: Rafał Pawłowski,
| | - Paweł Zalewski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Torun, Bydgoszcz, Poland,Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Julia Newton
- Population Health Sciences Institute, The Medical School, Newcastle University, Newcastle, United Kingdom
| | - Agnieszka Piątkowska
- Department of Emergency Medicine, Wroclaw Medical University, Wroclaw, Poland,1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Edward Koźluk
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Buszko
- Department of Biostatistics and Biomedical Systems Theory, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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Baysal E, Mutluer FO, Dagsali AE, Kumrulu UC, Huang HD, Aksu T. Improved health-related quality of life after cardioneuroablation in patients with vasovagal syncope. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01420-9. [PMID: 36357697 DOI: 10.1007/s10840-022-01420-9] [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: 09/22/2022] [Accepted: 11/04/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND As the most common cause of syncope, vasovagal syncope (VVS) is mediated by parasympathetic overactivity and/or sympathetic withdrawal. Although catheter ablation of ganglionated plexi or cardioneuroablation has been used to treat VVS, its role in quality of life (QoL) has not been formally evaluated. The aim of this study was to demonstrate if this novel treatment results in improvement QoL of patients with VVS. METHODS Twenty-seven consecutive patients (age: 34 ± 14 years, 51.8% male) with dominant cardioinhibitory type VVS were prospectively enrolled in the study. After confirmation of > 3 s asystole on head-up tilt testing (HUT), all patients underwent cardioneuroablation. ECGs were obtained prior to procedure and at 12-month follow-up visit. HUTs were repeated 1 month after cardioneuroablation procedures. QoL was assessed with the use of SF-36, EQ-5D, and EQ VAS questionnaires. RESULTS ECG, HUT, and QoL data were available in all patients. At 12-month follow-up, heart rate on rest ECG significantly increased (from 74 ± 15 to 84 ± 14 bpm, p = 0.003). Repeated HUTs were negative in 23 (85.1%) patients. All of 27 patients remained free of syncope. QoL assessed by SF-36 score significantly improved in postprocedural follow-up (92 ± 9 and 96 ± 11, p = 0.016). Similarly, significant improvements in mobility, self-care, and usual activity domains of EQ-5D were observed (mean scores of 3.0 ± 1.5 and 2.1 ± 1.3, p < 0.001; 1.3 ± 0.9 and 1.2 ± 0.6, p = 0.041; 1.7 ± 1.0 and 1.4 ± 0.8 respectively). EQ-VAS score also improved significantly (39 ± 24 to 77 ± 18, p < 0.001). CONCLUSION Our findings suggest that cardioneuroablation may be associated with intermediate term improvement in QoL in patients with VVS.
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Affiliation(s)
- Erkan Baysal
- Department of Cardiology, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey.
| | - Ferit Onur Mutluer
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | | | | | - Henry D Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
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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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