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Piotrowski R, Żuk A, Baran J, Sikorska A, Kryński T, Kułakowski P. Cardioneuroablation changes the type of vasovagal response in patients with asystolic reflex syncope. Auton Neurosci 2021; 235:102838. [PMID: 34186273 DOI: 10.1016/j.autneu.2021.102838] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 05/18/2021] [Accepted: 06/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardioneuroablation (CNA) has been recently proposed as a new therapy in patients with asystolic vasovagal syncope (VVS) caused by parasympathetic overactivity. OBJECTIVE To assess the impact of CNA on the type of VV response during tilt testing (TT). METHODS The study group consisted of 20 patients (7 males, mean age 38 ± 9). All patients had a history of syncope due to asystole and confirmed asystolic VVS at baseline TT (TT1). CNA was performed in the right and left atrium. The second TT (TT2) and Holter ECG were performed three months later. All patients completed one-year follow up. RESULTS At TT1, twenty patients had cardioinhibitory syncope and 1 had mixed VVS with asystole > 3 s. During one-year follow-up no spontaneous syncopal episodes were noted. At TT2, 6 patients had no syncope whereas the remaining 13 had syncope - twelve due to vasodepressor mechanism and only one due to asystole. Mean heart rate after CNA was significantly faster and heart rate variability parameter (SDNN) lower than before the procedure (82 ± 9 vs 69 ± 11 beats/min, p = 0.0003 and 74 ± 22 vs 143 ± 40 ms, p = 000001, respectively). These changes were similar in those who fainted during TT2 and those who did not (84 ± 10 vs 81 ± 5 beats/min, p = NS and 72 ± 24 vs 72 ± 19 ms, p = NS, respectively). CONCLUSIONS CNA profoundly affects type of VV reaction causing normalization of the response to tilting or changing cardiodepression to vasodepression. Changes in heart rate and heart rate variability are consistent with attenuation of parasympathetic activity.
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Affiliation(s)
- Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Anna Żuk
- 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 Kryński
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Piotr Kułakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
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Azizi Malamiri R, Momen AA, Nikkhah A, Khalilian MR, Ghaderian M, Najibi B, Samiei M. Usability of the head upright tilt test for differentiating between syncopal and seizure-like events in children. Acta Neurol Belg 2015; 115:575-9. [PMID: 25645711 DOI: 10.1007/s13760-015-0433-0] [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: 10/13/2014] [Accepted: 01/21/2015] [Indexed: 11/30/2022]
Abstract
The common diagnosis of loss of consciousness and clonic movements in children is seizure or epilepsy, but in a number of patients these symptoms could also be due to syncope. Over interpreted electroencephalography is misleading in a number of patients; therefore, in addition to a detailed and thorough history, a reliable test is needed to differentiate between these conditions. The aim of the study was to evaluate the utility of the head upright tilt test to differentiate between seizure-like events and syncope in children. A chart review descriptive study was conducted in a tertiary medical center in Ahvaz, Iran. We selected sixteen children (nine boys and seven girls) with convulsions of any type who were first diagnosed as epileptic based on the event description by their parents or caregivers to undergo the head upright tilt test. The main findings were the reproduction of previously presyncopal or syncopal symptoms in the tilted position. Fourteen children showed positive results after conducting the head upright tilt test, and their heart rates were significantly decreased compared to baseline at the onset of the syncopal or presyncopal manifestations. Systolic and diastolic blood pressures were significantly reduced in patients with positive results. In three children who initially had negative head upright tilt tests, intravenous isoproterenol was administered, and all three showed presyncopal and syncopal symptoms. The results indicate that the head upright tilt test could differentiate presyncopal and syncopal events in children who present with seizure-like movements but their history has clues for conclusive syncope.
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Affiliation(s)
- Reza Azizi Malamiri
- Department of Paediatric Neurology, Golestan Medical, Educational, and Research Center, Ahvaz Jundishapur University of Medical Sciences, # 90, Golestan Blvd., P.O. Box 6135733118, Ahvaz, Iran
| | - Ali Akbar Momen
- Department of Paediatric Neurology, Golestan Medical, Educational, and Research Center, Ahvaz Jundishapur University of Medical Sciences, # 90, Golestan Blvd., P.O. Box 6135733118, Ahvaz, Iran.
| | - Ali Nikkhah
- Department of Paediatric Neurology, Golestan Medical, Educational, and Research Center, Ahvaz Jundishapur University of Medical Sciences, # 90, Golestan Blvd., P.O. Box 6135733118, Ahvaz, Iran
| | - Mohammad Reza Khalilian
- Department of Paediatric Cardiology, Golestan Medical, Educational, and Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mehdi Ghaderian
- Department of Paediatric Cardiology, Child Growth and Development Research Center, Emam Hosein Hospital, Esfahan University of Medical Sciences, Esfahan, Iran
| | - Babak Najibi
- Department of Paediatric Cardiology, Golestan Medical, Educational, and Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mahboubeh Samiei
- Department of Paediatrics, Golestan Medical, Educational, and Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Erythrocytic hydrogen sulfide production is increased in children with vasovagal syncope. J Pediatr 2015; 166:965-9. [PMID: 25641243 DOI: 10.1016/j.jpeds.2014.12.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/03/2014] [Accepted: 12/09/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To explore the differences in erythrocyte hydrogen sulfide (H2S) production in children with vasovagal syncope (VVS). STUDY DESIGN A total of 54 children including 27 with VVS, aged 6-16 years (mean age 11.3 ± 3.3 years), and 27 healthy children, aged 3-17 years (mean age 10.4 ± 1.8 years) were included in the study. Children with VVS had symptoms of dizziness, pallor, blurred vision, nausea, and some had syncope. Erythrocyte H2S production was measured by a sulphur-sensitive electrode. Flow-mediated dilation (FMD) of brachial artery was measured for each patient by vascular ultrasound. RESULTS H2S production from erythrocytes was significantly increased in the children with VVS compared with controls (P < .01). The erythrocytic H2S production in the VVS-vasoinhibitory subgroup was obviously higher than that in VVS-cardioinhibitory (P < .05) and VVS-mixed inhibitory subgroups (P < .05). FMD in the VVS-vasoinhibitory subgroup was greater than that in the VVS-cardioinhibitory (P < .05) and the VVS-mixed subgroups (P < .05). The erythrocytic H2S production had a positive linear correlation with FMD in children with VVS (P < .05). CONCLUSIONS Increased erythrocyte H2S production may be involved in the pathogenesis of VVS in children.
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Mereu R, De Barbieri G, Perrone T, Mugellini A, Di Toro A, Bernardi L. Heart rate/blood pressure ratio as predictor of neuromediated syncope. Int J Cardiol 2013; 167:1170-5. [DOI: 10.1016/j.ijcard.2012.03.115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 02/03/2012] [Accepted: 03/10/2012] [Indexed: 12/25/2022]
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Karataş Z, Alp H, Sap F, Altın H, Baysal T, Karaarslan S. Usability of QTc dispersion for the prediction of orthostatic intolerance syndromes. Eur J Paediatr Neurol 2012; 16:469-74. [PMID: 22226850 DOI: 10.1016/j.ejpn.2011.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 12/09/2011] [Accepted: 12/18/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Syncope is defined as transient loss of consciousness and muscle tone, usually of short duration. Noncardiac causes of syncope are classified as orthostatic intolerance syndromes (OIS). QT and QTc (corrected QT) dispersions are the measurements of myocardial instability and show predisposition to arrhythmias. In this study; clinical findings, QT and QTc dispersions of the patients who were diagnosed as OIS were evaluated retrospectively. Also, the aim of the study is to clarify the association of clinical characteristics of unexplained syncope with the outcome of the QT and QTc dispersions in children. METHODS We designed a retrospective study including 152 children and adolescents who had repeated unexplained syncope or presyncope between June 2002 and August 2010. Head-up Tilt table test (HUTT) were performed for all patients. Control group consisted of 67 healthy children. The QT and QTc dispersions were measured from the 12 ECG leads. RESULTS Eighty-four (55.2%) patients had positive and 68 (44.8%) had negative response to HUTT. QT and QTc dispersions were significantly higher in HUTT-positive group than in negative (p < 0.01, p < 0.001 respectively). Also, QTc dispersion was significantly higher in both vasovagal syncope and postural orthostatic tachycardia syndrome groups than in HUTT-negative group (p < 0.001, p < 0.05 respectively). Specifity and sensitivity of QTc dispersion for predicting positive HUTT are 76.5% and 59.5% respectively. The positive predictive value of the test calculated as 75.8%. CONCLUSIONS These results revealed that we can use QTc dispersion measurement as a noninvasive electrocardiographic test to evaluate OIS for predicting positive result before performing HUTT.
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Affiliation(s)
- Zehra Karataş
- Selcuk University Meram, Department of Pediatric Cardiology, Beysehir Yolu, Meram, Konya, Turkey.
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Schroeder C, Tank J, Heusser K, Diedrich A, Luft FC, Jordan J. Physiological phenomenology of neurally-mediated syncope with management implications. PLoS One 2011; 6:e26489. [PMID: 22046292 PMCID: PMC3201957 DOI: 10.1371/journal.pone.0026489] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 09/28/2011] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Due to lack of efficacy in recent trials, current guidelines for the treatment of neurally-mediated (vasovagal) syncope do not promote cardiac pacemaker implantation. However, the finding of asystole during head-up tilt -induced (pre)syncope may lead to excessive cardioinhibitory syncope diagnosis and treatment with cardiac pacemakers as blood pressure is often discontinuously measured. Furthermore, physicians may be more inclined to implant cardiac pacemakers in older patients. We hypothesized that true cardioinhibitory syncope in which the decrease in heart rate precedes the fall in blood pressure is a very rare finding which might explain the lack of efficacy of pacemakers in neurally-mediated syncope. METHODS We studied 173 consecutive patients referred for unexplained syncope (114 women, 59 men, 42 ± 1 years, 17 ± 2 syncopal episodes). All had experienced (pre)syncope during head-up tilt testing followed by additional lower body negative suction. We classified hemodynamic responses according to the modified Vasovagal Syncope International Study (VASIS) classification as mixed response (VASIS I), cardioinhibitory without (VASIS IIa) or with asystole (VASIS IIb), and vasodepressor (VASIS III). Then, we defined the exact temporal relationship between hypotension and bradycardia to identify patients with true cardioinhibitory syncope. RESULTS Of the (pre)syncopal events during tilt testing, 63% were classified as VASIS I, 6% as VASIS IIb, 2% as VASIS IIa, and 29% as VASIS III. Cardioinhibitory responses (VASIS class II) progressively decreased from the youngest to the oldest age quartile. With more detailed temporal analysis, blood pressure reduction preceded the heart-rate decrease in all but six individuals (97%) overall and in 10 out of 11 patients with asystole (VASIS IIb). CONCLUSIONS Hypotension precedes bradycardia onset during head-up tilt-induced (pre)syncope in the vast majority of patients, even in those classified as cardioinhibitory syncope according to the modified VASIS classification. Furthermore, cardioinhibitory syncope becomes less frequent with increasing age.
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Affiliation(s)
- Christoph Schroeder
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany
- Experimental Clinical Research Center, Medical University Charité and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Jens Tank
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany
| | - Karsten Heusser
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Friedrich C. Luft
- Experimental Clinical Research Center, Medical University Charité and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Jens Jordan
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany
- * E-mail:
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Matsushima R, Tanaka H, Tamai H. Comparison of the active standing test and head-up tilt test for diagnosis of syncope in childhood and adolescence. Clin Auton Res 2005; 14:376-84. [PMID: 15666065 DOI: 10.1007/s10286-004-0182-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2003] [Revised: 02/26/2004] [Indexed: 10/25/2022]
Abstract
We examined 51 children and adolescents with orthostatic symptoms using two orthostatic tests, the active standing test (the AS test) and head-up tilt test (HUT), and compared circulatory responses, autonomic function in addition to the induction rate of syncope during short-time orthostasis. Syncope was induced in eight patients with both tests, in only six patients with the AS test and in only one patient with HUT. The induction rate was significantly higher with the AS test (p<0.0001). In addition, the AS test is common and daily postural motion and does not require a tilt table. We calculated percent changes in systolic blood pressure at the initial drop (DeltaID-SBP), in systolic blood pressure (DeltaSBP), in diastolic blood pressure (DeltaDBP), in heart rate (DeltaHR), component coefficient variation LF/HF (DeltaLF/HF) from supine to upright. DeltaHR were significantly larger in fainters than in non-fainters with both tests, although there was no difference in DeltaSBP and in DeltaDBP. In six fainters only with the AS test, DeltaHR was significantly larger with the AS test than with HUT. With the AS test DeltaID-SBP were correlative with DeltaLF/HF, and DeltaLF/HF were correlative with DeltaHR, whereas these relations were not clear in HUT. These results indicated the AS test caused cardiac sympathetic activation associated with an initial pressure drop, and was more prone to induce syncope with a greater HR increase in some patients. We conclude the AS test is as potential as HUT as a diagnostic test for syncope.
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Affiliation(s)
- Reiko Matsushima
- Dept. of Pediatrics, Daiichi-Towakai Hospital, Miyano-cho 2-17, Takatsuki-shi, Osaka, Japan, 569-0081,
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