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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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Chua SK, Chen WL, Chen LC, Shyu KG, Hung HF, Lee SH, Wang TL, Lai WT, Chen KJ, Liao ZY, Chuang CY, Chou CY. Enhancement of bicycle exercise capacity in patients with chronotropic incompetence through closed-loop stimulation: a randomized crossover trial. Europace 2023; 25:euad358. [PMID: 38042981 PMCID: PMC10751807 DOI: 10.1093/europace/euad358] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 11/22/2023] [Indexed: 12/04/2023] Open
Abstract
AIMS This study aimed to investigate the effectiveness of closed-loop stimulation (CLS) pacing compared with the traditional DDD mode in patients with chronotropic incompetence (CI) using bicycle-based cardiopulmonary exercise testing (CPET). METHODS AND RESULTS This single-centre, randomized crossover trial involved 40 patients with CI. Patients were randomized to receive either DDD-CLS or DDD mode pacing for 2 months, followed by a crossover to the alternative mode for an additional 2 months. Bicycling-based CPET was conducted at the 3- and 5-month follow-up visits to assess exercise capacity. Other cardiopulmonary exercise outcome measures and health-related quality of life (QoL) were also assessed. DDD-CLS mode pacing significantly improved exercise capacity, resulting in a peak oxygen uptake (14.8 ± 4.0 vs. 12.0 ± 3.6 mL/kg/min, P < 0.001) and oxygen uptake at the ventilatory threshold (10.0 ± 2.2 vs. 8.7 ± 1.8 mL/kg/min, P < 0.001) higher than those of the DDD mode. However, there were no significant differences in other cardiopulmonary exercise outcome measures such as ventilatory efficiency of carbon dioxide production slope, oxygen uptake efficiency slope, and end-tidal carbon dioxide between the two modes. Patients in the DDD-CLS group reported a better QoL, and 97.5% expressed a preference for the DDD-CLS mode. CONCLUSION DDD-CLS mode pacing demonstrated improved exercise capacity and QoL in patients with CI, highlighting its potential as an effective pacing strategy for this patient population.
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Affiliation(s)
- Su-Kiat Chua
- School of Medicine, College of Medicine, Fu Jen Catholic University, 510 Zhongzheng Road, Xinzhuang District, New Taipei City 24205, Taiwan
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Wen-Ling Chen
- School of Medicine, College of Medicine, Fu Jen Catholic University, 510 Zhongzheng Road, Xinzhuang District, New Taipei City 24205, Taiwan
- Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Lung-Ching Chen
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Kou-Gi Shyu
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Huei-Fong Hung
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Shih-Huang Lee
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Tzu-Lin Wang
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Wei-Ting Lai
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Kuan-Jen Chen
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Zhen-Yu Liao
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Cheng-Yen Chuang
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
| | - Ching-Yao Chou
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shih-Lin District, Taipei 11101, Taiwan
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Teixeira RA, Fagundes AA, Baggio Junior JM, Oliveira JCD, Medeiros PDTJ, Valdigem BP, Teno LAC, Silva RT, Melo CSD, Elias Neto J, Moraes Júnior AV, Pedrosa AAA, Porto FM, Brito Júnior HLD, Souza TGSE, Mateos JCP, Moraes LGBD, Forno ARJD, D'Avila ALB, Cavaco DADM, Kuniyoshi RR, Pimentel M, Camanho LEM, Saad EB, Zimerman LI, Oliveira EB, Scanavacca MI, Martinelli Filho M, Lima CEBD, Peixoto GDL, Darrieux FCDC, Duarte JDOP, Galvão Filho SDS, Costa ERB, Mateo EIP, Melo SLD, Rodrigues TDR, Rocha EA, Hachul DT, Lorga Filho AM, Nishioka SAD, Gadelha EB, Costa R, Andrade VSD, Torres GG, Oliveira Neto NRD, Lucchese FA, Murad H, Wanderley Neto J, Brofman PRS, Almeida RMS, Leal JCF. Brazilian Guidelines for Cardiac Implantable Electronic Devices - 2023. Arq Bras Cardiol 2023; 120:e20220892. [PMID: 36700596 PMCID: PMC10389103 DOI: 10.36660/abc.20220892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - Rodrigo Tavares Silva
- Universidade de Franca (UNIFRAN), Franca, SP - Brasil
- Centro Universitário Municipal de Franca (Uni-FACEF), Franca, SP - Brasil
| | | | - Jorge Elias Neto
- Universidade Federal do Espírito Santo (UFES), Vitória, ES - Brasil
| | - Antonio Vitor Moraes Júnior
- Santa Casa de Ribeirão Preto, Ribeirão Preto, SP - Brasil
- Unimed de Ribeirão Preto, Ribeirão Preto, SP - Brasil
| | - Anisio Alexandre Andrade Pedrosa
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Luis Gustavo Belo de Moraes
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | - Mauricio Pimentel
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | - Eduardo Benchimol Saad
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Hospital Samaritano, Rio de Janeiro, RJ - Brasil
| | | | | | - Mauricio Ibrahim Scanavacca
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Martino Martinelli Filho
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Batista de Lima
- Hospital Universitário da Universidade Federal do Piauí (UFPI), Teresina, PI - Brasil
- Empresa Brasileira de Serviços Hospitalares (EBSERH), Brasília, DF - Brasil
| | | | - Francisco Carlos da Costa Darrieux
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Sissy Lara De Melo
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Eduardo Arrais Rocha
- Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
| | - Denise Tessariol Hachul
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Silvana Angelina D'Orio Nishioka
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Roberto Costa
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Gustavo Gomes Torres
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN - Brasil
| | | | | | - Henrique Murad
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Rui M S Almeida
- Centro Universitário Fundação Assis Gurgacz, Cascavel, PR - Brasil
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4
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Choi YS, Jeong H, Yin RT, Avila R, Pfenniger A, Yoo J, Lee JY, Tzavelis A, Lee YJ, Chen SW, Knight HS, Kim S, Ahn HY, Wickerson G, Vázquez-Guardado A, Higbee-Dempsey E, Russo BA, Napolitano MA, Holleran TJ, Razzak LA, Miniovich AN, Lee G, Geist B, Kim B, Han S, Brennan JA, Aras K, Kwak SS, Kim J, Waters EA, Yang X, Burrell A, Chun KS, Liu C, Wu C, Rwei AY, Spann AN, Banks A, Johnson D, Zhang ZJ, Haney CR, Jin SH, Sahakian AV, Huang Y, Trachiotis GD, Knight BP, Arora RK, Efimov IR, Rogers JA. A transient, closed-loop network of wireless, body-integrated devices for autonomous electrotherapy. Science 2022; 376:1006-1012. [PMID: 35617386 PMCID: PMC9282941 DOI: 10.1126/science.abm1703] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Temporary postoperative cardiac pacing requires devices with percutaneous leads and external wired power and control systems. This hardware introduces risks for infection, limitations on patient mobility, and requirements for surgical extraction procedures. Bioresorbable pacemakers mitigate some of these disadvantages, but they demand pairing with external, wired systems and secondary mechanisms for control. We present a transient closed-loop system that combines a time-synchronized, wireless network of skin-integrated devices with an advanced bioresorbable pacemaker to control cardiac rhythms, track cardiopulmonary status, provide multihaptic feedback, and enable transient operation with minimal patient burden. The result provides a range of autonomous, rate-adaptive cardiac pacing capabilities, as demonstrated in rat, canine, and human heart studies. This work establishes an engineering framework for closed-loop temporary electrotherapy using wirelessly linked, body-integrated bioelectronic devices.
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Affiliation(s)
- Yeon Sik Choi
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Precision Biology Research Center, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - Hyoyoung Jeong
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Rose T. Yin
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
| | - Raudel Avila
- Department of Mechanical Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Anna Pfenniger
- Feinberg School of Medicine, Cardiology, Northwestern University, Chicago, IL 60611, USA
| | - Jaeyoung Yoo
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Jong Yoon Lee
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Sibel Health, Niles, IL, 60714, USA
| | - Andreas Tzavelis
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
- Medical Scientist Training Program, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Young Joong Lee
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Sheena W. Chen
- Department of General Surgery, The George Washington University, Washington, DC 20052, USA
- Department of Cardiothoracic Surgery, Veteran Affairs Medical Center, Washington, DC 20422, USA
| | - Helen S. Knight
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
| | - Seungyeob Kim
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Electronic Engineering, Incheon National University, 119 Academy-ro, Yeonsu-gu, Incheon, 406-772, Republic of Korea
| | - Hak-Young Ahn
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Precision Biology Research Center, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - Grace Wickerson
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Abraham Vázquez-Guardado
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | | | - Bender A. Russo
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
| | - Michael A. Napolitano
- Department of General Surgery, The George Washington University, Washington, DC 20052, USA
- Department of Cardiothoracic Surgery, Veteran Affairs Medical Center, Washington, DC 20422, USA
| | - Timothy J. Holleran
- Department of General Surgery, The George Washington University, Washington, DC 20052, USA
- Department of Cardiothoracic Surgery, Veteran Affairs Medical Center, Washington, DC 20422, USA
| | - Leen Abdul Razzak
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Alana N. Miniovich
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
| | - Geumbee Lee
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Beth Geist
- Feinberg School of Medicine, Cardiology, Northwestern University, Chicago, IL 60611, USA
| | | | - Shuling Han
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Jaclyn A. Brennan
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
| | - Kedar Aras
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
| | - Sung Soo Kwak
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Current Address: Center for Bionics of Biomedical Research Institute, Korea Institute of Science and Technology, Seoul 02792, Korea
| | - Joohee Kim
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Emily Alexandria Waters
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
- Center for Advanced Molecular Imaging, Northwestern University, Evanston, IL 60208, USA
| | - Xiangxing Yang
- Department of Electrical and Computer Engineering, University of Texas at Austin, Austin, Tx, 78712, USA
| | - Amy Burrell
- Feinberg School of Medicine, Cardiology, Northwestern University, Chicago, IL 60611, USA
| | - Keum San Chun
- Department of Electrical and Computer Engineering, University of Texas at Austin, Austin, Tx, 78712, USA
| | - Claire Liu
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
| | - Changsheng Wu
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Alina Y. Rwei
- Department of Chemical Engineering, Delft University of Technology, Van der Maasweg 9, 2629 HZ Delft, The Netherlands
| | - Alisha N. Spann
- Center for Advanced Molecular Imaging, Northwestern University, Evanston, IL 60208, USA
| | - Anthony Banks
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - David Johnson
- Feinberg School of Medicine, Cardiology, Northwestern University, Chicago, IL 60611, USA
| | - Zheng Jenny Zhang
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Chad R. Haney
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
- Center for Advanced Molecular Imaging, Northwestern University, Evanston, IL 60208, USA
| | - Sung Hun Jin
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Electronic Engineering, Incheon National University, 119 Academy-ro, Yeonsu-gu, Incheon, 406-772, Republic of Korea
| | - Alan Varteres Sahakian
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Electrical and Computer Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Yonggang Huang
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
- Department of Mechanical Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Civil and Environmental Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Gregory D. Trachiotis
- Department of Cardiothoracic Surgery, Veteran Affairs Medical Center, Washington, DC 20422, USA
| | - Bradley P. Knight
- Feinberg School of Medicine, Cardiology, Northwestern University, Chicago, IL 60611, USA
| | - Rishi K. Arora
- Feinberg School of Medicine, Cardiology, Northwestern University, Chicago, IL 60611, USA
| | - Igor R. Efimov
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
| | - John A. Rogers
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Mechanical Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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5
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Palmisano P, Guerra F, Aspromonte V, Dell’Era G, Pellegrino PL, Laffi M, Uran C, De Bonis S, Accogli M, Russo AD, Patti G, Santoro F, Torriglia A, Nigro G, Bisignani A, Coluccia G, Stronati G, Russo V, Ammendola E. Management of older patients with unexplained, recurrent, traumatic syncope and bifascicular block: implantable loop recorder versus empiric pacemaker implantation. Results of a propensity matched analysis. Heart Rhythm 2022; 19:1696-1703. [PMID: 35643299 DOI: 10.1016/j.hrthm.2022.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/09/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022]
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6
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Wang L, Malik A, Roop PS, Cheng LK, Paskaranandavadivel N. A framework for the design of a closed-loop gastric pacemaker for treating conduction block. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 216:106652. [PMID: 35124479 DOI: 10.1016/j.cmpb.2022.106652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 12/14/2021] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Gastrointestinal (GI) motility disorders can be significantly detrimental to the quality of life. Pacing, or long pulse gastric electrical stimulation, is a potential treatment option for treating GI motility disorders by modulating the slow wave activity. Open-loop pacing of the GI tract is the current standard for modulating dysrhythmic patterns, but it is known to be suboptimal and inefficient. Recent work on sensing intracellular potentials and pacing accordingly in a closed-loop has been shown to be effective at modulating dysrhythmic patterns. However, capturing intracellular potentials in an in-vivo setting is not viable. Therefore a closed-loop gastric electrical stimulation that can sense extracellular potentials and pace accordingly to modulate dysrhythmic patterns is required. This paper presents a closed-loop Gastric Electrical Stimulator (GES) design framework, which comprises of extracellular potential generation, sensing, and closed-loop actuation. METHODS This work leverages a pre-existing high-fidelity two-dimensional Interstitial Cells of Cajal (ICC) network modeling framework to mimic several normal and dysrhythmic patterns observed in experimental recordings of patients suffering from GI tract diseases. The activation patterns of the of the ICC network are captured by an extracellular potential generation model and is integrated with the GES in a closed-loop to validate the efficacy of the developed pacing algorithms. The proposed GES pacing algorithms extend existing offline filtering and activation detection methods to process the sensed extracellular potentials in real time. The GES detects bradygastric rhythms based on the sensed extracellular potentials and actuates the ICC network via pacing to rectify dysrhythmic patterns. RESULTS The proposed GES model is able to sense and process the generated noisy extracellular potentials, detect the bradygastric patterns, and modulate the slow wave activities to normal propagation effectively. CONCLUSIONS A closed-loop GES design, which can be applied in an experimental and clinical setting is developed and validated through the ICC network model. The proposed GES model has the ability to modulate a variety of bradygastric patterns, including conduction block effectively in a closed-loop.
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Affiliation(s)
- Luman Wang
- Department of Electrical, Computer and Software Engineering, University of Auckland, Auckland 1010, New Zealand.
| | - Avinash Malik
- Department of Electrical, Computer and Software Engineering, University of Auckland, Auckland 1010, New Zealand.
| | - Partha S Roop
- Department of Electrical, Computer and Software Engineering, University of Auckland, Auckland 1010, New Zealand.
| | - Leo K Cheng
- Auckland Bioengineering Institute, University of Auckland, New Zealand.
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7
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Tomaino M, Russo V, Giacopelli D, Gargaro A, Brignole M. Cardiac Pacing in Cardioinhibitory Reflex Syncope: Clinical Use of Closed-loop Stimulation. Arrhythm Electrophysiol Rev 2021; 10:244-249. [PMID: 35106176 PMCID: PMC8785081 DOI: 10.15420/aer.2021.45] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022] Open
Abstract
Cardiac pacing has been studied extensively in patients with reflex syncope over the past two decades. The heterogeneity of the forms and clinical manifestations of reflex syncope explain the controversial results of older randomised clinical trials. New evidence from recent trials has changed medical practice, now leading to clear indications for pacing in patients with asystolic syncope documented during carotid sinus massage, implantable cardiac monitoring or tilt testing. Given that recent trials in reflex syncope have been performed using the closed-loop stimulation algorithm, the authors will briefly discuss this pacing mode, review hypotheses about the mechanisms underlying its activation during syncope and provide practical instructions for programming and troubleshooting.
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Affiliation(s)
| | - Vincenzo Russo
- Department of Cardiology, University of Campania ‘Luigi Vanvitelli’, Ospedale Monaldi, Naples, Italy
| | | | | | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Programme, Ospedale San Luca, Milano, Italy
- Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
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8
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Jorge JG, Raj SR, Teixeira PS, Teixeira JAC, Sheldon RS. Likelihood of injury due to vasovagal syncope: a systematic review and meta-analysis. Europace 2021; 23:1092-1099. [PMID: 33693816 DOI: 10.1093/europace/euab041] [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: 11/07/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Vasovagal syncope (VVS) is the most common type of syncope and is usually considered a benign disorder. The potential for injury is worrisome but the likelihood is unknown. We aimed to determine the proportion of patients injured due to VVS. METHODS AND RESULTS A systematic search of studies published until August 2020 was performed in multiple medical and nursing databases. Included studies had data on the proportion of patients with injury due to VVS prior to study enrolment. Random effects methods were used. Twenty-three studies having 3593 patients met inclusion criteria. Patients were diagnosed clinically with VVS, and 82% had >2 syncopal episodes before enrolment. Tilt test was positive in 60% and 14 studies reported comorbidities (32.6% hypertensive). The weighted mean injury rate was 33.5% [95% confidence interval (CI): 27.3-40.5%]. The likelihood of injury correlated with population age (r = 0.4, P = 0.05), but not with sex, positive tilt test, or hypertension. The injury rates were 25.7% (95% CI: 19.1-32.8%) in studies with younger patients (mean age ≤50 years, n = 1803) and 43.4% (95% CI: 34.9-52.3%) in studies with older patients (P = 0.002). Nine studies reported major injuries; with a weighted mean rate of major injuries of 13.9% (95% CI: 9.5-19.8%). CONCLUSION Injuries due to syncope are frequent, occurring in 33% of patients with VVS. The risk of major injuries is substantial. Older patients are at higher risk. Clinicians should be aware of the risk of injuries when providing care and advice to patients with VVS.
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Affiliation(s)
- Juliana G Jorge
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Pedro S Teixeira
- Clinica Fit Labor Centro de Performance Humana, Niteroi, Rio de Janeiro, Brazil
| | - Jose A C Teixeira
- Clinica Fit Labor Centro de Performance Humana, Niteroi, Rio de Janeiro, Brazil
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
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9
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Palmisano P, Dell'Era G, Pellegrino PL, Ammendola E, Ziacchi M, Guerra F, Aspromonte V, Laffi M, Pimpini L, Santoro F, Boggio E, Guido A, Patti G, Brunetti ND, Nigro G, Biffi M, Russo AD, Gaggioli G, Accogli M. Causes of syncopal recurrences in patients treated with permanent pacing for bradyarrhythmic syncope: Findings from the SYNCOPACED registry. Heart Rhythm 2021; 18:770-777. [PMID: 33465512 DOI: 10.1016/j.hrthm.2021.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few studies have examined the causes of syncope/collapse recurrences in patients with a previously implanted pacemaker for bradyarrhythmic syncope. OBJECTIVE The purpose of this study was to assess the causes of syncope/collapse recurrences after pacemaker implantation for bradyarrhythmic syncope in a large patient population. METHODS The SYNCOpal recurrences in patients treated with permanent PACing for bradyarrhythmic syncope (SYNCOPACED) registry was a prospective multicenter observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for bradyarrhythmic syncope. During follow-up, the time to the first syncope/collapse recurrence was recorded. Patients with syncope/collapse recurrences underwent a predefined diagnostic workup aimed at establishing the mechanism of syncope/collapse. RESULTS During a median follow-up of 50 months, 213 patients (15.6%) reported at least 1 syncope/collapse recurrence. The risk of syncope/collapse recurrence was highest in patients who underwent implantation for cardioinhibitory vasovagal syncope (26.4%), followed by unexplained syncope and chronic bifascicular block (21.5%), cardioinhibitory carotid sinus syndrome (17.2%), atrial fibrillation needing pacing (15.5%), atrioventricular block (13.6%), and sinus node disease (12.5%) (P = .017). The most frequent cause of syncope/collapse recurrence was reflex syncope (27.7%), followed by orthostatic hypotension (26.3%), pacemaker or lead malfunction (5.6%), structural cardiac disease (5.2%), and atrial and ventricular tachyarrhythmias (4.7% and 3.8%, respectively). In 26.8% of cases, the mechanism of syncope/collapse remained unexplained. CONCLUSION In patients receiving a pacemaker for bradyarrhythmic syncope, reflex syncope and orthostatic hypotension are the most frequent mechanisms of syncope/collapse recurrence after implantation. Pacing system malfunction, structural cardiac diseases, and tachyarrhythmias are rare mechanisms. The mechanism remains unexplained in >25% of patients.
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Affiliation(s)
| | - Gabriele Dell'Era
- Azienda Ospedaliera Universitaria "Maggiore della Carità," Novara, Italy
| | | | - Ernesto Ammendola
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Matteo Ziacchi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi," Ancona, Italy
| | - Vittorio Aspromonte
- Cardiology - Coronary Care Unit, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - Mattia Laffi
- Cardiology Division, Villa Scassi Hospital, Genova ASL 3, Genova, Italy
| | - Lorenzo Pimpini
- Unit of Cardiology-CCU, Italian National Research Centre on Aging, Ancona, Italy
| | - Francesco Santoro
- Department of Cardiology, Bonomo Hospital, Andria, Italy; Department of Medical and Surgery Sciences, University of Foggia, Foggia, Italy
| | - Enrico Boggio
- Azienda Ospedaliera Universitaria "Maggiore della Carità," Novara, Italy
| | | | - Giuseppe Patti
- Azienda Ospedaliera Universitaria "Maggiore della Carità," Novara, Italy
| | | | - Gerardo Nigro
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Mauro Biffi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi," Ancona, Italy
| | - Germano Gaggioli
- Cardiology Division, Villa Scassi Hospital, Genova ASL 3, Genova, Italy
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10
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Palmisano P, Pellegrino PL, Ammendola E, Ziacchi M, Guerra F, Aspromonte V, Laffi M, Pimpini L, Santoro F, Boggio E, Guido A, Patti G, Brunetti ND, Nigro G, Biffi M, Dello Russo A, Gaggioli G, Accogli M, Dell’Era G. Risk of syncopal recurrences in patients treated with permanent pacing for bradyarrhythmic syncope: role of correlation between symptoms and electrocardiogram findings. Europace 2020; 22:1729-1736. [DOI: 10.1093/europace/euaa188] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 06/12/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
To evaluate the risk of syncopal recurrences after pacemaker implantation in a population of patients with syncope of suspected bradyarrhythmic aetiology.
Methods and results
Prospective, multicentre, observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for syncope of bradyarrhythmic aetiology (proven or presumed). Before pacemaker implantation, all patients underwent a cardiac work-up in order to establish the bradyarrhythmic aetiology of syncope. According to the results of the diagnostic work-up, patients were divided into three groups: Group A, patients in whom a syncope-electrocardiogram (ECG) correlation was established (n = 329, 24.1%); Group B, those in whom clinically significant bradyarrhythmias were detected without a documented syncope-ECG correlation (n = 877, 64.3%); and Group C, those in whom bradyarrhythmias were not detected and the bradyarrhythmic origin of syncope remained presumptive (n = 158, 11.6%). During a median follow-up of 50 months, 213 patients (15.6%) reported at least one syncopal recurrence. Patients in Groups B and C showed a significantly higher risk of syncopal recurrences than those in Group A [hazard ratios (HRs): 1.60 and 2.66, respectively, P < 0.05]. Failure to establish a syncope-ECG correlation during diagnostic work-up before pacemaker implantation was an independent predictor of syncopal recurrence on multivariate analysis (HR: 1.90; P = 0.002).
Conclusion
In selecting patients with syncope of suspected bradyarrhythmic aetiology for pacemaker implantation, establishing a correlation between syncope and bradyarrhythmias maximizes the efficacy of pacing and reduces the risk of syncopal recurrences.
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Affiliation(s)
| | | | - Ernesto Ammendola
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Matteo Ziacchi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I—Lancisi—Salesi”, Ancona, Italy
| | - Vittorio Aspromonte
- Cardiology - Coronary Care Unit, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - Mattia Laffi
- Cardiology Division, Villa Scassi Hospital, Genova, ASL 3, Genova, Italy
| | - Lorenzo Pimpini
- Unit of Cardiology-CCU, Italian National Reserch Centre on Aging, Ancona, Italy
| | - Francesco Santoro
- Department of Cardiology, Bonomo Hospital, Andria, Italy
- Department of Medical and Surgery Sciences, University of Foggia, Foggia, Italy
| | - Enrico Boggio
- Division of Cardiology, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Novara, Italy
| | | | - Giuseppe Patti
- Division of Cardiology, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Novara, Italy
| | | | - Gerardo Nigro
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Mauro Biffi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I—Lancisi—Salesi”, Ancona, Italy
| | - Germano Gaggioli
- Cardiology Division, Villa Scassi Hospital, Genova, ASL 3, Genova, Italy
| | | | - Gabriele Dell’Era
- Division of Cardiology, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Novara, Italy
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11
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Akella K, Olshansky B, Lakkireddy D, Gopinathannair R. Pacing Therapies for Vasovagal Syncope. J Atr Fibrillation 2020; 13:2406. [PMID: 33024506 DOI: 10.4022/jafib.2406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/24/2020] [Accepted: 03/25/2020] [Indexed: 01/02/2023]
Abstract
Vasovagal Syncope (VVS) is mediated by a cardiac autonomic reflex with resultant bradycardia and hypotension, precipitating syncope. While benign and mostly well controlled, recurrent VVS can be debilitating and warrants intervention. Non-pharmacological management of VVS have had variable success. In patients with recurrent cardioinhibitory VVS, permanent pacing can be effective. The utility of pacing to preempt the syncopal depends on the prominent temporal role of bradycardia during the vasovagal reflex. Current guidelines recommend pacing as a therapy to consider in older patients with recurrent VVS. Although younger patients can benefit, one should be cautious given the long-term risk of complications. Available data appears to favor a dual chamber pacemaker with closed loop stimulation algorithm to prevent recurrent cardioinhibitory VVS. Several aspects, including mechanistic understanding of VVS and appropriate patient selection, remain unclear, and require further study.
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Affiliation(s)
- Krishna Akella
- Kansas City Heart Rhythm Institute (KCHRI), Overland Park, KS, USA
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12
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Barón-Esquivias G, Barón-Solís C, Ordóñez A. Pacing for Patients Suffering From Cardioinhibitory Vasovagal Syncope Using the Closed-Loop System. Front Cardiovasc Med 2020; 6:192. [PMID: 32118042 PMCID: PMC7033422 DOI: 10.3389/fcvm.2019.00192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/18/2019] [Indexed: 11/18/2022] Open
Abstract
One in three vasovagal syncope (VVS) patients has syncopal recurrence after diagnosis, despite the standard recommendations for the avoidance of a recurrence, and one in five patients has more than one syncopal recurrence in the medium term. Given the high prevalence of VVS, there is a large population that continues to need effective treatment. There are numerous studies that use the implantable loop recorder (ILR) to document a cardioinhibitory response during VVS, with one study, ISSUE-3, demonstrating the efficacy of pacing using the rate-drop-response algorithm to trigger pacing and prevent syncopal recurrence in this population. There are more uncertainties in the studies that have used head-up tilt test (HUT) to select the population for pacing. We have recently performed the SPAIN randomized, controlled clinical trial using HUT to select the patients for pacing. The conclusion of the study was that, with the closed-loop system to introduce pacing, there was a significant reduction in the burden of syncope and a seven-fold increase in the time to first recurrence of syncope, which was greater than in the ISSUE-3 study. Since the completion of the SPAIN trial and its inclusion in the European guidelines, in our daily clinical practice, the use of this therapy is still recommended with caution in the context of the available literature, but it has increased our confidence in so doing. One in five patients with VVS needs treatment because of a high syncopal load. If an ILR is used to select the patients for pacing, the rate-drop-response algorithm can be recommended. In patients who have asystole on HUT, pacing with the closed-loop system has higher success and must now be considered as a tenable option for VVS patients.
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Affiliation(s)
- Gonzalo Barón-Esquivias
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain.,Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain.,Centro de Investigacion en Biomedicina en Red Cardiovascular (CIBER-CV), Madrid, Spain
| | - Carmen Barón-Solís
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain
| | - Antonio Ordóñez
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain.,Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain.,Centro de Investigacion en Biomedicina en Red Cardiovascular (CIBER-CV), Madrid, Spain.,Centro Superior de Investigaciones Científicas (CSIC), Madrid, Spain
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13
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Sutton R, de Jong JSY, Stewart JM, Fedorowski A, de Lange FJ. Pacing in vasovagal syncope: Physiology, pacemaker sensors, and recent clinical trials-Precise patient selection and measurable benefit. Heart Rhythm 2020; 17:821-828. [PMID: 32036025 DOI: 10.1016/j.hrthm.2020.01.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/26/2020] [Indexed: 10/25/2022]
Abstract
The role of pacing in vasovagal syncope (VVS) is considered from a physiological basis. Most VVS patients lose consciousness due to hypotension before severe bradycardia/asystole occurs. Patients who benefit from dual-chamber pacing typically are older with highly symptomatic, late-onset, frequent and severe syncope with short/no prodrome and documented severe cardioinhibition. Tilt testing is of value in patients with recurrent unexplained syncope to identify important hypotensive susceptibility stemming from reduced venous return and stroke volume (SV). A negative tilt test in vasovagal patients with spontaneous asystole documented by an implantable/insertable loop recorder is associated with lower syncope recurrence rates after pacemaker implantation. Pacing may be more effective if triggered by sensor detection of a parameter changing earlier in the reflex than bradycardia when SV may still be relatively preserved. In this regard, detection of right ventricular impedance offers promise. Conservatism is recommended, limiting pacing in VVS to a small subset of symptomatic older patients with clearly documented cardioinhibition and paying particular attention to the timing of loss of consciousness in relation to asystole/bradycardia. Understanding VVS physiology permits application of well-timed, appropriate pacing that yields benefit for highly symptomatic patients.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, London, United Kingdom; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Jelle S Y de Jong
- Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Julian M Stewart
- Departments of Pediatrics, Physiology and Medicine. New York Medical College. Valhalla, New York
| | - Artur Fedorowski
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Frederik J de Lange
- Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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14
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Barón-Esquivias G, Moya-Mitjans A, Martinez-Alday J, Ruiz-Granell R, Lacunza-Ruiz J, Garcia-Civera R, Gutiérrez-Carretero E, Romero-Garrido R, Morillo CA. Impact of dual-chamber pacing with closed loop stimulation on quality of life in patients with recurrent reflex vasovagal syncope: results of the SPAIN study. Europace 2019; 22:314-319. [DOI: 10.1093/europace/euz294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/01/2019] [Indexed: 12/26/2022] Open
Abstract
Abstract
Aims
Reflex vasovagal syncope (VVS) is the most common cause of syncope and patients with recurrent episodes may severely impair quality of life (QoL). This pre-specified analysis evaluated whether the clinically significant reduction in syncope burden demonstrated by dual-chamber pacing with closed loop stimulation (DDD-CLS) reported in the SPAIN trial translates into improved QoL.
Methods and results
Patients aged ≥40 years with ≥5 VVS episodes and cardioinhibitory response induced by head-up tilt testing were included. Patients were randomized 1:1 to active DDD-CLS pacing algorithm for 12 months followed by sham DDI mode for the remaining 12 months (Group A) or vice versa (Group B). QoL was assessed using the Short Form-36 (SF-36) health survey, Physical Component Score (PCS), and Mental Component Score (MCS) before randomization (baseline) and at 12- and 24-month follow-up. Fifty-four patients were enrolled from 11 participating centres. No significant carryover effect was detected for any variable, and the only period effect was observed in the vitality subdomain (P = 0.033). Mean SF-36 scores were higher in the DDD-CLS group vs. the DDI group for the eight subdomains and significantly different in physical role, bodily pain, and vitality (P < 0.05). The analysis of component summary scores indicated that DDD-CLS benefited both mental and physical components with significant differences in PCS when compared with the DDI group.
Conclusion
Dual-chamber pacing with closed loop stimulation determined a significant and clinically relevant improvement in QoL across both mental and physical components in patients with recurrent VVS.
Registration
Closed Loop Stimulation for Neuromediated Syncope (SPAIN Study); NCT01621464.
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Affiliation(s)
- Gonzalo Barón-Esquivias
- Department of Cardiology, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla. Av. Manuel Siurot, S/n, 41013 Sevilla, Spain
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
| | - Angel Moya-Mitjans
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Vall d’Hebron, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Jesús Martinez-Alday
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Basurto, Montevideo Etorb., 18, 48013 Bilbao, Spain
- Department of Cardiology, Clínica IMQ Zorrotzaurre, Ballets Olaeta, 4, 48014 Bilbao, Spain
| | - Ricardo Ruiz-Granell
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Clínico de Valencia, Av. de Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - Javier Lacunza-Ruiz
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 Murcia, Spain
| | - Roberto Garcia-Civera
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Clínico de Valencia, Av. de Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - Encarnación Gutiérrez-Carretero
- Department of Cardiology, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla. Av. Manuel Siurot, S/n, 41013 Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Melchor Fernández Almagro, 3, 28029 Madrid, Spain
| | - Rafael Romero-Garrido
- Department of Cardiology, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla. Av. Manuel Siurot, S/n, 41013 Sevilla, Spain
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Nuestra Señora de la Candelaria, Ctra. Gral. del Rosario, 145, 38010 Santa Cruz de Tenerife, Spain
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1 and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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15
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The benefit of closed loop stimulation in patients with cardioinhibitory vasovagal syncope confirmed by head-up tilt table testing: a systematic review and meta-analysis. J Interv Card Electrophysiol 2019; 55:105-113. [DOI: 10.1007/s10840-019-00531-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
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16
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Russo V, Rago A, De Rosa M, Papa AA, Simova I, Petrov I, Bonev N, Gargaro A, Golino P, Nigro G. Does cardiac pacing reduce syncopal recurrences in cardioinhibitory vasovagal syncope patients selected with head-up tilt test? Analysis of a 5-year follow-up database. Int J Cardiol 2018; 270:149-153. [PMID: 29980368 DOI: 10.1016/j.ijcard.2018.06.063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/05/2018] [Accepted: 06/18/2018] [Indexed: 12/18/2022]
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17
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Rattanawong P, Riangwiwat T, Chongsathidkiet P, Vutthikraivit W, Limpruttidham N, Prasitlumkum N, Kanjanahattakij N, Kanitsoraphan C. Closed-looped stimulation cardiac pacing for recurrent vasovagal syncope: A systematic review and meta-analysis. J Arrhythm 2018; 34:556-564. [PMID: 30327702 PMCID: PMC6174378 DOI: 10.1002/joa3.12102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/21/2018] [Accepted: 07/08/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vasovagal syncope (VVS) is defined by transient loss of consciousness with spontaneous rapid recovery. Recently, a closed-loop stimulation pacing system (CLS) has shown superior effectiveness to conventional pacing in refractory VVS. However, systematic review and meta-analysis has not been performed. We assessed the impact of CLS implantation and reduction in recurrent VVS events by a systematic review and a meta-analysis. METHODS We comprehensively searched the databases of MEDLINE and EMBASE from inception to September 2017. Included studies were published prospective or retrospective cohort, randomized controlled trial, and case-control studies that compared VVS events between recurrent, severe, or refractory cardioinhibitory VVS patient implanted with CLS and conventional pacing. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate odds ratios and 95% confidence intervals. RESULTS Six studies from November 2004 to October 2017 were included in this meta-analysis involving 224 recurrent, severe, or refractory cardioinhibitory VVS patients implanted with CLS and 163 recurrent, severe, or refractory VVS patients implanted with conventional pacing. CLS significantly reduced recurrent VVS events compared to conventional pacing (pooled odds ratio = 0.23, 95% confidence interval: 0.13-0.39, P = 0.000, I 2 = 36.5%) as well as subgroup of four randomized controlled trial studies (pooled odds ratio = 0.28, 95% confidence interval: 0.17-0.44, P = 0.000, I 2 = 39.2%). CONCLUSION Closed-loop stimulation significantly reduced recurrent VVS events up to 80% when compared to conventional pacing. Our study suggests that CLS is an effective tool for preventing syncope recurrences in patients with recurrent, severe, or refractory cardioinhibitory VVS.
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Affiliation(s)
- Pattara Rattanawong
- University of Hawaii Internal Medicine Residency ProgramHonoluluHawaii
- Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
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18
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Silvetti MS, Pazzano V, Battipaglia I, Di Mambro C, Calvieri C, Saputo FA, Verticelli L, Carotti A, Torcinaro S, Drago F. Physiological pacing in young patients with complex congenital heart defects. Pacing Clin Electrophysiol 2018; 41:967-977. [PMID: 29873818 DOI: 10.1111/pace.13409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 03/27/2018] [Accepted: 05/28/2018] [Indexed: 12/01/2022]
Abstract
AIM Young patients with operated complex congenital heart defects (CHD) often develop sinus node dysfunction (SND) requiring permanent pacing with rate-responsive function. Activity-driven sensors cannot account for nonmovement stress and cannot modulate heart rate physiologically. Closed Loop Stimulation (CLS, Biotronik, Berlin, Germany) is a physiological rate-responsive pacemaker based on the indirect measure of ventricular contractility. No data are available on the effects of such pacing strategy in young patients. METHODS We report a series of nine patients with CHD and SND who underwent single-chamber CLS-atrial pacing with endocardial or epicardial lead. During the first 30 days, the pacemaker was programmed in AAI pacing mode and then was switched to CLS-atrial pacing mode. An in-hospital control was scheduled 1-2 months later to evaluate the CLS response to neurovegetative stresses (i.e., nonmovement stress [Stroop color test, handgrip] and exercise stress test) and Holter monitor. CLS pacing was compared with rate-responsive accelerometer-driven pacing (AAIR). RESULTS At telemetric interrogation, CLS pacing showed a more physiological pattern of 24-h heart rate trends than accelerometer sensors. The data obtained during nonmovement/exercise stress demonstrated a physiological increase in the pacing rate with CLS, in synergy with spontaneous events. The accelerometer sensor histogram, during nonmovement stress, showed a "nonresponse" behavior (only lower rate events), and during exercise test showed most events in lower rate range. Holter monitoring showed increase of average and maximum heart rate compared with AAIR. CONCLUSION In young CHD patients, endocardial/epicardial CLS-atrial pacing demonstrated a physiological response of heart rate to neurovegetative and physical stresses.
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Affiliation(s)
- Massimo Stefano Silvetti
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Vincenzo Pazzano
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Irma Battipaglia
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Corrado Di Mambro
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Camilla Calvieri
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Fabio Anselmo Saputo
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Letizia Verticelli
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Adriano Carotti
- Heart Surgery Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | | | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
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Gopinathannair R, Salgado BC, Olshansky B. Pacing for Vasovagal Syncope. Arrhythm Electrophysiol Rev 2018; 7:95-102. [PMID: 29967681 PMCID: PMC6020179 DOI: 10.15420/aer.2018.22.2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/03/2018] [Indexed: 12/28/2022] Open
Abstract
Vasovagal syncope (VVS) is due to a common autonomic reflex involving the cardiovascular system. It is associated with bradycardia (cardioinhibitory response) and/or hypotension (vasodepressor response), likely mediated by parasympathetic activation and sympathetic inhibition. While generally a situational, isolated and/or self-limited event, for some, VVS is recurrent, unpredictable and debilitating. Conservative, non-pharmacological management may help, but no specific medical therapy has been proven widely effective. Permanent pacing may have specific benefit, but its value has been debated. The temporal causative association of bradycardia with syncope in those with VVS may help identify which patient could benefit from pacing but the timing and type of pacing in lieu of blood pressure changes may be critical. The mode, rate, pacing algorithm and time to initiate dual-chamber pacing preferentially with respect to the vasovagal reflex may be important to prevent or ameliorate the faint but completely convincing data are not yet available. Based on available data, DDD pacing with the closed loop stimulation algorithm appears a viable, if not the best, alternative presently to prevent recurrent VVS episodes. While several knowledge gaps remain, permanent pacing appears to have a role in managing select patients with VVS.
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Affiliation(s)
| | - Benjamin C Salgado
- Division of Cardiovascular Medicine, University of LouisvilleLouisville, USA
| | - Brian Olshansky
- Mercy Heart and Vascular Institute, Mason City; and the University of Iowa HospitalsIowa City, USA
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Ruzieh M, Grubb BP. Vasovagal syncope-role of closed loop stimulation pacing. Trends Cardiovasc Med 2018; 28:534-538. [PMID: 29843961 DOI: 10.1016/j.tcm.2018.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 04/26/2018] [Accepted: 05/13/2018] [Indexed: 10/16/2022]
Abstract
The benefit of conventional pacing in vasovagal syncope remains controversial and is currently recommended for patients with recurrent syncope and documented asystole. In the last two decades, a growing body of evidence has emerged supporting the use of a new sensing technique called closed loop stimulation or CLS, to treat refractory vasovagal syncope. CLS uses a sensing algorithm that can detect variation in cardiac contractility and respond to drop in blood pressure by increasing the heart rate. Multiple observational and randomized studies have assessed its efficacy and showed its superiority to conventional pacing in reducing the burden of syncopal attacks in patients with cardio-inhibitory vasovagal syncope.
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Affiliation(s)
- Mohammed Ruzieh
- Penn State Heart and Vascular Institute, 500 University Drive, PO Box 850, MC H047, Hershey, PA 17033, United States.
| | - Blair P Grubb
- Penn State Heart and Vascular Institute, 500 University Drive, PO Box 850, MC H047, Hershey, PA 17033, United States
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Ziacchi M, Palmisano P, Biffi M, Ricci RP, Landolina M, Zoni-Berisso M, Occhetta E, Maglia G, Botto G, Padeletti L, Boriani G. Clinically oriented device programming in bradycardia patients. J Cardiovasc Med (Hagerstown) 2018; 19:161-169. [DOI: 10.2459/jcm.0000000000000630] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Palmisano P, Ziacchi M, Biffi M, Ricci RP, Landolina M, Zoni-Berisso M, Occhetta E, Maglia G, Botto G, Padeletti L, Boriani G. Clinically oriented device programming in bradycardia patients. J Cardiovasc Med (Hagerstown) 2018; 19:170-180. [DOI: 10.2459/jcm.0000000000000629] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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23
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Velásquez JE, Gaviria MC, Estupiñán VL, Díaz-Martínez JC, Aristizábal JM, Marín JE, Uribe W, Duque M. Marcapasos con sensor de asa cerrada en disautonomía secundaria a enfermedad de Sandhoff. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Chinushi M, Tachikawa H, Chinushi Y, Yamaguchi T, Saitoh O, Tsuda T. Incorrect Holter-ECG analysis caused by the pacemaker delivering small high-frequency currents for thoracic impedance measurement. J Cardiol Cases 2017; 16:219-222. [DOI: 10.1016/j.jccase.2017.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/05/2017] [Accepted: 08/09/2017] [Indexed: 11/29/2022] Open
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Ruzieh M, Ammari Z, Dasa O, Karim S, Grubb B. Role of closed loop stimulation pacing (CLS) in vasovagal syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1302-1307. [DOI: 10.1111/pace.13194] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/17/2017] [Accepted: 08/28/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Mohammed Ruzieh
- Department of Internal Medicine; University of Toledo; Toledo OH USA
| | - Zaid Ammari
- Department of Internal Medicine; University of Toledo; Toledo OH USA
| | - Osama Dasa
- Department of Internal Medicine; University of Toledo; Toledo OH USA
| | - Saima Karim
- Department of Internal Medicine; University of Toledo; Toledo OH USA
| | - Blair Grubb
- Department of Internal Medicine; University of Toledo; Toledo OH USA
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Baron-Esquivias G, Morillo CA, Moya-Mitjans A, Martinez-Alday J, Ruiz-Granell R, Lacunza-Ruiz J, Garcia-Civera R, Gutierrez-Carretero E, Romero-Garrido R. Dual-Chamber Pacing With Closed Loop Stimulation in Recurrent Reflex Vasovagal Syncope. J Am Coll Cardiol 2017; 70:1720-1728. [DOI: 10.1016/j.jacc.2017.08.026] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 08/09/2017] [Accepted: 08/09/2017] [Indexed: 10/18/2022]
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Ziacchi M, Palmisano P, Ammendola E, Dell'era G, Guerra F, Aquilani S, Aspromonte V, Boriani G, Accogli M, Del Giorno G, Occhetta E, Capucci A, Ricci RP, Maglia G, Biffi M. Clinically guided pacemaker choice and setting: pacemaker expert programming study. Europace 2017; 19:1500-1507. [PMID: 27738057 DOI: 10.1093/europace/euw256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/18/2016] [Indexed: 11/14/2022] Open
Abstract
Aim The aim of this multicentre, observational, transversal study was to evaluate pacemaker (PM) choice and setting in a large number of patients, in order to understand their relationship with the patients' clinical characteristics. Methods and results The study enrolled a total of 1858 patients (71 ± 14 years, 54% male), consecutively evaluated during scheduled PM follow-up visits in 7 Italian cardiac arrhythmia centres. To evaluate the appropriateness of PM choice in relation to the patients' clinical characteristics, we analysed their rhythm disorders at the time of device implantation and the characteristics of the devices implanted. To evaluate the appropriateness of device setting, current rhythm disorders and device setting at the time of enrolment were analysed. In the overall study population, 64.3% of the patients received a PM with all of the features required for their rhythm disorder [80.8% in persistent atrioventricular (AV) block, 76.5% in atrial fibrillation needing pacing, 71.0% in sinus node disease, 58.7% in non-persistent atrioventricular block (AVB), 52.7% in neuro-mediated syncope]. The most frequent cause of inappropriate PM choice was the lack of an algorithm to promote intrinsic AV conduction in non-persistent AVB patients (38.1%). In 76.2% of the patients with an appropriate PM (n = 1301), the PM was optimally set for their rhythm disorder. Conclusions In the present 'real-world' registry, a large number of patients (35.7%) did not receive an optimal PM for their rhythm disorders. Moreover, one-fourth of appropriate PMs were not programmed according to the patients' clinical characteristics.
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Affiliation(s)
- Matteo Ziacchi
- Institute of Cardiology, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Ernesto Ammendola
- Department of Cardiology, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Gabriele Dell'era
- Division of Cardiology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I-Lancisi-Salesi", Ancona, Italy
| | - Stefano Aquilani
- Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | | | - Giuseppe Boriani
- Institute of Cardiology, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Cardiology, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | | | - Giuseppe Del Giorno
- Department of Cardiology, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Eraldo Occhetta
- Division of Cardiology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Alessandro Capucci
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I-Lancisi-Salesi", Ancona, Italy
| | | | - Giampiero Maglia
- Cardiology-Coronary Care Unit, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - Mauro Biffi
- Institute of Cardiology, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
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Abstract
Cardiac pacing for vasovagal syncope (VVS) addresses the cardioinhibitory component of the reflex but cannot directly affect vasodepression, which occurs in every reflex even when hidden by dominant cardioinhibition. The randomized controlled trials of pacing in VVS have, after almost 2 decades, determined that a small number of patients can benefit because their vasodepressor component is not severe. Early studies compared pacing with no therapy yielding highly significant benefits. Subsequently, all study patients had implanted devices with half being switched off. No benefit was seen. The ISSUE-3 study found significant benefit (P < 0.039) in prevention of syncope recurrence in older patients. A sub-study later showed those with negative tilt tests, otherwise indistinguishable from tilt-positives, had 5% recurrence in 21 months (P < 0.004). There is acceptance that pacing must be dual chamber, but the question of how pacing is delivered remains open. Relying on falling heart rate is insufficient, probably because it occurs too late. Other algorithms which indirectly detect neuroendocrine changes earlier than heart rate fall may have useful application. In clinical terms, the patient to be considered for pacing should not be young and have severe symptoms. Ideally, tilt testing should be negative implying vasodepression of lesser severity and, therefore, yielding fewer syncope recurrences. When selecting pacing, additional concern must be given to regression to the mean of symptoms, severe to less severe. Patients seek help when they are at their worst. Moreover, many years of pacing are unlikely to be free of complications related to implanted hardware.
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Affiliation(s)
- R Sutton
- Imperial College, National Heart & Lung Institute, London, UK
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Brignole M, Tomaino M, Aerts A, Ammirati F, Ayala-Paredes FA, Deharo JC, Del Rosso A, Hamdan MH, Lunati M, Moya A, Gargaro A. Benefit of dual-chamber pacing with Closed Loop Stimulation in tilt-induced cardio-inhibitory reflex syncope (BIOSync trial): study protocol for a randomized controlled trial. Trials 2017; 18:208. [PMID: 28472974 PMCID: PMC5415949 DOI: 10.1186/s13063-017-1941-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 04/11/2017] [Indexed: 12/04/2022] Open
Abstract
Background The efficacy of dual-chamber cardiac pacing in neuro-mediated reflex syncope with a cardio-inhibitory response to the Tilt-Table test (TT) has not been definitively assessed so far. The lack of reproducibility of results from previous studies may be partially explained by discrepancies in subject selection and some weaknesses in design and methods. The European Society of Cardiology (ESC) has set a class IIb indication to pacemaker implantation in this population recommending further research. Methods/design The BIOSync study is a multicenter, patient- and outcome-assessor-blind, randomized, parallel-arm, placebo-controlled trial with the objective of assessing the clinical benefit of cardiac pacing in patients with frequently recurrent reflex syncope, suspected (but not proven) to be triggered by asystolic pauses as showing a VASIS 2B response to the TT (>3-s pause regardless of blood pressure drop). The primary and secondary endpoints are time to first post-implantation recurrence of syncope or the combination of pre-syncope or syncope, respectively. One hundred and twenty-eight consenting patients will be 1:1 randomized to dual-chamber cardiac pacing ‘on’ or ‘off’ after pacemaker implantation, and followed up until the first adjudicated primary endpoint event for a maximum of 2 years. The so-called Closed Loop Stimulation function on top of dual-chamber pacing is the pacing mode selected in the study active arm. Participating patients are asked to self-report syncopal symptoms at least every 3 months with self-administered questionnaires addressed to an independent Adjudication Committee. Patients and members of the Adjudicating Committee are blinded to randomization. The study is designed to detect a 40% relative reduction in the 2-year incidence of syncopal recurrences with 80% statistical power. Discussion The BIOSync study is designed to definitively assess the benefit of pacing against placebo in reflex syncope patients with a cardio-inhibitory response to the TT. The study will also provide important information on the efficiency of the TT in appropriately selecting reflex syncope patients for cardiac pacing. Trial registration ClinicalTrials.gov, identifier: NCT02324920 (27 October 2016, date last accessed). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1941-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michele Brignole
- Ospedali del Tigullio, Arrhythmologic Centre, Department of Cardiology, Via Don Bobbio, 25, 16033, Lavagna, GE, Italy.
| | | | | | | | | | | | | | | | | | - Angel Moya
- University Hospital Vall d'Hebròn, Barcelona, Spain
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Piccirillo G, Moscucci F, Fiorucci C, Di Iorio C, Mastropietri F, Magrì D. Time- and frequency-domain analysis of beat to beat P-wave duration, PR interval and RR interval can predict asystole as form of syncope during head-up tilt. Physiol Meas 2016; 37:1910-1924. [PMID: 27681167 DOI: 10.1088/0967-3334/37/11/1910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
To seek possible differences in short-period temporal RR interval, P-wave and PR interval dispersion and spectral coherence in patients with a head-up tilt test positive for vasovagal syncope with or without prolonged asystole, severe symptoms and at high risk of trauma. We retrospectively reviewed 5 min ECG and blood pressure recordings obtained at baseline, at rest and during head-up tilt in 40 patients diagnosed as having recurrent vasovagal syncope confirmed at a head-up tilt test. We analysed autoregressive spectral power for all the ECG-derived variables, focusing on temporal P-wave and PR interval dispersion indexes as well as their spectral coherence calculated on the same 5 min recordings at rest and during tilt. ECG recordings obtained during tilt before syncope showed significantly lower P → PR spectral coherence and higher RR standard deviations in patients with tilt-induced asystole than in those without (0.567 ± 0.097 versus 0.670 ± 0.127, p: 0.010 and 84 ± 36 versus 46 ± 22 ms2, p < 0.0001). Differences in the RR standard deviations persisted also on the last hundred beats (-100) (113 ± 54 versus 34 ± 17 ms2, p < 0.0001). Multiple regression analysis identified a significantly negative association between the maximum RR intervals and P → PR coherence at rest (β: -0.3, p < 0.05) and positive association with RR-100 standard deviation during tilt-induced syncope (β: 0.621, p < 0.001). P → PR spectral coherence could be used to assess the risk of prolonged asystole in patients with tilt-induced vasovagal syncope as well as as a possible surrogate for tilt-testing during these patients' follow-up.
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Affiliation(s)
- Gianfranco Piccirillo
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, 'Sapienza' University of Rome, Rome, Italy
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Carlson D, Linde D, Isaacson B, Afshar P, Bourget D, Stanslaski S, Stypulkowski P, Denison T. A flexible algorithm framework for closed-loop neuromodulation research systems. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2013:6146-50. [PMID: 24111143 DOI: 10.1109/embc.2013.6610956] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Modulation of neural activity through electrical stimulation of tissue is an effective therapy for neurological diseases such as Parkinson's disease and essential tremor. Researchers are exploring improving therapy through adjustment of stimulation parameters based upon sensed data. This requires classifiers to extract features and estimate patient state. It also requires algorithms to appropriately map the state estimation to stimulation parameters. The latter, known as the control policy algorithm, is the focus of this work. Because the optimal control policy algorithms for the nervous system are not fully characterized at this time, we have implemented a generic control policy framework to facilitate exploratory research and rapid prototyping of new neuromodulation strategies.
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de la Ossa M, Duque M, Duque L. Tratamiento del síncope neuralmente mediado con marcapasos: utilidad del sensor de asa cerrada. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2014.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Sumiyoshi M. Role of permanent cardiac pacing for vasovagal syncope. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Increased heart rate caused by atrial pacing with the closed-loop stimulation function prevented micturition syncope. J Arrhythm 2013. [DOI: 10.1016/j.joa.2013.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Grubb BP, Kanjwal K. Economical selection of syncope patients for permanent cardiac pacing: a tilted view. BRITISH HEART JOURNAL 2013; 99:755-6. [DOI: 10.1136/heartjnl-2012-303438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Russo V, Rago A, Papa AA, Golino P, Calabrò R, Russo MG, Nigro G. The effect of dual-chamber closed-loop stimulation on syncope recurrence in healthy patients with tilt-induced vasovagal cardioinhibitory syncope: a prospective, randomised, single-blind, crossover study. Heart 2013; 99:1609-13. [PMID: 23723446 DOI: 10.1136/heartjnl-2013-303878] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
The current evidence for pacemaker therapy is reviewed in 2 different syncopal conditions: reflex syncope with cardioinhibitory response and syncope in patients with bundle branch block. Although recent trials support the use of pacemaker therapy in selected patients with reflex syncope in whom an asystole is documented during spontaneous syncope or in whom an asystole is provoked with adenosine-5'-triphosphate administration, the best strategy in these patients and in those with syncope and bundle branch block is not well established. Ongoing clinical trials will answer this question.
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Affiliation(s)
- Angel Moya
- Unitat Arrítmies, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain.
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