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TU B, LAI ZH, CHEN AY, WENG ZY, CAI SM, ZHANG ZX, ZHOU LK, ZHENG LH, YAO Y. Effectiveness of cardioneuroablation in different subtypes of vasovagal syncope. J Geriatr Cardiol 2024; 21:651-657. [PMID: 38973824 PMCID: PMC11224655 DOI: 10.26599/1671-5411.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Cardioneuroablation (CNA) has shown encouraging results in patients with vasovagal syncope (VVS). However, data on different subtypes was scarce. METHODS This observational study retrospectively enrolled 141 patients [mean age: 40 ± 18 years, 51 males (36.2%)] with the diagnosis of VVS. The characteristics among different types of VVS and the outcomes after CNA were analyzed. RESULTS After a mean follow-up of 4.3 ± 1.5 years, 41 patients (29.1%) experienced syncope/pre-syncope events after CNA. Syncope/pre-syncope recurrence significantly differed in each subtype (P = 0.04). The cardioinhibitory type of VVS had the lowest recurrence rate after the procedure (n = 6, 16.7%), followed by mixed (n = 26, 30.6%) and vasodepressive (n = 9, 45.0%). Additionally, a significant difference was observed in the analyses of the Kaplan-Meier survival curve (P = 0.02). Syncope/pre-syncope burden was significantly reduced after CNA in the vasodepressive type (P < 0.01). Vasodepressive types with recurrent syncope/pre-syncope after CNA have a lower baseline deceleration capacity (DC) level than those without (7.4 ± 1.0 ms vs. 9.0 ± 1.6 ms, P = 0.01). Patients with DC < 8.4 ms had an 8.1 (HR = 8.1, 95% CI: 2.2-30.0, P = 0.02) times risk of syncope/pre-syncope recurrence after CNA compared to patients with DC ≥ 8.4 ms, and this association still existed after adjusting for age and sex (HR = 8.1, 95% CI: 2.2-30.1, P = 0.02). CONCLUSIONS Different subtypes exhibit different event-free rates. The vasodepressive type exhibited the lowest event-free rate, but those patients with DC ≥ 8.4 ms might benefit from CNA.
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Affiliation(s)
- Bin TU
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Cardiac Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zi-Hao LAI
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ai-Yue CHEN
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Yuan WENG
- Cardiovascular Department, The First Affiliated Hospital, Fujian Medical University, Fujian Institute of Hypertension, Fujian, China
| | - Si-Min CAI
- Department of Cardiovascular, The Second Affiliated Hospital of Zhejiang University School of Medicine,Zhejiang, China
| | - Zhu-Xin ZHANG
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Kun ZHOU
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Hui ZHENG
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan YAO
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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2
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Aksu T, Tung R, De Potter T, Markman TM, Santangeli P, du Fay de Lavallaz J, Winterfield JR, Baykaner T, Alyesh D, Joza JE, Gopinathannair R, Badertscher P, Do DH, Hussein A, Osorio J, Dewland T, Perino A, Rodgers AJ, DeSimone C, Alfie A, Atwater BD, Singh D, Kumar K, Salcedo J, Bradfield JS, Upadhyay G, Sood N, Sharma PS, Gautam S, Kumar V, Forno ARJD, Woods CE, Rav-Acha M, Valeriano C, Kapur S, Enriquez A, Sundaram S, Glikson M, Gerstenfeld E, Piccini J, Tzou WS, Sauer W, d'Avila A, Shivkumar K, Huang HD. Cardioneuroablation for the management of patients with recurrent vasovagal syncope and symptomatic bradyarrhythmias: the CNA-FWRD Registry. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01789-9. [PMID: 38499825 DOI: 10.1007/s10840-024-01789-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/13/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Cardioneuroablation has been emerging as a potential treatment alternative in appropriately selected patients with cardioinhibitory vasovagal syncope (VVS) and functional AV block (AVB). However the majority of available evidence has been derived from retrospective cohort studies performed by experienced operators. METHODS The Cardioneuroablation for the Management of Patients with Recurrent Vasovagal Syncope and Symptomatic Bradyarrhythmias (CNA-FWRD) Registry is a multicenter prospective registry with cross-over design evaluating acute and long-term outcomes of VVS and AVB patients treated by conservative therapy and CNA. RESULTS The study is a prospective observational registry with cross-over design for analysis of outcomes between a control group (i.e., behavioral and medical therapy only) and intervention group (Cardioneuroablation). Primary and secondary outcomes will only be assessed after enrollment in the registry. The follow-up period will be 3 years after enrollment. CONCLUSIONS There remains a lack of prospective multicentered data for long-term outcomes comparing conservative therapy to radiofrequency CNA procedures particularly for key outcomes including recurrence of syncope, AV block, durable impact of disruption of the autonomic nervous system, and long-term complications after CNA. The CNA-FWRD registry has the potential to help fill this information gap.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, 34100, Istanbul, Turkey
| | - Roderick Tung
- The University of Arizona College of Medicine, Banner-University Medical Center, 755 E McDowell Road, Phoenix, AZ, 85006, USA
| | - Tom De Potter
- Department of Cardiology, OLV Hospital, Aalst, Belgium
| | - Timothy M Markman
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | - Tina Baykaner
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Daniel Alyesh
- South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80120, USA
| | | | | | | | - Duc H Do
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Ayman Hussein
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jose Osorio
- Arrhythmia Institute at Grandview, Birmingham, AL, USA
- Heart Rhythm Clinical Research Solutions, Birmingham, AL, USA
| | - Thomas Dewland
- Electrophysiology Section, Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Alexander Perino
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Albert J Rodgers
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | | | - Alberto Alfie
- Electrophysiology Section, Cardiology Division, Hospital Nacional Profesor Alejandro Posadas, Av. Illia y Marconi S/N 1684, El Palomar, Moron, Province of Buenos Aires, Argentina
| | | | - David Singh
- The Queens Medical Center, Honolulu, HI, USA
| | | | | | - Jason S Bradfield
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Gaurav Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC 9024, Chicago, IL, 60637, USA
| | - Nitesh Sood
- Arrhythmia Services, Southcoast Health, Fall River, MA, USA
| | - Parikshit S Sharma
- Department of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Sandeep Gautam
- Department of Cardiac Electrophysiology, University of Missouri-Columbia, Columbia, MO, USA
| | - Vineet Kumar
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Christopher E Woods
- Department of Cardiology, California Pacific Medical Center, San Francisco, CA, USA
| | - Moshe Rav-Acha
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, 9112102, Jerusalem, Israel
| | | | - Sunil Kapur
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andres Enriquez
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Sri Sundaram
- South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80120, USA
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, 9112102, Jerusalem, Israel
| | - Edward Gerstenfeld
- Electrophysiology Section, Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jonathan Piccini
- Duke Clinical Research Institute, Duke University Hospital, Durham, USA
| | - Wendy S Tzou
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Henry D Huang
- Department of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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Zangiabadian M, Soltani K, Gholinejad Y, Yahya R, Bastami S, Akbarzadeh MA, Sharifian Ardestani M, Aletaha A. Predictors of pacemaker requirement in patients with implantable loop recorder and unexplained syncope: A systematic review and meta-analysis. Clin Cardiol 2024; 47:e24221. [PMID: 38402528 PMCID: PMC10823547 DOI: 10.1002/clc.24221] [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: 09/23/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 02/26/2024] Open
Abstract
Identifying the underlying cause of unexplained syncope is crucial for appropriate management of recurrent syncopal episodes. Implantable loop recorders (ILRs) have emerged as valuable diagnostic tools for monitoring patients with unexplained syncope. However, the predictors of pacemaker requirement in patients with ILR and unexplained syncope remain unclear. In this study, we shed light on these prognostic factors. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane CENTRAL were systematically searched until May 04, 2023. Studies that evaluated the predictors of pacemaker requirement in patients with implantable loop recorder and unexplained syncope were included. The "Quality In Prognosis Studies" appraisal tool was used for quality assessment. The pooled odds ratio (OR) with 95% confidence intervals (CIs) was calculated. The publication bias was evaluated using Egger's and Begg's tests. Ten studies (n = 4200) were included. Right bundle branch block (OR: 3.264; 95% CI: 1.907-5.588, p < .0001) and bifascicular block (OR: 2.969; 95% CI: 1.859-4.742, p < .0001) were the strongest predictors for pacemaker implantation. Pacemaker requirement was more than two times in patients with atrial fibrillation, sinus bradycardia and first degree AV block. Valvular heart disease, diabetes mellitus, and hypertension were also significantly more in patients with pacemaker implantation. Age (standardized mean difference [SMD]: 0.560; 95% CI: 0.410/0.710, p < .0001) and PR interval (SMD: 0.351; 95% CI: 0.150/0.553, p = .001) were significantly higher in patients with pacemaker requirement. Heart conduction disorders, atrial arrhythmias and underlying medical conditions are main predictors of pacemaker device implantation following loop recorder installation in unexplained syncopal patients.
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Affiliation(s)
- Moein Zangiabadian
- Endocrinology and Metabolism Re‐search Center, Institute of Basic and Clinical Physiology SciencesKerman University of Medical SciencesKermanIran
| | - Kiarash Soltani
- Shahid Beheshti University of Medical SciencesSchool of MedicineTehranIran
| | - Yasaman Gholinejad
- Shahid Beheshti University of Medical SciencesSchool of MedicineTehranIran
| | - Reyhane Yahya
- Shahid Beheshti University of Medical SciencesSchool of MedicineTehranIran
| | - Shayan Bastami
- Shahid Beheshti University of Medical SciencesSchool of MedicineTehranIran
| | | | | | - Azadeh Aletaha
- Evidence Based Medicine Research Center, Endocrinology and Metabolism Clinical Sciences InstituteTehran University of medical SciencesTehranIran
- Endocrinology and Metabolism Clinical Sciences Institute, Endocrinology and Metabolism Research CenterTehran University of Medical SciencesTehranIran
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4
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Magnano M, Bissolino A, Budano C, Occhetta E, Rametta F. Endocardial ablation of epicardial ganglionated plexi: history, open questions and future prospects of cardioneuroablation. Minerva Cardiol Angiol 2023; 71:553-563. [PMID: 36305776 DOI: 10.23736/s2724-5683.22.06131-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Neurocardiogenic syncope is the most common cause of transient loss of consciousness and considerably reduces quality of life. Pharmacological and pacing therapy may not be fully efficacious and complications related to implanted hardware must be considered. In this context, cardioneuroablation (CNA) has been proposed to attenuate the vagal reflex with elimination of cardioinhibition. It has been shown that CNA is able to eliminate recurrences of syncope in over 90% of cases and no major complications are reported in the current literature. Despite these encouraging findings, CNA is only mentioned in current guidelines as a possible alternative treatment and has no real indication class. The diversity of mapping techniques, the absence of direct denervation control, the lack of a precise endpoint, the possible placebo effect, the short follow-up, and the question of the learning curve represent the major limitations of this promising procedure. The aim of this review was to look over the existing literature, analysing the novelties, the limitations, the unresolved issues and the outcome of CNA.
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Affiliation(s)
- Massimo Magnano
- Department of Cardiology, St. Andrea Hospital, Vercelli, Italy -
| | | | - Carlo Budano
- Maria Pia Hospital, GVM Care&Research Institution, Turin, Italy
| | - Eraldo Occhetta
- Department of Cardiology, St. Andrea Hospital, Vercelli, Italy
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5
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Advance in the understanding of vasovagal syncope in children and adolescents. World J Pediatr 2021; 17:58-62. [PMID: 32405708 DOI: 10.1007/s12519-020-00367-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Vasovagal syncope (VVS) accounts for 60-80% of cases of neurally mediated syncope. VVS results from acute orthostatic intolerance and recurrent syncopal attacks, which can seriously affect an individual's quality of life. In addition, some children even experience trauma during attacks. Therefore, it is particularly important to clarify the pathogenesis of VVS. The aim of our study is to reveal the latest research progress of VVS. DATA SOURCES Literature that involved the pathogenesis of VVS were selected from Cochrane Library (1990-2019), EMBASE (1991-2019) and PubMed (1968-2019) databases. RESULTS Hypovolemia, autonomic dysfunction, vasomotor dysfunction, baroreceptor reflex abnormalities, endothelial dysfunction, serotonin surges, and gut microbiota were involved in the underlying mechanism of VVS. CONCLUSIONS VVS is not always a benign prognosis. Various aspects were involved in its pathogenesis. Bezold-Jarish reflex, dysfunction of the autonomic nervous system, genetic factors and so on played important roles in VVS; however, the mechanism remains unclear.
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6
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Yamada Y, Fujiwara H, Banno H, Hikami K, Nakashima M, Tamaki M, Ito N. Complete atrioventricular dissociation and sinus arrest after pheochromocytoma resection. IJU Case Rep 2020; 3:108-111. [PMID: 32743485 PMCID: PMC7292089 DOI: 10.1002/iju5.12160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/20/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Although preoperative bradycardia has been reported in several pheochromocytoma cases, postoperative bradycardia has not. This is the first case report of complete atrioventricular dissociation and sinus arrest occurring after pheochromocytoma resection. CASE PRESENTATION A 38-year-old woman was referred for a left adrenal incidentaloma. Twenty-four hour urinary collection showed elevated noradrenaline. Iodine-123-meta-iodobenzylguanidine scintigraphy showed high tracer uptake in the left adrenal region. Open left adrenalectomy was performed, and histopathological examination confirmed the diagnosis of pheochromocytoma. Thirty minutes following surgery, complete atrioventricular dissociation and sinus arrest developed. Vagal reflex attenuation due to decreased noradrenaline after tumor removal and perioperative pain and fear were believed to be the causes. A temporary pacemaker was implanted to prevent sudden death due to vagal overstimulation. CONCLUSION Vagal reflex attenuation after pheochromocytoma resection can result in complete atrioventricular dissociation and sinus arrest. Adequate preoperative preparation and close monitoring during and after surgery are imperative.
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Affiliation(s)
- Yuya Yamada
- Urology DepartmentJapanese Red Cross Wakayama Medical CenterWakayamaJapan
| | - Hiroshi Fujiwara
- Urology DepartmentJapanese Red Cross Wakayama Medical CenterWakayamaJapan
| | - Haruka Banno
- Urology DepartmentJapanese Red Cross Wakayama Medical CenterWakayamaJapan
| | - Kensuke Hikami
- Urology DepartmentJapanese Red Cross Wakayama Medical CenterWakayamaJapan
| | - Masakazu Nakashima
- Urology DepartmentJapanese Red Cross Wakayama Medical CenterWakayamaJapan
| | - Masahiro Tamaki
- Urology DepartmentJapanese Red Cross Wakayama Medical CenterWakayamaJapan
| | - Noriyuki Ito
- Urology DepartmentJapanese Red Cross Wakayama Medical CenterWakayamaJapan
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7
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de Jong JS, Jardine DL, Lenders JW, Wieling W. Pacing in vasovagal syncope: A physiological paradox? Heart Rhythm 2020; 17:813-820. [DOI: 10.1016/j.hrthm.2019.09.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Indexed: 10/26/2022]
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8
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Pachon-M JC. Neurocardiogenic syncope: Pacemaker or cardioneuroablation? Heart Rhythm 2020; 17:829-830. [PMID: 32113895 DOI: 10.1016/j.hrthm.2020.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/20/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Jose Carlos Pachon-M
- Department of Cardiology, Sao Paulo University, Sao Paulo Heart Hospital, Sao Paulo, Brazil.
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9
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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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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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11
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Yasa E, Ricci F, Holm H, Persson T, Melander O, Sutton R, Fedorowski A, Hamrefors V. Cardiovascular Autonomic Dysfunction Is the Most Common Cause of Syncope in Paced Patients. Front Cardiovasc Med 2019; 6:154. [PMID: 31709267 PMCID: PMC6823818 DOI: 10.3389/fcvm.2019.00154] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Syncope and orthostatic intolerance in paced patients constitute a common clinical dilemma. We, thus, aimed to determine the etiology of syncope and/or symptoms of orthostatic intolerance in paced patients. Methods: Among 1,705 patients with unexplained syncope and/or orthostatic intolerance that were investigated by cardiovascular autonomic tests, including Valsalva maneuver, active standing, carotid sinus massage, and tilt-testing, 39 patients (2.3%; age 65.6 years; 39% women) had a cardiac implantable electronic device (CIED). We explored past medical history, diagnoses found during cardiovascular autonomic tests, and the further clinical workup, in case of negative initial evaluation. Results: An etiology was identified during cardiovascular autonomic tests in 36 of the 39 patients. Orthostatic hypotension (n = 16; 41%) and vasovagal syncope (n = 12; 31%) were the most common diagnoses. There were no cases of pacemaker dysfunction. The original pacing indications followed guidelines (sick-sinus-syndrome in 16, atrioventricular block in 16, atrial fibrillation with bradycardia in five). Twenty-two of the 39 patients (56%) had experienced syncope prior to the original CIED implantation. Orthostatic hypotension was diagnosed in seven (32%) and vasovagal syncope in nine (41%) of these patients. Of the 17 patients that had not experienced syncope prior to the original CIED implantation, nine patients (53%) were diagnosed with orthostatic hypotension and vasovagal syncope was diagnosed in three (18%). Of the 39 patients, two had implantable cardioverter-defibrillators to treat malignant ventricular arrhythmias diagnosed after syncopal episodes. Conclusion: Cardiovascular autonomic tests reveal the etiology of syncope and/or orthostatic intolerance in the majority of paced patients. The most common diagnosis was orthostatic hypotension (40%) followed by vasovagal syncope (30%), whereas there were no cases of pacemaker dysfunction. Our results emphasize the importance of a complete diagnostic work-up, including cardiovascular autonomic tests, in paced patients that present with syncope and/or orthostatic intolerance.
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Affiliation(s)
- Ekrem Yasa
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Fabrizio Ricci
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Institute of Cardiology, University "G. d'Annunzio", Chieti, Italy.,Department of Neuroscience and Imaging, ITAB - Institute Advanced Biomedical Technologies, University "G. d'Annunzio", Chieti, Italy
| | - Hannes Holm
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Torbjörn Persson
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,National Heart and Lung Institute, Imperial College, Hammersmith Hospital, London, United Kingdom
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
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Yasa E, Ricci F, Holm H, Persson T, Melander O, Sutton R, Hamrefors V, Fedorowski A. Pacing therapy in the management of unexplained syncope: a tertiary care centre prospective study. Open Heart 2019; 6:e001015. [PMID: 30997138 PMCID: PMC6443123 DOI: 10.1136/openhrt-2019-001015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 12/22/2022] Open
Abstract
Objective Pacemaker (PM) therapy is effective when syncope is associated with bradycardia, but syncope recurrences and fall injuries after PM implantation may occur. We aimed to survey indications and outcomes of PM implantation, following evaluation of unexplained syncope. Methods Among 1666 consecutive unpaced patients investigated in a tertiary syncope unit by carotid-sinus massage (CSM), head-up tilt test (HUT) and ECG monitoring, 106 (6.4%; age, 65 ± 17 years) received a PM. We assessed bradycardia detection methods, PM implantation indications, and explored incidence of recurrent syncope, fall-related fractures and mortality. Results Indications for PM therapy were met in 32/106 patients (30%) by CSM, in 41/106 (39%) by HUT, in 14/106 patients (13%) by implantable loop-recorder (ILR) and in 19/106 (18%) by standard ECG. Sinus arrest with asystole was the predominant PM indication during CSM/HUT and external ECG monitoring, whereas ILR detected proportionally the same numbers o f asystole due to sinus arrest and atrioventricular block. During follow-up (median, 4.3 years), 15 patients (14%) had syncope recurrence, 15 suffered fall-related fractures and 9 died. Neither syncope recurrence nor fall-related fractures were dependent on initial PM indication. The composite endpoint of recurrent syncope/fall-related fracture was associated with treated hypertension (OR 2.45; 95% CI 1.00 to 6.0), reduced glomerular filtration rate (OR 1.63 per 10 mL/min↓; 95% CI 1.22 to 2.19) and atrial fibrillation (OR 3.98; 95% CI 1.11 to 14.3). Recurrent syncope predicted increased mortality (OR 9.20; 95% CI 1.89 to 44.8). Conclusions Cardiovascular autonomic testing and ECG monitoring effectively identify pacing indications in patients with unexplained syncope. After PM implantation, treated hypertension, renal failure and atrial fibrillation predict syncope recurrence and fall-related injury. Recurrent syncope predicts increased mortality.
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Affiliation(s)
- Ekrem Yasa
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Fabrizio Ricci
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Neuroscience, Imaging and Clinical Sciences, Universita degli Studi Gabriele d'Annunzio Chieti e Pescara, Chieti Scalo, Italy
| | - Hannes Holm
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Torbjörn Persson
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,National Heart and Lung Institute, Imperial College School of Medicine, London, United Kingdom
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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13
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Grubb BP. Editorial commentary: Pacing for syncope: Progress and promise. Trends Cardiovasc Med 2018; 28:427. [PMID: 29853425 DOI: 10.1016/j.tcm.2018.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Blair P Grubb
- Heart and Vascular Center, 3000 Arlington Ave. Toledo, OH 43614, United States.
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14
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Sutton R. Pacing in neurocardiogenic/vasovagal syncope. Herzschrittmacherther Elektrophysiol 2018; 29:208-213. [PMID: 29802445 DOI: 10.1007/s00399-018-0564-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/03/2018] [Indexed: 06/08/2023]
Abstract
Pacing for neurocardiogenic or vasovagal syncope (VVS) has been practised for five decades, but the 1986 advent of tilt testing provided a means of diagnosis frequently revealing, in the early days, asystole caused by VVS. This was the basis for pacing these patients and the first studies created enthusiasm followed by randomised controlled trials, which were imperfectly designed, "confirming" benefit. When better trial design was employed, there was no obvious benefit. However, some cardiologists had seen patients experience a huge positive difference with pacing, so they set out to identify them. Two studies using ECG loop recorders to document heart rhythm during spontaneous attacks allowed better patient selection for pacing and appeared to achieve the aim. Further, it was noted in the second study, a randomised controlled trial (RCT) with good design, that tilt testing added a further dimension to the identification of the patient who would benefit. Thus, loop recorders are used to show asystole in spontaneous attacks and when tilt testing is negative, implying a lesser vasodepressor component, the patient will have the best outcome. From the available evidence, pacing should be dual-chamber in older patients (>40 years) with severe symptoms and in whom standard measures have demonstrably failed. The method of triggering pacing and its timing of introduction have not yet been resolved. Today's method is rate-hysteresis but there is another sensed event as an alternative: right ventricular impedance, which is now in RCT with substantial pilot evidence in its favour.
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Affiliation(s)
- Richard Sutton
- National Heart and Lung Institute, Hammersmith Hospital Campus, B block South, 2nd floor, NHLI-Cardiovascular Science, Imperial College, Du Cane Road, W12 0NN, London, UK.
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He L, Wang L, Li L, Liu X, Yu Y, Zeng X, Li H, Gu Y. A single-center randomized controlled trial observing the safety and efficacy of modified step-up graded Valsalva manoeuver in patients with vasovagal syncope. PLoS One 2018; 13:e0191880. [PMID: 29381726 PMCID: PMC5790265 DOI: 10.1371/journal.pone.0191880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 01/07/2018] [Indexed: 11/19/2022] Open
Abstract
Non-pharmacological therapies, especially the physical maneuvers, are viewed as important and promising strategies for reducing syncope recurrences in vasovagal syncope (VVS) patients. We observed the efficacy of a modified Valsalva maneuver (MVM) in VVS patients. 72 VVS patients with syncope history and positive head-up tilt table testing (HUTT) results were randomly divided into conventional treatment group (NVM group, n = 36) and conventional treatment plus standard MVM for 30 days group (MVM group, n = 36). Incidence of recurrent syncope after 12 months (6.5% vs. 41.2%, P<0.01) and rate of positive HUTT after 30 days (9.7% vs.79.4%, P<0.01) were significantly lower in MVM group than in NVM group. HRV results showed that low frequency (LF), LF/ high frequency (HF), standard deviation of NN intervals (SDNN) and standard deviation of all 5-min average NN intervals (SDANN) values were significantly lower in the NVM and MVM groups than in the control group at baseline. After 30 days treatment, LF, LF/HF, SDNN, SDANN values were significantly higher compared to baseline in MVM group. Results of Cox proportional hazard model showed that higher SDNN and SDANN values at 30 days after intervention were protective factors, while positive HUTT at 30 days after intervention was risk factor for recurrent syncope. Our results indicate that 30 days MVM intervention could effectively reduce the incidence of recurrent syncope up to 12 months in VVS patients, possibly through improving sympathetic function of VVS patients.
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Affiliation(s)
- Li He
- Department of Cardiology, Puai Hospital, Huazhong University of Science and Technology, Wuhan, Hubei province, China
| | - Lan Wang
- Department of Neurology, Puai Hospital, Huazhong University of Science and Technology, Wuhan, Hubei province, China
| | - Lun Li
- Department of Cardiology, Puai Hospital, Huazhong University of Science and Technology, Wuhan, Hubei province, China
| | - Xiaoyan Liu
- Department of Cardiology, Puai Hospital, Huazhong University of Science and Technology, Wuhan, Hubei province, China
| | - Yijun Yu
- Department of Cardiology, Puai Hospital, Huazhong University of Science and Technology, Wuhan, Hubei province, China
| | - Xiaoyun Zeng
- Department of Neurology, Puai Hospital, Huazhong University of Science and Technology, Wuhan, Hubei province, China
| | - Huanhuan Li
- Department of Cardiology, Puai Hospital, Huazhong University of Science and Technology, Wuhan, Hubei province, China
| | - Ye Gu
- Department of Cardiology, Puai Hospital, Huazhong University of Science and Technology, Wuhan, Hubei province, China
- * E-mail:
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16
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Asystole and Loss of Consciousness. JACC Clin Electrophysiol 2017; 3:1599-1600. [PMID: 29759843 DOI: 10.1016/j.jacep.2017.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/09/2017] [Accepted: 08/17/2017] [Indexed: 11/21/2022]
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17
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Sutton R. Reply to 'Letter to the Editor' regarding the article 'Should we treat severe vasovagal syncope with a pacemaker?'. J Intern Med 2017. [PMID: 28643889 DOI: 10.1111/joim.12642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Richard Sutton
- National Heart & Lung institute, Imperial College, Hammersmith Hospital, London, UK
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