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Bačkorová B, Lazúrová Z, Lewaskiewicz P, Mitro P, Lazúrová I. Increased adrenocortical activity in patients with vasovagal syncope. Auton Neurosci 2024; 254:103196. [PMID: 38959624 DOI: 10.1016/j.autneu.2024.103196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/16/2024] [Accepted: 06/20/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE Syncope is a transient loss of consciousness resulting from cerebral hypoperfusion. Vasovagal syncope (VVS) is a form of orthostatic intolerance (OI). Its clinical signs such as dizziness and hypotension may mimic symptoms of adrenal insufficiency. The objective of this study was to evaluate the adrenal gland function in patients with vasovagal syncope after stimulation with synthetic adrenocorticotropic hormone (ACTH). DESIGN Case-control study on patients with VVS and healthy controls. METHODS The study involved 42 participants, including 27 patients diagnosed with VVS using the head-up tilt test and 15 healthy individuals with no history of syncope or any orthostatic symptoms. Serum cortisol and aldosterone concentrations were measured under basal conditions and at 30 and 60 min after intramuscular ACTH stimulation. RESULTS Patients with VVS had significantly higher cortisol levels at baseline (441 ± 143 vs. 331 ± 84.7 nmol/L, p = 0.01), at 30 min (802 ± 143 vs. 686 ± 105 nmol/L, p = 0.01) and at 60 min (931 ± 141 nmol/L vs. 793 ± 147 nmol/L, p = 0.001) after ACTH administration (Synacthen 250 μg). Plasma aldosterone increased after ACTH stimulation, but did not show significant differences among groups. Furthermore, there was also no significant correlation between cortisol levels and blood pressure or heart rate. CONCLUSION Patients diagnosed with VVS have higher cortisol levels both at baseline and after ACTH stimulation. This finding indicates that individuals with VVS have higher adrenocortical activity potentially as a response to the orthostatic stress induced by syncope, which acts as a stressful stimulus on the autonomic nervous system.
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Affiliation(s)
- Barbora Bačkorová
- Department of Internal Medicine, Medical Faculty P.J. Šafárik University Košice, Slovakia
| | - Zora Lazúrová
- Department of Internal medicine 4, Medical faculty, P.J. Šafárik University, Košice, Slovakia
| | - Paulina Lewaskiewicz
- Department of Internal medicine 4, Medical faculty, P.J. Šafárik University, Košice, Slovakia
| | - Peter Mitro
- Department of Cardiology 1, Medical faculty P.J. Šafárik University, Košice, Slovakia
| | - Ivica Lazúrová
- Department of Internal Medicine, Medical Faculty P.J. Šafárik University Košice, Slovakia.
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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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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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Santos Silva G, Fonseca P, Cardoso F, Almeida J, Ribeiro S, Oliveira M, Sanfins V, Gonçalves H, Pachon M JC, Barra S, Primo J, Lourenço A, Fontes-Carvalho R. Cardioneuroablation for severe neurocardiogenic syncope. Rev Port Cardiol 2023; 42:821-829. [PMID: 37268266 DOI: 10.1016/j.repc.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 06/04/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Cardioneuroablation (CNA), a technique based on radiofrequency ablation of cardiac vagal ganglia, was developed to treat recurrent vasovagal syncope (VVS) with a predominant cardioinhibitory component, as an alternative to pacemaker implantation. The aim of our study was to evaluate the safety and success rate of CNA guided by extracardiac vagal stimulation in patients with highly symptomatic cardioinhibitory VVS. METHODS Prospective study of patients who underwent anatomically guided CNA at two cardiology centers. All patients had a history of recurrent syncope with a predominant cardioinhibitory component and refractory to conventional measures. Acute success was determined by the absence or significant reduction of cardiac parasympathetic response to extracardiac vagal stimulation. The primary endpoint was the recurrence of syncope during follow-up. RESULTS In total, 19 patients (13 males; mean age 37.8±12.9 years) were included. Ablation was acutely successful in all patients. One patient had a convulsive episode after the procedure, which was deemed unrelated to the ablation, requiring admission to intensive care but without sequelae. No other complications occurred. At a mean follow-up of 21.0±13.2 months (range 3-42 months), 17 patients remained free of syncope. The remaining two patients had recurrence of syncope and, despite undergoing a new ablation procedure, required pacemaker implantation during follow-up. CONCLUSION Cardioneuroablation, confirmed by extracardiac vagal stimulation, appears to be an effective and safe treatment option for highly symptomatic patients with refractory VVS with a predominant cardioinhibitory component, providing a new potential approach as an alternative to pacemaker implantation.
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Affiliation(s)
- Gualter Santos Silva
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - Paulo Fonseca
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - Filipa Cardoso
- Hospital Senhora da Oliveira, Cardiology Department, Guimarães, Portugal
| | - João Almeida
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - Sílvia Ribeiro
- Hospital Senhora da Oliveira, Cardiology Department, Guimarães, Portugal
| | - Marco Oliveira
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - Víctor Sanfins
- Hospital Senhora da Oliveira, Cardiology Department, Guimarães, Portugal
| | - Helena Gonçalves
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | | | - Sérgio Barra
- Hospital da Luz Arrábida, Cardiology Department, V. N. Gaia, Portugal.
| | - João Primo
- Centro Hospitalar Vila Nova de Gaia/Espinho, Cardiology Department, V. N. Gaia, Portugal
| | - António Lourenço
- Hospital Senhora da Oliveira, Cardiology Department, Guimarães, Portugal
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Kadado AJ, Gobeil K, Motta J, Chalhoub F. Transcatheter Leadless Pacemaker for the Treatment of Vasovagal Syncope. Crit Pathw Cardiol 2023; 22:88-90. [PMID: 37249900 DOI: 10.1097/hpc.0000000000000325] [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: 05/31/2023]
Abstract
Vasovagal syncope (VVS) is largely a benign condition focused on patient education, lifestyle modification, and avoidance of triggers. However, a subset of patients may benefit from permanent pacemaker placement. Commonly, patients with VVS are younger and those requiring pacing have symptoms associated with severe cardioinhibitory syncope. With the advent of leadless pacemaker systems, a lot of the risks associated with traditional transvenous pacemaker systems are mitigated. In this article, we provide a comprehensive review of the data available for the treatment of cardioinhibitory vasovagal syncope using leadless pacemaker systems.
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Affiliation(s)
- Anis John Kadado
- From the Department of Cardiovascular Disease, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Kyle Gobeil
- Department of Cardiovascular Disease, Yale University School of Medicine, New Haven, CT
| | - Jishu Motta
- From the Department of Cardiovascular Disease, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Fadi Chalhoub
- From the Department of Cardiovascular Disease, University of Massachusetts Medical School-Baystate, Springfield, MA
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6
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Rivarola EWR, Hachul D, Wu TC, Pisani C, Scarioti VD, Hardy C, Darrieux F, Scanavacca M. Long-Term Outcome of Cardiac Denervation Procedures: The Anatomically Guided Septal Approach. JACC Clin Electrophysiol 2023; 9:1344-1353. [PMID: 37558291 DOI: 10.1016/j.jacep.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Functional bradycardia is a challenging condition that affects a healthy population. Ganglionated plexus ablation has emerged as a therapeutic alternative to avoid a pacemaker. OBJECTIVES The purpose of this study is to evaluate long-term effects of anatomically guided cardiac denervation. METHODS This is a prospective longitudinal study that included 36 patients with symptomatic functional bradycardia. Electroanatomic reconstruction of both atria was carried out, and the main septal ganglionated plexi were anatomically located and targeted. RESULTS Ablation endpoints were: 1) heart rate increment; 2) Wenckebach cycle length shortening; and 3) atrio-Hisian (AH) interval shortening. A sinus node denervation was obtained in all patients with an increment of 21.6% in the mean heart rate. All patients presented a negative atropine test after ablation. Twenty-eight (77.7%) patients presented immediate sings of atrioventricular node denervation, with a shortening of 15.6% of mean Wenckebach cycle length and 15.9% of the mean AH interval. All heart rate variability parameters showed a significant reduction after 12 months, enduring after 18 months. Thirty (83.3%) patients remained free of events after a mean follow-up of 52.1 ± 35.2 months. One patient (2.77%) presented acute sinus node artery occlusion during ablation with persistent sinus dysfunction and had a pacemaker implantation; 3 (8.3%) other patients evolved with sinus tachycardia, and 4 (11.1%) patients presented syncope recurrence during follow-up, 3 (8.3%) of them requiring a pacemaker implantation. No other tachyarrhythmia was observed. CONCLUSIONS The anatomically guided septal approach is an effective technique for syncope prevention, promoting long-lasting autonomic changes. No significant proarrhythmia effect has been observed during the long-term follow-up.
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Affiliation(s)
- Esteban W R Rivarola
- Arrhythmia Unit-Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - Denise Hachul
- Arrhythmia Unit-Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - Tan Chen Wu
- Arrhythmia Unit-Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - Cristiano Pisani
- Arrhythmia Unit-Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - Vinicius D Scarioti
- Arrhythmia Unit-Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - Carina Hardy
- Arrhythmia Unit-Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - Francisco Darrieux
- Arrhythmia Unit-Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - Mauricio Scanavacca
- Arrhythmia Unit-Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil.
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7
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Prakash A, Sutton R. Prospective randomized study comparing permanent pacing with rate drop response and closed loop stimulation in patients with vasovagal syncope where permanent pacing is indicated and selected as the appropriate treatment option. J Cardiovasc Electrophysiol 2023; 34:1744-1749. [PMID: 37393604 DOI: 10.1111/jce.15991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/10/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Pacing for vasovagal syncope is established. Two pacing algorithms are available. The rate-drop-response (RDR-Medtronic) is triggered by falling heart rate acting with modified rate-hysteresis. The closed loop stimulation or system (CLS-Biotronik) is triggered by impedance changes in the right ventricle reflecting falling volume and rising contractility. These are very different physiologically. Both algorithms carry favorable reports in clinical use. METHODS A randomized-controlled superiority trial is proposed to compare the two algorithms for the control of vasovagal syncope in patients for whom pacing is indicated by current guidelines in North America and Europe. Available recent evidence may be seen as supporting superiority of CLS. No comparison between the two algorithms has been made. In this trial, patients will be centrally randomized to one or other algorithm on a 1:1 basis. Two-hundred-seventy-six patients in each group will be recruited. Sample size is determined using a confidence interval of 95%, a power of 90%, and a drop-out rate of 10% to detect an 11% difference between CLS and RDR. Recurrent symptom comparison will be made by an independent committee. The Co-primary endpoints will be recurrent syncope burden compared with that in 24-months preimplant, and occurrence of syncope in 24-months follow-up. Each outcome will be compared between the two algorithms. Secondary endpoints will be program and drug therapy changes over 24-months follow-up and quality of life by questionnaire at baseline,1 and 2 years. RESULTS AND CONCLUSIONS These are anticipated to clarify the device algorithm choice and, therefore, to improve patient care.
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Affiliation(s)
- Atul Prakash
- Rutgers Medical School, Newark, New Jersey, USA
- Prime Health Care, Newark, New Jersey, USA
- St Mary's General Hospital, Passaic, New Jersey, USA
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital Campus of National Heart & Lung Institute, Imperial College, London, UK
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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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Xia G, Jin JF, Ye Y, Wang XD, Hu B, Pu JL. The effects of ALDH2 Glu487Lys polymorphism on vasovagal syncope patients undergoing head-up tilt test supplemented with sublingual nitroglycerin. BMC Cardiovasc Disord 2022; 22:451. [PMID: 36307771 PMCID: PMC9617361 DOI: 10.1186/s12872-022-02901-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background and objective Head-up tilt test (HUTT) is clinically advantageous for diagnosing patients with vasovagal syncope (VVS). Nitroglycerin is mainly used as a stimulant during HUTT, and mitochondrial aldehyde dehydrogenase 2 (ALDH2) is involved in the metabolism of nitroglycerin (NTG). ALDH2 Glu487Lys polymorphism (ALDH2 rs671) is the most common variant in the East Asian population. This study aimed to assess the effects of ALDH2 rs671 on VVS patients undergoing HUTT supplemented with sublingual NTG (HUTT-NTG). Methods Patients with recurrent VVS (at least 2 times) who were admitted to the syncope center of our hospital were enrolled. All VVS patients have undergone HUTT. The polymorphism of Glu487Lys gene of ALDH2 was measured by the DNA Microarray Chip Method. The results of HUTT-NTG of VVS patients with different ALDH2 genotypes were compared and their hemodynamic characteristics were assessed. Results A total of 199 VVS patients were enrolled, including 101 patients in the ALDH2*1/*1 group and 98 patients in the ALDH2*2 group. Among patients undergoing HUTT-NTG, 70.3% of patients in the ALDH2*1/*1 group and 68.4% of patients in the ALDH2*2 group were positive, and the difference between the two groups was not statistically significant (P = 0.77). The proportions of VASIS I, VASIS II, and VASIS III were 40.6%, 8.9%, and 20.8% in the ALDH2*1/*1 group, respectively, and the corresponding proportions in the ALDH2*2 group were 36.7%, 11.2%, and 20.4%, respectively. There was no statistically significant difference between the two groups (P = 0.91). The hemodynamic characteristics of different genotypes in VVS patients undergoing HUTT-NTG were compared, and no statistically significant difference was found. The median time of syncopal episode occurred after NTG administration in the ALDH2*1/*1 group was 6 min (interquartile range [IQR]: 5.0–9.0), and it was 6.0 min in the ALDH2*2 group (IQR: 4.25–8.0, P = 0.64). Conclusion ALDH2 Glu487Lys polymorphism did not affect the outcome of VVS patients undergoing HUTT-NTG, and no significant change in the hemodynamic characteristics of different genotypes was found.
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Morillo CA, Brignole M. Pacing for vasovagal syncope: Tips for use in practice. Auton Neurosci 2022; 241:102998. [DOI: 10.1016/j.autneu.2022.102998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 05/17/2022] [Accepted: 05/30/2022] [Indexed: 11/27/2022]
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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [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]
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJ, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. Grupo de trabajo sobre estimulación cardiaca y terapia de resincronización cardiaca de la Sociedad Europea de Cardiología (ESC). Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM, Leyva F, Linde C, Abdelhamid M, Aboyans V, Arbelo E, Asteggiano R, Barón-Esquivias G, Bauersachs J, Biffi M, Birgersdotter-Green U, Bongiorni MG, Borger MA, Čelutkienė J, Cikes M, Daubert JC, Drossart I, Ellenbogen K, Elliott PM, Fabritz L, Falk V, Fauchier L, Fernández-Avilés F, Foldager D, Gadler F, De Vinuesa PGG, Gorenek B, Guerra JM, Hermann Haugaa K, Hendriks J, Kahan T, Katus HA, Konradi A, Koskinas KC, Law H, Lewis BS, Linker NJ, Løchen ML, Lumens J, Mascherbauer J, Mullens W, Nagy KV, Prescott E, Raatikainen P, Rakisheva A, Reichlin T, Ricci RP, Shlyakhto E, Sitges M, Sousa-Uva M, Sutton R, Suwalski P, Svendsen JH, Touyz RM, Van Gelder IC, Vernooy K, Waltenberger J, Whinnett Z, Witte KK. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace 2022; 24:71-164. [PMID: 34455427 DOI: 10.1093/europace/euab232] [Citation(s) in RCA: 140] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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14
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Aksu T, Yalin K. Why is the Tilt Table Test Still Useful to Define who Should or Should Not Get A Pacemaker with Vasovagal Syncope? J Atr Fibrillation 2021; 13:2384. [PMID: 34950331 DOI: 10.4022/jafib.2384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/15/2020] [Accepted: 01/08/2021] [Indexed: 11/10/2022]
Abstract
The the tilt table test (TTT )has been used identify appropriate candidates for pacing in the majority of randomized trials. However, in recent years, it has been claimed-based largely on International Study on Syncope of Uncertain Etiology (ISSUE) studies-that the TTT demonstrates only a weak correlation with the mechanism documented by implantable loop recorder (ILR) at the time of syncope and thus confounds the correct diagnosis. Thus, cardiac pacing was supported in patients with recurrent vasovagal syncope (VVS) in whom clinically relevant asystole had been documented by ILR. In the present Editorial, we tried to discuss potential role of TTT in diagnostic workflow of VVS based on current data.
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Affiliation(s)
- Tolga Aksu
- University of Health Sciences, KocaeliDerince Education and Research Hospital, Kocaeli, Turkey
| | - Kıvanc Yalin
- Istanbul-Cerrahpasa University, Faculty of Medicine, Istanbul, Turkey
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15
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021; 42:3427-3520. [PMID: 34455430 DOI: 10.1093/eurheartj/ehab364] [Citation(s) in RCA: 865] [Impact Index Per Article: 288.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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16
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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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17
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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18
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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19
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Brignole M, Russo V, Arabia F, Oliveira M, Pedrote A, Aerts A, Rapacciuolo A, Boveda S, Deharo JC, Maglia G, Nigro G, Giacopelli D, Gargaro A, Tomaino M. Cardiac pacing in severe recurrent reflex syncope and tilt-induced asystole. Eur Heart J 2021; 42:508-516. [PMID: 33279955 PMCID: PMC7857694 DOI: 10.1093/eurheartj/ehaa936] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/26/2020] [Accepted: 11/03/2020] [Indexed: 12/16/2022] Open
Abstract
Aim The benefit of cardiac pacing in patients with severe recurrent reflex syncope and asystole induced by tilt testing has not been established. The usefulness of tilt-table test to select candidates for cardiac pacing is controversial. Methods and results We randomly assigned patients aged 40 years or older who had at least two episodes of unpredictable severe reflex syncope during the last year and a tilt-induced syncope with an asystolic pause longer than 3 s, to receive either an active (pacing ON; 63 patients) or an inactive (pacing OFF; 64 patients) dual-chamber pacemaker with closed loop stimulation (CLS). The primary endpoint was the time to first recurrence of syncope. Patients and independent outcome assessors were blinded to the assigned treatment. After a median follow-up of 11.2 months, syncope occurred in significantly fewer patients in the pacing group than in the control group [10 (16%) vs. 34 (53%); hazard ratio, 0.23; P = 0.00005]. The estimated syncope recurrence rate at 1 year was 19% (pacing) and 53% (control) and at 2 years, 22% (pacing) and 68% (control). A combined endpoint of syncope or presyncope occurred in significantly fewer patients in the pacing group [23 (37%) vs. 40 (63%); hazard ratio, 0.44; P = 0.002]. Minor device-related adverse events were reported in five patients (4%). Conclusion In patients aged 40 years or older, affected by severe recurrent reflex syncope and tilt-induced asystole, dual-chamber pacemaker with CLS is highly effective in reducing the recurrences of syncope. Our findings support the inclusion of tilt testing as a useful method to select candidates for cardiac pacing. Study registration ClinicalTrials.gov identifier NCT02324920, Eudamed number CIV-05-013546.
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Affiliation(s)
- Michele Brignole
- Department of Cardiovascular, Neural and Metabolic Sciences, Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Piazzale Brescia 20, Milano 20149, Italy.,Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 24, 16033 Lavagna, Italy
| | - Vincenzo Russo
- Department of Cardiology, Chair of Cardiology, University of the Study of Campania "Luigi Vanvitelli", Ospedale Monaldi, Via leonardo Bianchi, 80131 Napoli, Italy
| | - Francesco Arabia
- Department of Cardiology, Unit of Arrhythmology, A.O. Pugliese-Ciaccio, Viale Papa Pio X, 83, 88100 Castanzaro, Italy
| | - Mario Oliveira
- Cardiology Department, Santa Marta Hospital-University Central Hospital of Lisbon, Rue de Santa Marta, 50, 1150-140 Lisboa, Portugal
| | - Alonso Pedrote
- Division of Arrhythmology, Virgen del Rocio University Hospital, Avenida Manuel Siurot, 40013 Sevilla, Spain
| | - Arnaud Aerts
- Department of Cardiology, Zuyderland Medisch Centrum, Henri Dunantstraat, 5 6419PC Heerlen, The Netherlands
| | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, via Sergio Pansini 5, 80100 Napoli, Italy
| | - Serge Boveda
- Heart Rhythm Department, Clinique Pasteur, 45 avenue de Lombez - BP 27617 - 31076 Toulouse Cedex 3, France.,Universitair Ziekenhuis Brussel-VUB, Heart Rhythm Management Centre, Laarbeeklaan 101 1090 Brussels, Belgium
| | - Jean Claude Deharo
- Department of Cardiology, Hôpital La Timone Adultes, 264 Rue Saint-Pierre 13385 Marseille Cedex 5, France
| | - Giampiero Maglia
- Department of Cardiology, Unit of Arrhythmology, A.O. Pugliese-Ciaccio, Viale Papa Pio X, 83, 88100 Castanzaro, Italy
| | - Gerardo Nigro
- Department of Cardiology, Chair of Cardiology, University of the Study of Campania "Luigi Vanvitelli", Ospedale Monaldi, Via leonardo Bianchi, 80131 Napoli, Italy
| | - Daniele Giacopelli
- Research Clinical Unit, Biotronik Italy, Via delle Industrie, 11 20090 Vimodrone (MI), Italy
| | - Alessio Gargaro
- Research Clinical Unit, Biotronik Italy, Via delle Industrie, 11 20090 Vimodrone (MI), Italy
| | - Marco Tomaino
- Department of Cardiology, Ospedale Generale Regionale, Via Lorenz Böhler 5 39100 Bolzano, Italy
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20
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Doundoulakis I, Gatzoulis KA, Arsenos P, Dilaveris P, Skiadas I, Tsiachris D, Antoniou C, Soulaidopoulos S, Karystinos G, Pylarinou V, Drakopoulou M, Sideris S, Vlachopoulos C, Tousoulis D. Permanent pacemaker implantation in unexplained syncope patients with borderline sinus bradycardia and electrophysiology study-proven sinus node disease. J Arrhythm 2021; 37:189-195. [PMID: 33664902 PMCID: PMC7896452 DOI: 10.1002/joa3.12460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/22/2020] [Accepted: 10/25/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Significant sinus bradycardia (SB) in the context of sinus node dysfunction (SND) has been associated with neurological symptoms. The objective was to evaluate the effect of permanent pacing on the incidence of syncope in patients with rather mild degrees of SB, unexplained syncope, and "positive" invasive electrophysiologic testing. METHODS This was an observational study based on a prospective registry of 122 consecutive mild SB patients (61.90 ± 18.28 years, 61.5% male, 57.88 ± 7.73 bpm) presenting with recurrent unexplained pre and syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). Τhe implantation of a permanent antibradycardia pacemaker (ABP) was offered to all patients according to the results of the EPS. Eighty patients received the ABP, while 42 denied. RESULTS The mean of reported syncope episodes was 2.23 ± 1.29 (or presyncope 2.36 ± 1.20) in the last 12 months before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (50.39 ± 32.40 months), the primary outcome event (syncope) occurred in 18 of 122 patients (14.8%), 6 of 80 (7.5%) in the ABP group as compared to 12 of 42 (28.6%) in the no pacemaker group (P = .002). CONCLUSIONS Among patients with mild degree of SB and a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined SND after differentiating reflex syncope, identifies a subset of patients who will benefit from permanent pacing.
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Affiliation(s)
- Ioannis Doundoulakis
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Konstantinos A. Gatzoulis
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Petros Arsenos
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Polychronis Dilaveris
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Ioannis Skiadas
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | | | | | - Stergios Soulaidopoulos
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - George Karystinos
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Voula Pylarinou
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Maria Drakopoulou
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Skevos Sideris
- State Department of Cardiology“Hippokration” HospitalAthensGreece
| | - Charalambos Vlachopoulos
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Dimitrios Tousoulis
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
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21
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Permanent pacing for recurrent vasovagal syncope: New answers or just more questions? J Electrocardiol 2021; 65:88-90. [PMID: 33581411 DOI: 10.1016/j.jelectrocard.2021.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 11/23/2022]
Abstract
Vasovagal syncope (VVS) is a clinical condition related to bradycardia (cardioinhibitory response) and/or hypotension (vasodepressor response), likely mediated by parasympathetic overactivity and sympathetic withdrawal. Although clinical presentation is usually related to a self-limited event, frequent episodes or events without prodrome might be debilitating. There are limited medical therapies proven effective in randomized clinical trials. In patients not responsive to standard therapy, permanent pacemaker therapy may be suggested. However, the role of cardiac pacing for the prevention of syncope recurrences remains controversial due to difficulties to exclude potential role of the vasodepressor component during the episode.
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Brignole M, Rivasi G. New insights in diagnostics and therapies in syncope: a novel approach to non-cardiac syncope. Heart 2021; 107:864-873. [PMID: 33462120 DOI: 10.1136/heartjnl-2020-318261] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/29/2020] [Indexed: 12/27/2022] Open
Abstract
This article aims to give advice on how to identify and manage patients with syncope who are at risk of severe outcomes, that is, at risk of trauma, potentially life-threatening episodes or frequent recurrences reducing quality of life. The first step of syncope diagnostic assessment is to identify patients with cardiac syncope, and once established, these patients must receive the adequate mechanism-specific treatment. If cardiac syncope is unlikely, reflex (neurally mediated) syncope and orthostatic hypotension are the most frequent causes of transient loss of consciousness. For these presentations, efficacy of therapy is largely determined by the mechanism of syncope rather than its aetiology or clinical features. The identified mechanism of syncope should be carefully assessed and assigned either to hypotensive or bradycardic phenotype, which will determine the choice of therapy (counteracting hypotension or counteracting bradycardia). The results of recent trials indicate that 'mechanism-specific therapy' is highly effective in preventing recurrences. Established mechanism-specific treatment strategies include withdrawal of hypotensive drugs, applying fludrocortisone and midodrine for the hypotensive phenotype and cardiac pacing in the bradycardic phenotype.
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Affiliation(s)
- Michele Brignole
- Department of Cardiovascular, Neural and Metabolic Sciences, Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence, Firenze, Italy
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23
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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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24
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Chaumont C, Bourilhon J, Chastan N, Mirolo A, Eltchaninoff H, Anselme F. Recurrent seizures in a young woman: when video-EEG diagnoses a cardiac cause: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 33426439 PMCID: PMC7780438 DOI: 10.1093/ehjcr/ytaa236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/19/2020] [Accepted: 06/30/2020] [Indexed: 12/05/2022]
Abstract
Background While transient loss of consciousness is a frequent presenting symptom, differential diagnosis between syncope and epilepsy can be challenging. Misdiagnosis of epilepsy leads to important psychosocial consequences and eliminates the opportunity to treat patient’s true condition. Case summary A 39-year-old woman presenting with recurrent seizures since her childhood was referred to neurological consultation. Electroencephalograms (EEGs) and magnetic resonance imaging previously performed were normal. A sleep-deprived video-EEG was performed and highlighted after 12 h of sleep deprivation a progressive dropping of the heart rate followed by a complete heart block without ventricular escape rhythm and asystole for about 30 s. Her EEG recording later showed diffuse slow waves traducing a global cerebral dysfunction and suffering. The diagnosis of vaso-vagal syncope with predominant cardioinhibitory response was made and a dual-chamber pacemaker with rate-drop response algorithm was implanted. After a 2 years of follow-up, the patient remained free of syncope. Discussion Patients presenting with loss of consciousness and convulsion are often diagnosed with epilepsy despite normal EEGs. In patients presenting with recurrent seizures with unclear diagnosis of epilepsy or in a situation of drug-resistant epilepsy, syncope diagnosis should always be considered and a risk stratification is necessary. The benefit of pacemaker implantation in patients with recurrent vaso-vagal syncope is still very controversial. Only patients presenting with spontaneous asystole should be considered for pacemaker implantation in case of recurrent vaso-vagal syncope.
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Affiliation(s)
- Corentin Chaumont
- Department of Cardiology, Rouen University Hospital, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Julie Bourilhon
- Department of Neurology, Rouen University Hospital, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Nathalie Chastan
- Department of Neurology, Rouen University Hospital, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Adrian Mirolo
- Department of Cardiology, Rouen University Hospital, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Hélène Eltchaninoff
- Department of Cardiology, Rouen University Hospital, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Frédéric Anselme
- Department of Cardiology, Rouen University Hospital, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
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Aksu T, Guler TE, Bozyel S, Yalin K, Gopinathannair R. Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation. Europace 2020; 22:1320-1327. [DOI: 10.1093/europace/euaa230] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
Aims
Previous reports have suggested that cardioneuroablation (CNA) can be effective in reducing syncopal recurrences in patients with vasovagal syncope (VVS). This study assessed the efficacy of CNA in preventing a positive response to head-up tilt testing (HUT).
Methods and results
This is a single-centre retrospective study reviewing prospectively collected data. Fifty-one consecutive patients with VVS were included in the study. After confirmation of >3 s asystole on HUT, all patients underwent CNA. Head-up tilt testing was repeated 1 month after CNA. The main outcome measures were recurrence of syncope episode and positive response on HUT. During a median follow-up period of 11 months (interquartile range 3–27 months), all but 3 (5.8%) of 51 patients were free of syncope. Repeated HUTs were negative in 44 (86.2%) patients. When patients with recurrent syncope were excluded, vasodepressor response was seen in three cases and cardioinhibitory response in one case, respectively. Cardioneuroablation caused significant and durable shortening of RR interval in all cases. This effect was significantly higher in patients without positive HUT responses.
Conclusion
This pilot study shows that CNA can effectively prevent recurrent syncopal episodes in patients with refractory VVS. Head-up tilt testing seems as a valuable diagnostic tool not only to select suitable candidates and but also to evaluate success of CNA.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Tumer Erdem Guler
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Serdar Bozyel
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Kivanc Yalin
- Department of Cardiology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Catheter ablation of right atrial ganglionated plexi to treat cardioinhibitory neurocardiogenic syncope: a long-term follow-up prospective study. J Interv Card Electrophysiol 2020; 61:499-510. [DOI: 10.1007/s10840-020-00840-9] [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: 05/02/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
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Safety and efficacy of leadless pacemaker for cardioinhibitory vasovagal syncope. Heart Rhythm 2020; 17:1575-1581. [PMID: 32389681 DOI: 10.1016/j.hrthm.2020.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Single-chamber leadless pacemakers (LPs) have been shown to be an effective alternative to conventional transvenous pacemakers (CTPs), but their benefit in the context of cardioinhibitory vasovagal syncope (CI-VVS) is unknown. OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of LP compared with dual-chamber CTP for CI-VVS. METHODS We conducted a multicenter, retrospective study comparing patients who received LP or dual-chamber CTP for drug-refractory CI-VVS. CI-VVS was diagnosed clinically and supported by cardiac monitoring and head-up tilt table testing. The primary efficacy endpoint was freedom from syncope during follow-up. Secondary endpoints included device efficacy and safety estimated by device-related major and minor adverse events (AEs). RESULTS Seventy-two patients (24 LP, 48 CTP; age 32 ± 5.5 years; 90% female; syncope frequency 7.6 ± 3.4 per year) were included. At 1 year, 91% of patients (22/24) in the LP group and 94% of patients (43/48) in the CTP group met the primary efficacy endpoint (P = .7). Device efficacy endpoint was met in 92% of the LP group and 98% of the CTP group (P = .2). Early major AEs occurred in 2 of 24 in the LP group and 3 of 48 in the CTP group (P = .4). Late major AEs occurred in 0 of 24 in the LP group and 2 of 48 in the CTP group (P = 1). CONCLUSION In patients with CI-VVS, single-chamber LP demonstrated equivalent efficacy in reducing syncopal events compared to dual-chamber CTP, with a similar safety profile.
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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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Strano S, Toni D, Ammirati F, Sanna T, Tomaino M, Brignole M, Mazza A, Nguyen BL, Di Bonaventura C, Ricci RP, Boriani G. Neuro-arrhythmology: a challenging field of action and research: a review from the Task Force of Neuro-arrhythmology of Italian Association of Arrhythmias and Cardiac Pacing. J Cardiovasc Med (Hagerstown) 2020; 20:731-744. [PMID: 31567632 DOI: 10.2459/jcm.0000000000000866] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
: There is a growing interest in the study of the mechanisms of heart and brain interactions with the aim to improve the management of high-impact cardiac rhythm disorders, first of all atrial fibrillation. However, there are several topics to which the scientific interests of cardiologists and neurologists converge constituting the basis for enhancing the development of neuro-arrhythmology. This multidisciplinary field should cover a wide spectrum of diseases, even beyond the classical framework corresponding to stroke and atrial fibrillation and include the complex issues of seizures as well as loss of consciousness and syncope. The implications of a more focused interaction between neurologists and cardiologists in the field of neuro-arrhythmology should include in perspective the institution of research networks specifically devoted to investigate 'from bench to bedside' the complex pathophysiological links of the abovementioned diseases, with involvement of scientists in the field of biochemistry, genetics, molecular medicine, physiology, pathology and bioengineering. An investment in the field could have important implications in the perspectives of a more personalized approach to patients and diseases, in the context of 'precision'medicine. Large datasets and electronic medical records, with the approach typical of 'big data' could enhance the possibility of new findings with potentially important clinical implications. Finally, the interaction between neurologists and cardiologists involved in arrythmia management should have some organizational implications, with new models of healthcare delivery based on multidisciplinary assistance, similarly to that applied in the case of syncope units.
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Affiliation(s)
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome
| | | | - Tommaso Sanna
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Institute of Cardiology, Rome
| | - Marco Tomaino
- Department of Cardiology, Ospedale di Bolzano, Bolzano
| | - Michele Brignole
- Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna
| | - Andrea Mazza
- Cardiology Division, Santa Maria della Stella Hospital, Orvieto
| | | | | | | | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
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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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Rocha BML, Gomes RV, Cunha GJL, Silva BMV, Pocinho R, Morais R, Araújo I, Fonseca C. Diagnostic and therapeutic approach to cardioinhibitory reflex syncope: A complex and controversial issue. Rev Port Cardiol 2019; 38:661-673. [PMID: 31813672 DOI: 10.1016/j.repc.2018.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/10/2018] [Accepted: 11/14/2018] [Indexed: 01/02/2023] Open
Abstract
Syncope is defined as a transient loss of consciousness due to global cerebral hypoperfusion and is one of the leading causes of emergency department admission. The initial approach should focus on excluding non-syncopal causes for loss of consciousness and risk stratification for cardiac cause, in order to ensure an appropriate etiological investigation and therapeutic approach. Vasovagal syncope (VVS), the most common type of syncope, should be assumed once other causes are excluded. Pathophysiologically, the vasovagal reflex is the result of a paradoxical autonomic response, leading to hypotension and/or bradycardia. VVS has not been shown to affect mortality, but morbidity may be considerable in those with recurrent syncopal episodes. The management of VVS includes both non-pharmacological and pharmacological measures that act on various levels of the reflex arc that triggers the syncopal episode. However, most are of uncertain benefit given the scarcity of high-quality supporting evidence. Pacemaker therapy may be considered in recurrent refractory cardioinhibitory reflex syncope, for which it is currently considered a robust intervention, as noted in the European guidelines. Non-randomized and unblinded studies have shown a potential benefit of pacing in recurrent VVS, but double-blinded randomized controlled trials have not consistently demonstrated positive results. We performed a comprehensive review of the current literature and recent advances in cardiac pacing and pacing algorithms in VVS, and discuss the diagnostic and therapeutic approach to the complex patient with recurrent VVS and reduced quality of life.
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Affiliation(s)
- Bruno M L Rocha
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal.
| | - Rita V Gomes
- Unidade de Insuficiência Cardíaca, Serviço de Medicina III, Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal; Serviço de Cardiologia, Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal
| | - Gonçalo J L Cunha
- Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Beatriz M V Silva
- Serviço de Cardiologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Rita Pocinho
- Serviço de Medicina Interna 1.2, Hospital de São José, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Rui Morais
- Unidade de Insuficiência Cardíaca, Serviço de Medicina III, Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Inês Araújo
- Unidade de Insuficiência Cardíaca, Serviço de Medicina III, Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Cândida Fonseca
- Unidade de Insuficiência Cardíaca, Serviço de Medicina III, Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal; NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
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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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Goldberger ZD, Petek BJ, Brignole M, Shen WK, Sheldon RS, Solbiati M, Deharo JC, Moya A, Hamdan MH. ACC/AHA/HRS Versus ESC Guidelines for the Diagnosis and Management of Syncope. J Am Coll Cardiol 2019; 74:2410-2423. [DOI: 10.1016/j.jacc.2019.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 08/26/2019] [Accepted: 09/05/2019] [Indexed: 01/07/2023]
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da Cunha GJL, Rocha BML, Gomes RV, Silva BV, Mendes G, Morais R, Araújo IF, Fonseca C. A systematic review on recurrent cardioinhibitory vasovagal syncope: Does pacing therapy break the fall? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1400-1407. [DOI: 10.1111/pace.13790] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 07/04/2019] [Accepted: 08/18/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Gonçalo José Lopes da Cunha
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Bruno Miguel Lopes Rocha
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Rita Ventura Gomes
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
- Cardiology DepartmentHospital de Vila Franca de Xira Lisbon Portugal
| | - Beatriz Valente Silva
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Gonçalo Mendes
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
- Internal Medicine Department, Hospital de São BernardoCentro Hospitalar de Setúbal Setúbal Portugal
| | - Rui Morais
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Inês Fornelos Araújo
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Cândida Fonseca
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
- NOVA Medical School, Faculdade de Ciências MédicasUniversidade Nova de Lisboa Lisbon Portugal
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Diagnostic and therapeutic approach to cardioinhibitory reflex syncope: A complex and controversial issue. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Feitosa-Filho GS, Peixoto JM, Pinheiro JES, Afiune Neto A, Albuquerque ALTD, Cattani ÁC, Nussbacher A, Camarano AA, Sichinels AH, Sousa ACS, de Alencar Filho AC, Gravina CF, Sobral Filho DC, Pitthan E, Costa EFDA, Duarte EDR, Freitas EVD, Moriguchi EH, Mesquita ET, Fernandes F, Fuchs FC, Feitosa GS, Pierre H, Pereira Filho I, Helber I, Borges JL, Garcia JMDA, Souza JAGD, Zanon JCDC, Alves JDC, Mohallem KL, Chaves LMDSM, Moura LAZ, Silva MCAD, Toledo MADV, Assunção MELSDM, Wajngarten M, Gonçalves MJO, Lopes NHM, Rodrigues NL, Toscano PRP, Rousseff P, Maia RAR, Franken RA, Miranda RD, Gamarski R, Rosa RF, Santos SCDM, Galera SC, Grespan SMDS, Silva TCRD, Esteves WADM. Updated Geriatric Cardiology Guidelines of the Brazilian Society of Cardiology - 2019. Arq Bras Cardiol 2019; 112:649-705. [PMID: 31188969 PMCID: PMC6555565 DOI: 10.5935/abc.20190086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
| | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brazil
| | | | - Abrahão Afiune Neto
- Universidade Federal de Goiás (UFG), Goiânia, GO - Brazil
- UniEVANGÉLICA, Anápolis, GO - Brazil
| | | | | | | | | | | | | | | | | | - Dario Celestino Sobral Filho
- Universidade de Pernambuco (UPE), Recife, PE - Brazil
- Pronto-Socorro Cardiológico Universitário de Pernambuco (PROCAPE), Recife, PE - Brazil
| | - Eduardo Pitthan
- Universidade Federal da Fronteira Sul (UFFS), Chapecó, SC - Brazil
| | - Elisa Franco de Assis Costa
- Sociedade Brasileira de Geriatria e Gerontologia (SBGG), Rio de Janeiro, RJ - Brazil
- Universidade Federal de Goiás (UFG), Goiânia, GO - Brazil
| | | | | | | | | | - Fábio Fernandes
- Instituto do Coração (Incor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brazil
- Departamento de Insuficiência Cardíaca (DEIC) da Sociedade Brasileira de Cardiologia (SBC), Rio de Janeiro, RJ - Brazil
| | - Felipe Costa Fuchs
- Universidade Federal do Rio Grande do Sul (UFRS), Porto Alegre, RS - Brazil
| | | | - Humberto Pierre
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brazil
| | | | - Izo Helber
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brazil
| | | | | | | | | | | | | | | | | | - Márcia Cristina Amélia da Silva
- Universidade de Pernambuco (UPE), Recife, PE - Brazil
- Pronto-Socorro Cardiológico Universitário de Pernambuco (PROCAPE), Recife, PE - Brazil
| | | | | | | | | | - Neuza Helena Moreira Lopes
- Instituto do Coração (Incor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brazil
| | | | | | | | | | | | | | - Roberto Gamarski
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ - Brazil
| | | | | | | | | | | | - William Antonio de Magalhães Esteves
- Hospital Vera Cruz, Belo Horizonte, MG - Brazil
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brazil
- Universidade de Itaúna, Itaúna, MG - Brazil
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Lee JZ, Mulpuru SK, Shen WK. The Role of Pacing in Elderly Patients with Unexplained Syncope. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0608-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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38
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Block CL. ECG of the Month. J Am Vet Med Assoc 2019; 254:206-208. [PMID: 30605375 DOI: 10.2460/javma.254.2.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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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Paech C, Wagner F, Mensch S, Antonin Gebauer R. Cardiac pacing in cardioinhibitory syncope in children. CONGENIT HEART DIS 2018; 13:1064-1068. [DOI: 10.1111/chd.12682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/27/2018] [Accepted: 09/12/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Christian Paech
- Department for Pediatric Cardiology; University of Leipzig-Heart Center; Leipzig Germany
| | - Franziska Wagner
- Department for Pediatric Cardiology; University of Leipzig-Heart Center; Leipzig Germany
| | - Sebastian Mensch
- Department for Pediatric Cardiology; University of Leipzig-Heart Center; Leipzig Germany
| | - Roman Antonin Gebauer
- Department for Pediatric Cardiology; University of Leipzig-Heart Center; Leipzig Germany
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Sardu C, Marfella R, Testa G, Santamaria M, Sacra C, Ranauro A, Paolisso G, Rizzo MR, Barbieri M. ELectrophysiological mechanisms underlying the Inhibitory CArdiac syncope without asystolic significant pause: Therapeutic and prognostic implications. The ELICA randomized trial. Medicine (Baltimore) 2018; 97:e11757. [PMID: 30075596 PMCID: PMC6081146 DOI: 10.1097/md.0000000000011757] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/06/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate syncope recurrence in patients with a 2A cardioinhibitory response to the head up tilt testing (HUT). METHODS In this study, we enrolled 72 consecutive patients affected by syncope with cardioinhibitory response without asystolic significant pause to HUT (2A type). In these patients, we randomly performed electrophysiological study (ES). In case of sino-atrial node, atrio-ventricular node dysfunction, and sustained arrhythmias induction, the ES resulted positive. ES was positive in 9 patients (group A), then treated by catheter ablation, and/or by devices implants. Otherwise, ES resulted negative (group B), and these patients did not receive an interventional treatment. However, after ES, we evaluated syncope recurrence during 360 days follow-up. RESULTS There was a lower statistical significant syncope recurrence at follow-up, comparing group A to group B of patients [n of events 9 (40.9%) vs 8 (57.1%), P < .05]. At multivariate analysis, ES result was the only factor predicting syncope recurrence at follow-up (hazard ratio = 27.63, 95% confidence interval = 1.02-54.24, P < .005). CONCLUSION The positivity to ES study, and successful interventional therapies may reduce the burden of syncope recurrence at 360 days follow-up in 2A HUT subjects.Clinical trial number: NCT02861274.
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Affiliation(s)
- Celestino Sardu
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Naples
| | - Raffaele Marfella
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Naples
| | - Gianluca Testa
- Department of Medicine and Health Sciences, University of Molise
| | - Matteo Santamaria
- Cardiovascular and Arrhythmias Department, John Paul II Research and Care Foundation, Campobasso, Italy
| | - Cosimo Sacra
- Cardiovascular and Arrhythmias Department, John Paul II Research and Care Foundation, Campobasso, Italy
| | - Alfredo Ranauro
- Department of Medicine and Health Sciences, University of Molise
| | - Giuseppe Paolisso
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Naples
| | - Maria Rosaria Rizzo
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Naples
| | - Michelangela Barbieri
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Naples
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Gampa A, Upadhyay GA. Treatment of Neurocardiogenic Syncope: From Conservative to Cutting-edge. J Innov Card Rhythm Manag 2018; 9:3221-3231. [PMID: 32477815 PMCID: PMC7252686 DOI: 10.19102/icrm.2018.090702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 12/11/2017] [Indexed: 11/23/2022] Open
Abstract
Neurocardiogenic syncope is the most frequent cause of syncope in the general population. Many years have been spent on determining an effective treatment for this condition. Conventional treatment usually follows a tiered approach for neurocardiogenic syncope, as follows: first, lifestyle modification, including increased fluid intake and the introduction of physical counterpressure maneuvers, is tried; then the use of targeted pharmacologic therapy, particularly agents that support blood pressure or that drive blood pressure is attempted; and, finally, pacemaker implantation in patients with a predominant cardioinhibitory component to their syncopal episodes is performed. More recently, autonomic modulation with cardiac ganglion ablation has emerged as a promising treatment modality for patients refractory to traditional approaches. In this review, we sought to summarize the existing therapies for neurocardiogenic syncope and explore the latest research on new modalities of treatment.
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Affiliation(s)
- Amulya Gampa
- Department of Internal Medicine, the University of Chicago Medicine, Chicago, IL, USA
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, the University of Chicago Medicine, Chicago, IL, USA
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Morita H. Editorial commentary: To pace, or not to pace in vasovagal syncope? Trends Cardiovasc Med 2018; 28:539-540. [PMID: 29970287 DOI: 10.1016/j.tcm.2018.06.005] [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: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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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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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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Baron-Esquivias G, Morillo CA. La estimulación definitiva en el paciente con síncope neuromediado. Lecciones del estudio SPAIN. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 980] [Impact Index Per Article: 163.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Definitive Pacing Therapy in Patients With Neuromediated Syncope. Lessons From the SPAIN Study. ACTA ACUST UNITED AC 2018; 71:320-322. [PMID: 29295807 DOI: 10.1016/j.rec.2017.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 10/06/2017] [Indexed: 11/24/2022]
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The Placebo Effect in Cardiology: Understanding and Using It. Can J Cardiol 2017; 33:1535-1542. [DOI: 10.1016/j.cjca.2017.09.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 12/18/2022] Open
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