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Abstract
Catheter-based neuromodulation of intrinsic cardiac autonomic nervous system is increasingly being used to improve outcomes in patients with vasovagal syncope and bradyarrhythmias caused by vagal overactivity. However, there is still no consensus for patient selection, technical steps, and procedural end points. This review takes the reader on a practical exploration of neuromodulation for bradyarrhythmias, concentrating on the critical aspects of proper patient selection, evidence-based insights, and anatomic intricacies within the intrinsic cardiac autonomic nervous system. Also discussed are different mapping techniques and outcome measures. Future directions to optimize the utilization of this technique in clinical practice are highlighted.
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Affiliation(s)
- Asad Khan
- Division of Cardiology, Rush University Medical Center, 1717 West Congress Parkway, Chicago, IL 60612, USA
| | - Henry D Huang
- Division of Cardiology, Rush University Medical Center, 1717 West Congress Parkway, Chicago, IL 60612, USA
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul 34100, Turkey.
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2
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Hanna P, Ardell JL. Cardiac Neuroanatomy and Fundamentals of Neurocardiology. Card Electrophysiol Clin 2024; 16:229-237. [PMID: 39084716 DOI: 10.1016/j.ccep.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Cardiac control is mediated via nested-feedback reflex control networks involving the intrinsic cardiac ganglia, intra-thoracic extra-cardiac ganglia, spinal cord, brainstem, and higher centers. This control system is optimized to respond to normal physiologic stressors; however, it can be catastrophically disrupted by pathologic events such as myocardial ischemia. In fact, it is now recognized that cardiac disease progression reflects the dynamic interplay between adverse remodeling of the cardiac substrate coupled with autonomic dysregulation. With advances in understanding of this network dynamic in normal and pathologic states, neuroscience-based neuromodulation therapies can be devised for the management of acute and chronic cardiac pathologies.
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Affiliation(s)
- Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, USA; UCLA Neurocardiology Research Program of Excellence, UCLA, Los Angeles, CA 90095, USA
| | - Jeffrey L Ardell
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, USA; UCLA Neurocardiology Research Program of Excellence, UCLA, Los Angeles, CA 90095, USA.
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3
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Aksu T. Cardioneuroablation for the treatment of reflex syncope and functional bradyarrhythmias: A Scientific Statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS) and the Latin American Heart Rhythm Society (LAHRS). Europace 2024; 26:euae206. [PMID: 39082698 PMCID: PMC11350289 DOI: 10.1093/europace/euae206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 07/18/2024] [Indexed: 08/29/2024] Open
Abstract
Cardioneuroablation has emerged as a potential alternative to cardiac pacing in selected cases with vasovagal reflex syncope, extrinsic vagally induced sinus bradycardia-arrest or atrioventricular block. The technique was first introduced decades ago, and its use has risen over the past decade. However, as with any intervention, proper patient selection and technique are a prerequisite for a safe and effective use of cardioneuroablation therapy. This document aims to review and interpret available scientific evidence and provide a summary position on the topic.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, İçerenköy Mah. Hastahane Sok. 4,4/1 34752 Ataşehir/İstanbul, Turkey
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Marrese A, Persico R, Parlato E, Faccenda D, Salucci A, Comparone G, Pergola V, Ammirati G, Addeo L, Fonderico C, Cocchiara L, Volpe A, Visconti P, Rapacciuolo A, Strisciuglio T. Cardioneuroablation: the known and the unknown. Front Cardiovasc Med 2024; 11:1412195. [PMID: 39131701 PMCID: PMC11310060 DOI: 10.3389/fcvm.2024.1412195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/28/2024] [Indexed: 08/13/2024] Open
Abstract
Cardioneuroablation (CNA) is a novel interventional procedure for the treatment of recurrent vasovagal syncope (VVS) and advanced atrioventricular block secondary to hyperactivation of vagal tone in young patients. By damaging the cardiac parasympathetic ganglia, CNA seems to be able to mitigate and/or abolish the excessive vagal activity and improve patients' outcome. This review is intended to give a detailed and comprehensive overview of the current evidences regarding (1) the clinical applications of CNA (2) the identification of ablation targets and procedural endpoints (3) the medium-long term effect of the procedure and its future perspectives. However, clinical data are still limited, and expert consensus or recommendations in the guidelines regarding this technique are still lacking.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - T. Strisciuglio
- Department of Cardiology, University of Naples Federico II, Naples, Italy
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Önder ŞE, Güler TE, Bozyel S, Dalgıç N, Şipal A, Çağdaş M, Kılıç E, Huang H, Aksu T. Step-by-step application of a new ganglionated plexus mapping method in a patient with vasovagal syncope. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01885-w. [PMID: 39046609 DOI: 10.1007/s10840-024-01885-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 07/17/2024] [Indexed: 07/25/2024]
Affiliation(s)
- Şükriye Ebru Önder
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Tümer Erdem Güler
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Serdar Bozyel
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Nur Dalgıç
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Abdülcebbar Şipal
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Metin Çağdaş
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Emre Kılıç
- Bioritim Sağlık Hizmetleri, Bursa, Turkey
| | - Henry Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Tolga Aksu
- Faculty of Medicine, Yeditepe University, Istanbul, Turkey.
- Department of Cardiology, Yeditepe University Hospital, 34742, Istanbul, Turkey.
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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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Penela D, Berruezo A, Roten L, Futyma P, Richter S, Falasconi G, Providencia R, Chun J. Cardioneuroablation for vasovagal syncope: insights on patients' selection, centre settings, procedural workflow and endpoints-results from an European Heart Rhythm Association survey. Europace 2024; 26:euae106. [PMID: 38781099 PMCID: PMC11114473 DOI: 10.1093/europace/euae106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/18/2024] [Indexed: 05/25/2024] Open
Abstract
AIMS Cardioneuroablation (CNA) is a catheter-based intervention for recurrent vasovagal syncope (VVS) that consists in the modulation of the parasympathetic cardiac autonomic nervous system. This survey aims to provide a comprehensive overview of current CNA utilization in Europe. METHODS AND RESULTS A total of 202 participants from 40 different countries replied to the survey. Half of the respondents have performed a CNA during the last 12 months, reflecting that it is considered a treatment option of a subset of patients. Seventy-one per cent of respondents adopt an approach targeting ganglionated plexuses (GPs) systematically in both the right atrium (RA) and left atrium (LA). The second most common strategy (16%) involves LA GP ablation only after no response following RA ablation. The procedural endpoint is frequently an increase in heart rate. Ganglionated plexus localization predominantly relies on an anatomical approach (90%) and electrogram analysis (59%). Less utilized methods include pre-procedural imaging (20%), high-frequency stimulation (17%), and spectral analysis (10%). Post-CNA, anticoagulation or antiplatelet therapy is prescribed, with only 11% of the respondents discharging patients without such medication. Cardioneuroablation is perceived as effective (80% of respondents) and safe (71% estimated <1% rate of procedure-related complications). Half view CNA emerging as a first-line therapy in the near future. CONCLUSION This survey offers a snapshot of the current implementation of CNA in Europe. The results show high expectations for the future of CNA, but important heterogeneity exists regarding indications, procedural workflow, and endpoints of CNA. Ongoing efforts are essential to standardize procedural protocols and peri-procedural patient management.
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Affiliation(s)
- Diego Penela
- Humanitas Research Center, Milano, Italy
- Heart Institute, Teknon Medical Center Barcelona, Spain
| | | | - Laurent Roten
- Department of Cardiology, Inselspital-Bern University Hospital, University of Bern, Bern, Switzerland
| | - Piotr Futyma
- St. Joseph’s Heart Rhythm Center Rzeszow and Medical College, University of Rzeszow, Rzeszow, Poland
| | - Sergio Richter
- Heart Center Dresden, University Hospital, Technical University Dresden, Dresden, Germany
| | - Giulio Falasconi
- Humanitas Research Center, Milano, Italy
- Heart Institute, Teknon Medical Center Barcelona, Spain
| | - Rui Providencia
- St Bartholomew’s Hospital, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Julian Chun
- Cardioangiologisches Centrum Bethanien, Agaplesion Bethanien Krankenhaus, Frankfurt, Germany
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Aksu T, Chung MK. Cardioneuroablation for Cardioinhibitory Vasovagal Syncope: Rationale, Approaches, and Its Role in Long-Term Management. CURRENT CARDIOVASCULAR RISK REPORTS 2024; 18:55-64. [PMID: 38707611 PMCID: PMC11064987 DOI: 10.1007/s12170-024-00736-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/07/2024]
Abstract
Purpose of Review Cardioneuroablation (CNA) has emerged as a potential alternative to pacemaker therapy in well-selected cases with vasovagal syncope (VVS). In recent years, the number of CNA procedures performed by electrophysiologists has considerably risen. However, some important questions, including proper patient selection and long-term results, remain unanswered. The present article aims to critically review and interpret latest scientific evidence for clinical indications and how to approach long-term management. Recent Findings CNA is a new approach that has been supported mainly by retrospective or observational data for its use in syncope. Overall, in mixed population studies treated with CNA, 83.3 to 100% have been reported to be free of syncope over follow-up periods of 6 to 52.1 months. For studies including patients who underwent CNA with pure VVS, 73.2 to 100% have been reported to be syncope-free over follow-up periods of 4 to 45.1 months. One large meta-analysis showed 91.9% freedom from syncope after CAN. To date, only one randomized controlled trial with small case number has been performed of CNA compared to non-pharmacological treatment in VVS. In this study of 48 patients with an average of 10 ± 9 spontaneous syncopal episodes prior to study enrollment and 3 ± 2 episodes in the year prior to CNA. After CNA, 92% were free of syncope compared with 46% treated with optimal non-pharmacological treatment to prevent new syncope episodes (P = 0.0004). To date, most studies have included younger patients (< 60 years of age). There are only limited data in patients older than 60, and some studies suggest less of an effect in relatively older patients. Summary Cardioneuroablation can be performed to decrease syncope recurrence in adult patients aged < 60 years, with severe or recurrent cardioinhibitory syncope without prodromal symptoms, after proven failure of conventional therapies. Due to a paucity of data supporting efficacy in older individuals or for vasodepressor components, CNA in adult patients aged > 60 years or in the presence of a dominant vasodepressor should be considered investigational in severely symptomatic patients after proven failure of pharmacological and non-pharmacological therapies.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Faculty of Medicine, Yeditepe University Hospital, Istanbul 34742, Turkey
| | - Mina K. Chung
- Heart, Vascular, and Thoracic Institute, and Lerner Research Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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Herweg B, Patel RS, Noujaim S, Spano J, Mencer N, Vijayaraman P. Cryoballoon cardioneuroablation: New electrophysiological insights. Heart Rhythm O2 2024; 5:209-216. [PMID: 38690146 PMCID: PMC11056456 DOI: 10.1016/j.hroo.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Background Cardioneuroablation (CNA) targeting ganglionated plexi has shown promise in treating vasovagal syncope. Only radiofrequency ablation has been used to achieve this goal thus far. Objective The purpose of this study was to investigate the utility of cryoballoon ablation (CBA) of the pulmonary veins (PVs) as a potential simplified approach to CNA. Methods We report our observations of autonomic modulation in a series of 17 patients undergoing CBA for atrial fibrillation and our early experience using CBA of the PVs in 3 patients with malignant vagal syncope. In 17 patients undergoing CBA of AF, sinus cycle length was recorded intraprocedurally after ablation of individual PVs. Results The most pronounced shortening of the sinus cycle length was observed after isolation of the right upper PV, which was ablated last. Reduced sinus node recovery time and atrioventricular (AV) nodal effective refractory period were observed after CBA. Resting heart rate was elevated by 6-7 bpm after CBA and persisted during 12-month follow-up. CBA of the PVs was performed in 3 patients with recurrent vagal syncope mediated by sinus arrest (n = 2) and AV block (n = 1). In all patients, isolation of the right upper PV resulted in marked shortening of sinus cycle length. During follow-up of 178 ± 43 days (134-219 days), CNA resulted in abolition of pauses, bradycardia-related symptoms, and syncope in all patients. Conclusion CBA of the PVs (particularly the right upper PV) may be a predictable anatomic CNA approach in patients with refractory vagal syncope due to sinus arrest and/or AV block and may warrant systematic investigation as a tool to perform CNA.
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Affiliation(s)
- Bengt Herweg
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Ritesh S. Patel
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Sami Noujaim
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | | | - Nicholas Mencer
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
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Piotrowski R, Baran J, Sikorska A, Niedzwiedz M, Krynski T, Kulakowski P. Cardioneuroablation: comparison of acute effects of the right vs. left atrial approach in patients with reflex syncope: the ROMAN2 study. Europace 2024; 26:euae042. [PMID: 38315895 PMCID: PMC10873699 DOI: 10.1093/europace/euae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/25/2023] [Accepted: 01/24/2024] [Indexed: 02/07/2024] Open
Affiliation(s)
- Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Jakub Baran
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Agnieszka Sikorska
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Michał Niedzwiedz
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Tomasz Krynski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
| | - Piotr Kulakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Grenadierow 51/59 Street, 04-073 Warsaw, Poland
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Aksu T, Po SS. How to perform cardioneuroablation for vasovagal syncope and functional bradycardia. Heart Rhythm 2024; 21:100-105. [PMID: 37776935 DOI: 10.1016/j.hrthm.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/21/2023] [Accepted: 09/21/2023] [Indexed: 10/02/2023]
Affiliation(s)
- Tolga Aksu
- Faculty of Medicine, Yeditepe University, Istanbul, Turkey.
| | - Sunny S Po
- University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
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12
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Traykov V, Shalganov T. Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life. Curr Cardiol Rep 2023; 25:1839-1849. [PMID: 37982935 DOI: 10.1007/s11886-023-01997-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE OF REVIEW Vasovagal syncope (VVS) is a common entity causing transient loss of consciousness and affecting quality of life. Guideline-recommended therapy involves conservative measures and pacing in selected patients. Cardioneuroablation (CNA) targeting the ganglionated plexi in the heart has been shown to reduce excessive vagal excitation, which plays a major role in the pathophysiology of VVS and functional bradycardia. RECENT FINDINGS The introduction of CNA has fueled research into its value for the treatment of VVS. Multiple observational studies and one randomized trial have demonstrated the safety and efficacy of CNA and the positive impact on quality of life. This review describes the rationale and CNA procedural techniques and outcomes. Patient selection and future directions have also been described. Cardioneuroablation is a promising treatment for patients with recurrent VVS and functional bradycardia. Further large-scale randomized studies are needed to further verify the safety and efficacy of this approach.
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Affiliation(s)
- Vassil Traykov
- Department of Invasive Electrophysiology, Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, 1407 N. Vaptzarov blvd 51B, Sofia, Bulgaria.
| | - Tchavdar Shalganov
- Department of Electrophysiology, Clinic of Cardiology, National Heart Hospital, Sofia, Bulgaria
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13
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Chung WH, Masuyama K, Challita R, Hayase J, Mori S, Cha S, Bradfield JS, Ardell JL, Shivkumar K, Ajijola OA. Ischemia-induced ventricular proarrhythmia and cardiovascular autonomic dysreflexia after cardioneuroablation. Heart Rhythm 2023; 20:1534-1545. [PMID: 37562487 DOI: 10.1016/j.hrthm.2023.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Cardioneuroablation (CNA) is an attractive treatment of vasovagal syncope. Its long-term efficacy and safety remain unknown. OBJECTIVE The purpose of this study was to develop a chronic porcine model of CNA to examine the susceptibility to ventricular tachyarrhythmia (ventricular tachycardia/ventricular fibrillation [VT/VF]) and cardiac autonomic function after CNA. METHODS A percutaneous CNA model was developed by ablation of left- and right-sided ganglionated plexi (n = 5), confirmed by histology. Reproducible bilateral vagal denervation was confirmed after CNA by extracardiac vagal nerve stimulation (VNS) and histology. Chronic studies included 16 pigs randomized to CNA (n = 8) and sham ablation (n = 8, Control). After 6 weeks, animals underwent hemodynamic studies, assessment of cardiac sympathetic and parasympathetic function using sympathetic chain stimulation and direct VNS, respectively, and proarrhythmic potential after left anterior descending (LAD) coronary artery ligation. RESULTS After CNA, extracardiac VNS responses remained abolished for 6 weeks despite ganglia remaining in ablated ganglionated plexi. In the CNA group, direct VNS resulted in paradoxical increases in blood pressure, but not in sham-ablated animals (CNA group vs sham group: 8.36% ± 7.0% vs -4.83% ± 8.7%, respectively; P = .009). Left sympathetic chain stimulation (8 Hz) induced significant corrected QT interval prolongation in the CNA group vs the sham group (11.23% ± 4.0% vs 1.49% ± 4.0%, respectively; P < .001). VT/VF after LAD ligation was more prevalent and occurred earlier in the CNA group than in the control group (61.44 ± 73.7 seconds vs 245.11 ± 104.0 seconds, respectively; P = .002). CONCLUSION Cardiac vagal denervation is maintained long-term after CNA in a porcine model. However, chronic CNA was associated with cardiovascular dysreflexia, diminished cardioprotective effects of cardiac vagal tone, and increased susceptibility to VT/VF in ischemia. These potential long-term negative effects of CNA suggest the need for rigorous clinical studies on CNA.
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Affiliation(s)
- Wei-Hsin Chung
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California; China Medical University Hospital, Taichung, Taiwan
| | - Kiyoshi Masuyama
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Ronald Challita
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Steven Cha
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jeffery L Ardell
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California.
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14
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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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Almeida S. Cardioneuroablation: A game-changer for vasovagal syncope. Rev Port Cardiol 2023; 42:831-833. [PMID: 37263497 DOI: 10.1016/j.repc.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
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16
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Cai S, Zheng L, Yao Y. Cardioneuroablation for vasovagal syncope alters head-up tilt test response and reduces cardiac deceleration capacity. HeartRhythm Case Rep 2023; 9:773-778. [PMID: 38047189 PMCID: PMC10691945 DOI: 10.1016/j.hrcr.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Simin Cai
- Center of Arrhythmia, Huazhong Fuwai Hospital, Heart Center, Henan Provincial People’s Hospital, The People’s Hospital of Zhengzhou University, Henan, China
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihui Zheng
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Yarkoni M, Rehman WU, Bajwa A, Yarkoni A, Rehman AU. Ganglionated Plexus Ablation Procedures to Treat Vasovagal Syncope. Int J Mol Sci 2023; 24:13264. [PMID: 37686062 PMCID: PMC10487499 DOI: 10.3390/ijms241713264] [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: 08/07/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Vasovagal syncope (VVS) refers to a heterogeneous group of conditions whereby the cardiovascular reflexes normally controlling the circulation are interrupted irregularly in response to a trigger, resulting in vasodilation, bradycardia, or both. VVS affects one-third of the population at least once in their lifetime or by the age of 60, reduces the quality of life, and may cause disability affecting certain routines. It poses a considerable economic burden on society, and, despite its prevalence, there is currently no proven pharmacological treatment for preventing VVS. The novel procedure of ganglionated plexus (GP) ablation has emerged rapidly in the past two decades, and has been proven successful in treating syncope. Several parameters influence the success rate of GP ablation, including specific ablation sites, localization and surgical techniques, method of access, and the integration of other interventions. This review aims to provide an overview of the existing literature on the physiological aspects and clinical effectiveness of GP ablation in the treatment of VVS. Specifically, we explore the association between GPs and VVS and examine the impact of GP ablation procedures as reported in human clinical trials. Our objective is to shed light on the therapeutic significance of GP ablation in eliminating VVS and restoring normal sinus rhythm, particularly among young adults affected by this condition.
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Affiliation(s)
- Merav Yarkoni
- Heart and Vascular Institute, United Health Services, Johnson City, NY 13790, USA; (W.u.R.); (A.B.); (A.Y.); (A.u.R.)
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18
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Li L, Po S, Yao Y. Cardioneuroablation for Treating Vasovagal Syncope: Current Status and Future Directions. Arrhythm Electrophysiol Rev 2023; 12:e18. [PMID: 37457436 PMCID: PMC10345939 DOI: 10.15420/aer.2023.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/05/2023] [Indexed: 07/18/2023] Open
Abstract
Syncope is defined by transient and spontaneous loss of consciousness with rapid recovery. Vasovagal syncope (VVS) is the most common form of syncope and is strongly associated with hypervagotonia. There is, however, a lack of effective therapies for VVS. Cardioneuroablation (CNA) is an emerging and promising intervention for VVS with favourable outcomes. CNA has been shown to suppress excessive excitation of vagal activity through ablating the cardiac ganglionated plexi. CNA in the management of VVS requires more structured and comprehensive studies and several issues concerning patient selection, selection of ablation targets, ablation endpoints and the long-term effect of CNA are yet to be determined. This review describes its clinical applications and future directions based on current research data and the authors' own experiences.
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Affiliation(s)
- Le Li
- Cardiac Arrhythmia Center, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Sunny Po
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, US
| | - Yan Yao
- Cardiac Arrhythmia Center, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
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Brignole M, Aksu T, Calò L, Debruyne P, Deharo JC, Fanciulli A, Fedorowski A, Kulakowski P, Morillo C, Moya A, Olshansky B, Piotrowski R, Stec S, Wichterle D. Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope. Europace 2023; 25:euad033. [PMID: 37021351 PMCID: PMC10227654 DOI: 10.1093/europace/euad033] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 04/07/2023] Open
Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Piazzale Brescia 2, 20149 Milano, Italy
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, 34755 Ataşehir/İstanbul, Turkey
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, 00169 Roma, Italy
| | | | - Jean Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, France and Aix Marseille Université, C2VN, 13005 Marseille, France
| | - Alessandra Fanciulli
- Department of Neurology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine, Karolinska Institute, 17177 Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 20502 Malmö, Sweden
| | - Piotr Kulakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Carlos Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, T2N 1N4 Calgary, AB, Canada
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, 08028 Barcelona, Spain
| | - Brian Olshansky
- Division of Cardiology, University of Iowa Hospitals, 52242 Iowa City, IA, USA
| | - Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Sebastian Stec
- Division of Electrophysiology, Cardioneuroablation, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), 11336 Prague, Czechia
- Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, 11336 Prague, Czechia
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Pachon-M J, Pachon E, Aksu T, Gopinathannair R, Kautzner J, Yao Y, Kusumoto F. Cardioneuroablation: where are we at? Heart Rhythm O2 2023. [DOI: 10.1016/j.hroo.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
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21
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Cai S, Zheng L, Yao Y. Selection of patients with symptomatic vagal-induced sinus node dysfunction: Who will be the best candidate for cardioneuroablation? Front Physiol 2023; 14:1088881. [PMID: 36824466 PMCID: PMC9942778 DOI: 10.3389/fphys.2023.1088881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
Sinus node dysfunction is a multifaceted disorder with variable manifestations, the prevalence of which increases with age. In a specific group of patients, excessive vagal activity may be the sole cause for this condition. These patients are characterized as having recurrent daytime symptoms attributed to bradyarrhythmia, no evidence of organic sinus node lesions, cardiac vagal overactivation, and are non-elderly. For sinus node dysfunction patients, a permanent pacemaker implantation appears to be the ultimate solution, although it is not an etiological treatment. Cardioneuroablation is a promising emerging therapy that can fundamentally eliminate symptoms in a highly selective sub-set of sinus node dysfunction patients by cardiac vagal nerve denervation. Denervation with ablation for vagal-induced sinus node dysfunction can effectively improve sinus bradycardia and reduce syncope. To date, guidelines for selection of suitable candidates for cardioneuroablation remain lacking. The primary objective of this study was to distinguish the nature of abnormal sinus node function and to find methods for quantifying vagal tone. Clear selection criteria could help physicians in identification of patients with autonomic imbalance, thereby maximizing patient benefits and the success rate of cardioneuroablations.
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Affiliation(s)
- Simin Cai
- Cardiac Arrhythmia Center, Heart Center, The People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Huazhong Fuwai Hospital, Zhengzhou, Henan, China
| | - Lihui Zheng
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China,*Correspondence: Lihui Zheng, ; Yan Yao,
| | - Yan Yao
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China,*Correspondence: Lihui Zheng, ; Yan Yao,
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22
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Procedural Characteristics and Medications to Prevent Sinus Node Artery Occlusion During Cardioneuroablation. JACC Case Rep 2022; 7:101719. [PMID: 36591438 PMCID: PMC9800184 DOI: 10.1016/j.jaccas.2022.101719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
INTRODUCTION Cardioneuroablation is increasingly being utilized to improve outcomes in patients with vagally mediated bradyarrhythmias. However, there are still controversial issues in the field including patient selection, safety and efficacy, and procedural end-points. AREAS COVERED In this review, the current role of cardioneuroablation is summarized, and controversial issues related to the modality are discussed. EXPERT OPINION According to small open-label cohort studies, overall freedom from syncope recurrence was higher than 90% after cardioneuroablation in patients with vasovagal syncope (VVS). Use of the electrogram-based strategy or high-frequency stimulation demonstrate similar success rate except in procedures limited to the right atrium. Based on a recently published randomized controlled trial and metanalysis, it may be possible now to make a strong recommendation for cardioneuroablation in patients <40 years of age, and those with the cardioinhibitory or mixed type of VVS who continue to experience frequent and/or burdensome syncope recurrences. Considering patients with VVS are prone to significant placebo/expectation effect, sham-controlled trials may help to quantify the placebo effect. In well-selected patients with functional atrioventricular block and sinus bradycardia, may result in encouraging medium-term outcomes. However, functional bradycardia is identified in a minority of patients presenting with high-grade atrioventricular block or sinus node dysfunction.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Asad Khan
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Henry Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
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Reek D, Deiß M, El Bouchikhi H. Cardioneuroablation of the right anterior ganglionated plexus in symptomatic sinus bradycardia after extensive weight loss. Europace 2022; 24:1178. [PMID: 35106554 DOI: 10.1093/europace/euab331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- David Reek
- Department of Cardiology, Augsburg University Hospital, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Michael Deiß
- Department of Cardiology, Augsburg University Hospital, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Hind El Bouchikhi
- Department of Cardiology, Augsburg University Hospital, Stenglinstr. 2, 86156 Augsburg, Germany
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The "heart brain" and neuromodulation for vasovagal syncope. Auton Neurosci 2021; 236:102892. [PMID: 34666205 DOI: 10.1016/j.autneu.2021.102892] [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: 07/05/2021] [Revised: 09/02/2021] [Accepted: 09/29/2021] [Indexed: 11/22/2022]
Abstract
It is well known that the autonomic nervous system (ANS) is a major contributor in etiopathogenesis of vasovagal syncope (VVS). Catheter based neuromodulation (CNA) of the intrinsic cardiac ANS has evolved rapidly from being an experimental unproven procedure to its current status as an increasingly performed ablation procedure in many major hospitals worldwide. The present review aims to bring the anatomical elements of intrinsic cardiac ANS and clinical application of intrinsic cardiac neuromodulation together, by reviewing anatomical terminologies and clinical data, in order to provide a practical assistance to the electrophysiology community.
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Wieling W, Jardine DL. Cardioneuroablation for recurrent vasovagal syncope: Important questions need to be answered. Heart Rhythm 2021; 18:2167-2168. [PMID: 34481983 DOI: 10.1016/j.hrthm.2021.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - David L Jardine
- Department of General Medicine, Christchurch Hospital, University of Otago, Christchurch, New Zealand
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Vandenberk B, Morillo CA, Sheldon RS, Chew DS, Aksu T, Raj SR. Clinician needs and perceptions about cardioneuroablation for recurrent vasovagal syncope: An international clinician survey. Heart Rhythm 2021; 18:2160-2166. [PMID: 34419666 DOI: 10.1016/j.hrthm.2021.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/11/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cardioneuroablation (CNA) targets the intrinsic cardiac autonomic nervous system ganglionated plexi located in the peri-atrial epicardial fat. There is increasing interest in CNA as a treatment of vasovagal syncope (VVS), despite no randomized clinical trial (RCT) data. OBJECTIVE The purpose of this study was to poll the opinion on CNA) for VVS. METHODS A REDCap (Research Electronic Data Capture) survey was administered to international physicians treating patients with VVS on their opinion about patient selection criteria, ablation approach, RCT design, and most appropriate end points for CNA procedures. RESULTS The survey was completed by 118 physicians; 86% were cardiac electrophysiologists. The majority of respondents (79%) would consider referring a patient with refractory VVS for CNA, and 27% have performed CNA for VVS themselves. Most felt patient selection should require a head-up tilt test with a cardioinhibitory response (67%) and suggest a minimum age of 18 years with a median of 3 (interquartile range 2-5) episodes in the past year. There were differences in patient selection between physicians who have performed CNA themselves and those who have not. The majority felt that the ablation strategy should include both atria (70%) with an anatomical approach in combination with autonomic stimulation (85%). Performing a sham procedure in the control arm was supported by 56% of respondents, providing equipoise in RCT design. The preferred primary outcome was freedom from syncope within 1 year of follow-up. CONCLUSION There is widespread support for well-designed RCTs to confirm the hypothesized clinical benefit of CNA, provide data to guide the risk-benefit equations during patient selection, and appropriately estimate the placebo effect.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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