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Choubdar PA, Gruber M, Pachon-M JC, Manu S, Razminia M, Clark J. Fluoroscopy-free cardioneuroablation for functional bradycardia: a single-center experience. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01926-4. [PMID: 39384700 DOI: 10.1007/s10840-024-01926-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 09/23/2024] [Indexed: 10/11/2024]
Abstract
BACKGROUND Cardioneuroablation (CNA) is an emerging treatment for cardioinhibitory syncope and functional AV block. This study aimed to evaluate the safety and efficacy of a fluoroless CNA approach using three-dimensional mapping and extracardiac vagal stimulation (ECVS). METHODS This prospective observational study included 22 patients (mean age 21 years) with clinically significant functional bradycardia who underwent fluoroless CNA. Procedural success was defined as elimination or significant attenuation of the vagal response to ECVS. RESULTS CNA was successfully performed in all patients with a mean procedure time of 251 min. Fluoroscopy was avoided in 91% of cases. At a mean follow-up of 11.4 months, 77% of patients remained symptom-free. Among pacemaker patients, 90% did not require further pacing, and 6/10 (60%) have had their pacemakers turned off. No complications were seen during the procedure. CONCLUSIONS Fluoroscopy-free CNA is a safe and effective treatment for functional bradycardia, offering high procedural success rates and favorable symptom-free outcomes while minimizing radiation exposure.
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Affiliation(s)
| | - Megan Gruber
- Department of Cardiovascular Disease, Metrohealth Medical Center, Cleveland, OH, USA
- Department of Clinical Electrophysiology, Norton Audubon Hospital, Louisville, KY, USA
| | | | - Stephen Manu
- Department of Pediatric Cardiology, Akron Children's Hospital, Akron, OH, USA
| | - Mansour Razminia
- Department of Cardiac Electrophysiology, St. Joseph Hospital, Elgin, IL, USA
| | - John Clark
- Department of Pediatric Cardiology, Akron Children's Hospital, Akron, OH, USA
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Wang C, Liao Y, Wang S, Tian H, Huang M, Dong XY, Shi L, Li YQ, Sun JH, Du JB, Jin HF. Guidelines for the diagnosis and treatment of neurally mediated syncope in children and adolescents (revised 2024). World J Pediatr 2024; 20:983-1002. [PMID: 39110332 PMCID: PMC11502568 DOI: 10.1007/s12519-024-00819-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/17/2024] [Indexed: 10/25/2024]
Abstract
BACKGROUND Significant progress has been made in the diagnosis and treatment of pediatric syncope since the publication of the "2018 Chinese Pediatric Cardiology Society (CPCS) guideline for diagnosis and treatment of syncope in children and adolescents" ("2018 Edition Guidelines"). Therefore, we have revised and updated it to assist pediatricians in effectively managing children with syncope. DATA SOURCES According to the "2018 Edition Guidelines", the expert groups collected clinical evidence, evaluated preliminary recommendations, and then organized open-ended discussions to form the recommendations. This guideline was developed by reviewing the literature and studies in databases including PubMed, Cochrane, EMBASE, China Biomedical Database, and Chinese Journal Full-text Database up to April 2024. Search terms included "syncope", "children", "adolescents", "diagnosis", and "treatment." RESULTS The guidelines were based on the latest global research progress and were evidence-based. The classification of syncope etiology, diagnostic procedures, postural tests, such as the active standing test, head-up tilt test, and active sitting test, clinical diagnosis, and individualized treatment for neurally mediated syncope in pediatric population were included. CONCLUSIONS The guidelines were updated based on the latest literature. The concepts of sitting tachycardia syndrome and sitting hypertension were introduced and the comorbidities of neurally mediated syncope were emphasized. Some biomarkers used for individualized treatment were underlined. Specific suggestions were put forward for non-pharmacological therapies as well as the follow-up process. The new guidelines will provide comprehensive guidance and reference for the diagnosis and treatment of neurally mediated syncope in children and adolescents.
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Affiliation(s)
- Cheng Wang
- Department of Pediatric Cardiovasoloy, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China
| | - Shuo Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Hong Tian
- Department of Pediatric Cardiology, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Min Huang
- Department of Pediatric Cardiology, Shanghai Children's Hospital, Shanghai, 201102, China
| | - Xiang-Yu Dong
- Department of Pediatrics, Lanzhou University Second Hospital, Lanzhou, 730020, China
| | - Lin Shi
- Department of Pediatric Cardiology, Capital Institute of Pediatrics, Beijing, 100020, China
| | - Ya-Qi Li
- Department of Pediatric Cardiology, Capital Institute of Pediatrics, Beijing, 100020, China
| | - Jing-Hui Sun
- Department of Pediatrics, Jilin University First Hospital, Changchun, 130021, China
| | - Jun-Bao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China.
| | - Hong-Fang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China.
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, 100191, China.
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Liu N, Prasad R, Iyer I, Sheikh S, Turka J, Dweik L, Bain M, Santangeli P, Chung MK. Cardioneuroablation can be an effective strategy to treat glossopharyngeal neuralgia-related sinus bradycardia and pauses. J Cardiovasc Electrophysiol 2024; 35:2076-2080. [PMID: 39160775 DOI: 10.1111/jce.16407] [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: 01/23/2024] [Revised: 07/02/2024] [Accepted: 08/05/2024] [Indexed: 08/21/2024]
Abstract
INTRODUCTION Cardioneuroablation (CNA) has proven effectiveness in addressing hypervagotonia symptoms, such as neurocardiogenic syncope. METHODS AND RESULTS In this case, we present the first-time application of CNA in a case of vago-glossopharyngeal neuralgia (VGPN). A 59-year-old female with near-syncope, sinus bradycardia, and sinus pauses triggered by recurrent right-sided neck pain was diagnosed with VGPN. The patient underwent successful treatment with carbamazepine and CNA. Subsequent follow-up revealed the sustained absence of sinus bradycardia or pauses, even upon neck pain resurgence after discontinuing carbamazepine. CONCLUSION In this patient, CNA successfully prevented pauses associated with VGPN, avoiding permanent pacemaker implantation.
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Affiliation(s)
- Nana Liu
- Department of CV Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, USA
| | - Rohan Prasad
- Department of Internal Medicine, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Indiresha Iyer
- Department of Internal Medicine, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Shehryar Sheikh
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jashanjit Turka
- Department of Internal Medicine, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Loai Dweik
- Department of Internal Medicine, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Mark Bain
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pasquale Santangeli
- Department of CV Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, USA
| | - Mina K Chung
- Department of CV Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, USA
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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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Armani Prata A, Katsuyama E, Scardini P, Antunes V, Granja J, Coan AC, Fukunaga C, Pachón Mateos JC. Cardioneuroablation in patients with vasovagal syncope: An updated systematic review and meta-analysis. Heart Rhythm 2024:S1547-5271(24)03079-0. [PMID: 39067734 DOI: 10.1016/j.hrthm.2024.07.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 07/11/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Cardioneuroablation (CNA) is a novel procedure that shows promising results in reducing syncope recurrence in patients with refractory vasovagal syncope (VVS). However, its effectiveness and safety remain controversial. OBJECTIVE We performed an updated meta-analysis evaluating CNA efficacy and safety in patients with refractory VVS. METHODS PubMed, Embase, and Cochrane databases were systematically searched for CNA studies in patients with refractory VVS. Our primary efficacy end point was syncope recurrence, and our safety end point was periprocedural complications. Prespecified subgroup analyses were performed for (1) the ganglionated plexus (GP) targeting method and (2) the GP location of ablation. RESULTS We included 27 observational studies and 1 randomized controlled trial encompassing 1153 patients with refractory VVS who underwent CNA. The median age was 39.6 years, and follow-up was 21.4 months. The overall weighted rate of syncope recurrence after CNA was 5.94% (95% confidence interval [CI] 3.37%-9.01%; I2 = 64%), and the rate of periprocedural complications was 0.99% (95% CI 0.14%-2.33%; I2 = 0%). Our prespecified subgroup analysis using the GP targeting method and GP ablation location showed a higher prevalence of syncope recurrence in the electroanatomic mapping subgroup (6.21%; 95% CI 2.93%-10.28%; I2 = 0%) and in the right atrium approach (15.78%; 95% CI 3.61%-33.14%; I2 = 65.2%). CONCLUSION This study supports the efficacy and safety of CNA in preventing syncope recurrence in patients with VVS. Furthermore, the electroanatomic mapping method of GP targeting and the right atrium approach were associated with a higher syncope recurrence rate than other methods.
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Affiliation(s)
- Alonzo Armani Prata
- Department of Medicine, Federal University of Espirito Santo, Vitória, Brazil.
| | - Eric Katsuyama
- Department of Medicine, Centro Universitário Faculdade de Medicina do ABC, Santo André, Brazil
| | - Pedro Scardini
- Department of Medicine, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória, Vitória, Brazil
| | - Vanio Antunes
- Department of Medicine, Porto Alegre Health Sciences Federal University, Porto Alegre, Brazil
| | - João Granja
- Department of Medicine, Federal University of Bahia, Salvador, Brazil
| | - Ana Carolina Coan
- Department of Medicine, Federal University of Espirito Santo, Vitória, Brazil
| | - Christian Fukunaga
- Department of Medicine, Centro Universitário Faculdade de Medicina do ABC, Santo André, Brazil
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Li H, Shao W, Yu X, Gao L, Yuan Y. Efficacy of catheter ablation in ganglionated plexus for malignant vasovagal syncope children. Cardiol Young 2024; 34:1571-1576. [PMID: 38572563 DOI: 10.1017/s1047951124000659] [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] [Indexed: 04/05/2024]
Abstract
AIM Malignant vasovagal syncope in children seriously affects their physical and mental health. Our study aimed to explore the efficacy of catheter ablation in ganglionated plexus with malignant vasovagal syncope children. CONCLUSION Catheter ablation of ganglionated plexus was safe and effective in children with malignant vasovagal syncope and can be used as a treatment option for these children. METHODS A total of 20 children diagnosed with malignant vasovagal syncope were enrolled in Beijing Children's Hospital, affiliated with Capital Medical University. All underwent catheter ablation treatment of ganglionated plexus. Ganglionated plexuses of the left atrium were identified by high-frequency stimulation and/or anatomic landmarks being targeted by radiofrequency catheter ablation. The efficacy of the treatment was evaluated by comparing the remission rate of post-operative syncopal symptoms and the rate of negative head-up tilt results. Safety and adverse events were evaluated. RESULTS After follow-up for 2.5 (0.6-5) years, the syncope symptom scores were decreased significantly compared with before treatment [3 (2-4) versus 5 (3-8) scores, P < 0.01]. Eighty-five per cent (17/20) children no longer experienced syncope, whilst 80% (16/20) children showed negative head-up tilt test after treatment. No adverse effects such as cardiac arrhythmia occurred in the children.
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Affiliation(s)
- Hongxia Li
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wei Shao
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xia Yu
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lu Gao
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yue Yuan
- Department of Cardiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Zhang Q, Shi F, Song B, Bao Y, Cao Y. Safety observation of antiarrhythmic drug use in a patient with sinus bradycardia following atrial fibrillation radiofrequency ablation combined with cardiac neural ablation: a case report. Pan Afr Med J 2024; 48:63. [PMID: 39355708 PMCID: PMC11444084 DOI: 10.11604/pamj.2024.48.63.43881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/02/2024] [Indexed: 10/03/2024] Open
Abstract
This study assessed the safety of Antiarrhythmic Drug (AAD) administration in a patient experiencing sinus bradycardia following radiofrequency ablation for Atrial Fibrillation (AF), followed by cardiac ganglion ablation. Post-AF radiofrequency ablation, the employment of AADs is a prevalent clinical practice; however, these drugs may exacerbate bradycardia, leading to increased patient discomfort and treatment complexity. The decision to employ AADs in patients with sinus bradycardia post-AF ablation poses a significant clinical challenge. This investigation aimed to ascertain the safety of AADs in such patients. The study encompassed a single case, wherein a patient with pre- and post-procedure sinus bradycardia was treated with AADs following AF radiofrequency ablation and cardiac ganglion ablation, with a subsequent safety assessment. The findings indicate that AADs can be safely administered to patients with sinus bradycardia after these procedures, offering valuable insights for clinical decision-making. This case report underscores the intricacies of post-AF ablation management in patients with sinus bradycardia and advocates for personalized therapeutic strategies. The results enhance the clinical knowledge regarding the safety of AADs in this patient subset and may guide future treatment protocols. Nonetheless, the study's conclusions are drawn from a single case, and further research with larger cohorts is essential to substantiate these findings and elucidate the long-term safety and efficacy of this therapeutic approach.
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Affiliation(s)
- Qijun Zhang
- Cardiovascular Department, The Affiliated People's Hospital of Ningbo University, Ningbo, 315000, ZheJia, People's Republic of China
| | - Feiqin Shi
- Ningbo Yinzhou N°2 Hospital Community, Ningbo, 315143, ZheJia, People's Republic of China
| | - Bingjie Song
- Cardiovascular Department, The Affiliated People's Hospital of Ningbo University, Ningbo, 315000, ZheJia, People's Republic of China
| | - Yingchun Bao
- Cardiovascular Department, The Affiliated People's Hospital of Ningbo University, Ningbo, 315000, ZheJia, People's Republic of China
| | - Yong Cao
- Cardiovascular Department, The Affiliated People's Hospital of Ningbo University, Ningbo, 315000, ZheJia, People's Republic of China
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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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Pachon-M JC, Pachon-M EI, Pachon CTC, Santillana-P TG, Lobo TJ, Pachon-M JC, Higuti C, Zerpa-A JC, Pachon MZC, Ortencio FA, Osorio TG, Peixoto LA. Long-term outcomes of cardioneuroablation with and without extra-cardiac vagal stimulation confirmation in severe cardioinhibitory neurocardiogenic syncope. J Cardiovasc Electrophysiol 2024; 35:641-650. [PMID: 38240356 DOI: 10.1111/jce.16188] [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: 10/06/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Cardioneuroablation (CNA) is a novel therapeutic approach for functional bradyarrhythmias, specifically neurocardiogenic syncope or atrial fibrillation, achieved through endocardial radiofrequency catheter ablation of vagal innervation, obviating the need for pacemaker implantation. Originating in the nineties, the first series of CNA procedures was published in 2005. Extra-cardiac vagal stimulation (ECVS) is employed as a direct method for stepwise denervation control during CNA. OBJECTIVE This study aimed to compare the long-term follow-up outcomes of patients with severe cardioinhibitory syncope undergoing CNA with and without denervation confirmation via ECVS. METHOD A cohort of 48 patients, predominantly female (56.3%), suffering from recurrent syncope (5.1 ± 2.5 episodes annually) that remained unresponsive to clinical and pharmacological interventions, underwent CNA, divided into two groups: ECVS and NoECVS, consisting of 34 and 14 cases, respectively. ECVS procedures were conducted with and without atrial pacing. RESULTS Demographic characteristics, left atrial size, and ejection fraction displayed no statistically significant differences between the groups. Follow-up duration was comparable, with 29.1 ± 15 months for the ECVS group and 31.9 ± 20 months for the NoECVS group (p = .24). Notably, syncope recurrence was significantly lower in the ECVS group (two cases vs. four cases, Log Rank p = .04). Moreover, the Hazard ratio revealed a fivefold higher risk of syncope recurrence in the NoECVS group. CONCLUSION This study demonstrates that concluding CNA with denervation confirmation via ECVS yields a higher success rate and a substantially reduced risk of syncope recurrence compared to procedures without ECVS confirmation.
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Affiliation(s)
- Jose Carlos Pachon-M
- Sao Paulo University, Sao Paulo, Brazil
- Sao Paulo Heart Hospital, Sao Paulo, Brazil
| | - Enrique I Pachon-M
- Sao Paulo University, Sao Paulo, Brazil
- Sao Paulo Heart Hospital, Sao Paulo, Brazil
| | | | | | | | - Juan C Pachon-M
- Sao Paulo University, Sao Paulo, Brazil
- Sao Paulo Heart Hospital, Sao Paulo, Brazil
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10
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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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11
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Chakraborty P, Chen PS, Gollob MH, Olshansky B, Po SS. Potential consequences of cardioneuroablation for vasovagal syncope: A call for appropriately designed, sham-controlled clinical trials. Heart Rhythm 2024; 21:464-470. [PMID: 38104955 DOI: 10.1016/j.hrthm.2023.12.004] [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: 08/16/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
Cardioneuroablation (CNA) is being increasingly used to treat patients with vasovagal syncope (VVS). Bradycardia, in the cardioinhibitory subtype of VVS, results from transient parasympathetic overactivity leading to sinus bradycardia and/or atrioventricular block. By mitigating parasympathetic overactivity, CNA has been shown to improve VVS symptoms in clinical studies with relatively small sample sizes and short follow-up periods (<5 years) at selected centers. However, CNA may potentially tip the autonomic balance to a state of sympathovagal imbalance with attenuation of cardiac parasympathetic activity. A higher heart rate is associated with adverse cardiovascular events and increased mortality in healthy populations without cardiovascular diseases. Chronic sympathovagal imbalance may also affect the pathophysiology of spectra of cardiovascular disorders including atrial and ventricular arrhythmias. This review addresses potential long-term pathophysiological consequences of CNA for VVS.
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Affiliation(s)
- Praloy Chakraborty
- Heart Rhythm Institute, Section of Cardiovascular Diseases, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Peter Munk Cardiac Centre, Toronto General Hospital and University Health Network, Toronto, Ontario, Canada
| | - Peng-Sheng Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael H Gollob
- Peter Munk Cardiac Centre, Toronto General Hospital and University Health Network, Toronto, Ontario, Canada
| | - Brian Olshansky
- Department of Internal Medicine - Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Sunny S Po
- Heart Rhythm Institute, Section of Cardiovascular Diseases, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
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12
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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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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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