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Fedorowski A, Fanciulli A, Raj SR, Sheldon R, Shibao CA, Sutton R. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat Rev Cardiol 2024; 21:379-395. [PMID: 38163814 DOI: 10.1038/s41569-023-00962-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London, UK
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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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Joza J, Gustavo Bravosi da Rosa L, Alturki A, Anglesio V, Sanchez-Somonte P, Poletaev V, Bernier M, Verma A, Essebag V. Cardioneuroablation as a strategy to prevent pacemaker implantation in young patients with vasovagal syncope. IJC HEART & VASCULATURE 2024; 51:101360. [PMID: 38379634 PMCID: PMC10877404 DOI: 10.1016/j.ijcha.2024.101360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
Background Cardioneuroablation (CNA) is an ablation technique that targets epicardial ganglionic plexi to reduce syncope burden and avoid pacemaker implantation in patients with cardioinhibitory vasovagal syncope (VVS). This study aims to demonstrate feasibility and safety of CNA in high-risk refractory VVS patients using continuous monitoring with an implantable loop recorder (ILR). Methods Data was collected prospectively for patients undergoing CNA. Patients were required to have recurrent syncope with documented asystole, refractory to conservative measures. Ganglionic plexi (GPs) were identified by fragmented signals and high frequency stimulation (HFS). Ablation was performed until loss of positive response to HFS, Wenckebach cycle shortening was achieved, or an increase in sinus rate of > 20 bpm. Follow-up was performed through remote and clinic follow-up of their ILRs. Results Between December 2020 and July 2023 six patients (mean age 29 ± 3, 67 % female)underwent CNA. The baseline heart rate and Wenckebach cycle length was 63.2 ± 15 bpm and 582 ms before and 91 ± 5 bpm and 358 ms after ablation respectively. During a median follow-up of 13.4 months, 3/5 patients had no further syncopal episodes, 1 had a recurrence, underwent repeat CNA with no further episodes at 1 year, and 1 had 5 syncopal events, which was a dramatic reduction from nearly daily episodes pre-CNA. There were no procedure related complications. Conclusions A dramatic reduction in documented pauses and syncope burden was noted post CNA. Appropriate patient selection with rigorous objective follow-up in an experienced center is necessary. Larger studies are required to confirm these findings.
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Affiliation(s)
| | | | - Ahmed Alturki
- McGill University Health Center, Montreal, Quebec, Canada
| | | | | | | | - Martin Bernier
- McGill University Health Center, Montreal, Quebec, Canada
| | - Atul Verma
- McGill University Health Center, Montreal, Quebec, Canada
| | - Vidal Essebag
- McGill University Health Center, Montreal, Quebec, Canada
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
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Russo V, Tomaino M, Parente E, Comune A, Giacopelli D, Napoli P, Gargaro A, Brignole M. Temporal relationship between haemodynamic changes and activation of closed-loop stimulation during a tilt-induced vasovagal syncope. Europace 2024; 26:euae045. [PMID: 38340330 PMCID: PMC10886438 DOI: 10.1093/europace/euae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/06/2024] [Indexed: 02/12/2024] Open
Abstract
AIMS A dual-chamber pacemaker with closed-loop stimulation (CLS) mode is effective in reducing syncopal recurrences in patients with asystolic vasovagal syncope (VVS). In this study, we explored the haemodynamic and temporal relationship of CLS during a tilt-induced vasovagal reflex. METHODS AND RESULTS Twenty patients underwent a tilt test under video recording 3.9 years after CLS pacemaker implantation. Three patients were excluded from the analysis because of no VVS induced by the tilt test (n = 1) and protocol violation (n = 2). In 14 of the remaining 17 patients, CLS pacing emerged during the pre-syncopal phase of circulatory instability when the mean intrinsic heart rate (HR) was 88 ± 12 b.p.m. and systolic blood pressure (SBP) was 108 ± 19 mmHg. The CLS pacing rate thereafter rapidly increased to 105 ± 14 b.p.m. within a median of 0.1 min [inter-quartile range (IQR), 0.1-0.7 min] when the SBP was 99 ± 21 mmHg. At the time of maximum vasovagal effect (syncope or pre-syncope), SBP was 63 ± 17 mmHg and the CLS rate was 95 ± 13 b.p.m. The onset of CLS pacing was 1.7 min (IQR, 1.5-3.4) before syncope or lowest SBP. The total duration of CLS pacing was 5.0 min (IQR, 3.3-8.3). Closed-loop stimulation pacing was not observed in three patients who had a similar SBP decrease from 142 ± 22 mmHg at baseline to 69 ± 4 mmHg at the time of maximum vasovagal effect, but there was no significant increase in HR (59 ± 1 b.p.m.). CONCLUSION The reproducibility of a vasovagal reflex was high. High-rate CLS pacing was observed early during the pre-syncopal phase in most patients and persisted, although attenuated, at the time of maximum vasovagal effect. REGISTRATION ClinicalTrials.gov identifier: NCT06038708.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, 80126 Naples, Italy
| | - Marco Tomaino
- Department of Cardiology, Ospedale Generale Regionale, Bolzano, Italy
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, 80126 Naples, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, 80126 Naples, Italy
| | | | - Paola Napoli
- Research Clinical Unit, Biotronik Italy, Milan, Italy
| | | | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Department of Cardiology, S. Luca Hospital, Piazzale Brescia 20, 20149 Milan, Italy
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van Dijk JG. Understanding how closed-loop stimulation pacing suppresses cardioinhibition in vasovagal syncope. Europace 2024; 26:euae046. [PMID: 38340323 PMCID: PMC10886441 DOI: 10.1093/europace/euae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Affiliation(s)
- J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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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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Portugal G. Reflex syncope: Insights into physiology. Rev Port Cardiol 2023; 42:811-812. [PMID: 37023980 DOI: 10.1016/j.repc.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Affiliation(s)
- Guilherme Portugal
- Departamento de Arritmologia, Serviço de Cardiologia, Hospital de Santa Marta, CHULC EPE, Lisbon, Portugal; Instituto de Fisiologia, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal.
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Fedorowski A, Kulakowski P, Brignole M, de Lange FJ, Kenny RA, Moya A, Rivasi G, Sheldon R, Van Dijk G, Sutton R, Deharo JC. Twenty-five years of research on syncope. Europace 2023; 25:euad163. [PMID: 37622579 PMCID: PMC10450792 DOI: 10.1093/europace/euad163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 08/26/2023] Open
Abstract
Over the last 25 years, the Europace journal has greatly contributed to dissemination of research and knowledge in the field of syncope. More than 400 manuscripts have been published in the journal. They undoubtedly improved our understanding of syncope. This symptom is now clearly differentiated from other forms of transient loss of consciousness. The critical role of vasodepression and/or cardioinhibition as final mechanisms of reflex syncope is emphasized. Current diagnostic approach sharply separates between cardiac and autonomic pathways. Physiologic insights have been translated, through rigorously designed clinical trials, into non-pharmacological or pharmacological interventions and interventional therapies. The following manuscript is intended to give the reader the current state of the art of knowledge of syncope by highlighting landmark contributions of the Europace journal.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Eugeniavägen 3, 171 76 Solna, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Piotr Kulakowski
- Department of Cardiology, Medical Centre for Postgraduate Education, Grochowski Hospital, Ul. Grenadierow 51/59, 04-073 Warsaw, Poland
| | - Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Piazzale Brescia 20, 20149 Milan, Italy
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, 152-160 Pearse St, Dublin, Ireland
- Mercer Institute for Successful Ageing, St. James Hospital, James St, Dublin 8, D08 NHY1Ireland
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, Carrer de Sabino Arana 5-19, 08028 Barcelona, Spain
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Robert Sheldon
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute, 3310 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Gert Van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, Du Cane Road, London, W12 0HS, United Kingdom
| | - Jean-Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France and Aix Marseille Université, C2VN, 264 Rue Saint-Pierre, 13005 Marseille, France
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Lin J, Liu Q, Jiang R, Chen S, Yu L, Jiang C. Selective anatomical catheter ablation of left atrial ganglionated plexus for vasovagal syncope: Left superior and right anterior ganglionated plexus ablation. Pacing Clin Electrophysiol 2023; 46:1010-1018. [PMID: 37377409 DOI: 10.1111/pace.14769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Vasovagal syncope (VVS) is one of the most common causes of syncope. Traditional treatment has not achieved satisfactory results. The purpose of this study was to assess the feasibility and efficacy of selective anatomical catheter ablation of left atrial ganglionated plexus (GP) as a therapeutic strategy for the patients of symptomatic VVS. METHODS A total of 70 patients with at least once recurrent syncopal episode of VVS with a positive head-up tilt test were enrolled. They were divided into GP ablation group and control group. Patients in GP ablation group received anatomical catheter ablation of left superior ganglionated plexus (LSGP) and right anterior ganglionated plexus (RAGP). Patients in the control group were guideline-directed conventional therapy. The primary endpoint was VVS recurrences. The secondary endpoint was the recurrence of syncope and prodrome events. RESULTS There were no statistical differences in clinical characteristics between the ablation group (n = 35) and the control group (n = 35). Over a follow-up of 12 months, the ablation group had significantly lower syncope recurrence compared with the control group (5.7% vs. 25.7%, p = .02), and the ablation group had significantly lower syncope and prodrome recurrence compared with the control group (11.4% vs. 51.4%, p < .001). In GP ablation, 88.6% of the patients showed significant vagal response during LSGP ablation, and 88.6% of the patients showed significantly increased heart rate during RAGP ablation. CONCLUSIONS For patients with recurrent VVS, selective anatomical catheter ablation of LSGP and RAGP is superior to conventional therapy in reducing syncope recurrence.
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Affiliation(s)
- Jianwei Lin
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Shiquan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Lu Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
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Heyman I, Brorsson A, Persson T, Londos E. Pacemaker Implants and Their Influence on the Daily Life of Patients with Dementia with Lewy Bodies: A Qualitative Case Study. Neurol Ther 2023; 12:1359-1373. [PMID: 37326788 PMCID: PMC10310613 DOI: 10.1007/s40120-023-00513-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Dementia with Lewy bodies (DLB) is an incurable form of dementia associated with detriments to the daily life of patients and carers from their family. Symptoms of orthostatic hypotension, syncope, and falls are supportive of DLB diagnosis. These symptoms may also be present among people with sick sinus syndrome (SSS), and subsequent pacemaker treatment to manage bradyarrhythmia is associated with improved cognitive function. The prevalence of SSS seems to be higher among people with underlying Lewy body pathology compared to the general age-matched population (5.2% vs. 0.17%). To our knowledge, how people with DLB and their family carers may experience pacemaker treatment to manage bradyarrhythmia has not been previously reported. Therefore, the aim of this study was to explore how people with DLB experience daily life following a pacemaker implant to manage associated symptoms of bradyarrhythmia. METHODS A qualitative case study design was used. Two men with DLB and their spouse carers were repeatedly interviewed as a dyad within 1 year following implant of a dual-chamber rate-adaptive (DDD-CLS) pacemaker to manage SSS in the men. Content analysis was used to assess the qualitative interview data collected. RESULTS Three categories emerged: (1) gaining control, (2) maintaining a social life, and (3) being influenced by concurrent diseases. Less syncope/falls and remote pacemaker monitoring increased a sense of control in everyday life, while perceived physical and/or cognitive improvements influenced social participation. The men were still affected by concurrent diseases, which continuously influenced each couple's daily life. CONCLUSION Identifying and managing concurrent bradyarrhythmia through a pacemaker implant could improve well-being for people with DLB.
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Affiliation(s)
- Isak Heyman
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
| | - Annika Brorsson
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Family Medicine, Lund University, Malmö, Sweden
- Centre for Primary Health Care Research, Skåne Region, Malmö, Sweden
| | - Torbjörn Persson
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Elisabet Londos
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
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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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Parker WH, Olshansky B. Autonomic modulation: Getting it "just right". Heart Rhythm O2 2023; 4:414-415. [PMID: 37361618 PMCID: PMC10288019 DOI: 10.1016/j.hroo.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Affiliation(s)
| | - Brian Olshansky
- Address reprint requests and correspondence: Dr Brian Olshansky, Division of Cardiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242.
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San Antonio R. Time for a paradigm shift: from pacing to ablation in reflex syncope. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01521-z. [PMID: 37052860 DOI: 10.1007/s10840-023-01521-z] [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: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Rodolfo San Antonio
- Heart Disease Institute, Bellvitge Institute for Biomedical Research (IDIBELL), Bellvitge University Hospital, Feixa Llarga st., L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
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15
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Soni B, Gupta D, Gopinathannair R. Quality of life improvement following cardioneuroablation for vasovagal syncope: expected or too early to say? J Interv Card Electrophysiol 2023:10.1007/s10840-023-01489-w. [PMID: 36705871 DOI: 10.1007/s10840-023-01489-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: 01/08/2023] [Accepted: 01/17/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Bosky Soni
- Department of Medicine, University of Pittsburgh School of Medicine, Harrisburg, PA, USA
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
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16
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Muacevic A, Adler JR, Cossor F, Raza S. Vasovagal Syncope and Pulseless Electrical Activity Cardiac Arrest in Patients With Immunoglobulin Light Chain Cardiac Amyloidosis: A Case Series. Cureus 2023; 15:e34107. [PMID: 36843747 PMCID: PMC9946906 DOI: 10.7759/cureus.34107] [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] [Accepted: 01/22/2023] [Indexed: 01/24/2023] Open
Abstract
Immunoglobulin light chain (AL) amyloidosis may lead to amyloid fibril deposition into peripheral and autonomic nerves, resulting in resting and orthostatic hypotension. While most patients die from progressive heart failure, the most commonly proposed cardiac rhythm associated with sudden death is pulseless electrical activity (PEA). Herein, we describe four patients with severe AL cardiac amyloidosis who had witnessed cardiac arrest with pulseless electrical activity as a result of vasovagal syncope. Healthcare providers should be aware of severe autonomic dysfunction in cardiac amyloidosis and the potential for an abnormal vasovagal response leading to syncope or death.
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Hatoum T, Raj S, Sheldon RS. Current approach to the treatment of vasovagal syncope in adults. Intern Emerg Med 2023; 18:23-30. [PMID: 36117230 DOI: 10.1007/s11739-022-03102-w] [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: 08/10/2022] [Accepted: 09/05/2022] [Indexed: 02/01/2023]
Abstract
Vasovagal syncope (VVS) is the most common cause of transient loss of consciousness. Although not associated with mortality, it causes injuries, reduces quality of life, and is associated with anxiety and depression. The European and North American cardiac societies recently published syncope clinical practice guidelines. Most patients with VVS do well after specialist evaluation, reassurance and education. Adequate hydration, increased salt intake when not contraindicated, and careful withdrawal of diuretics and specific hypotension-inducing drugs are a reasonable initial strategy. Physical counterpressure maneuvers might be helpful but can be of limited efficacy in older patients and those with short or no prodromes. Orthostatic training lacks long term efficacy and is troubled by non-compliance. Yoga might be helpful, although the biomedical mechanism is unknown. Almost a third of VVS patients continue to faint despite these conservative measures. Metoprolol was not helpful in a pivotal randomized clinical trial. Fludrocortisone and midodrine significantly reduce syncope recurrences with tolerable side effects, when titrated to target doses. Pacing therapy with specialized sensors appears promising in carefully selected population who have not responded conservative measures. Cardioneuroablation may be helpful but has not been studied in a formal clinical trial.
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Affiliation(s)
- Tarek Hatoum
- Libin Cardiovascular Institute, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Satish Raj
- Libin Cardiovascular Institute, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Robert Stanley Sheldon
- Libin Cardiovascular Institute, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
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18
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Gopinathannair R, Olshansky B, Turagam MK, Gautam S, Futyma P, Akella K, Tanboga HI, Bozyel S, Yalin K, Padmanabhan D, Shenthar J, Lakkireddy D, Aksu T. Permanent pacing versus cardioneuroablation for cardioinhibitory vasovagal syncope. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01456-x. [PMID: 36562915 DOI: 10.1007/s10840-022-01456-x] [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: 09/19/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND We compared the efficacy and safety of cardioneuroablation (CNA) vs. permanent pacing (PM) for recurrent cardioinhibitory vasovagal syncope (CI-VVS). METHODS One hundred sixty-two patients (CNA = 61, PM = 101), age 36 + 11 years) with syncope frequency of 6.7 ± 3.9/year were included in this multicenter study. All patients with CNA were provided by a single center, while patients with PM were provided by 4 other centers. In the CNA arm, an electroanatomic mapping guided approach was used to detect and ablate ganglionated plexus sites. Dual chamber rate drop response (RDR) or close loop stimulation (CLS) transvenous and leadless pacemakers were implanted using standard technique. The primary endpoint was freedom from syncope. RESULTS Of 101 patients in the PM group, 39 received dual-chamber pacemaker implants with the CLS algorithm, 38 received dual-chamber pacemakers with the RDR algorithm, and 24 received a leadless pacemaker. At 1-year follow-up, 97% and 89% in the CNA and PM group met the primary endpoint (adjusted HR = 0.27, 95% CI 0.06-1.24, p = 0.09). No significant differences in adverse events were noted between groups. There was no significant association between age (HR:1.01, 95% CI 0.96-1.06, p = 0.655), sex (HR:1.15, 95% CI 0.38-3.51, p = 0.809), and syncope frequency in the past year (HR:1.10, 95% CI 0.97-1.25, p = 0.122) and the primary outcome in univariable analyses. CONCLUSIONS After adjustment for patient characteristics, the medium-term syncope recurrence risk of CI-VVS patients who underwent CNA was similar to that of a population of patients undergoing pacemaker implantation with a similar safety profile.
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Affiliation(s)
- Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute and Research Foundation, 5100 W 110Th St, Ste 200, Overland Park, KS, 66211, USA.
| | - Brian Olshansky
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mohit K Turagam
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sandeep Gautam
- Division of Cardiovascular Medicine, University of Missouri-Columbia, Columbia, MO, USA
| | - Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszow, Poland
| | | | - Halil Ibrahim Tanboga
- Department of Cardiology, Nisantasi University & Hisar Intercontinental Hospital, Istanbul, Turkey
| | - Serdar Bozyel
- University of Health Sciences, Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey
| | - Kivanc Yalin
- Department of Cardiology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Deepak Padmanabhan
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Jayaprakash Shenthar
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, 5100 W 110Th St, Ste 200, Overland Park, KS, 66211, USA
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Tonegawa-Kuji R, Inoue YY, Nakai M, Kanaoka K, Sumita Y, Miyazaki Y, Wakamiya A, Shimamoto K, Ueda N, Nakajima K, Kataoka N, Wada M, Yamagata K, Ishibashi K, Miyamoto K, Nagase S, Aiba T, Miyamoto Y, Iwanaga Y, Kusano K. Clinical Predictors of Pacing Device Implantation in Implantable Cardiac Monitor Recipients for Unexplained Syncope. CJC Open 2022; 5:259-267. [PMID: 37124961 PMCID: PMC10140738 DOI: 10.1016/j.cjco.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background Implantable cardiac monitors (ICMs) help investigate the cause of unexplained syncope, but the probability and predictors of needing a pacing device thereafter remain unclear. Methods We retrospectively analyzed the data of patients who received ICM insertion for unexplained syncope with suspected arrhythmic etiology. The data were obtained from a nationwide database obtained between April 1, 2012 and March 31, 2020. Multivariable mixed-effects survival analysis was performed to identify predictors of pacing device implantation (PDI), and a risk score model was developed accordingly. Results In total, 2905 patients (age: 72 years [range: 60-78]) implanted with ICMs to investigate the cause of syncope were analyzed. During the median follow-up period of 128 days (range: 68-209) days, 473 patients (16%) underwent PDI. Older age, history of atrial fibrillation, bundle branch block (BBB), and diabetes were independent predictors of PDI in multivariable analysis. A risk score model was developed with scores ranging from 0 to 32 points. When patients with the lowest quartile score (0-13 points) were used as a reference, those with higher quartiles had a higher risk of PDI (second quartile: 14-15 points, hazard ratio [HR]: 3.86, 95% confidence interval [CI]: 2.62-5.68; third quartile: 16-18 points, HR: 4.67, 95% CI: 3.14-6.94; fourth quartile: 19-32 points, HR: 6.59, 95% CI: 4.47-9.71). Conclusions The 4 identified predictors are easily assessed during the initial evaluation of patients with syncope. They may help identify patients with a higher risk of requiring permanent PDI.
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20
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de Lange FJ, Hofland WPME, Ferrara A, Gargaro A, Brignole M, van Dijk JG. A novel and practical method to add video monitoring to tilt table testing. Europace 2022; 25:762-766. [PMID: 36351661 PMCID: PMC9935048 DOI: 10.1093/europace/euac193] [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: 08/01/2022] [Accepted: 10/05/2022] [Indexed: 11/11/2022] Open
Abstract
AIMS We describe a novel, practical, and inexpensive method to add video recording during tilt table testing (TTT): Open-Access-Video-TTT. METHODS AND RESULTS The Open-Access-Video-TTT set-up uses a personal computer (PC) to capture screen video data from a non-invasive-beat-to-beat (NIBTB) haemodynamic blood pressure (BP) device, combined with video recording of a patient, using Open Broadcaster Software (OBS®). The new Open-Access-Video-TTT set up was tested with both the Finometer (model Finapres Nova®, Medical Systems, the Netherlands) and the Task Force® Touch Cardio monitor (CNSystems, Austria). For this, the Finapres Nova® was enabled in 'remote' mode and Real Video Network Computing (RealVNC®) was installed on the PC/laptop. The Task Force® has a DisplayPort (DP) port, for which a DP/ high-definition multimedia interface (HDMI) cable and a video capture card is used to merge the signals to the PC/laptop. With this method the combined images are stored as a new video signal. TTT can be performed with any routine protocol. CONCLUSIONS Open Access-Video-TTT worked well for both the Finapres NOVA® and the Task Force Monitor ®. This novel method can be used easily by all physicians who wish to add video recording during TTT who do not have access to an electroencephalogram machine.
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Affiliation(s)
| | - Willem Petrus Merijn Emmanuël Hofland
- Amsterdam UMC, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Heart Centre, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | | | | | | | - Jan Gerrit van Dijk
- Department of Neurology, Leiden University Medical Centre, Albinusdreef 2, Zuid Holland, 2333 ZA Leiden, The Netherlands
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21
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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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22
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Wiegand U. Herzschrittmachertherapie bei Sinusknotenerkrankung, Reflexsynkopen, seltenen Herzerkrankungen & besonderen Situationen. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1738-0836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDurch die neuen ESC-Leitlinien zur Herzschrittmacher- und kardialen Resynchronisationstherapie ändert sich die Indikationsstellung nur in wenigen Bereichen. Für Patienten mit
Tachykardie-Bradykardie-Syndrom, bei denen Vorhofflimmern nicht primär mit Katheterablation behandelt werden soll, wird die Indikation zur Schrittmachertherapie erleichtert. Gleiches gilt
aber auch für Patienten mit Sinusknotenerkrankung und vermutetem Symptom-EKG-Zusammenhang, die nun im Gegensatz zu den Leitlinien von 2013 auch bei leichter Symptomatik und ohne definierte
Pausenlänge im Einzelfall einen Schrittmacher erhalten können. Bei Verdacht auf Reflexsynkopen wird analog zur Synkopenleitlinie von 2018 ein diagnostischer Algorithmus aus
Kipptischuntersuchung, Karotis-Druckversuch und – im Fall von nicht diagnostischen Ergebnissen – Implantation eines Ereignisrekorders empfohlen. Erstmals finden sich auch eigenständige
Indikationen zur Schrittmachertherapie nach Implantation von Transkatheter-Aortenklappen.
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Affiliation(s)
- Uwe Wiegand
- Klinik für Kardiologie, Rhythmologie und Elektrophysiologie, Sana-Klinikum Remscheid GmbH, Remscheid, Deutschland
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23
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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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24
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Sheldon R, Talajic M, Tang A, Becker G, Essebag V, Sultan O, Baranchuk A, Ritchie D, Morillo C, Krahn A, Brignole M, Manns B, Maxey C, Raj SR. Randomized Pragmatic Trial of Pacemaker Versus Implantable Cardiac Monitor in Syncope and Bifascicular Block. JACC Clin Electrophysiol 2022; 8:239-248. [PMID: 35210082 DOI: 10.1016/j.jacep.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/01/2021] [Accepted: 10/08/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES In this study, the authors tested whether a strategy of empiric permanent pacing reduces major composite events more effectively than acting on the results of an implantable cardiac monitor (ICM). BACKGROUND Syncope may be caused by intermittent complete heart block in patients with bifascicular heart block, but competing diagnoses coexist. Whether empiric permanent pacing or acting on investigative results provides best care is unknown. METHODS This was a multinational, randomized, pragmatic clinical trial of patients ≥50 years of age with bifascicular block, preserved left ventricular function, and ≥1 syncope in the preceding year. The primary composite outcome measure comprised cardiovascular death, syncope, bradycardia resulting in pacemaker insertion, and device complications. RESULTS There were 57 and 58 subjects randomized to receive a pacemaker or ICM. A total of 41 patients had left bundle branch block and 74 had right bundle branch block and a left fascicular block. Patients were followed for a median 33 months. There were fewer composite primary outcomes in patients randomized to pacemaker compared with ICM, respectively (20 [35%] vs 44 [76%]; chi square P < 0.0001), with lower actuarial probabilities of a primary outcome (0.45 and 1.00; P < 0.001). Syncope was as likely in the groups randomized to receive a pacemaker or ICM (29% vs 26%, chi-square P = 0.95). CONCLUSIONS Empiric permanent pacing compared with ICM reduced major adverse events but not syncope in older patients with bifascicular block and recent syncope. There remains a substantial likelihood of syncope recurrence in patients who receive a permanent pacemaker likely caused by vasodepressor syncope. (Syncope: Pacing or Recording in the Later Years [SPRITELY]; NCT01423994).
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Affiliation(s)
- Robert Sheldon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.
| | | | - Anthony Tang
- University of Western Ontario, London, Ontario, Canada
| | | | | | - Omar Sultan
- Regina General Hospital, Regina, Saskatchewan, Canada
| | | | - Debbie Ritchie
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Carlos Morillo
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Krahn
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Braden Manns
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Connor Maxey
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
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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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[ESC guidelines 2021 on cardiac pacing and cardiac resynchronization therapy : What's new?]. Herz 2022; 47:31-40. [PMID: 35006289 DOI: 10.1007/s00059-021-05089-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 12/11/2022]
Abstract
The new European Society of Cardiology (ESC) guidelines on cardiac pacing and cardiac resynchronization therapy were presented together with the new ESC heart failure guidelines at the ESC congress in September. The new document includes detailed sections on patient evaluation and clinical assessment, implantation, minimizing complications and patient follow-up. The guidelines have been updated and expanded particularly on the approach to reflex syncope, the indications after transcatheter aortic valve implantation (TAVI) and the perioperative management. The indications for cardiac resynchronization therapy (CRT) are now in line with the simultaneously published ESC heart failure guidelines. New physiological forms of stimulation and leadless pacing are now included in the guidelines.
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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: 111] [Impact Index Per Article: 55.5] [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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Yuan P, Lian Z, Wang Y, Wang Y, Zhang C, Du J, Huang Y, Liao Y. Poincaré Plot Is Useful for Distinguishing Vasovagal Syncope From Postural Tachycardia Syndrome in Children. Front Pediatr 2022; 10:758100. [PMID: 35372154 PMCID: PMC8965582 DOI: 10.3389/fped.2022.758100] [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: 08/13/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To explore the role of the Poincaré plot derived from a 24-hour Holter recording in distinguishing vasovagal syncope (VVS) from postural tachycardia syndrome (POTS) in pediatric patients. MATERIALS AND METHODS Pediatric patients with VVS or POTS, hospitalized in Peking University First Hospital between January 2012 and December 2018, were included in a derivation study. The transverse axis (T), longitudinal axis (L), T/L ratio, product T × L, distance between the origin and the proximal end of the longitudinal axis (pro-D), and distance between the origin and distal end of the longitudinal axis (dis-D) of the Poincaré plot were compared between the VVS and POTS groups, and the differential diagnostic performance of the above-mentioned graphic parameters was evaluated using receiver operating characteristic curve analysis. A validation study was conducted in pediatric patients hospitalized between January 2019 and December 2020. RESULTS In school-aged children, the T, L, T/L, T × L, and dis-D values of patients with VVS were greater than those of patients with POTS; in adolescents, the T, T/L, T × L, and pro-D values of patients with VVS were greater than those of patients with POTS. Using a T/L cut-off value of 0.3 to distinguish between the two diseases, the sensitivity and specificity were 91.0 and 90.5%, respectively, for the total participants; 91.6 and 88.9%, respectively, for the school-aged children; and 82.1 and 95.7%, respectively, for the adolescents. In the validation study, a T/L cut-off value of 0.3 yielded an accuracy, sensitivity, and specificity of 81.8, 87.2, and 77.6%, respectively, in the total participants; 76.5, 82.6, and 71.4%, respectively, in the school-aged children; and 89.2, 93.8, and 85.7%, respectively, in the adolescents, in distinguishing VVS from POTS validated by clinical diagnosis. CONCLUSIONS The graphic parameters of the Poincaré plot are significantly different between VVS and POTS in pediatric patients, and the T/L of the Poincaré plot may be a useful measure to help differentiate VVS from POTS in children and adolescents.
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Affiliation(s)
- Piaoliu Yuan
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Zhouhui Lian
- Wang Xuan Institute of Computer Science, Peking University, Beijing, China
| | - Yuanyuan Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Yaru Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China.,Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
| | - Yaqian Huang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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29
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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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30
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Tomaino M, Russo V, Giacopelli D, Gargaro A, Brignole M. Cardiac Pacing in Cardioinhibitory Reflex Syncope: Clinical Use of Closed-loop Stimulation. Arrhythm Electrophysiol Rev 2021; 10:244-249. [PMID: 35106176 PMCID: PMC8785081 DOI: 10.15420/aer.2021.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022] Open
Abstract
Cardiac pacing has been studied extensively in patients with reflex syncope over the past two decades. The heterogeneity of the forms and clinical manifestations of reflex syncope explain the controversial results of older randomised clinical trials. New evidence from recent trials has changed medical practice, now leading to clear indications for pacing in patients with asystolic syncope documented during carotid sinus massage, implantable cardiac monitoring or tilt testing. Given that recent trials in reflex syncope have been performed using the closed-loop stimulation algorithm, the authors will briefly discuss this pacing mode, review hypotheses about the mechanisms underlying its activation during syncope and provide practical instructions for programming and troubleshooting.
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Affiliation(s)
| | - Vincenzo Russo
- Department of Cardiology, University of Campania ‘Luigi Vanvitelli’, Ospedale Monaldi, Naples, Italy
| | | | | | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Programme, Ospedale San Luca, Milano, Italy
- Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
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31
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Ali M, Pachon Maetos JC, Kichloo A, Masudi S, Grubb BP, Kanjwal K. Management strategies for vasovagal syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:2100-2108. [PMID: 34748224 DOI: 10.1111/pace.14402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/18/2021] [Accepted: 10/31/2021] [Indexed: 11/30/2022]
Abstract
Vasovagal syncope (VVS) (or neurocardiogenic syncope) is a common clinical condition that is challenging to both physicians and patients alike. Severe episodes of recurrent syncope can result in physical injury as well as psychological distress. This article provides a brief overview of current management strategies and a detailed overview of therapeutic modalities such as closed loop stimulation (CLS) and cardioneuroablation (CNA).
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Affiliation(s)
- Muzaffar Ali
- Sheri Kashmir Institute, Department of Cardiology, Srinagar, Jammu and Kashmir, India
| | | | - Asim Kichloo
- Central Michigan University, Internal Medicine, Saginaw, Michigan, USA.,Samaritan Medical Center, Internal Medicine, Watertown, New York, USA
| | - Sundas Masudi
- University of Liverpool School of Medicine, Liverpool, UK
| | - Blair P Grubb
- Division of cardiology, University of Toledo, Toledo, Ohio, USA
| | - Khalil Kanjwal
- Section of Cardiac electrophysiology, McLaren Greater Lansing, Lansing, Michigan, USA
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32
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Sheldon R, Faris P, Tang A, Ayala-Paredes F, Guzman J, Marquez M, Morillo CA, Krahn AD, Kus T, Ritchie D, Safdar S, Maxey C, Raj SR. Midodrine for the Prevention of Vasovagal Syncope : A Randomized Clinical Trial. Ann Intern Med 2021; 174:1349-1356. [PMID: 34339231 DOI: 10.7326/m20-5415] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Recurrent vasovagal syncope is common, responds poorly to treatment, and causes physical trauma and poor quality of life. Midodrine prevents hypotension and syncope during tilt tests in patients with vasovagal syncope. OBJECTIVE To determine whether midodrine can prevent vasovagal syncope in usual clinical conditions. DESIGN Randomized, double-blind, placebo-controlled clinical trial. (ClinicalTrials.gov: NCT01456481). SETTING 25 university hospitals in Canada, the United States, Mexico, and the United Kingdom. PATIENTS Patients with recurrent vasovagal syncope and no serious comorbid conditions. INTERVENTION Patients were randomly assigned 1:1 to placebo or midodrine and followed for 12 months. MEASUREMENTS The primary outcome measure was the proportion of patients with at least 1 syncope episode during follow-up. RESULTS The study included 133 patients who had had a median of 6 syncope episodes in the prior year (median age, 32 years; 73% female). Compared with patients receiving placebo, fewer patients receiving midodrine had at least 1 syncope episode (28 of 66 [42%] vs. 41 of 67 [61%]). The relative risk was 0.69 (95% CI, 0.49 to 0.97; P = 0.035). The absolute risk reduction was 19 percentage points (CI, 2 to 36 percentage points), and the number needed to treat to prevent 1 patient from having syncope was 5.3 (CI, 2.8 to 47.6). The time to first syncope was longer with midodrine (hazard ratio, 0.59 [CI, 0.37 to 0.96]; P = 0.035; log-rank P = 0.031). Adverse effects were similar in both groups. LIMITATION Small study size, young and healthy patients, relatively short observation period, and high proportion of patients from 1 center. CONCLUSION Midodrine can reduce the recurrence of syncope in healthy, younger patients with a high syncope burden. PRIMARY FUNDING SOURCE The Canadian Institutes of Health Research.
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Affiliation(s)
- Robert Sheldon
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Peter Faris
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Anthony Tang
- University of Western Ontario, London, Ontario, Canada (A.T.)
| | | | - Juan Guzman
- McMaster University, Hamilton, Ontario, Canada (J.G.)
| | - Manlio Marquez
- Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.M.)
| | - Carlos A Morillo
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Andrew D Krahn
- University of British Columbia, Vancouver, British Columbia, Canada (A.D.K.)
| | - Teresa Kus
- University of Montreal, Montreal, Quebec, Canada (T.K.)
| | - Debbie Ritchie
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Shahana Safdar
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Connor Maxey
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Satish R Raj
- University of Calgary, Calgary, Alberta, Canada, and Vanderbilt University School of Medicine, Nashville, Tennessee (S.R.R.)
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33
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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: 783] [Impact Index Per Article: 261.0] [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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34
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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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35
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Electrocardiographic Patterns in Patients with Neurally Mediated Syncope. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57080808. [PMID: 34441014 PMCID: PMC8399501 DOI: 10.3390/medicina57080808] [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: 06/16/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022]
Abstract
The baseline electrocardiogram (ECG) is less informative in neurally mediated syncope (NMS) than in arrhythmic syncope. However, some of the ECG patterns present in NMS can have diagnostic and prognostic value in such patients. Electrocardiographic documentation of a syncopal spell and thus identification of the ECG changes can be performed during tilt table test (TTT) or during prolonged ECG monitoring. This work reviews the specific ECG patterns in NMS, which are primarily related to the cardioinhibitory reflex. In addition, there are other ECG findings present in patients with NMS that are being analyzed, such as increased heart rate variability as well as specific QRS voltage patterns. In addition to the diagnostic and prognostic value, these ECG patterns in NMS may help improving the selection of patients for pacemaker implant.
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36
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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: 61] [Impact Index Per Article: 20.3] [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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37
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Linde C, Crijns HJGM. Pacing for repeated vagal reflex-mediated syncope: an old problem with a solution. Eur Heart J 2021; 42:517-519. [PMID: 33332532 DOI: 10.1093/eurheartj/ehaa975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cecilia Linde
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden.,Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | - Harry J G M Crijns
- Maastricht University Medical Center, Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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38
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Lauder L, da Costa BR, Ewen S, Scholz SS, Wijns W, Lüscher TF, Serruys PW, Edelman ER, Capodanno D, Böhm M, Jüni P, Mahfoud F. Randomized trials of invasive cardiovascular interventions that include a placebo control: a systematic review and meta-analysis. Eur Heart J 2021; 41:2556-2569. [PMID: 32666097 DOI: 10.1093/eurheartj/ehaa495] [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: 01/16/2020] [Revised: 04/01/2020] [Accepted: 05/27/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS The difference in the benefit of invasive cardiovascular interventions compared with placebo controls has not been analysed systematically. METHODS AND RESULTS MEDLINE and Web of Science were searched through 29 March 2020. Randomized, placebo-controlled trials of invasive cardiovascular interventions (including catheter-based interventions and pacemaker-like devices) investigating predefined primary outcomes were included. Standardized mean differences (SMD) and odds ratios were calculated for continuous and dichotomous outcomes, respectively. Meta-regression analyses were performed to assess whether estimates of treatment effects were associated with methodological characteristics of trials. Thirty trials, including 4102 patients, were analysed. The overall risk of bias was judged to be low in only 43% of the trials. Ten trials (33%) demonstrated statistically significant superiority of invasive interventions over placebo controls for the respective predefined primary outcomes. In almost half of the 16 trials investigating continuous predefined primary outcomes, the SMD between the active and placebo procedure indicated a small (n = 4) to moderate (n = 3) treatment effect of active treatment over placebo. In contrast, one trial indicated a small treatment effect in favour of the placebo procedure. In the remaining trials, there was no relevant treatment effect of active treatment over placebo. In trials with a protocol-mandated stable and symmetrical use of co-interventions, the superiority of active procedures vs. invasive placebo procedures was significantly larger as compared with trials with frequent or unbalanced changes in co-interventions (P for interaction 0.027). CONCLUSIONS The additional treatment effect of invasive cardiovascular interventions compared with placebo controls was small in most trials.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str., Gebäude 41.1, 66421 Homburg/Saar, Germany
| | - Bruno R da Costa
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, 155 College Street, Toronto, ON M5T 3M6, Canada.,Institute of Primary Health Care (BIHAM), University of Bern, Mittelstraße 43, 3012 Bern, Switzerland
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str., Gebäude 41.1, 66421 Homburg/Saar, Germany
| | - Sean S Scholz
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str., Gebäude 41.1, 66421 Homburg/Saar, Germany
| | - William Wijns
- The Lambe Institute for Translational Medicine and CURAM, National University of Ireland, University Road, Galway H91 TK33, Ireland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, Schlieren Campus, University of Zürich, Wagistrasse 12, 8952 Schlieren, Switzerland.,Royal Brompton and Harefield Hospital Trust, Imperial College London, Sydney Street, London SW3 6NP, UK
| | - Patrick W Serruys
- The National Lung and Heart Institute, Imperial College London, Dovehouse St, Chelsea, London SW3 6LY, UK
| | - Elazer R Edelman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,Institute for Medical Engineering and Science, MIT, 77 Massachusetts Ave., Cambridge, MA 02139, USA
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Via S. Citelli, 31 Catania, Italy
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str., Gebäude 41.1, 66421 Homburg/Saar, Germany
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, 155 College Street, Toronto, ON M5T 3M6, Canada.,Department of Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M6, Canada
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str., Gebäude 41.1, 66421 Homburg/Saar, Germany.,Institute for Medical Engineering and Science, MIT, 77 Massachusetts Ave., Cambridge, MA 02139, USA
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Moïse NS, Flanders WH, Flanders NH, Pariaut R. Optimizing single-chamber pacing in dogs Part 1: Rate determinations, rate interventions and hysteresis. Vet J 2021; 272:105650. [PMID: 33715961 DOI: 10.1016/j.tvjl.2021.105650] [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: 07/03/2020] [Revised: 01/23/2021] [Accepted: 02/25/2021] [Indexed: 11/30/2022]
Abstract
Determining ideal pacing rates to meet physiological needs and optimizing programming to prevent unnecessary right ventricular pacing in dogs requires an understanding of heart rate profiles and applicable pacing technology. The heart rate and rhythm of the dog is complex necessitating investigation of rate requirements of activity and circadian influences. Overlaying this information are a multiplicity of other factors such as age, breed, temperament, cardiovascular disease and underlining rhythm disorders that contribute to the difficulty in making general conclusions. However, all such information permits better implementation of programming options with the goal of better outcomes. In this review (Part 1 of a two-part review) instantaneous heart rate, rolling average heart rate, simple average heart rate, heart rate tachograms, RR interval tachograms (2D, 3D and dynamic), and Poincaré plots (2D, 3D and dynamic) are discussed as they apply to decisions in the determination and examination of pacing rates for dogs programmed in the VVI pacing mode (Ventricular paced, Ventricular sensed, Inhibited pacing). The applicable pacing operations available for three pacemaker companies are reviewed (Abbott, Biotronik/Dextronix, and Medtronic). The programmable options considered include: slowest pacing rate without additional features to extend the pacing interval, sleep/rest rate preferences, hysteresis to lengthen pacing interval following intrinsic beats, and intermittent increases in pacing following abrupt loss of intrinsic rhythm. Recommendations are suggested for follow-up of individual dogs with examination of pacing statistics and Holter monitoring.
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Affiliation(s)
- N Sydney Moïse
- Section of Cardiology, Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA.
| | - Wyatt H Flanders
- Department of Physics, University of Washington, Seattle, WA 98195, USA
| | | | - Romain Pariaut
- Section of Cardiology, Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
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40
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Moïse NS, Flanders WH, Flanders NH, Pariaut R. Optimizing single-chamber pacing in dogs. Part 2: Rate adaptive pacing. Vet J 2021; 272:105630. [PMID: 33674172 DOI: 10.1016/j.tvjl.2021.105630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/26/2021] [Accepted: 02/09/2021] [Indexed: 12/30/2022]
Abstract
Proper programming of pacemakers for dogs in the rate adaptive mode requires an understanding of the rate requirements for each individual and the interplay of programmable features. The specific advantages and disadvantages of the rate adaptive mode should be considered on a case by case basis. Fundamentally, two components are linked in the implementation of rate adaptive pacing: (1) sensing the need for a change in rate and (2) responding with the appropriate alteration in pacing rate. The programming interaction of these two components are interdependent and affected by the rates programmed. These features may be adjusted manually or automatically. In this review (Part 2 of a two-part review) the considerations required to program each aspect that optimizes the pacing rate profile are reviewed. These include the lower rate, upper sensor rate, activities of daily life rate, sensor threshold, acceleration and deceleration, slope, activities of daily life zone, exertion zone, automatic versus manual adjustments and closed loop stimulation. The programming features of pacemakers manufactured by three companies are summarized (Abbott, formerly St. Jude; Biotronik/Dextronix; Medtronic). Means of assessing the success of pacemaker programing is examined through examples of pacemaker data, Holter analysis, Poincaré plots and tachograms. Finally, the questions and considerations for rate adaptive pacing in dogs that demand investigation are proposed.
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Affiliation(s)
- N Sydney Moïse
- Section of Cardiology, Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA.
| | - Wyatt H Flanders
- Department of Physics, University of Washington, Seattle, WA 98195, USA
| | | | - Romain Pariaut
- Section of Cardiology, Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
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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: 22] [Impact Index Per Article: 7.3] [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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Palmisano P, Dell'Era G, Pellegrino PL, Ammendola E, Ziacchi M, Guerra F, Aspromonte V, Laffi M, Pimpini L, Santoro F, Boggio E, Guido A, Patti G, Brunetti ND, Nigro G, Biffi M, Russo AD, Gaggioli G, Accogli M. Causes of syncopal recurrences in patients treated with permanent pacing for bradyarrhythmic syncope: Findings from the SYNCOPACED registry. Heart Rhythm 2021; 18:770-777. [PMID: 33465512 DOI: 10.1016/j.hrthm.2021.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few studies have examined the causes of syncope/collapse recurrences in patients with a previously implanted pacemaker for bradyarrhythmic syncope. OBJECTIVE The purpose of this study was to assess the causes of syncope/collapse recurrences after pacemaker implantation for bradyarrhythmic syncope in a large patient population. METHODS The SYNCOpal recurrences in patients treated with permanent PACing for bradyarrhythmic syncope (SYNCOPACED) registry was a prospective multicenter observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for bradyarrhythmic syncope. During follow-up, the time to the first syncope/collapse recurrence was recorded. Patients with syncope/collapse recurrences underwent a predefined diagnostic workup aimed at establishing the mechanism of syncope/collapse. RESULTS During a median follow-up of 50 months, 213 patients (15.6%) reported at least 1 syncope/collapse recurrence. The risk of syncope/collapse recurrence was highest in patients who underwent implantation for cardioinhibitory vasovagal syncope (26.4%), followed by unexplained syncope and chronic bifascicular block (21.5%), cardioinhibitory carotid sinus syndrome (17.2%), atrial fibrillation needing pacing (15.5%), atrioventricular block (13.6%), and sinus node disease (12.5%) (P = .017). The most frequent cause of syncope/collapse recurrence was reflex syncope (27.7%), followed by orthostatic hypotension (26.3%), pacemaker or lead malfunction (5.6%), structural cardiac disease (5.2%), and atrial and ventricular tachyarrhythmias (4.7% and 3.8%, respectively). In 26.8% of cases, the mechanism of syncope/collapse remained unexplained. CONCLUSION In patients receiving a pacemaker for bradyarrhythmic syncope, reflex syncope and orthostatic hypotension are the most frequent mechanisms of syncope/collapse recurrence after implantation. Pacing system malfunction, structural cardiac diseases, and tachyarrhythmias are rare mechanisms. The mechanism remains unexplained in >25% of patients.
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Affiliation(s)
| | - Gabriele Dell'Era
- Azienda Ospedaliera Universitaria "Maggiore della Carità," Novara, Italy
| | | | - Ernesto Ammendola
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Matteo Ziacchi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi," Ancona, Italy
| | - Vittorio Aspromonte
- Cardiology - Coronary Care Unit, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - Mattia Laffi
- Cardiology Division, Villa Scassi Hospital, Genova ASL 3, Genova, Italy
| | - Lorenzo Pimpini
- Unit of Cardiology-CCU, Italian National Research Centre on Aging, Ancona, Italy
| | - Francesco Santoro
- Department of Cardiology, Bonomo Hospital, Andria, Italy; Department of Medical and Surgery Sciences, University of Foggia, Foggia, Italy
| | - Enrico Boggio
- Azienda Ospedaliera Universitaria "Maggiore della Carità," Novara, Italy
| | | | - Giuseppe Patti
- Azienda Ospedaliera Universitaria "Maggiore della Carità," Novara, Italy
| | | | - Gerardo Nigro
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Mauro Biffi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi," Ancona, Italy
| | - Germano Gaggioli
- Cardiology Division, Villa Scassi Hospital, Genova ASL 3, Genova, Italy
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Palmisano P, Pellegrino PL, Ammendola E, Ziacchi M, Guerra F, Aspromonte V, Laffi M, Pimpini L, Santoro F, Boggio E, Guido A, Patti G, Brunetti ND, Nigro G, Biffi M, Dello Russo A, Gaggioli G, Accogli M, Dell’Era G. Risk of syncopal recurrences in patients treated with permanent pacing for bradyarrhythmic syncope: role of correlation between symptoms and electrocardiogram findings. Europace 2020; 22:1729-1736. [DOI: 10.1093/europace/euaa188] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 06/12/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
To evaluate the risk of syncopal recurrences after pacemaker implantation in a population of patients with syncope of suspected bradyarrhythmic aetiology.
Methods and results
Prospective, multicentre, observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for syncope of bradyarrhythmic aetiology (proven or presumed). Before pacemaker implantation, all patients underwent a cardiac work-up in order to establish the bradyarrhythmic aetiology of syncope. According to the results of the diagnostic work-up, patients were divided into three groups: Group A, patients in whom a syncope-electrocardiogram (ECG) correlation was established (n = 329, 24.1%); Group B, those in whom clinically significant bradyarrhythmias were detected without a documented syncope-ECG correlation (n = 877, 64.3%); and Group C, those in whom bradyarrhythmias were not detected and the bradyarrhythmic origin of syncope remained presumptive (n = 158, 11.6%). During a median follow-up of 50 months, 213 patients (15.6%) reported at least one syncopal recurrence. Patients in Groups B and C showed a significantly higher risk of syncopal recurrences than those in Group A [hazard ratios (HRs): 1.60 and 2.66, respectively, P < 0.05]. Failure to establish a syncope-ECG correlation during diagnostic work-up before pacemaker implantation was an independent predictor of syncopal recurrence on multivariate analysis (HR: 1.90; P = 0.002).
Conclusion
In selecting patients with syncope of suspected bradyarrhythmic aetiology for pacemaker implantation, establishing a correlation between syncope and bradyarrhythmias maximizes the efficacy of pacing and reduces the risk of syncopal recurrences.
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Affiliation(s)
| | | | - Ernesto Ammendola
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Matteo Ziacchi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I—Lancisi—Salesi”, Ancona, Italy
| | - Vittorio Aspromonte
- Cardiology - Coronary Care Unit, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - Mattia Laffi
- Cardiology Division, Villa Scassi Hospital, Genova, ASL 3, Genova, Italy
| | - Lorenzo Pimpini
- Unit of Cardiology-CCU, Italian National Reserch Centre on Aging, Ancona, Italy
| | - Francesco Santoro
- Department of Cardiology, Bonomo Hospital, Andria, Italy
- Department of Medical and Surgery Sciences, University of Foggia, Foggia, Italy
| | - Enrico Boggio
- Division of Cardiology, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Novara, Italy
| | | | - Giuseppe Patti
- Division of Cardiology, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Novara, Italy
| | | | - Gerardo Nigro
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Mauro Biffi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I—Lancisi—Salesi”, Ancona, Italy
| | - Germano Gaggioli
- Cardiology Division, Villa Scassi Hospital, Genova, ASL 3, Genova, Italy
| | | | - Gabriele Dell’Era
- Division of Cardiology, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Novara, Italy
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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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van Dijk JG, Ghariq M, Kerkhof FI, Reijntjes R, van Houwelingen MJ, van Rossum IA, Saal DP, van Zwet EW, van Lieshout JJ, Thijs RD, Benditt DG. Novel Methods for Quantification of Vasodepression and Cardioinhibition During Tilt-Induced Vasovagal Syncope. Circ Res 2020; 127:e126-e138. [DOI: 10.1161/circresaha.120.316662] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Rationale:
Assessing the relative contributions of cardioinhibition and vasodepression to the blood pressure (BP) decrease in tilt-induced vasovagal syncope requires methods that reflect BP physiology accurately.
Objective:
To assess the relative contributions of cardioinhibition and vasodepression to tilt-induced vasovagal syncope using novel methods.
Methods and Results:
We studied the parameters determining BP, that is, stroke volume (SV), heart rate (HR), and total peripheral resistance (TPR), in 163 patients with tilt-induced vasovagal syncope documented by continuous ECG and video EEG monitoring. We defined the beginning of cardioinhibition as the start of an HR decrease (HR) before syncope and used logarithms of SV, HR, and TPR ratios to quantify the multiplicative relation BP=SV·HR·TPR. We defined 3 stages before syncope and 2 after it based on direction changes of these parameters. The earliest BP decrease occurred 9 minutes before syncope. Cardioinhibition was observed in 91% of patients at a median time of 58 seconds before syncope. At that time, SV had a strong negative effect on BP, TPR a lesser negative effect, while HR had increased (all
P
<0.001). At the onset of cardioinhibition, the median HR was at 98 bpm higher than baseline. Cardioinhibition thus initially only represented a reduction of the corrective HR increase but was nonetheless accompanied by an immediate acceleration of the ongoing BP decrease. At syncope, SV and HR contributed similarly to the BP decrease (
P
<0.001), while TPR did not affect BP.
Conclusions:
The novel methods allowed the relative effects of SV, HR, and TPR on BP to be assessed separately, although all act together. The 2 major factors lowering BP in tilt-induced vasovagal syncope were reduced SV and cardioinhibition. We suggest that the term vasodepression in reflex syncope should not be limited to reduced arterial vasoconstriction, reflected in TPR, but should also encompass venous pooling, reflected in SV.
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Affiliation(s)
- J. Gert van Dijk
- From the Department of Neurology (J.G.v.D., M.G., F.I.K., R.R., I.A.v.R., D.P.S., R.D.T.), Leiden University Medical Centre, the Netherlands
| | - Maryam Ghariq
- From the Department of Neurology (J.G.v.D., M.G., F.I.K., R.R., I.A.v.R., D.P.S., R.D.T.), Leiden University Medical Centre, the Netherlands
| | - Fabian I. Kerkhof
- From the Department of Neurology (J.G.v.D., M.G., F.I.K., R.R., I.A.v.R., D.P.S., R.D.T.), Leiden University Medical Centre, the Netherlands
| | - Robert Reijntjes
- From the Department of Neurology (J.G.v.D., M.G., F.I.K., R.R., I.A.v.R., D.P.S., R.D.T.), Leiden University Medical Centre, the Netherlands
| | - Marc J. van Houwelingen
- Department of Experimental Cardiology, Erasmus Medical Centre, Rotterdam, the Netherlands (M.J.v.H.)
| | - Ineke A. van Rossum
- From the Department of Neurology (J.G.v.D., M.G., F.I.K., R.R., I.A.v.R., D.P.S., R.D.T.), Leiden University Medical Centre, the Netherlands
| | - Dirk P. Saal
- From the Department of Neurology (J.G.v.D., M.G., F.I.K., R.R., I.A.v.R., D.P.S., R.D.T.), Leiden University Medical Centre, the Netherlands
- Franciscus Gasthuis en Vlietland, Rotterdam/Schiedam, the Netherlands (D.P.S.)
| | - Erik W. van Zwet
- Department of Medical Statistics (E.W.v.Z.), Leiden University Medical Centre, the Netherlands
| | - Johannes J. van Lieshout
- Department of Internal medicine, University Medical Centre, Amsterdam, the Netherlands (J.J.v.L.)
- MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, Queen’s Medical Centre, School of Life Sciences, University of Nottingham Medical School, United Kingdom (J.J.v.L.)
| | - Roland D. Thijs
- From the Department of Neurology (J.G.v.D., M.G., F.I.K., R.R., I.A.v.R., D.P.S., R.D.T.), Leiden University Medical Centre, the Netherlands
- Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands (R.D.T.)
| | - David G. Benditt
- Cardiovascular Division, Arrhythmia Center, Department of Medicine, University of Minnesota, Minneapolis (D.G.B.)
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Aksu T, Erdem Guler T. Cardioneuroablation in the Management of Vasovagal Syncope, Sinus Node Dysfunction and Functional Atrioventricular Block: Patient Selection Based on Supporting Evidence. J Atr Fibrillation 2020; 13:2396. [PMID: 33024497 PMCID: PMC7533142 DOI: 10.4022/jafib.2396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/11/2020] [Accepted: 03/16/2020] [Indexed: 11/10/2022]
Abstract
The problem with the regulation of the autonomic nervous system or paroxysmal reflex vagal activation episodes may have an important role in the pathophysiology of vasovagal syncope (VVS), sinus bradycardia or periods of sinus arrest, and variable-degree atrioventricular block (AVB). Because existence of structural heart disease tends to shift the vagosympathetic balance towards a sympathetic predominance, vagally-mediated bradyarrhythmias (VMB) usually occurs in young individuals with structurally normal hearts. However, similar reflex problems may be observed in the elderly people and even those with structural heart disease. Modification of the efferent arm of autonomic nervous system by ablation of main ganglionated plexi (GPs) is called as cardioneuroablation (CNA) and seems as a promising treatment option for appropriately selected patients with VMB. This review outlines the process of patient selection for CNA on the basis of supporting evidence.
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Affiliation(s)
- Tolga Aksu
- University of Health Sciences, Kocaeli Derince Training and Research Hospital, Department of Cardiology, Kocaeli, Turkey
| | - Tumer Erdem Guler
- University of Health Sciences, Kocaeli Derince Training and Research Hospital, Department of Cardiology, Kocaeli, Turkey
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48
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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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Cardioinhibitory syncope: from pathophysiology to treatment—should we think on cardioneuroablation? J Interv Card Electrophysiol 2020; 59:441-461. [DOI: 10.1007/s10840-020-00758-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 04/23/2020] [Indexed: 02/07/2023]
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50
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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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