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Dell'Era G, Ghiglieno C, De Vecchi F, Santagostino M, Annunziata L, Baldassarre I, Giacopelli D, Patti G. Closed loop stimulation in left bundle branch area pacing. Pacing Clin Electrophysiol 2024. [PMID: 38850280 DOI: 10.1111/pace.15022] [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: 10/14/2023] [Revised: 03/09/2024] [Accepted: 05/22/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Closed Loop Stimulation (CLS) is a rate-responsive algorithm that adjusts heart rate (HR) based on changes in intracardiac impedance measured from the right ventricle lead. However, the use of CLS in conduction system pacing has not been investigated. In this retrospective study, we aimed to assess whether CLS with left bundle branch area pacing (LBBAP) can generate an appropriate distribution of HR in daily life. METHODS AND RESULTS Our study included 24 patients with CLS pacing and chronotropic incompetence, comparing them with 19 patients receiving DDD pacing, all with LBBAP. Cumulative HR distribution charts were generated using data from a single device interrogation with a minimum follow-up period of 30 days. In DDD-CLS mode, there was a higher percentage of atrial pacing compared to DDD mode (median 58% [interquartile range 29%-83%] vs. 13% [10%-26%], p = .001), and CLS-paced beats were present across all frequency bins. The distribution of beats between the groups was similar (p = .643), resulting in comparable mean HR (72 bpm [70-77] vs. 73 bpm [65-75], p = .615). CONCLUSIONS In the context of LBBAP, CLS effectively modulates pacing rates over a wide frequency range. This lead position does not adversely affect the rate-responsive performance of the algorithm.
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Affiliation(s)
- Gabriele Dell'Era
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore della Carità, Novara, Italy
| | - Chiara Ghiglieno
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore della Carità, Novara, Italy
| | - Federica De Vecchi
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore della Carità, Novara, Italy
| | - Matteo Santagostino
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore della Carità, Novara, Italy
| | | | | | | | - Giuseppe Patti
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore della Carità, Novara, Italy
- Università del Piemonte Orientale Amedeo Avogadro, Novara, Italy
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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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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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4
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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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5
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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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Świerżyńska E, Oręziak A, Główczyńska R, Rossillo A, Grabowski M, Szumowski Ł, Caprioglio F, Sterliński M. Rate-Responsive Cardiac Pacing: Technological Solutions and Their Applications. SENSORS (BASEL, SWITZERLAND) 2023; 23:s23031427. [PMID: 36772467 PMCID: PMC9920425 DOI: 10.3390/s23031427] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 05/12/2023]
Abstract
Modern cardiac pacemakers are equipped with a function that allows the heart rate to adapt to the current needs of the patient in situations of increased demand related to exercise and stress ("rate-response" function). This function may be based on a variety of mechanisms, such as a built-in accelerometer responding to increased chest movement or algorithms sensing metabolic demand for oxygen, analysis of intrathoracic impedance, and analysis of the heart rhythm (Q-T interval). The latest technologies in the field of rate-response functionality relate to the use of an accelerometer in leadless endocavitary pacemakers; in these devices, the accelerometer enables mapping of the mechanical wave of the heart's work cycle, enabling the pacemaker to correctly sense native impulses and stimulate the ventricles in synchrony with the cycles of atria and heart valves. Another modern system for synchronizing pacing rate with the patient's real-time needs requires a closed-loop system that continuously monitors changes in the dynamics of heart contractions. This article discusses the technical details of various solutions for detecting and responding to situations related to increased oxygen demand (e.g., exercise or stress) in implantable pacemakers, and reviews the results of clinical trials regarding the use of these algorithms.
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Affiliation(s)
- Ewa Świerżyńska
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
- Correspondence:
| | - Artur Oręziak
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Renata Główczyńska
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Antonio Rossillo
- Department of Cardiology, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Łukasz Szumowski
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
| | | | - Maciej Sterliński
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
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Teixeira RA, Fagundes AA, Baggio Junior JM, Oliveira JCD, Medeiros PDTJ, Valdigem BP, Teno LAC, Silva RT, Melo CSD, Elias Neto J, Moraes Júnior AV, Pedrosa AAA, Porto FM, Brito Júnior HLD, Souza TGSE, Mateos JCP, Moraes LGBD, Forno ARJD, D'Avila ALB, Cavaco DADM, Kuniyoshi RR, Pimentel M, Camanho LEM, Saad EB, Zimerman LI, Oliveira EB, Scanavacca MI, Martinelli Filho M, Lima CEBD, Peixoto GDL, Darrieux FCDC, Duarte JDOP, Galvão Filho SDS, Costa ERB, Mateo EIP, Melo SLD, Rodrigues TDR, Rocha EA, Hachul DT, Lorga Filho AM, Nishioka SAD, Gadelha EB, Costa R, Andrade VSD, Torres GG, Oliveira Neto NRD, Lucchese FA, Murad H, Wanderley Neto J, Brofman PRS, Almeida RMS, Leal JCF. Brazilian Guidelines for Cardiac Implantable Electronic Devices - 2023. Arq Bras Cardiol 2023; 120:e20220892. [PMID: 36700596 PMCID: PMC10389103 DOI: 10.36660/abc.20220892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - Rodrigo Tavares Silva
- Universidade de Franca (UNIFRAN), Franca, SP - Brasil
- Centro Universitário Municipal de Franca (Uni-FACEF), Franca, SP - Brasil
| | | | - Jorge Elias Neto
- Universidade Federal do Espírito Santo (UFES), Vitória, ES - Brasil
| | - Antonio Vitor Moraes Júnior
- Santa Casa de Ribeirão Preto, Ribeirão Preto, SP - Brasil
- Unimed de Ribeirão Preto, Ribeirão Preto, SP - Brasil
| | - Anisio Alexandre Andrade Pedrosa
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Luis Gustavo Belo de Moraes
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | - Mauricio Pimentel
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | - Eduardo Benchimol Saad
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Hospital Samaritano, Rio de Janeiro, RJ - Brasil
| | | | | | - Mauricio Ibrahim Scanavacca
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Martino Martinelli Filho
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Batista de Lima
- Hospital Universitário da Universidade Federal do Piauí (UFPI), Teresina, PI - Brasil
- Empresa Brasileira de Serviços Hospitalares (EBSERH), Brasília, DF - Brasil
| | | | - Francisco Carlos da Costa Darrieux
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Sissy Lara De Melo
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Eduardo Arrais Rocha
- Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
| | - Denise Tessariol Hachul
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Silvana Angelina D'Orio Nishioka
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Roberto Costa
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Gustavo Gomes Torres
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN - Brasil
| | | | | | - Henrique Murad
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Rui M S Almeida
- Centro Universitário Fundação Assis Gurgacz, Cascavel, PR - Brasil
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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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Palmisano P, Guerra F, Aspromonte V, Dell’Era G, Pellegrino PL, Laffi M, Uran C, De Bonis S, Accogli M, Russo AD, Patti G, Santoro F, Torriglia A, Nigro G, Bisignani A, Coluccia G, Stronati G, Russo V, Ammendola E. Management of older patients with unexplained, recurrent, traumatic syncope and bifascicular block: implantable loop recorder versus empiric pacemaker implantation. Results of a propensity matched analysis. Heart Rhythm 2022; 19:1696-1703. [PMID: 35643299 DOI: 10.1016/j.hrthm.2022.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/09/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022]
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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJ, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. Grupo de trabajo sobre estimulación cardiaca y terapia de resincronización cardiaca de la Sociedad Europea de Cardiología (ESC). Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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12
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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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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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14
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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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15
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021; 42:3427-3520. [PMID: 34455430 DOI: 10.1093/eurheartj/ehab364] [Citation(s) in RCA: 791] [Impact Index Per Article: 263.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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16
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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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17
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Bosch R. [Autonomic nervous system and reflex syncope]. Herzschrittmacherther Elektrophysiol 2021; 32:330-334. [PMID: 34189616 DOI: 10.1007/s00399-021-00775-2] [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: 05/10/2021] [Accepted: 05/18/2021] [Indexed: 11/24/2022]
Abstract
This review discusses important aspects of pathophysiology, diagnosis and therapy of reflex syncope. The autonomic nervous system plays a crucial role in the origin of this frequently observed form of syncope. In most cases, reflex syncopes occur under specific circumstances. Thus, a detailed history is essential. Besides a physical exam und a normal 12-lead ECG, dedicated tests like tilt-table-testing, carotid massage and the implantation of a loop recorder often assist in making the correct diagnosis. The basis of therapy for all patients is reassurance about the benign course of the disease as well as education about adequate measures. Pharmacotherapy is reserved to a minority of patients. In older patients with repeat or severe syncopes and documented asystoles, pacemaker therapy is a valuable option.
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Affiliation(s)
- Ralph Bosch
- Cardio Centrum Ludwigsburg-Bietigheim (CCLB), Asperger Str. 48, 71634, Ludwigsburg, Deutschland.
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18
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Sutton R, Fedorowski A, Olshansky B, Gert van Dijk J, Abe H, Brignole M, de Lange F, Kenny RA, Lim PB, Moya A, Rosen SD, Russo V, Stewart JM, Thijs RD, Benditt DG. Tilt testing remains a valuable asset. Eur Heart J 2021; 42:1654-1660. [PMID: 33624801 PMCID: PMC8245144 DOI: 10.1093/eurheartj/ehab084] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/05/2020] [Accepted: 02/05/2021] [Indexed: 12/19/2022] Open
Abstract
Head-up tilt test (TT) has been used for >50 years to study heart rate/blood pressure adaptation to positional changes, to model responses to haemorrhage, to assess orthostatic hypotension, and to evaluate haemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension. During these studies, some subjects experienced syncope due to vasovagal reflex. As a result, tilt testing was incorporated into clinical assessment of syncope when the origin was unknown. Subsequently, clinical experience supports the diagnostic value of TT. This is highlighted in evidence-based professional practice guidelines, which provide advice for TT methodology and interpretation, while concurrently identifying its limitations. Thus, TT remains a valuable clinical asset, one that has added importantly to the appreciation of pathophysiology of syncope/collapse and, thereby, has improved care of syncopal patients.
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Affiliation(s)
| | - Artur Fedorowski
- Department of Cardiology, Skåne University Hospital and Lund University, Malmö, Sweden
| | - Brian Olshansky
- Department of Cardiology, University of Iowa, Iowa City, IA, USA
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, The Netherlands
| | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Michele Brignole
- Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milano, Italy
| | - Frederik de Lange
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Heart Centre, Amsterdam, The Netherlands
| | | | - Phang Boon Lim
- Department of Cardiology, Hammersmith Hospital, Imperial College, London, UK
| | - Angel Moya
- Department of Cardiology, Dexeus University Hospital, Barcelona, Spain
| | - Stuart D Rosen
- National Heart & Lung Institute, Royal Brompton Hospital, Imperial College, London, UK
| | - Vincenzo Russo
- Department of Translational Sciences, University of Campania, Naples, Italy
| | - Julian M Stewart
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, The Netherlands
| | - David G Benditt
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
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19
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Brignole M, Sutton R, Fedorowski A. Are convictions more dangerous enemies of truth than lies? Eur Heart J 2021; 42:1711-1712. [PMID: 33734355 DOI: 10.1093/eurheartj/ehab164] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Michele Brignole
- Faint & Fall Programme, Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, ospedale San Luca, Via Magnasco 2, 20149 Milan, Italy
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, Ducane Road, London, UK
| | - Artur Fedorowski
- Department of Cardiology, Skane University Hospital, Malmo, Sweden
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20
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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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21
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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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22
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Heart rate distribution in paced and non-paced patients with severe recurrent reflex syncope and tilt-induced asystole: Findings from the BIOSync CLS study. Int J Cardiol 2021; 335:52-54. [PMID: 33887343 DOI: 10.1016/j.ijcard.2021.04.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Undiagnosed sinus or atrioventricular node dysfunction may bias estimation of the real efficacy of cardiac pacing in preventing vasovagal reflex syncope. We assessed this hypothesis in the BIOSync CLS trial which showed that dual-chamber pacing with closed loop stimulation (CLS) remarkably reduced recurrences of syncope. METHODS AND RESULTS In the study patients aged 40 years or older with ≥2 episodes of loss of consciousness in the last year and an asystolic response to Tilt-Table test were randomized to pacing ON (DDD-CLS mode) or pacing OFF (ODO mode). We utilized the available pacemaker diagnostic data in a total of 103 patients (52 pacing ON, 51 pacing OFF) to generate cumulative distribution charts for heart rate (HR) and percentage of pacing. At 12 months, we did not find evidence of suspected sinus or atrioventricular node dysfunction. Beats were similarly distributed between groups (p = 0.96), with an average HR of 76 ± 8 bpm (pacing ON) versus 77 ± 7 bpm (pacing OFF). In the active group, the median percentage of atrial and ventricular pacing was 47% and 0%, respectively. Intolerance to high pacing rates was reported in only one patient (1.6%) and was easily resolved by reprogramming the maximum CLS pacing rate. CONCLUSIONS We did not find evidence of suspected sinus or atrioventricular node dysfunction in the BIOSync CLS patients. The benefit of pacing should be ascribed to pacing prevention of pure vasovagal episodes. CLS algorithm modulated pacing rates over a wide frequency range, consistently competing with sinus node.
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23
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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24
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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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25
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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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26
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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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27
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Aksu T, Guler TE, Bozyel S, Yalin K, Gopinathannair R. Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation. Europace 2020; 22:1320-1327. [DOI: 10.1093/europace/euaa230] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
Aims
Previous reports have suggested that cardioneuroablation (CNA) can be effective in reducing syncopal recurrences in patients with vasovagal syncope (VVS). This study assessed the efficacy of CNA in preventing a positive response to head-up tilt testing (HUT).
Methods and results
This is a single-centre retrospective study reviewing prospectively collected data. Fifty-one consecutive patients with VVS were included in the study. After confirmation of >3 s asystole on HUT, all patients underwent CNA. Head-up tilt testing was repeated 1 month after CNA. The main outcome measures were recurrence of syncope episode and positive response on HUT. During a median follow-up period of 11 months (interquartile range 3–27 months), all but 3 (5.8%) of 51 patients were free of syncope. Repeated HUTs were negative in 44 (86.2%) patients. When patients with recurrent syncope were excluded, vasodepressor response was seen in three cases and cardioinhibitory response in one case, respectively. Cardioneuroablation caused significant and durable shortening of RR interval in all cases. This effect was significantly higher in patients without positive HUT responses.
Conclusion
This pilot study shows that CNA can effectively prevent recurrent syncopal episodes in patients with refractory VVS. Head-up tilt testing seems as a valuable diagnostic tool not only to select suitable candidates and but also to evaluate success of CNA.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Tumer Erdem Guler
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Serdar Bozyel
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Kivanc Yalin
- Department of Cardiology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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28
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Safety and efficacy of leadless pacemaker for cardioinhibitory vasovagal syncope. Heart Rhythm 2020; 17:1575-1581. [PMID: 32389681 DOI: 10.1016/j.hrthm.2020.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Single-chamber leadless pacemakers (LPs) have been shown to be an effective alternative to conventional transvenous pacemakers (CTPs), but their benefit in the context of cardioinhibitory vasovagal syncope (CI-VVS) is unknown. OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of LP compared with dual-chamber CTP for CI-VVS. METHODS We conducted a multicenter, retrospective study comparing patients who received LP or dual-chamber CTP for drug-refractory CI-VVS. CI-VVS was diagnosed clinically and supported by cardiac monitoring and head-up tilt table testing. The primary efficacy endpoint was freedom from syncope during follow-up. Secondary endpoints included device efficacy and safety estimated by device-related major and minor adverse events (AEs). RESULTS Seventy-two patients (24 LP, 48 CTP; age 32 ± 5.5 years; 90% female; syncope frequency 7.6 ± 3.4 per year) were included. At 1 year, 91% of patients (22/24) in the LP group and 94% of patients (43/48) in the CTP group met the primary efficacy endpoint (P = .7). Device efficacy endpoint was met in 92% of the LP group and 98% of the CTP group (P = .2). Early major AEs occurred in 2 of 24 in the LP group and 3 of 48 in the CTP group (P = .4). Late major AEs occurred in 0 of 24 in the LP group and 2 of 48 in the CTP group (P = 1). CONCLUSION In patients with CI-VVS, single-chamber LP demonstrated equivalent efficacy in reducing syncopal events compared to dual-chamber CTP, with a similar safety profile.
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de Jong JS, Jardine DL, Lenders JW, Wieling W. Pacing in vasovagal syncope: A physiological paradox? Heart Rhythm 2020; 17:813-820. [DOI: 10.1016/j.hrthm.2019.09.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Indexed: 10/26/2022]
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Abstract
Reflex atrioventricular block is well-recorded although it is considered rare. Recent data suggests that it is less rare than has been supposed. It has been shown to occur in both vasovagal and carotid sinus reflexes. It has to be distinguished from paroxysmal atrioventricular block due to ventricular conduction tissue disease. Low chronic adenosine levels combined with adenosine release may mimic reflex atrioventricular block. Explanations of the mechanism of these phenomena have been lacking until the recent past. The relevance of reflex atrioventricular block to clinical decision-making is as a possible indication for pacing the heart with consideration given to the vasodepressor component of the reflex.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, London, United Kingdom
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31
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Barón-Esquivias G, Barón-Solís C, Ordóñez A. Pacing for Patients Suffering From Cardioinhibitory Vasovagal Syncope Using the Closed-Loop System. Front Cardiovasc Med 2020; 6:192. [PMID: 32118042 PMCID: PMC7033422 DOI: 10.3389/fcvm.2019.00192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/18/2019] [Indexed: 11/18/2022] Open
Abstract
One in three vasovagal syncope (VVS) patients has syncopal recurrence after diagnosis, despite the standard recommendations for the avoidance of a recurrence, and one in five patients has more than one syncopal recurrence in the medium term. Given the high prevalence of VVS, there is a large population that continues to need effective treatment. There are numerous studies that use the implantable loop recorder (ILR) to document a cardioinhibitory response during VVS, with one study, ISSUE-3, demonstrating the efficacy of pacing using the rate-drop-response algorithm to trigger pacing and prevent syncopal recurrence in this population. There are more uncertainties in the studies that have used head-up tilt test (HUT) to select the population for pacing. We have recently performed the SPAIN randomized, controlled clinical trial using HUT to select the patients for pacing. The conclusion of the study was that, with the closed-loop system to introduce pacing, there was a significant reduction in the burden of syncope and a seven-fold increase in the time to first recurrence of syncope, which was greater than in the ISSUE-3 study. Since the completion of the SPAIN trial and its inclusion in the European guidelines, in our daily clinical practice, the use of this therapy is still recommended with caution in the context of the available literature, but it has increased our confidence in so doing. One in five patients with VVS needs treatment because of a high syncopal load. If an ILR is used to select the patients for pacing, the rate-drop-response algorithm can be recommended. In patients who have asystole on HUT, pacing with the closed-loop system has higher success and must now be considered as a tenable option for VVS patients.
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Affiliation(s)
- Gonzalo Barón-Esquivias
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain.,Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain.,Centro de Investigacion en Biomedicina en Red Cardiovascular (CIBER-CV), Madrid, Spain
| | - Carmen Barón-Solís
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain
| | - Antonio Ordóñez
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain.,Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain.,Centro de Investigacion en Biomedicina en Red Cardiovascular (CIBER-CV), Madrid, Spain.,Centro Superior de Investigaciones Científicas (CSIC), Madrid, Spain
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32
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Sutton R, de Jong JSY, Stewart JM, Fedorowski A, de Lange FJ. Pacing in vasovagal syncope: Physiology, pacemaker sensors, and recent clinical trials-Precise patient selection and measurable benefit. Heart Rhythm 2020; 17:821-828. [PMID: 32036025 DOI: 10.1016/j.hrthm.2020.01.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/26/2020] [Indexed: 10/25/2022]
Abstract
The role of pacing in vasovagal syncope (VVS) is considered from a physiological basis. Most VVS patients lose consciousness due to hypotension before severe bradycardia/asystole occurs. Patients who benefit from dual-chamber pacing typically are older with highly symptomatic, late-onset, frequent and severe syncope with short/no prodrome and documented severe cardioinhibition. Tilt testing is of value in patients with recurrent unexplained syncope to identify important hypotensive susceptibility stemming from reduced venous return and stroke volume (SV). A negative tilt test in vasovagal patients with spontaneous asystole documented by an implantable/insertable loop recorder is associated with lower syncope recurrence rates after pacemaker implantation. Pacing may be more effective if triggered by sensor detection of a parameter changing earlier in the reflex than bradycardia when SV may still be relatively preserved. In this regard, detection of right ventricular impedance offers promise. Conservatism is recommended, limiting pacing in VVS to a small subset of symptomatic older patients with clearly documented cardioinhibition and paying particular attention to the timing of loss of consciousness in relation to asystole/bradycardia. Understanding VVS physiology permits application of well-timed, appropriate pacing that yields benefit for highly symptomatic patients.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, London, United Kingdom; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Jelle S Y de Jong
- Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Julian M Stewart
- Departments of Pediatrics, Physiology and Medicine. New York Medical College. Valhalla, New York
| | - Artur Fedorowski
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Frederik J de Lange
- Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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Ikeya Y, Nakai T, Murata N, Monden M, Ogaku A, Hori K, Watanabe R, Arai M, Okumura Y. Effective Pacing Intervention by Closed-loop Stimulation Using a Coronary Vein Lead in a Post-tricuspid Valve Replacement Patient. Intern Med 2020; 59:963-966. [PMID: 32238662 PMCID: PMC7184078 DOI: 10.2169/internalmedicine.4018-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
To avoid the negative effects associated with pacing, pacemakers are designed to achieve a pacing cadence as close to physiological pacing as possible. In closed-loop stimulation (CLS; a type of rate-responsive functionality used in pacemakers), the changes in impedance (which correlates with the contractility of the myocardium around the lead tip electrode) are tracked, and the paced heart rate is adjusted accordingly. We herein report a case in which we implanted a pacemaker in a post-tricuspid valve replacement patient. A ventricular lead positioned in the coronary vein exhibited good CLS functionality, and the patient's dizziness and heart failure improved.
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Affiliation(s)
- Yukitoshi Ikeya
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Nobuhiro Murata
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Masaki Monden
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Akihito Ogaku
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Koichiro Hori
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Masaru Arai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Japan
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Barón-Esquivias G, Moya-Mitjans A, Martinez-Alday J, Ruiz-Granell R, Lacunza-Ruiz J, Garcia-Civera R, Gutiérrez-Carretero E, Romero-Garrido R, Morillo CA. Impact of dual-chamber pacing with closed loop stimulation on quality of life in patients with recurrent reflex vasovagal syncope: results of the SPAIN study. Europace 2019; 22:314-319. [DOI: 10.1093/europace/euz294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/01/2019] [Indexed: 12/26/2022] Open
Abstract
Abstract
Aims
Reflex vasovagal syncope (VVS) is the most common cause of syncope and patients with recurrent episodes may severely impair quality of life (QoL). This pre-specified analysis evaluated whether the clinically significant reduction in syncope burden demonstrated by dual-chamber pacing with closed loop stimulation (DDD-CLS) reported in the SPAIN trial translates into improved QoL.
Methods and results
Patients aged ≥40 years with ≥5 VVS episodes and cardioinhibitory response induced by head-up tilt testing were included. Patients were randomized 1:1 to active DDD-CLS pacing algorithm for 12 months followed by sham DDI mode for the remaining 12 months (Group A) or vice versa (Group B). QoL was assessed using the Short Form-36 (SF-36) health survey, Physical Component Score (PCS), and Mental Component Score (MCS) before randomization (baseline) and at 12- and 24-month follow-up. Fifty-four patients were enrolled from 11 participating centres. No significant carryover effect was detected for any variable, and the only period effect was observed in the vitality subdomain (P = 0.033). Mean SF-36 scores were higher in the DDD-CLS group vs. the DDI group for the eight subdomains and significantly different in physical role, bodily pain, and vitality (P < 0.05). The analysis of component summary scores indicated that DDD-CLS benefited both mental and physical components with significant differences in PCS when compared with the DDI group.
Conclusion
Dual-chamber pacing with closed loop stimulation determined a significant and clinically relevant improvement in QoL across both mental and physical components in patients with recurrent VVS.
Registration
Closed Loop Stimulation for Neuromediated Syncope (SPAIN Study); NCT01621464.
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Affiliation(s)
- Gonzalo Barón-Esquivias
- Department of Cardiology, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla. Av. Manuel Siurot, S/n, 41013 Sevilla, Spain
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
| | - Angel Moya-Mitjans
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Vall d’Hebron, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Jesús Martinez-Alday
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Basurto, Montevideo Etorb., 18, 48013 Bilbao, Spain
- Department of Cardiology, Clínica IMQ Zorrotzaurre, Ballets Olaeta, 4, 48014 Bilbao, Spain
| | - Ricardo Ruiz-Granell
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Clínico de Valencia, Av. de Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - Javier Lacunza-Ruiz
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 Murcia, Spain
| | - Roberto Garcia-Civera
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Universitario Clínico de Valencia, Av. de Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - Encarnación Gutiérrez-Carretero
- Department of Cardiology, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla. Av. Manuel Siurot, S/n, 41013 Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Melchor Fernández Almagro, 3, 28029 Madrid, Spain
| | - Rafael Romero-Garrido
- Department of Cardiology, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla. Av. Manuel Siurot, S/n, 41013 Sevilla, Spain
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain
- Department of Cardiology, Hospital Nuestra Señora de la Candelaria, Ctra. Gral. del Rosario, 145, 38010 Santa Cruz de Tenerife, Spain
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1 and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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da Cunha GJL, Rocha BML, Gomes RV, Silva BV, Mendes G, Morais R, Araújo IF, Fonseca C. A systematic review on recurrent cardioinhibitory vasovagal syncope: Does pacing therapy break the fall? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1400-1407. [DOI: 10.1111/pace.13790] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 07/04/2019] [Accepted: 08/18/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Gonçalo José Lopes da Cunha
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Bruno Miguel Lopes Rocha
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Rita Ventura Gomes
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
- Cardiology DepartmentHospital de Vila Franca de Xira Lisbon Portugal
| | - Beatriz Valente Silva
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Gonçalo Mendes
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
- Internal Medicine Department, Hospital de São BernardoCentro Hospitalar de Setúbal Setúbal Portugal
| | - Rui Morais
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Inês Fornelos Araújo
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
| | - Cândida Fonseca
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco XavierCentro Hospitalar Lisboa Ocidental Lisbon Portugal
- NOVA Medical School, Faculdade de Ciências MédicasUniversidade Nova de Lisboa Lisbon Portugal
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Lee JZ, Mulpuru SK, Shen WK. The Role of Pacing in Elderly Patients with Unexplained Syncope. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0608-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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37
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Rattanawong P, Riangwiwat T, Chongsathidkiet P, Vutthikraivit W, Limpruttidham N, Prasitlumkum N, Kanjanahattakij N, Kanitsoraphan C. Closed-looped stimulation cardiac pacing for recurrent vasovagal syncope: A systematic review and meta-analysis. J Arrhythm 2018; 34:556-564. [PMID: 30327702 PMCID: PMC6174378 DOI: 10.1002/joa3.12102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/21/2018] [Accepted: 07/08/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vasovagal syncope (VVS) is defined by transient loss of consciousness with spontaneous rapid recovery. Recently, a closed-loop stimulation pacing system (CLS) has shown superior effectiveness to conventional pacing in refractory VVS. However, systematic review and meta-analysis has not been performed. We assessed the impact of CLS implantation and reduction in recurrent VVS events by a systematic review and a meta-analysis. METHODS We comprehensively searched the databases of MEDLINE and EMBASE from inception to September 2017. Included studies were published prospective or retrospective cohort, randomized controlled trial, and case-control studies that compared VVS events between recurrent, severe, or refractory cardioinhibitory VVS patient implanted with CLS and conventional pacing. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate odds ratios and 95% confidence intervals. RESULTS Six studies from November 2004 to October 2017 were included in this meta-analysis involving 224 recurrent, severe, or refractory cardioinhibitory VVS patients implanted with CLS and 163 recurrent, severe, or refractory VVS patients implanted with conventional pacing. CLS significantly reduced recurrent VVS events compared to conventional pacing (pooled odds ratio = 0.23, 95% confidence interval: 0.13-0.39, P = 0.000, I 2 = 36.5%) as well as subgroup of four randomized controlled trial studies (pooled odds ratio = 0.28, 95% confidence interval: 0.17-0.44, P = 0.000, I 2 = 39.2%). CONCLUSION Closed-loop stimulation significantly reduced recurrent VVS events up to 80% when compared to conventional pacing. Our study suggests that CLS is an effective tool for preventing syncope recurrences in patients with recurrent, severe, or refractory cardioinhibitory VVS.
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Affiliation(s)
- Pattara Rattanawong
- University of Hawaii Internal Medicine Residency ProgramHonoluluHawaii
- Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
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Virag N, Erickson M, Taraborrelli P, Vetter R, Lim PB, Sutton R. Predicting vasovagal syncope from heart rate and blood pressure: A prospective study in 140 subjects. Heart Rhythm 2018; 15:1404-1410. [DOI: 10.1016/j.hrthm.2018.04.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Indexed: 01/23/2023]
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39
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Morita H. Editorial commentary: To pace, or not to pace in vasovagal syncope? Trends Cardiovasc Med 2018; 28:539-540. [PMID: 29970287 DOI: 10.1016/j.tcm.2018.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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Gopinathannair R, Salgado BC, Olshansky B. Pacing for Vasovagal Syncope. Arrhythm Electrophysiol Rev 2018; 7:95-102. [PMID: 29967681 PMCID: PMC6020179 DOI: 10.15420/aer.2018.22.2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/03/2018] [Indexed: 12/28/2022] Open
Abstract
Vasovagal syncope (VVS) is due to a common autonomic reflex involving the cardiovascular system. It is associated with bradycardia (cardioinhibitory response) and/or hypotension (vasodepressor response), likely mediated by parasympathetic activation and sympathetic inhibition. While generally a situational, isolated and/or self-limited event, for some, VVS is recurrent, unpredictable and debilitating. Conservative, non-pharmacological management may help, but no specific medical therapy has been proven widely effective. Permanent pacing may have specific benefit, but its value has been debated. The temporal causative association of bradycardia with syncope in those with VVS may help identify which patient could benefit from pacing but the timing and type of pacing in lieu of blood pressure changes may be critical. The mode, rate, pacing algorithm and time to initiate dual-chamber pacing preferentially with respect to the vasovagal reflex may be important to prevent or ameliorate the faint but completely convincing data are not yet available. Based on available data, DDD pacing with the closed loop stimulation algorithm appears a viable, if not the best, alternative presently to prevent recurrent VVS episodes. While several knowledge gaps remain, permanent pacing appears to have a role in managing select patients with VVS.
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Affiliation(s)
| | - Benjamin C Salgado
- Division of Cardiovascular Medicine, University of LouisvilleLouisville, USA
| | - Brian Olshansky
- Mercy Heart and Vascular Institute, Mason City; and the University of Iowa HospitalsIowa City, USA
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Sutton R. Pacing in neurocardiogenic/vasovagal syncope. Herzschrittmacherther Elektrophysiol 2018; 29:208-213. [PMID: 29802445 DOI: 10.1007/s00399-018-0564-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/03/2018] [Indexed: 06/08/2023]
Abstract
Pacing for neurocardiogenic or vasovagal syncope (VVS) has been practised for five decades, but the 1986 advent of tilt testing provided a means of diagnosis frequently revealing, in the early days, asystole caused by VVS. This was the basis for pacing these patients and the first studies created enthusiasm followed by randomised controlled trials, which were imperfectly designed, "confirming" benefit. When better trial design was employed, there was no obvious benefit. However, some cardiologists had seen patients experience a huge positive difference with pacing, so they set out to identify them. Two studies using ECG loop recorders to document heart rhythm during spontaneous attacks allowed better patient selection for pacing and appeared to achieve the aim. Further, it was noted in the second study, a randomised controlled trial (RCT) with good design, that tilt testing added a further dimension to the identification of the patient who would benefit. Thus, loop recorders are used to show asystole in spontaneous attacks and when tilt testing is negative, implying a lesser vasodepressor component, the patient will have the best outcome. From the available evidence, pacing should be dual-chamber in older patients (>40 years) with severe symptoms and in whom standard measures have demonstrably failed. The method of triggering pacing and its timing of introduction have not yet been resolved. Today's method is rate-hysteresis but there is another sensed event as an alternative: right ventricular impedance, which is now in RCT with substantial pilot evidence in its favour.
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Affiliation(s)
- Richard Sutton
- National Heart and Lung Institute, Hammersmith Hospital Campus, B block South, 2nd floor, NHLI-Cardiovascular Science, Imperial College, Du Cane Road, W12 0NN, London, UK.
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Ruzieh M, Ammari Z, Dasa O, Karim S, Grubb B. Role of closed loop stimulation pacing (CLS) in vasovagal syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1302-1307. [DOI: 10.1111/pace.13194] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/17/2017] [Accepted: 08/28/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Mohammed Ruzieh
- Department of Internal Medicine; University of Toledo; Toledo OH USA
| | - Zaid Ammari
- Department of Internal Medicine; University of Toledo; Toledo OH USA
| | - Osama Dasa
- Department of Internal Medicine; University of Toledo; Toledo OH USA
| | - Saima Karim
- Department of Internal Medicine; University of Toledo; Toledo OH USA
| | - Blair Grubb
- Department of Internal Medicine; University of Toledo; Toledo OH USA
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