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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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Brignole M, Rivasi G, Fedorowski A. Mechanism-based therapy of non-cardiac syncope: a practical guide. Europace 2024; 26:euae073. [PMID: 38529800 PMCID: PMC10988836 DOI: 10.1093/europace/euae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/08/2024] [Indexed: 03/27/2024] Open
Abstract
The term non-cardiac syncope includes all forms of syncope, in which primary intrinsic cardiac mechanism and non-syncopal transient loss of consciousness can be ruled out. Reflex syncope and orthostatic hypotension are the most frequent aetiologies of non-cardiac syncope. As no specific therapy is effective for all types of non-cardiac syncope, identifying the underlying haemodynamic mechanism is the essential prerequisite for an effective personalized therapy and prevention of syncope recurrences. Indeed, choice of appropriate therapy and its efficacy are largely determined by the syncope mechanism rather than its aetiology and clinical presentation. The two main haemodynamic phenomena leading to non-cardiac syncope include either profound hypotension or extrinsic asystole/pronounced bradycardia, corresponding to two different haemodynamic syncope phenotypes, the hypotensive and bradycardic phenotypes. The choice of therapy-aimed at counteracting hypotension or bradycardia-depends on the given phenotype. Discontinuation of blood pressure-lowering drugs, elastic garments, and blood pressure-elevating agents such as fludrocortisone and midodrine are the most effective therapies in patients with hypotensive phenotype. Cardiac pacing, cardioneuroablation, and drugs preventing bradycardia such as theophylline are the most effective therapies in patients with bradycardic phenotype of extrinsic cause.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Department of Cardiology, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
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Brignole M, Groppelli A, Russo V, Fedorowski A, van Dijk G, Alboni P. The Rate of Asystolic Reflex Syncope Is Not Influenced by Age. JACC Clin Electrophysiol 2023:S2405-500X(23)00901-5. [PMID: 38243997 DOI: 10.1016/j.jacep.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND The head-up tilt test (HUT) and other evidence suggest that the vagal effect on the heart decreases with age. OBJECTIVES The main aim of the study was to assess whether this age effect also affects the rate of asystole in spontaneous reflex syncope (RS). METHOD We performed an analysis of pooled individual data from 4 studies that recruited patients ≥40 years of age affected by certain or suspected RS who received an implantable loop recorder (ILR) and reported follow-up data on syncope recurrence. We assessed the presence of asystolic syncope of >3 seconds or nonsyncopal asystole of >6 seconds recorded by ILR and compared the findings to tilt test results on the same patients. RESULTS A total of 1,046 patients received ILR because of unexplained syncope. Of these, 201 (19.2%) had a documentation of an asystolic event of 10-second (Q1-Q3: 6- to 15-second) duration. They were subdivided in 3 age tertiles: ≤60 years (n = 64), 61 to 72 years (n = 72), and ≥73 years (n = 65). The rate of asystolic events was similar in the 3 subgroups (50.1%, 50.1%, and 49.2%, respectively; P = 0.99). Conversely, the rate of asystolic syncope induced during HUT (performed in 169 of 201) was greatly age dependent (31.0%, 12.1%, and 11.1% in increasing age tertiles, respectively; P = 0.009). CONCLUSIONS The rate of the spontaneous asystolic form of RS documented by ILR is constant at any age >40 years. Conversely, the rate of asystolic syncope induced by HUT is higher in younger patients and decreases with age. The contrasting results between spontaneous and tilt-induced events cast doubt on the concept that asystole in RS is less common in older patients.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milan, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milan, Italy.
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Monaldi Hospital, Naples, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Solna, Sweden; Department of Medicine, Karolinska Institute, Solna, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Paolo Alboni
- Section of Cardiology, Ospedale Privato Quisisana, Ferrara, Italy
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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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Brignole M, Aksu T, Calò L, Debruyne P, Deharo JC, Fanciulli A, Fedorowski A, Kulakowski P, Morillo C, Moya A, Olshansky B, Piotrowski R, Stec S, Wichterle D. Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope. Europace 2023; 25:euad033. [PMID: 37021351 PMCID: PMC10227654 DOI: 10.1093/europace/euad033] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 04/07/2023] Open
Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Piazzale Brescia 2, 20149 Milano, Italy
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, 34755 Ataşehir/İstanbul, Turkey
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, 00169 Roma, Italy
| | | | - Jean Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, France and Aix Marseille Université, C2VN, 13005 Marseille, France
| | - Alessandra Fanciulli
- Department of Neurology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine, Karolinska Institute, 17177 Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 20502 Malmö, Sweden
| | - Piotr Kulakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Carlos Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, T2N 1N4 Calgary, AB, Canada
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, 08028 Barcelona, Spain
| | - Brian Olshansky
- Division of Cardiology, University of Iowa Hospitals, 52242 Iowa City, IA, USA
| | - Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Sebastian Stec
- Division of Electrophysiology, Cardioneuroablation, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), 11336 Prague, Czechia
- Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, 11336 Prague, Czechia
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Russo V, Parente E, Groppelli A, Rivasi G, Tomaino M, Gargaro A, Giacopelli D, Ungar A, Parati G, Fedorowski A, Sutton R, van Dijk JG, Brignole M. Prevalence of asystole during tilt test-induced vasovagal syncope may depend on test methodology. Europace 2023; 25:263-269. [PMID: 36796797 PMCID: PMC10103574 DOI: 10.1093/europace/euac154] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
This review addresses tilt-testing methodology by searching the literature which reports timing of asystole and loss of consciousness (LOC). Despite the Italian protocol being the most widely adopted, its stipulations are not always followed to the letter of the European Society of Cardiology guidelines. The discrepancies permit reassessment of the incidence of asystole when tilt-down is early, impending syncope, compared with late, established LOC. Asystole is uncommon with early tilt down and diminishes with increasing age. However, if LOC is established as test-end, asystole is more common, and it is age-independent. Thus, the implications are that asystole is commonly under-diagnosed by early tilt-down. The prevalence of asystolic responses observed using the Italian protocol with a rigorous tilt down time is numerically close to that observed during spontaneous attacks by electrocardiogram loop recorder. Recently, tilt-testing has been questioned as to its validity but, in selection of pacemaker therapy in older highly symptomatic vasovagal syncope patients, the occurrence of asystole has been shown to be an effective guide for treatment. The use of head-up tilt test as an indication for cardiac pacing therapy requires pursuing the test until complete LOC. This review offers explanations for the findings and their applicability to practice. A novel interpretation is offered to explain why pacing induced earlier may combat vasodepression by raising the heart rate when sufficient blood remains in the heart.
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Affiliation(s)
- Vincenzo Russo
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Erika Parente
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Marco Tomaino
- Ospedale Generale Regionale, Via Lorenz Böhler, 5, 39100 Bolzano, Italy
| | - Alessio Gargaro
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Daniele Giacopelli
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300RC Leiden, The Netherlands
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
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Brignole M, Rivasi G, Fedorowski A, Ståhlberg M, Groppelli A, Ungar A. Tests for the identification of reflex syncope mechanism. Expert Rev Med Devices 2023; 20:109-119. [PMID: 36814102 DOI: 10.1080/17434440.2023.2174428] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Treatment efficacy of reflex syncope is mainly related to the mechanism underlying syncope rather than its etiology or clinical presentation. The predominant mechanism underlying reflex syncope can be assigned to hypotensive or to bradycardic phenotypes. AREAS COVERED Methodology and diagnostic criteria of the most useful tests for the identification of hypotensive and bradycardic phenotypes are discussed. Diagnostic tests for the hypotensive phenotype include office blood pressure measurement with active standing test, home, and wearable blood pressure monitoring, 24-h ambulatory blood pressure monitoring and tilt table test. Diagnostic tests for the bradycardic phenotype include carotid sinus massage, tilt table test and prolonged ECG monitoring. EXPERT OPINION In reflex syncope, the documentation of bradycardia/asystole during a syncopal episode does not rule out the possibility that a preceding or parallel hypotensive reflex plays an important role. Similarly, even when a hypotensive mechanism is established, the possibility of an associated cardioinhibitory reflex should be investigated. Investigating the mechanism of reflex syncope is mandatory in patients with severe recurrent episodes, with the final aim to develop a personalized treatment strategy. Recent trials have demonstrated the benefits of personalized mechanism-based therapy, thus highlighting the importance of a comprehensive assessment of the mechanisms underlying syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Marcus Ståhlberg
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Antonella Groppelli
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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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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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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Huang T, O'Leary E, Alexander ME, Bevilacqua L, Fynn-Thompson F, DeWitt ES, Bezzerides VJ, Mah DY. Pacemaker use for the treatment of reflex-mediated syncope: 40-year experience at a single paediatric institution. Cardiol Young 2021; 32:1-6. [PMID: 34709150 DOI: 10.1017/s1047951121004340] [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] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Reflex-mediated syncope occurs in 15% of children and young adults. In rare instances, pacemakers are required to treat syncopal episodes associated with transient sinus pauses or atrioventricular block. This study describes a single centre experience in the use of permanent pacemakers to treat syncope in children and young adults. MATERIALS AND METHODS Patients with significant pre-syncope or syncope and pacemaker implantation from 1978 to 2018 were reviewed. Data collected included the age of presentation, method of diagnosis, underlying rhythm disturbance, age at implant, type of pacemaker implanted, procedural complications and subsequent symptoms. RESULTS Fifty patients were identified. Median age at time of the first syncopal episode was 10.2 (range 0.3-20.4) years, with a median implant age of 14.9 (0.9-34.3) years. Significant sinus bradycardia/pauses were the predominant reason for pacemaker implant (54%), followed by high-grade atrioventricular block (30%). Four (8%) patients had both sinus pauses and atrioventricular block documented. The majority of patients had dual-chamber pacemakers implanted (58%), followed by ventricular pacemakers (38%). Median follow-up was 6.7 (0.4-33.0) years. Post-implant, 4 (8%) patients continued to have syncope, 7 (14%) had complete resolution of their symptoms, and the remaining reported a decrease in their pre-syncopal episodes and no further syncope. Twelve (24%) patients had complications, including two infections and eight lead malfunctions. CONCLUSIONS Paediatric patients with reflex-mediated syncope can be treated with pacing. Complication rates are high (24%); as such, permanent pacemakers should be reserved only for those in whom asystole from sinus pauses or atrioventricular block has been well documented.
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Affiliation(s)
- Thomas Huang
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Edward O'Leary
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mark E Alexander
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Laura Bevilacqua
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Francis Fynn-Thompson
- Department of Cardiovascular Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elizabeth S DeWitt
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Vassilios J Bezzerides
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Diagnosis and prevention of the vasodepressor type of neurally mediated syncope in Japanese patients. PLoS One 2021; 16:e0251450. [PMID: 34170907 PMCID: PMC8232444 DOI: 10.1371/journal.pone.0251450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/27/2021] [Indexed: 01/04/2023] Open
Abstract
We investigated circulatory dynamics in patients with vasodepressor type neurally mediated syncope (VT-NMS) by performing high-resolution Holter electrocardiography and a correlation analysis of changes in adenylate cyclase activity, blood pressure, and pulse during the head-up tilt test. Holter electrocardiography was performed for 30 patients. Adenylate cyclase activity was evaluated in lymphocytes from blood samples taken at rest and during the head-up tilt test. There was no change in autonomic nerve fluctuation during electrocardiography in VT-NMS patients, but our results showed a significant difference in blood pressure and adenylate cyclase activity between VT-NMS patients and healthy volunteers; the systolic blood pressure of VT-NMS patients decreased after 5 min, while at 10 min, the adenylate cyclase activity was the highest (0.53%) and the systolic blood pressure was the lowest (111.8 mm Hg). Pulse rates increased after 10 min. VT-NMS patients showed higher blood pressure, pulse rate, and adenylate cyclase activity during the tilt test than did healthy volunteers. In patients with syncope, standing for longer than 10 minutes may increase the risk of VT-NMS. From our results, we consider it likely that high systolic blood pressure and adenylate cyclase activity at rest cause fainting in VT-NMS patients. Our findings may be helpful for identifying individuals with a high risk of developing NMS in the healthy population.
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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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13
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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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14
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Pediatric radiofrequency ablation of cardiac parasympathetic ganglia to achieve vagal denervation. HeartRhythm Case Rep 2020; 6:879-883. [PMID: 33204627 PMCID: PMC7653474 DOI: 10.1016/j.hrcr.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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15
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Liao Y, Du J. Pathophysiology and Individualized Management of Vasovagal Syncope and Postural Tachycardia Syndrome in Children and Adolescents: An Update. Neurosci Bull 2020; 36:667-681. [PMID: 32367250 PMCID: PMC7271077 DOI: 10.1007/s12264-020-00497-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/31/2020] [Indexed: 12/12/2022] Open
Abstract
Vasovagal syncope (VVS) and postural tachycardia syndrome (POTS) are the main forms of orthostatic intolerance in pediatrics and both are underlying causes of neurally-mediated syncope. In recent years, increasing attention has been paid to the management of VVS and POTS in children and adolescents. A number of potential mechanisms are involved in their pathophysiology, but the leading cause of symptoms varies among patients. A few studies thus have focused on the individualized treatment of VVS or POTS based on selected hemodynamic parameters or biomarkers that can predict the therapeutic effect of certain therapies and improve their effectiveness. This review summarizes the latest developments in individualized treatment of VVS and POTS in children and indicates directions for further research in this field.
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Affiliation(s)
- Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China.
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16
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Sutton R. Diagnostic Tools to Assess Dysfunction of Autonomic Control of the Heart. J Atr Fibrillation 2020; 13:2402. [PMID: 33024502 DOI: 10.4022/jafib.2402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/18/2020] [Accepted: 03/19/2020] [Indexed: 11/10/2022]
Abstract
The most important diagnostic tool available in assessment of dysfunction of the autonomic control of the heart is the clinical history which must be taken in the greatest possible detail including from the patient and witnesses of the syncope/event. Correct history taking will make many diagnoses avoiding need for further testing and guide further investigation if needed and when appropriate. This paper focusses on the investigation of patients when required, the available tests, their indications, how to perform them for maximum yield and how to interpret the results. Tilt-testing, carotid sinus massage, active stand, cardiovascular autonomic nervous system tests, ambulatory blood pressure and insertable ECG loop recorder are covered.
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Affiliation(s)
- Richard Sutton
- Cardiac Dept., Hammersmith Hospital Campus of National Heart & Lung Institute, Imperial College, London, United Kingdom
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17
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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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18
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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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19
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Strano S, Toni D, Ammirati F, Sanna T, Tomaino M, Brignole M, Mazza A, Nguyen BL, Di Bonaventura C, Ricci RP, Boriani G. Neuro-arrhythmology: a challenging field of action and research: a review from the Task Force of Neuro-arrhythmology of Italian Association of Arrhythmias and Cardiac Pacing. J Cardiovasc Med (Hagerstown) 2020; 20:731-744. [PMID: 31567632 DOI: 10.2459/jcm.0000000000000866] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
: There is a growing interest in the study of the mechanisms of heart and brain interactions with the aim to improve the management of high-impact cardiac rhythm disorders, first of all atrial fibrillation. However, there are several topics to which the scientific interests of cardiologists and neurologists converge constituting the basis for enhancing the development of neuro-arrhythmology. This multidisciplinary field should cover a wide spectrum of diseases, even beyond the classical framework corresponding to stroke and atrial fibrillation and include the complex issues of seizures as well as loss of consciousness and syncope. The implications of a more focused interaction between neurologists and cardiologists in the field of neuro-arrhythmology should include in perspective the institution of research networks specifically devoted to investigate 'from bench to bedside' the complex pathophysiological links of the abovementioned diseases, with involvement of scientists in the field of biochemistry, genetics, molecular medicine, physiology, pathology and bioengineering. An investment in the field could have important implications in the perspectives of a more personalized approach to patients and diseases, in the context of 'precision'medicine. Large datasets and electronic medical records, with the approach typical of 'big data' could enhance the possibility of new findings with potentially important clinical implications. Finally, the interaction between neurologists and cardiologists involved in arrythmia management should have some organizational implications, with new models of healthcare delivery based on multidisciplinary assistance, similarly to that applied in the case of syncope units.
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Affiliation(s)
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome
| | | | - Tommaso Sanna
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Institute of Cardiology, Rome
| | - Marco Tomaino
- Department of Cardiology, Ospedale di Bolzano, Bolzano
| | - Michele Brignole
- Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna
| | - Andrea Mazza
- Cardiology Division, Santa Maria della Stella Hospital, Orvieto
| | | | | | | | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
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20
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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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21
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Hu F, Zheng L, Liang E, Ding L, Wu L, Chen G, Fan X, Yao Y. Right anterior ganglionated plexus: The primary target of cardioneuroablation? Heart Rhythm 2019; 16:1545-1551. [PMID: 31330187 DOI: 10.1016/j.hrthm.2019.07.018] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Catheter ablation of ganglionated plexus (GP) as cardioneuroablation in the left atrium (LA) has been used to treat vasovagal syncope (VVS). OBJECTIVE The purpose of this study was to assess the effects of ablation of GPs on heart rate and to observe the acute, short-term, and long-term effects after cardioneuroablation. METHODS A total of 115 consecutive patients with VVS who underwent cardioneuroablation were enrolled. GPs of the LA were identified by high-frequency stimulation and/or anatomic landmarks being targeted by radiofrequency catheter ablation. RESULTS During ablation of right anterior ganglionated plexus (RAGP), heart rate increased from 61.3 ± 12.2 bpm to 82.4 ± 14.7 bpm (P <.001), whereas during ablation of other GPs only vagal responses were observed. During follow-up of 21.4 ± 13.1 months (median 18 months), 106 participants (92.2%) had no recurrence of syncope or presyncope. Holter data showed that minimal heart rate significantly increased at all follow-up time points (all P<.05), and mean heart rate remained higher than baseline 12 months after ablation (P = .001). CONCLUSION Cardioneuroablation via GP ablation in the LA effectively inhibited the recurrence of VVS. Ablation of RAGP could increase heart rate immediately and for the long term. This unique phenomenon may provide a new potential approach for treatment of neural reflex syncope or bradyarrhythmias.
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Affiliation(s)
- Feng Hu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihui Zheng
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Erpeng Liang
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ligang Ding
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lingmin Wu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gang Chen
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohan Fan
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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22
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Does A Therapy for Reflex Vasovagal Syncope Really Exist? High Blood Press Cardiovasc Prev 2019; 26:273-281. [DOI: 10.1007/s40292-019-00327-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022] Open
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23
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Novel Therapeutic Options in the Management of Reflex Syncope. Am J Ther 2019; 26:e268-e275. [PMID: 30839375 DOI: 10.1097/mjt.0000000000000923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Syncope is a symptom associated with a wide range of pathological conditions, ranging from benign to life threatening. The most frequent is the reflex syncope that may be challenging to treat because of the complex and partially unknown pathophysiological mechanism that has to be addressed by the chosen therapy. AREAS OF UNCERTAINTY Head-up tilt testing is so far the only clinical test able to reproduce reflex syncope, but its diagnostic yield has been recently redefined. A new mechanism such as adenosine-sensitive syncope and idiopathic atrioventricular block have been recently described, and the appropriate therapy is not yet established. There is uncertainty on the efficacy of theophylline and on the use of cardiac pacing in these patients. DATA SOURCES Clinical trial published data and position paper from the main expert groups on fludrocortisone, midodrine, etilefrine, beta-blockers, and cardiac pacing as useful therapies for patients affected by reflex syncope. THERAPEUTIC ADVANCES Theophylline proved in observational trials to be efficient in preventing reflex syncope recurrences in patients with documented spontaneous paroxysmal conduction disorders comparable to cardiac pacing in a subgroup of patients. Reboxetine and sibutramine may elicit a significant pressor and tachycardic effect able to delay the onset of symptoms during head-up tilt testing. Droxidopa has short-term effects on improving the symptoms because of orthostatic hypotension. Cardiac pacing is effective in preventing reflex syncope recurrences with best results when the indication for pacemaker implantation was based on the documentation of bradycardia or asystole during the spontaneous event by a cardiac monitor. External compression using elastic bandage or compressive stockings is able to prevent the decrease in blood pressure in patients with orthostatic hypotension. CONCLUSIONS The optimal management of the complex diagnostic and therapeutic options can be achieved following a standardized and evidence-based approach to the patient with syncope.
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24
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Oebel S, Hindricks G. [Management of syncope in clinical practice : What has changed according to the new ESC guidelines 2018?]. Herz 2018; 43:701-709. [PMID: 30341445 DOI: 10.1007/s00059-018-4757-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Syncope is a common problem in clinical practice, which affects approximately 1% of patients admitted to European emergency departments. The clinical practice guidelines for the diagnosis and management of syncope published by the European Society of Cardiology (ESC) are based on the newest scientific data in the field and have provided clinical cardiologists with a structured therapeutic approach for affected patients over many years. The previous ESC guidelines on syncope were published in 2009 and are compared to the most recent edition, which was published in 2018. This review summarizes the most important innovations with respect to the diagnostic principles and treatment of syncope. The initial assessment of the patient and the risk stratification in the emergency department are the focus of the review. Another important topic that is adequately covered in the current guidelines is the rising significance of implantable loop recorders for the evaluation of unexplained syncope and the assessment of potential indications for a definitive treatment with a pacemaker or implantable cardioverter defibrillator (ICD). Additional changes involve the evidence level with respect to the use of other diagnostic (ECG monitoring, tilt testing) and therapeutic measures (indications for pacemaker implantation, catheter ablation of tachycardiac rhythm disorders).
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Affiliation(s)
- S Oebel
- Abteilung für Rhythmologie, HELIOS Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Deutschland
| | - G Hindricks
- Abteilung für Rhythmologie, HELIOS Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Deutschland.
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25
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Unterhuber M, Tomaino M, Brignole M. [Do we need syncope units? : Experience from Bolzano, South Tyrol (Italy)]. Herzschrittmacherther Elektrophysiol 2018; 29:199-203. [PMID: 29761334 DOI: 10.1007/s00399-018-0561-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/03/2018] [Indexed: 11/28/2022]
Abstract
Syncope is a common cause for presentation to the emergency department. Because of the numerous differential diagnoses which can be life-threatening, it can be a challenging work-up for the physician. This often results in admission rates that are too high and hospital stays that are too long with consequent high costs. Several studies have shown the inferiority of best-clinical practice to an evidence-based approach in syncope work-up, which results in underdiagnosis and often incorrect diagnosis of syncope. The consequences are undirected therapies and subsequently high recurrence rates of syncope, which lead to limited quality of life and readmissions. For this reason, the European Society of Cardiology (ESC) Guidelines for the diagnosis and management of syncope recommend the organization of Syncope Units. Through a standardized and evidence-based approach, the diagnostic and therapeutic work-up can be done in a safe and effective manner, allowing an organized follow-up and further management of patients with syncope. This article summarizes the reasons for the need of syncope units and explains the practical implementation of the guidelines using the example of the Syncope Unit in Bolzano, South Tyrol (Italy).
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Affiliation(s)
- Matthias Unterhuber
- Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland. .,Regionalkrankenhaus Bozen, L. Böhler-Str. 5, 39100, Bozen, Italien.
| | - Marco Tomaino
- Regionalkrankenhaus Bozen, L. Böhler-Str. 5, 39100, Bozen, Italien
| | - Michele Brignole
- Department of Cardiology, Ospedali Tigullio, 16033, Lavagna, Italien
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