EP News: Case Reports

Abstract

Neurally mediated syncope is a common cause of syncope in pediatric patients and, when recurrent, can significantly affect quality of life. In these patients, exposure to enhanced parasympathetic tone can result in both significant sinus slowing and conduction delay through the atrioventricular (AV) node. Historically, these patients were often treated with a pacemaker. Recently, cardioneuroablation of parasympathetic ganglion and inputs has shown promise as a therapeutic approach in adults, but its role in pediatric patients remains unclear. Kumthekar et al (https://doi.org/10.1016/j.hrcr.2020.09.004) shared a case of a 16-year-old boy with congenital thoracic scoliosis who experienced a 6-second high-grade AV block without a ventricular escape after spinal fusion surgery. The patient continued to experience paroxysmal of AV block with and without symptoms recorded by an implantable loop recorder. When presented with more traditional options, the family wanted to pursue ablation. The team targeted traditional regions of AV nodal parasympathetic ganglia using 3-dimensional mapping without fluoroscopy. A neurostimulator was used at 15 Hz with 15 V at a 0.15 ms pulse width to further map potential ablation targets. After this procedure, the patient did not experience further episodes of presyncope or syncope or paroxysms of high-grade AV block. Of interest, he presented with atrial fibrillation with rapid ventricular rates requiring sotalol therapy for 3 months. This case shows the potential application of cardioneuroablation in a pediatric patient; however, the postprocedure sustained atrial fibrillation occurrence also prompts concern of proarrhythmia related to altering autonomic balance.