Pacing or ablation for vasovagal syncope: one size does not fit all.

Abstract

Practical decision pathway for the management of vasovagal syncope. Please see text for details. White circles demonstrate sites of grouping of autonomic ganglia defined as ganglionated plexi (GP). The superior right atrial GP (RSGP) located on the posterosuperior surface of the right atrium adjacent to the junction of the superior vena cava and the right atrium; the superior left atrial GP (LSGP) is on the posterosuperior surface of the left atrium between the pulmonary veins; the inferior (posterior) right atrial GP (RIGP) located adjacent to the interatrial groove; the inferior left atrial GP (LIGP) is identified on the posterolateral surface of the left atrium; and the Marshall tract GP (MTGP) located adjacent the vein of Marshall. *Response to atropine which accelerates sinus node automaticity and increases the speed of atrioventricular conduction should be evaluated in all cases prior recommending CNA to confirm adequate procedural response. A sinus rate increase of ≥25% or a sinus rate ≥90 bpm in the first 15 min after infusion should be considered as a positive response.7,13 CLS, closed loop stimulation; CNA, cardioneuroablation; HUT, head-up tilt table test; and ILR, implantable loop recorder.