Recurrent Vasovagal Syncope Research Articles

PO-03-073 CARDIONEUROABLATION FOR THE MANAGEMENT OF PATIENTS WITH RECURRENT VASOVAGAL SYNCOPE AND SYMPTOMATIC BRADYARRHYTHMIAS: THE CNA-FWRD CROSS-OVER TRIAL AND PROSPECTIVE REGISTRY

Cardioneuroablation (CNA) has been introduced as a potential alternative treatment strategy in appropriately selected patients for prevention of recurrent cardioinhibitory vasovagal syncope (VVS) and functional atrioventricular block (AVB). The Cardioneuroablation for the Management of Patients with Recurrent Vasovagal Syncope and Symptomatic Bradyarrhythmias (CNA-FWRD) Registry is a multicenter prospective registry and Cross-Over Trial with the objective of examining acute and long-term outcomes of CNA in appropriately selected patients with recurrent VVS and AVB. The main study will be a prospective cross-over design with patients randomized to two groups receiving 6-month treatment interventions in alternate order: Medical therapy followed by CNA (Group 1) or CNA followed by Medical therapy (group 2). Patients declining the cross-over study will be eligible for inclusion in a parallel prospective registry. Details of inclusion and exclusion criteria are provided in Table 1. Functional AVB is defined as sudden change from physiologic atrioventricular conduction to transient second- or third-degree AVB resulting in symptomatic pauses longer than 2 seconds. All fragmented EGMs that demonstrated 3 or more deflectionsin the regions that are known to be consistent with probable localization of ganlionated plexus (GP) will be identified and tagged (Figure 1). In each VVS patient, the GPs will be targeted in the following order: the superior left atrial GP, the Marshall tract GP (MTGP), the inferior left atrial GP, the superior right atrial GP (RSGP), and finally the inferior right atrial GP. Additional right atrial ablation on the superior aspect on the interatrial septum will be performed for RSGP. In patients with AVB, the posteromedial left atrial GP, MTGP and RSGP will be ablated, respectively. The primary outcome is 12-month syncope recurrence post catheter ablation. Secondary outcomes include procedure-related complications, freedom from syncope at 12 months, freedom from AVB at 12 months, need for repeat GP ablation, quality of life at 12 months. Study enrollment began for (8) sites on June 20, 2022. So far, 59 patients have been enrolled into the registry. There remains lack of procedural standardization CNA as a treatment strategy and limited long-term data for key outcomes including recurrence of syncope, durable impact of disruption of the autonomic nervous system and long-term complications. CNA-FWRD has the potential to help fill this information gap.Tabled 1Inclusion and Exclusion Criteria for Study Cohort (PO-03-073)DiagnosisInclusion criteriaExclusion criteriaVVSAt least 3 vasovagal syncope episodes in the preceding 12 monthsPresence of arrhythmic conditions that can cause syncopeAge < 60 yearsPresence of evidence related to structural heart disease> 3s asystole on head-up tilt testingPrevious history of catheter ablation> 3s asystole on ambulatory ECG monitoringPresence of inheritable arrhythmic conditionsPositive response to atropine testOrthostatic hypotension on Head-up tilt table testUnresponsiveness to conventional treatment modalitiesPseudo-syncopePresence of proven indication for Pacemaker implantationAbnormal thyroid function levelsUsage of negative chronotropic drugsChronotropic incompetence at exercise stress testAVBAll AVB casesHistorySymptomatic bradycardiaUse of negative chronotropic or dromotropic drugsLaboratoryassessmentNormal thyroid function testsThyroid function abnormalitySuspicionof obstructive sleep apneaNegative polysomnogramPositive polysomnogramBaselineECGLeft bundle brunch blockExerciseStress TestChronotropic incompetenceOccurrence or worsening of AVB with exerciseEPSSupra-Hisian AVBIntra/infra-Hisian AVBParoxysmal AVBBaselineECGNormal PR interval or first degree AVBSecond or third degree AVBHolter RecordingPR prolongation before second or third degree AVB episodeConstant PR before second or third degree AVB episodeDecrease in sinus rate during or just prior to second or third degree AVB episodeIncrease in sinus rate during second or third degree AVB episodeResolution of AVB with an increase in sinus rateResolution of AVB with a constant sinus rateEPSBaseline H-V interval <55msecBaseline H-V interval ≥55 msecIntra/infra-Hisian AVB by atrial pacing at rates of 150 bpm or lessPersistent AVBBaselineECGSecond or third degree AVBAtropine responseComplete resolution of atrioventricular conduction or conversion to first degree AVB with atropine infusionAVB unresponsive to atropine testExercise stress testComplete resolution of AVB or conversion to first degree AVB with exercise testAVB unresponsive to exercise stress testEPSBaseline H-V interval <55msecBaseline H-V interval ≥55 msecIntra/infra-Hisian AVB by atrial pacing at rates of 150 bpm or less Open table in a new tab

The Seventh Prevention of Syncope Trial (POST VII)—A randomized clinical trial of atomoxetine for the prevention of vasovagal syncope: Rationale and study design

Vasovagal syncope (VVS) is common, recurs, and is associated with markedly reduced quality of life, anxiety, and frequent injuries. The few pharmacological therapies for VVS proven to have a moderate benefit in reducing recurrences are limited to patients without coexisting conditions such as hypertension or heart failure. Although there is some data to suggest Atomoxetine, a norepinephrine reuptake transport inhibitor (NET), may be a promising treatment option, an adequately powered randomized placebo-controlled trial is needed. POST VII is a multicenter, randomized, double-blind, placebo-controlled, crossover study that will randomize 180 patients with VVS and at least 2 syncopal spells in the preceding year to a target daily dose of atomoxetine 80 mg daily or to a matching placebo, with an observation period of 6 months in each phase and with a 1-week washout period between phases. The primary end point will be the proportion of patients with at least one syncope recurrence in each arm analyzed with an intention-to-treat approach. The secondary end points include total syncope burden, quality of life, cost, and cost-effectiveness. Assuming a 33% relative risk reduction in syncope recurrence with atomoxetine, and a dropout rate of 16%, the enrollment of 180 patients will give an 85% power of reaching a positive conclusion about atomoxetine, with P=.05. This will be the first adequately powered trial to determine whether atomoxetine is effective in preventing VVS. If proven effective, atomoxetine might become the first-line pharmacological treatment for recurrent VVS.

Impact of the COVID-19 pandemic on clinical autonomic practice in Europe A survey of the European Academy of Neurology (EAN) and the European Federation of Autonomic Societies (EFAS).

To investigate the impact of the coronavirus-disease-2019 (COVID-19) pandemic on European clinical autonomic practice. Eighty-four neurology-driven or interdisciplinary autonomic centers in 22 European countries were invited to fill in a web-based survey between September and November 2021. Forty-six centers completed the survey (55%). During the first pandemic year, the number of performed tilt-table tests, autonomic outpatient and inpatient visits decreased respectively by 50%, 45% and 53%, and every-third center reported major adverse events due to postponed examinations or visits. The most frequent newly-diagnosed or worsened cardiovascular autonomic disorders after COVID-19 infection included postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension, and recurrent vasovagal syncope, deemed likely related to the infection by ≥50% of the responders. Forty-seven percent of the responders also reported about people with new-onset of orthostatic intolerance, but negative tilt-table findings, and 16% about people with psychogenic pseudosyncope after COVID-19. Most patients were treated non-pharmacologically and symptomatic recovery at follow-up was observed in ≥45% of cases. By contrast, low frequencies of newly-diagnosed cardiovascular autonomic disorders following COVID-19 vaccination were reported, most frequently POTS and recurrent vasovagal syncope, and most of the responders judged a causal association unlikely. Non-pharmacological measures were the preferred treatment choice, with 50-100% recovery rates at follow-up. Cardiovascular autonomic disorders may develop or worsen following a COVID-19 infection, while the association with COVID-19 vaccines remains controversial. Despite the severe pandemic impact on European clinical autonomic practice, a specialized diagnostic work-up was pivotal to identify non-autonomic disorders in people with post-COVID-19 orthostatic complaints.

Selective Modulation of the Cardiac Autonomic Nervous System: A New Therapeutic Strategy for Cardioinhibitory Vasovagal Syncope

Vasovagal syncope (VVS) is the most common type of syncope. The overall prognosis of VVS is usually benign, although the quality of life can be affected when syncope is recurrent and refractory to conventional therapy. Multiple treatment options exist for patients with recurrent VVS, although the effect is modest. In this focused review, we briefly discussed the plausible pathophysiological mechanisms of VVS. We used three case examples to update the current state of cardioneuroablation (CNA) in patients with recurrent cardioinhibitory response as a potential therapeutic option. This article includes review of studies and reports on CNA summarizing the principles of this therapeutic approach; various ways of mapping to localize the parasympathetic ganglionic plexi for ablation; description of technique of extra-cardiac vagal stimulation to confirm parasympathetic denervation of the heart as well as the end points and outcomes of the reported studies. Moreover, we reviewed the pros, cons, gaps, and future directions of this potential therapeutic option in treating patients with VVS.

Clinical Associations of Injuries Caused by Vasovagal Syncope: A Cohort Study From a Tertiary Syncope Unit.

Background Recent research has revealed that vasovagal syncope (VVS) leads to a high incidence of injuries; however, clinical associations of injury are not well-established. We present data from an ongoing VVS cohort and aimed to determine characteristics associated with VVS-related injury. Methods and Results Between 2017 and 2020, consecutive patients ≥18 years of age presenting to a tertiary syncope unit and diagnosed with VVS were included. Clinical characteristics relevant to syncope were obtained for the index episode. The outcome was incidence of injury during VVS, documented by clinical evaluation at the syncope clinic. Among 1115 patients (mean age, 45.9 years; 48% women), 260 injuries (23%) occurred. History of VVS-related injuries (adjusted relative risk [aRR], 1.80 [95% CI, 1.42-2.29]), standing position (aRR, 1.34 [95% CI, 1.06-1.68]), and female sex (aRR, 1.30 [95% CI, 1.06-1.60]) were associated with injury, whereas recurrent VVS (aRR, 0.63 [95% CI, 0.49-0.81]) and syncope in the noon/afternoon (aRR, 0.70 [95% CI, 0.56-0.87]) and evening/night (aRR, 0.43 [95% CI, 0.33-0.57]) compared with morning hours were associated with lower risk. There was a trend for higher rates of injury with overweight/obesity (aRR, 1.23 [95% CI, 0.99-1.54]) and syncope occurring at home (aRR, 1.22 [95% CI, 0.98-1.51]). In a per-syncope analysis considering up to 3 previous episodes (n=2518, 36% traumatic), syncope at home (aRR, 1.33 [95% CI, 1.17-1.51]) and absence of prodromes (aRR, 1.34 [95% CI, 1.09-1.61]) were associated with injury. Conclusions Patient characteristics, VVS presentations, the circumstances, and surroundings can determine the risk of injury. These associations of VVS-related injury identify at-risk individuals and high-risk situations. Future prospective studies are needed to investigate potential strategies for prevention of post-VVS injury in recurrent cases.

Permanent pacing versus cardioneuroablation for cardioinhibitory vasovagal syncope.

We compared the efficacy and safety of cardioneuroablation (CNA) vs. permanent pacing (PM) for recurrent cardioinhibitory vasovagal syncope (CI-VVS). One hundred sixty-two patients (CNA = 61, PM = 101), age 36 + 11years) with syncope frequency of 6.7 ± 3.9/year were included in this multicenter study. All patients with CNA were provided by a single center, while patients with PM were provided by 4 other centers. In the CNA arm, an electroanatomic mapping guided approach was used to detect and ablate ganglionated plexus sites. Dual chamber rate drop response (RDR) or close loop stimulation (CLS) transvenous and leadless pacemakers were implanted using standard technique. The primary endpoint was freedom from syncope. Of 101 patients in the PM group, 39 received dual-chamber pacemaker implants with the CLS algorithm, 38 received dual-chamber pacemakers with the RDR algorithm, and 24 received a leadless pacemaker. At 1-year follow-up, 97% and 89% in the CNA and PM group met the primary endpoint (adjusted HR = 0.27, 95% CI 0.06-1.24, p = 0.09). No significant differences in adverse events were noted between groups. There was no significant association between age (HR:1.01, 95% CI 0.96-1.06, p = 0.655), sex (HR:1.15, 95% CI 0.38-3.51, p = 0.809), and syncope frequency in the past year (HR:1.10, 95% CI 0.97-1.25, p = 0.122) and the primary outcome in univariable analyses. After adjustment for patient characteristics, the medium-term syncope recurrence risk of CI-VVS patients who underwent CNA was similar to that of a population of patients undergoing pacemaker implantation with a similar safety profile.

Cardioneuroablation for the effective treatment of recurrent vasovagal syncope to restore driving abilities.

Cardioneuroablation for the effective treatment of recurrent vasovagal syncope to restore driving abilities.

The effects of ALDH2 Glu487Lys polymorphism on vasovagal syncope patients undergoing head-up tilt test supplemented with sublingual nitroglycerin

Background and objectiveHead-up tilt test (HUTT) is clinically advantageous for diagnosing patients with vasovagal syncope (VVS). Nitroglycerin is mainly used as a stimulant during HUTT, and mitochondrial aldehyde dehydrogenase 2 (ALDH2) is involved in the metabolism of nitroglycerin (NTG). ALDH2 Glu487Lys polymorphism (ALDH2 rs671) is the most common variant in the East Asian population. This study aimed to assess the effects of ALDH2 rs671 on VVS patients undergoing HUTT supplemented with sublingual NTG (HUTT-NTG). MethodsPatients with recurrent VVS (at least 2 times) who were admitted to the syncope center of our hospital were enrolled. All VVS patients have undergone HUTT. The polymorphism of Glu487Lys gene of ALDH2 was measured by the DNA Microarray Chip Method. The results of HUTT-NTG of VVS patients with different ALDH2 genotypes were compared and their hemodynamic characteristics were assessed.ResultsA total of 199 VVS patients were enrolled, including 101 patients in the ALDH2*1/*1 group and 98 patients in the ALDH2*2 group. Among patients undergoing HUTT-NTG, 70.3% of patients in the ALDH2*1/*1 group and 68.4% of patients in the ALDH2*2 group were positive, and the difference between the two groups was not statistically significant (P = 0.77). The proportions of VASIS I, VASIS II, and VASIS III were 40.6%, 8.9%, and 20.8% in the ALDH2*1/*1 group, respectively, and the corresponding proportions in the ALDH2*2 group were 36.7%, 11.2%, and 20.4%, respectively. There was no statistically significant difference between the two groups (P = 0.91). The hemodynamic characteristics of different genotypes in VVS patients undergoing HUTT-NTG were compared, and no statistically significant difference was found. The median time of syncopal episode occurred after NTG administration in the ALDH2*1/*1 group was 6 min (interquartile range [IQR]: 5.0–9.0), and it was 6.0 min in the ALDH2*2 group (IQR: 4.25–8.0, P = 0.64).ConclusionALDH2 Glu487Lys polymorphism did not affect the outcome of VVS patients undergoing HUTT-NTG, and no significant change in the hemodynamic characteristics of different genotypes was found.

ATOMOXETINE FOR SUPPRESSION OF VASOVAGAL SYNCOPE: A CLINICAL CASE SERIES

ATOMOXETINE FOR SUPPRESSION OF VASOVAGAL SYNCOPE: A CLINICAL CASE SERIES

Clinical Efficacy of Catheter Ablation in the Treatment of Vasovagal Syncope.

Catheter ablation of ganglionated plexi (GPs) performed as cardioneuroablation in the left atrium (LA) has been reported previously as a treatment for vasovagal syncope (VVS). However, the efficacy and safety of catheter ablation in the treatment of VVS remains unclear. The objective of this study is to explore the efficacy and safety of catheter ablation in the treatment of VVS and to compare the different ganglion-mapping methods for prognostic effects. A total of 108 patients with refractory VVS who underwent catheter ablation were retrospectively enrolled. Patients preferred to use high-frequency stimulation (HFS) (n = 66), and anatomic landmark (n = 42) targeting is used when HFS failed to induce a positive reaction. The efficacy of the treatment is evaluated by comparing the location and probability of the intraoperative vagal reflex, the remission rate of postoperative syncope symptoms, and the rate of negative head-up tilt (HUT) results. Adverse events are analyzed, and safety is evaluated. After follow-up for 8 (5, 15) months, both HFS mapping and anatomical ablation can effectively improve the syncope symptoms in VVS patients, and 83.7% of patients no longer experienced syncope (<0.001). Both approaches to catheter ablation in the treatment of VVS effectively inhibit the recurrence of VVS; they are safe and effective. Therefore, catheter ablation can be used as a treatment option for patients with symptomatic VVS.

Pacing for vasovagal syncope: Tips for use in practice.

Vasovagal syncope (VVS) continues to be the most frequent cause of syncope in all age groups. Recent randomized double-blinded trials (RCTs) provide further support for pacing in selected cases of patients with recurrent refractory VVS with significant cardio-inhibitory response either documented spontaneously or induced during head-up tilt testing (HUTT). Cardiac pacing is the only therapy of proven efficacy for the predominant cardio-inhibitory phenotype of vasovagal (reflex) syncope; however, several questions regarding the best candidates remain. The current review focuses on practical tips for use of cardiac pacing in practice.

SGLT2-inhibitors reduce the cardiac autonomic neuropathy dysfunction and vaso-vagal syncope recurrence in patients with type 2 diabetes mellitus: the SCAN study

BackgroundIn patients with type 2 diabetes mellitus (T2DM) the vaso-vagal syncope (VVS) recurrence could be due to the alteration of autonomic system function, evaluated by heart rate variability (HRV), and by 123I-metaiodobenzylguanidine (123I-mIBG) myocardial scintigraphy indexes: Heart to Mediastinum ratio (H/Mlate), and Washout rate (WR). The SGLT2-I could modulate/reduce autonomic dysfunction in T2DM patients with VVS. This effect could reduce the VVS recurrence in T2DM patients. MethodsIn a prospective multicenter study, after propensity score matching, we studied a population of 324 T2DM patients with VVS, divided into 161 SGLT2-I-users vs. 163 Non-SGLT2-I users. In these patients as SGLT2-I-users vs. Non-SGLT2-I users, we investigated the HRV and 123I-MIBG modifications and VVS recurrence at 12 months of follow-up. ResultsAt follow-up end, the SGLT2-I-users vs. Non-SGLT2-I users had best glucose homeostasis and lower values of inflammatory markers, and resting heart rate (p < 0.05). The SGLT2-I-users vs. Non-SGLT2-I users evidenced the lowest low frequency/high frequency ratio (LF/HFr), a significant difference for all the indexes of autonomic dysfunction via ECG Holter analysis, and higher values of H/Mlate (p < 0.05). Finally, comparing SGLT2-I-users vs. Non-SGLT2-I users, we found a higher rate of VVS recurrence events, specifically of the vasodepressor VVS recurrence at 1-year follow-up (p < 0.05). We did not find a significant difference of mixed and cardio-inhibitory VVS recurrence events at 1 year of follow-up in the study cohorts (p > 0.05). At the Cox regression analysis H/Mlate (0.710, [0.481–0.985]), and SGLT2-I therapy (0.550, [0.324–0.934]) predicted all causes of syncope recurrence at 1 year of follow-up. ConclusionsNon-SGLT2-I users vs. SGLT2-I-users had alterations of the autonomic nervous system, with a higher rate of VVS recurrence at 1 year of follow-up. The indexes of cardiac denervation predicted the VVS recurrence, while the SGLT2-I reduced the risk of VVS recurrence.Clinical trial registration number: NCT03717207.

Implementation of supervised physical training to reduce vasovagal syncope recurrence: A randomized controlled trial.

Physical techniques used for the prevention of vasovagal syncope have limited evidence for efficacy. We aimed to evaluate multimodal supervised physical training as a treatment approach. In this 1:1 randomized trial, patients with ≥2 episodes of clinically diagnosed vasovagal syncope were included. On top of standard care, the intervention arm performed supervised tilt training and aerobic exercise in six sessions at a cardiac rehabilitation center (three sessions during the first month, and then at 3-month intervals), plus home tilt training. The control arm received standard care with a similar protocol of home tilt training. The primary outcome was time to first syncopal recurrence during 1year of follow-up. Fifty participants were randomized (mean age: 34.5 ± 14.8 years; 64% female). The rate of syncopal recurrence was 28% and 64% within the intervention and control arms, respectively, with significantly higher syncope-free survival at 1year in the intervention arm (Log-rank p = .003). The frequency of recurrent syncopal events was significantly lower with physical training (p = .017). Participants in the intervention arm reported significantly higher adherence to the home tilt training program (80% vs. 52%; p = .037). Among patients with recurrent vasovagal syncope, a supervised program of tilt training and aerobic exercise reduced syncopal recurrence. Future trials are warranted to further investigate multimodal supervised physical techniques as a therapeutic approach in treating vasovagal syncope.

PO-641-02 THE EFFECT OF YOGA THERAPY ON PATIENTS WITH RECURRENT VASOVAGAL SYNCOPE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Yoga therapy may reduce the symptomatic burden and improve the quality of life in patients with recurrent vasovagal syncope (VVS). Treatment of VVS is challenging as current medical therapy is limited. The recently published LIVE-Yoga study showed that yoga as adjunctive therapy is superior to standard therapy alone. However, the data on yoga therapy for VVS treatment is less clear.

Effect of psychotherapy on recurrence of events and quality of life in patients with vasovagal syncope

Emotional distress is related to recurrence of syncope compromising patient's quality of life (QoL). The aim of this study was to determine if weekly sessions of psychotherapy reduce recurrence of events and improve QoL by SF-36 among patients with refractory vasovagal syncope. A randomised controlled pilot trial including 10 patients with recurrent vasovagal syncope and positive tilt table test was conducted. Known cardiac disease and ongoing psychotherapeutic interventions were the main exclusion criteria. All patients received standard of care treatment. Additionally, after randomisation, half of the patients underwent weekly sessions of psychotherapy for 12 months. Analysis of recurrence of events and QoL showed no significant change in the control group but, in the intervention group, there was a significant reduction in the rate of near-syncope episodes per month (5.7 ± 1.4 × 1.7 ± 1.0; P < 0.01), syncope in 1 year (4.6 ± 0.9 × 1.0 ± 0.7; P < 0.01) and a significant improvement in the overall assessment of QoL (44.1 ± 10.0 vs. 70.3 ± 10.3, P < 0.01). In conclusion, patients with refractory vasovagal syncope undergoing regular psychotherapeutic intervention had less recurrence of events and improved their quality of life in 1 year.Trial Registration: ClinicalTrials.gov number, NCT04252729.

Oral and intravenous hydration in the treatment of orthostatic hypotension and postural tachycardia syndrome.

Hydration with water and salt is the mainstay of treatment for autonomic nervous system disorders that impair orthostatic tolerance. The goal is to expand intravascular volume to compensate for the downward displacement of blood volume that occurs when standing and thereby sustain cerebral perfusion and restore quality of life. Despite strong consensus recommendations for salt supplementation as standard treatment of these disorders, published evidence of benefit is relatively weak, and no randomized clinical trials have occurred. This review summarizes the physiological rationale for hydration and evaluates the literature on oral and intravenous hydration in the treatment of neurogenic orthostatic hypotension, postural tachycardia syndrome, and recurrent vasovagal syncope. We conclude that oral salt replacement is indicated for treatment of neurogenic orthostatic hypotension because these patients have excessive renal sodium excretion, and for treatment of chronic orthostatic intolerance because these patients are often hypovolemic. As not all patients are able to tolerate sufficient oral hydration, there is also a role for intravenous volume-loading in severe cases of postural tachycardia syndrome. We offer guidance, based on review of the literature and the clinical judgment of a cardiologist and neurologist with experience treating autonomic disorders, regarding the option of ongoing intravenous hydration for treatment of severe, refractory cases of postural tachycardia syndrome.

Effect of Yoga on Clinical Outcomes and Quality of Life in Patients With Vasovagal Syncope (LIVE-Yoga).

This study aims to determine the impact of yoga as an adjunct to standard therapy versus standard therapy alone on the symptomatic burden in patients with recurrent vasovagal syncope (VVS). There is a significant reduction in the quality of life (QoL) of patients with recurrent VVS. Existing management therapies have been largely ineffective. Recent trials have demonstrated the efficacy of yoga in diseases with autonomic imbalance, suggesting its possible utility in VVS. Patients with recurrent VVS were randomized to receive either a specialized yoga training program in addition to current guideline-based therapy (intervention arm, group 1) or current guideline-based therapy alone (control arm, group 2). The primary outcome was a composite of the number of episodes of syncope and presyncope at 12months. Secondary outcomes included QoL assessment by World Health Organization Quality of Life Brief Field questionnaire (WHOQoL-BREF) scores and Syncope Functional Status Questionnaire scores at 12months, head up tilt test, and heart rate variability at 6weeks. A total of 55 patients underwent randomization. The mean number of syncopal or presyncopal events at 12months was 0.7 ± 0.7 in the intervention arm compared to 2.52 ± 1.93 in the control arm (P < 0.01). In the intervention arm, 13 (43.3%) patients remained free of events versus 4 (16.0%) patients in the control arm (P = 0.02). QoL at 12months showed significant improvement of all Syncope Functional Status Questionnaire scores and 2 domains of WHOQoL-BREF scores (P < 0.05). Yoga as adjunctive therapy is superior to standard therapy alone in reducing the symptomatic burden and improving QoL in patients with recurrent VVS.

Analysis of Type a Personality in Patients with Recurrent Vasovagal Syncope

Analysis of Type a Personality in Patients with Recurrent Vasovagal Syncope

Cardioneuroablation for recurrent vasovagal syncope: Important questions need to be answered

Vasovagal reflex syncope (VVS) is the most common cause of transient loss of consciousness in any setting and at all ages. Although the reflex is benign and occurs in otherwise healthy persons, the morbidity and injuries resulting from VVS can be major. In patients with frequent and burdensome cardioinhibitory VVS, cardiac pacemakers have been implanted. Cardiac pacing does seem to be beneficial for some patients, but patient selection and types of pacemakers are debated.1,2 More recently, cardioneuroablation (CNA) procedures have emerged as a novel therapy for VVS, and positive results in small open-label cohort studies have been reported.

Clinician needs and perceptions about cardioneuroablation for recurrent vasovagal syncope: An international clinician survey.

Cardioneuroablation (CNA) targets the intrinsic cardiac autonomic nervous system ganglionated plexi located in the peri-atrial epicardial fat. There is increasing interest in CNA as a treatment of vasovagal syncope (VVS), despite no randomized clinical trial (RCT) data. The purpose of this study was to poll the opinion on CNA) for VVS. A REDCap (Research Electronic Data Capture) survey was administered to international physicians treating patients with VVS on their opinion about patient selection criteria, ablation approach, RCT design, and most appropriate end points for CNA procedures. The survey was completed by 118 physicians; 86% were cardiac electrophysiologists. The majority of respondents (79%) would consider referring a patient with refractory VVS for CNA, and 27% have performed CNA for VVS themselves. Most felt patient selection should require a head-up tilt test with a cardioinhibitory response (67%) and suggest a minimum age of 18 years with a median of 3 (interquartile range 2-5) episodes in the past year. There were differences in patient selection between physicians who have performed CNA themselves and those who have not. The majority felt that the ablation strategy should include both atria (70%) with an anatomical approach in combination with autonomic stimulation (85%). Performing a sham procedure in the control arm was supported by 56% of respondents, providing equipoise in RCT design. The preferred primary outcome was freedom from syncope within 1 year of follow-up. There is widespread support for well-designed RCTs to confirm the hypothesized clinical benefit of CNA, provide data to guide the risk-benefit equations during patient selection, and appropriately estimate the placebo effect.