Recurrence Of Syncope Research Articles

Isolated very low QRS voltage in at least one frontal lead is associated with vasovagal syncope in children.

To assess whether isolated very low QRS voltage of ≤0.3 mV in the frontal leads might be a marker for diagnosing paediatric vasovagal syncope and the risk of recurrence. We included 118 children with vasovagal syncope, comprising 70 males and 48 females in our retrospective analysis. All patients underwent head-up tilt test and supine 12-lead electrocardiography. Furthermore, the QRS voltage was measured from each one of the 12 leads on basal electrocardiography. Patients were followed up for 6-24 months (average, 16 months). Eighty-six patients (73%) patients displayed isolated very low QRS voltage in frontal leads. Furthermore, the patients were classified into two groups based on the presence or absence of isolated very low QRS voltage. Enhanced syncopic spells over the past 6 months, and the positive rates of head-up tilt test were observed in patients having isolated very low QRS voltage in the frontal leads than those without isolated very low QRS voltage (p < 0.05). The single factor and time-to-event analyses also showed an increased syncope recurrence rate in patients with isolated very low QRS voltage in frontal leads when compared with those without isolated very low QRS voltage (p < 0.01). Isolated very low QRS voltage in frontal leads is correlated with the positive response of the head-up tilt test in children who experience syncope and its recurrence post-treatment. Hence, isolated very low QRS voltage in frontal leads might become a novel diagnostic indicator and a risk factor for syncope recurrence in children with vasovagal syncope.

Endocardial ablation of ganglionated plexus for the treatment of carotid sinus syndrome.

Carotid sinus syndrome (CSS), characterized by exaggerated vagal responses leading to asystolic pauses with carotid sinus massage (CSM), often necessitates pacemaker implantation. This study investigates cardioneuroablation (CNA) as an alternative strategy for CSS. Prospective study of consecutive patients referred for CNA due to CSS. All patients underwent CSM, atropine test and 24-h Holter monitoring before the procedure and at 6 months. The primary objective was the absence of any cardioinhibitory response to CSM following CNA. Secondary objectives included the combined endpoint of syncope and presyncope-free survival, pacemaker-free survival, differences in heart rate variation (HRV), as well as differences in the pre- and postprocedure atropine tests and in the SF-36 quality-of-life questionnaire. A total of 13 consecutive patients (84.6% male, mean age 63.8 ± 12.3 years) were included. CSM revealed a symptomatic asystolic pause in all patients before CNA (7.3 [5.6-10.5] s). After the procedure, all the patients had a negative CSM, and only one patient (7.7%) had a positive CSM at 6 months. After a median follow-up of 11.2 (10.6-16.3) months, syncope or presyncope-free survival was 84.6%, and none required pacemaker implantation. There was an improvement in the energy and health change items in the SF-36 questionnaire. There was a reduction in HR increase in the atropine test at 6 months (pre-CNA: 66% [52-84] vs. post-CNA 26.0% (19.8-29.3]; p = .008) and in HRV parameters. In this proof-of-efficacy study, performed in patients affected by asystolic CSS, CNA was effective in reducing the rate of cardioinhibitory responses, suggesting a potential efficacy in also reducing syncopal recurrences. Controlled trials are warranted to corroborate clinical findings.

Predictors of Clinical Success of Cardioneuroablation in Patients WithSyncope: Results of a Multicenter Study.

Cardioneuroablation (CNA) is a promising treatment for syncope. This study sought to analyze the success and risk of CNA ,and to describe predictive factors of CNA success in patients with syncope. Seventy-seven consecutive patients with syncope treated with CNA in 22 hospitals and at least 6months of follow-up were included. Patients with reflex cardioinhibitory, mixed syncope, functional sinus node dysfunction (SND), or functional atrioventricular block were included. The primary endpoint was the recurrence of syncope after the CNA. Mean age was 49.3 ± 13.4 years and 54.5% were women. Five (6.5%) patients presented complications. Three patients presented SND, 1 required a pacemaker. During a median follow-up of 12months (Q1-Q3: 8-20months), 26 (33.8%) patients had recurrence of syncope. Women had a significantly higher risk of recurrence compared with men (HR: 3.3; 95% CI: 1.2-8.8; P=0.016). Patients >50 years of age had a significantly lower risk of recurrence compared with younger patients (HR: 0.3; 95%CI: 0.1-0.9; P=0.032). The risk of recurrence in mixed syncope was significantly higher than in cardioinhibitory syncope (HR: 4.4; 95%CI: 1.1-17.5; P=0.033). Syncope recurrence was significantly less frequent in patients treated with general anesthesia or deep sedation compared with conscious sedation (HR: 0.2; 95%CI: 0.1-0.6; P=0.002). Finally, the number of radiofrequency applications (≤30 or >30) had a significant association with CNA success (HR: 0.4; 95%CI: 0.2-0.9; P=0.042). These results were adjusted for confounding factors. In this multicenter study, the effectiveness of CNA was less than previously reported. We found a 3.9% risk of SND. Male sex, age >50 years, cardioinhibitory syncope, general anesthesia or deep sedation, and >30 radiofrequency applications could predict success of CNA for syncope.

Continuous Rhythm Monitoring With Implanted Loop Recorders in Children and Adolescents With Brugada Syndrome

BackgroundYoung (<18 years of age) patients with Brugada syndrome (BrS) are often under-represented in BrS studies and their management, especially related to syncopal episodes, remains unclear. ObjectivesThis study sought to describe the arrhythmia prevalence among young patients with BrS undergoing continuous rhythm monitoring by implantable loop recorder (ILR) and to assess the etiology behind syncope of undetermined origin. MethodsA total of 147 patients with BrS with ILR were enrolled in 12 international centers and divided into pediatric (age <12 years; n = 77, 52%) and adolescents (age 13-18 years; n = 70, 48%). ResultsMean age was 11.3 years, 53 patients (36.1%) were female, and 31 (21.1%) had spontaneous type 1 electrocardiograms. Over a median follow-up of 3.6 years (Q1-Q3: 1.6-4.8 years), an arrhythmic event was recorded in 33 patients (22.4%), mainly of nonventricular origin: 15 atrial (10.2%) and 16 bradyarrhythmic events (10.9%). Ventricular arrhythmias occurred in 4 patients, all with spontaneous BrS, and were fever-related in one-half. Among all patients with recurrence of syncope during follow-up, true arrhythmic syncope was documented in 5 (17.8%), and it was due to bradyarrhythmias or atrial arrhythmias in 3 cases (60%). ConclusionsContinuous rhythm monitoring with ILRs in young patients with BrS detects a broad range of arrhythmias. Ventricular arrhythmias occur predominantly in patients with spontaneous type 1 electrocardiograms and during fever. Despite the young age, bradyarrhythmias and atrial arrhythmias are frequent and represent the cause of arrhythmic syncope in 60% of patients. Young patients with BrS with syncope of undetermined origin may benefit from ILR implant.

The triggers of situational syncope do not influence the head-up tilt test response and prognosis.

The study evaluated the positivity rate, haemodynamic responses, and prognosis in terms of syncopal recurrence among patients with situational syncope (SS) stratified according to the underlying situational triggers. We retrospectively evaluated all consecutive patients with SS who underwent nitroglycerine (NTG)-potentiated head-up tilt test (HUTT) at Syncope Unit of the University of Campania 'Luigi Vanvitelli'-Monaldi Hospital from 1 March 2017 to 1 May 2023. All patients were followed for at least one year. The study population was divided according to the underlying triggers (micturition, swallow, defaecation, cough/sneeze, post-exercise). Two hundred thirty-six SS patients (mean age 50 ± 19.3 years; male 63.1%) were enrolled; among them, the situational trigger was micturition in 109 patients (46.2%); swallow in 32 (13.6%) patients; defaecation in 35 (14.8%) patients; post-exercise in 41 (17.4%) patients; and cough/sneeze in 17 (7.2%) patients. There were no significant differences in baseline clinical characteristics and HUTT responses between different situational triggers. The Kaplan-Meier analysis did not show a statistically different rate of syncope recurrence across patients stratified by baseline situational triggers (log-rank P = 0.21). Situational syncope appears to be a homogenous syndrome, and different triggers do not impact the HUTT response or syncope recurrence at 1 year.

Diagnostic and intervention value of implantable cardiac monitor in patients over 60 years of age with unexplained syncope

Objective: To investigate the value of implantable cardiac monitor (ICM) in the diagnosis and treatment of patients over 60 years old with unexplained syncope. Methods: This was a multi-center, prospective cohort study. Between June 2018 and April 2021, patients over the age of 60 with unexplained syncope at Beijing Hospital, Fuwai Hospital, Beijing Anzhen Hospital and Puren Hospital were enrolled. Patients were divided into 2 groups based on their decision to receive ICM implantation (implantation group and conventional follow-up group). The endpoint was the recurrence of syncope and cardiogenic syncope as determined by positive cardiac arrhythmia events recorded at the ICM or diagnosed during routine follow-up. Kaplan-Meier survival analysis was used to compare the differences of cumulative diagnostic rate between the 2 groups. A multivariate Cox regression analysis was performed to determine independent predictors of diagnosis of cardiogenic syncope in patients with unexplained syncope. Results: A total of 198 patients with unexplained syncope, aged (72.9±8.25) years, were followed for 558.0 (296.0,877.0) d, including 98 males (49.5%). There were 100 (50.5%) patients in the implantation group and 98 (49.5%) in the conventional follow-up group. Compared with conventional follow-up group, patients in the implantation group were older, more likely to have comorbidities, had a higher proportion of first degree atrioventricular block indicated by baseline electrocardiogram, and had a lower body mass index (all P<0.05). During the follow-up period, positive cardiac arrhythmia events were recorded in 58 (58.0%) patients in the ICM group. The diagnosis rate (42.0% (42/100) vs. 4.1% (4/98), P<0.001) and the intervention rate (37.0% (37/100) vs. 2.0% (2/98), P<0.001) of cardiogenic syncope in the implantation group were higher than those in the conventional follow-up group (all P<0.001). Kaplan-Meier survival analysis showed that the cumulative diagnostic rate of cardiogenic syncope was significantly higher in the implantation group than in the traditional follow-up group (HR=11.66, 95%CI 6.49-20.98, log-rank P<0.001). Multivariate analysis indicated that ICM implantation, previous atrial fibrillation, diabetes mellitus or first degree atrioventricular block in baseline electrocardiogram were independent predictors for cardiogenic syncope (all P<0.05). Conclusions: ICM implantation improves the diagnosis and intervention rates in patients with unexplained syncope, and increases diagnostic efficiency in patients with unexplained syncope.

Serotonin and vasovagal syncope.

The goal of this manuscript was to review the biological and clinical evidence that serotonin neurotransmission might play an important role in the physiology and treatment of vasovagal syncope. The authors reviewed PubMed and handsearches of secondary sources for papers related to the Bezold-Jarisch reflex and serotonin, the plausible involvement of the Bezold-Jarisch reflex in vasovagal syncope, and three lines of clinical evidence involving serotonin and the syncope. The Bezold-Jarisch reflex was first described following the infusion of veratrum alkaloids into animals in the 19th century. The reflex is triggered by serotonin stimulation chemoreceptors and mechanoreceptors in the the left ventricle. The afferent component of the reflex is carried by unmyelinated type C vagal nerve fibers, which results in parasympathetic efferent stimulation that causes bradycardia. The similarity of the combination of hypotension and bradycardia in the Bezold-Jarisch reflex and in vasovagal syncope led to the suggestion that the reflex was the cause of the syndrome. Three lines of evidence implicate the serotonin 5HT3 receptors in the heart in the reflex. There is genetic and physiologic evidence for the serotonin 5HT1A and 5HT3 receptors and the serotonin reuptake transporter (SERT). Acute blockade of SERT induces vasovagal syncope in humans undergoing head-up tilt table testing, and SERT inhibition reduces hypotension and bradycardia during spinal anaesthesia. Finally, three randomized clinical trials of SERT inhibitors uniformly reported that they significantly reduce the likelihood of vasovagal syncope recurrences. Multiple lines of evidence implicate serotonin neurotransmission in the cause of vasovagal syncope.

Therapeutic options for neurocardiogenic syncope: a meta-analysis of randomised trials with and without blinding

BackgroundNeurocardiogenic syncope is a common condition with significant associated psychological and physical morbidity. The effectiveness of therapeutic options for neurocardiogenic syncope beyond placebo remains uncertain.MethodsThe primary endpoint was the risk...

Cardioneuroablation guided by extracardiac vagal stimulation for cardioinhibitory vasovagal syncope

Abstract Introduction Vasovagal Syncope (VVS) is often linked to abnormal autonomic reflexes, with hypervagotonia identified as a key mechanism, especially in cases with pronounced cardioinhibition. Cardioneuroablation (CNA), which involves radiofrequency ablation of cardiac vagal ganglia, targets parasympathetic hyperactivity, offering a promising treatment for recurrent VVS. This study evaluates the effectiveness and safety of anatomically guided CNA, which may provide an alternative treatment option to pacemaker implantation for younger patients with severe cardioinhibitory VVS. Methods Consecutive patients between January 2019 and October 2023 who underwent CNA at two cardiology centers were enrolled. All patients had a history of recurrent syncope, predominantly cardioinhibitory and unresponsive to conventional treatments. Patients showed no signs of conduction system disease, evidenced by normal rate responses in treadmill stress tests and 24-hour Holter monitoring. Electroanatomic mapping of the left atrium and pulmonary veins was performed. Extracardiac vagal stimulation (ECVS) through the right internal jugular vein, with or without atrial pacing, was utilized to assess baseline responses of the sinus and atrioventricular (AV) nodes. The ablation strategy was tailored based on rhythm disturbances triggered by ECVS, using sequential and anatomically guided ablation of ganglionated parasympathetic plexuses. Radiofrequency ablation, conducted with an irrigated catheter, was guided by the ablation index. Acute success was defined as the absence or significant reduction of cardiac parasympathetic response to ECVS, indicated by the elimination of asystole, severe bradycardia, or AV block. The primary endpoint was syncope recurrence during follow-up. Results The study included 25 patients (16 males; mean age 36 ± 12 years). All had documented cardioinhibition, identified through ECG monitoring (N=12), implantable loop recorders (N=5), or head-up tilt tests (N=8). The average number of syncopal episodes per patient in the year preceding ablation was 2.7, ranging from 1 to 10. Ablation was acutely successful in all cases. Post-ablation, there were no immediate complications related to the procedure, except for one convulsion deemed unrelated. Over a mean follow-up of 17 ± 14 months, 23 patients remained syncope-free. Two patients experienced syncope recurrence; despite undergoing a repeat ablation, they eventually required pacemaker implantation. Conclusion The results of this study suggest that CNA guided by ECVS, may offer a promising treatment for patients with refractory cardioinhibitory VVS. While the procedure showed a high rate of acute success and a notable reduction in syncope recurrence, further research is warranted to fully establish its role as an alternative to pacemaker implantation.

Cardioneuroablation for asystolic reflex syncope with or without the use of extra cardiac vagal stimulation-one year follow-up results

Abstract Background Extra-Cardiac Vagal Stimulation (ECVS) during cardioneuroablation (CNA) has been introduced to confirm total vagal denervation – a clear intra-procedural end-point. However, whether the use of ECVS is associated with better outcome than simple intra-procedural assessment of CNA-induced changes in basic ECG parameters, has not been established. Purpose To compare one-year efficacy of CNA performed with versus without ECVS. Methods This retrospective analysis included 90 patients (age: 37±12 years, 39 males) divided into 2 groups: ECVS(+) (n=41, general anesthesia and total muscle relaxation, settings: 50 Hz, 0.05 ms, 1 V/kg (&amp;lt;70V) for 5 s) and ECVS(-) group (n=49, light sedation). CNA strategy was the same in all patients and was based on presumed anatomical localization of ganglionated plexi, combined with identification of ablation targets at sites with fragmented bipolar atrial electrograms. The end-point in the ECVS (+) group was complete vagal denervation, confirmed by ECVS, whereas in the ECVS (-) group - significant (&amp;gt;30%) acceleration of sinus rate. The primary endpoint was syncope recurrence during one-year follow-up. Results Both groups were comparable concerning clinical and demographic parameters. Primary endpoint occurred in 4 (10%) patients in the ECVS(+) group and in 7 (14%) patients in the ECVS(-) group (p=0.7481) (Figure). No complications were reported. Conclusions These preliminary results suggest that the use of ECVS only slightly improves the one-year CNA efficacy, however, prospective larger studies and longer follow-up are needed to confirm these initial findings.

When the dual-chamber pacing system is the optimal choice for Brugada patients in need of implantable cardiac defibrillator.

Abstract This letter discusses key points from Esposito et al.'s case report on a Brugada Syndrome (BrS) patient treated with S-ICD and later TV-ICD due to recurrent syncope. It highlights the significance of asystole in BrS-related. Additionally, it recommends dual-chamber TV-ICD systems with CLS algorithms for optimal management, citing their efficacy in reducing syncopal recurrences. Finally, it underscores the importance of considering reflex bradyarrhythmias in device selection for BrS patients at increased sudden cardiac death risk.

Cardioneuroablation for Cardioinhibitory Vasovagal Syncope: Rationale, Approaches, and Its Role in Long-Term Management.

Cardioneuroablation (CNA) has emerged as a potential alternative to pacemaker therapy in well-selected cases with vasovagal syncope (VVS). In recent years, the number of CNA procedures performed by electrophysiologists has considerably risen. However, some important questions, including proper patient selection and long-term results, remain unanswered. The present article aims to critically review and interpret latest scientific evidence for clinical indications and how to approach long-term management. CNA is a new approach that has been supported mainly by retrospective or observational data for its use in syncope. Overall, in mixed population studies treated with CNA, 83.3 to 100% have been reported to be free of syncope over follow-up periods of 6 to 52.1 months. For studies including patients who underwent CNA with pure VVS, 73.2 to 100% have been reported to be syncope-free over follow-up periods of 4 to 45.1 months. One large meta-analysis showed 91.9% freedom from syncope after CAN. To date, only one randomized controlled trial with small case number has been performed of CNA compared to non-pharmacological treatment in VVS. In this study of 48 patients with an average of 10 ± 9 spontaneous syncopal episodes prior to study enrollment and 3 ± 2 episodes in the year prior to CNA. After CNA, 92% were free of syncope compared with 46% treated with optimal non-pharmacological treatment to prevent new syncope episodes (P = 0.0004). To date, most studies have included younger patients (< 60 years of age). There are only limited data in patients older than 60, and some studies suggest less of an effect in relatively older patients. Cardioneuroablation can be performed to decrease syncope recurrence in adult patients aged < 60 years, with severe or recurrent cardioinhibitory syncope without prodromal symptoms, after proven failure of conventional therapies. Due to a paucity of data supporting efficacy in older individuals or for vasodepressor components, CNA in adult patients aged > 60 years or in the presence of a dominant vasodepressor should be considered investigational in severely symptomatic patients after proven failure of pharmacological and non-pharmacological therapies.

Mechanism-based therapy of non-cardiac syncope: a practical guide.

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.

Cardioneuroablation for the management of patients with recurrent vasovagal syncope and symptomatic bradyarrhythmias: the CNA-FWRD Registry.

Cardioneuroablation has been emerging as a potential treatment alternative in appropriately selected patients with cardioinhibitory vasovagal syncope (VVS) and functional AV block (AVB). However the majority of available evidence has been derived from retrospective cohort studies performed by experienced operators. The Cardioneuroablation for the Management of Patients with Recurrent Vasovagal Syncope and Symptomatic Bradyarrhythmias (CNA-FWRD) Registry is a multicenter prospective registry with cross-over design evaluating acute and long-term outcomes of VVS and AVB patients treated by conservative therapy and CNA. The study is a prospective observational registry with cross-over design for analysis of outcomes between a control group (i.e., behavioral and medical therapy only) and intervention group (Cardioneuroablation). Primary and secondary outcomes will only be assessed after enrollment in the registry. The follow-up period will be 3years after enrollment. There remains a lack of prospective multicentered data for long-term outcomes comparing conservative therapy to radiofrequency CNA procedures particularly for key outcomes including recurrence of syncope, AV block, durable impact of disruption of the autonomic nervous system, and long-term complications after CNA. The CNA-FWRD registry has the potential to help fill this information gap.

Asystole on loop recorder in patients with unexplained syncope and negative tilt testing: age distribution and clinical predictors

BackgroundApproximately 50% of patients with unexplained syncope and negative head-up tilt test (HUTT) who have an electrocardiogram (ECG) documentation of spontaneous syncope during implantable loop recorder (ILR) show an asystolic pause at the time of the event.ObjectiveThe aim of the study was to evaluate the age distribution and clinical predictors of asystolic syncope detected by ILR in patients with unexplained syncope and negative HUTT.MethodsThis research employed a retrospective, single-center study of consecutive patients. The ILR-documented spontaneous syncope was classified according to the International Study on Syncope of Uncertain Etiology (ISSUE) classification.ResultsAmong 113 patients (54.0 ± 19.6 years; 46% male), 49 had an ECG-documented recurrence of syncope during the observation period and 28 of these later (24.8%, corresponding to 57.1% of the patients with a diagnostic event) had a diagnosis of asystolic syncope at ILR: type 1A was present in 24 (85.7%), type 1B in 1 (3.6%), and type 1C in 3 (10.7%) patients. The age distribution of asystolic syncope was bimodal, with a peak at age < 19 years and a second peak at the age of 60–79 years. At Cox multivariable analysis, syncope without prodromes (OR 3.7; p = 0.0008) and use of beta blockers (OR 3.2; p = 0.002) were independently associated to ILR-detected asystole.ConclusionsIn patients with unexplained syncope and negative HUTT, the age distribution of asystolic syncope detected by ILR is bimodal, suggesting a different mechanism responsible for asystole in both younger and older patients. The absence of prodromes and the use of beta blockers are independent predictors of ILR-detected asystole.

Bradycardia risk stratification with implantable loop recorder after unexplained syncope

BackgroundAn implantable loop recorder is an effective tool for diagnosing unexplained syncope. However, after a first episode in non-high-risk patients, the usefulness of implantable loop recorder implantation remains unclear. AimsTo analyse relevant risk factors for significant bradycardia in order to identify patients who do or do not benefit from implantable loop recorder implantation. Also, to study whether implantable loop recorder implantation with remote monitoring is associated with less recurrence of traumatic syncope. MethodsThis was a retrospective monocentric study including patients with implantable loop recorder implantation after unexplained syncope, using remote monitoring and iterative consultations. ResultsTwo hundred and thirty-seven patients were implanted for unexplained syncope. Significant bradycardia occurred in 53 patients (22.4%): 23 (43.4%) caused by paroxysmal atrioventricular block and 30 (56.6%) caused by sinus node dysfunction, leading to permanent pacemaker implantation in 48 patients. Compared with younger patients, there was a 3.46-fold increase (95% confidence interval 1.92–6.23; P<0.0001) in the risk of significant bradycardia in patients aged≥60 years. Based on multivariable analysis, only “typical syncope” was associated with significant bradycardia occurrence (hazard ratio 3.14, 95% confidence interval 1.75–5.65; P=0.0001). There was no recurrence of significant bradycardia with traumatic complications among patients implanted for traumatic syncope. ConclusionsThis study shows that: (1) implantable loop recorders identify more significant bradycardia in patients aged≥60 presenting with a first non-high-risk typical syncope, suggesting that an implantable loop recorder should be implanted after a first episode of unexplained syncope in such conditions; and (2) after traumatic syncope, implantable loop recorder implantation is safe, and is associated with little or no recurrence of traumatic syncope.

Long-term outcomes of cardioneuroablation with and without extra-cardiac vagal stimulation confirmation in severe cardioinhibitory neurocardiogenic syncope.

Cardioneuroablation (CNA) is a novel therapeutic approach for functional bradyarrhythmias, specifically neurocardiogenic syncope or atrial fibrillation, achieved through endocardial radiofrequency catheter ablation of vagal innervation, obviating the need for pacemaker implantation. Originating in the nineties, the first series of CNA procedures was published in 2005. Extra-cardiac vagal stimulation (ECVS) is employed as a direct method for stepwise denervation control during CNA. This study aimed to compare the long-term follow-up outcomes of patients with severe cardioinhibitory syncope undergoing CNA with and without denervation confirmation via ECVS. A cohort of 48 patients, predominantly female (56.3%), suffering from recurrent syncope (5.1 ± 2.5 episodes annually) that remained unresponsive to clinical and pharmacological interventions, underwent CNA, divided into two groups: ECVS and NoECVS, consisting of 34 and 14 cases, respectively. ECVS procedures were conducted with and without atrial pacing. Demographic characteristics, left atrial size, and ejection fraction displayed no statistically significant differences between the groups. Follow-up duration was comparable, with 29.1 ± 15 months for the ECVS group and 31.9 ± 20 months for the NoECVS group (p = .24). Notably, syncope recurrence was significantly lower in the ECVS group (two cases vs. four cases, Log Rank p = .04). Moreover, the Hazard ratio revealed a fivefold higher risk of syncope recurrence in the NoECVS group. This study demonstrates that concluding CNA with denervation confirmation via ECVS yields a higher success rate and a substantially reduced risk of syncope recurrence compared to procedures without ECVS confirmation.

The Rate of Asystolic Reflex Syncope Is Not Influenced by Age

BackgroundThe head-up tilt test (HUT) and other evidence suggest that the vagal effect on the heart decreases with age. ObjectivesThe main aim of the study was to assess whether this age effect also affects the rate of asystole in spontaneous reflex syncope (RS). MethodWe 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. ResultsA 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). ConclusionsThe 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.

Cardioneuroablation for recurrent vasovagal syncope and functional sinus bradycardia: a case series

Patients with recurrent vasovagal syncope with cardioinhibitory or mixed mechanism, or with symptomatic functional sinus bradycardia or AV block can be treated with cardioneuroablation. Material and methods: A case series of 5 patients is presented &amp;ndash; four with recurrent syncope and/or symptomatic sinus bradycardia, and one with paroxysmal atrial &amp;#64257; brillation and recurrent syncope. After a con&amp;#64257; rmation of the syncope mechanism with tilt table test, and after positive atropine test, radiofrequency catheter cardioneuroablation was performed (this was adjunctive procedure for the patient with atrial &amp;#64257; brillation who received pulmonary vein isolation). During short-term follow-up none of the patients had syncopal recurrence. Conclusion: Catheter neuromodulation provided very good short-term results and lack of serious complications in this &amp;#64257; rst case series in Bulgaria.

Theophylline in the prevention of vasovagal syncope recurrences.

The present work aimed to study the efficacy and patient compliance of oral theophylline treatment in the prevention of vasovagal syncope recurrences. High blood adenosine may trigger vasovagal syncope. Theophylline is an adenosine receptor antagonist. In 44 patients with vasovagal syncope (8 men and 34 women, age 46.4±3.2 years) with an average 4.8±0.74 syncopal episodes (range 1-20, median 4,5 episodes) oral theophylline therapy was started with dose 2x100/200 mg, which was further increased if necessary. All patients were treated by non-pharmacological measures which were not effective. Patients were followed in regular intervals on an outpatient basis in 6-month intervals. After the start of treatment patients were followed for the mean of 17.1±2.1 months (2-51 months, median 12 months). The total number of syncopal episodes decreased from 4.8±0.74 to 1.73±0.45 (p=0.0006). The occurrence of syncopal episodes per year decreased from 4.07±0.80/year to 1.50±0.54 /year during the treatment period (p=0.001). After agradual increase in theophylline dosage, in 34 patients no syncopal recurrences were observed. In 10 persons syncopal recurrences persisted despite treatment. Side effects leading to discontinuation of treatment were present in 14 patients - gastrointestinal intolerance (7 patients), palpitations (6 patients) and headache (3 patients). The addition of oral theophylline preparation to non-pharmacological treatment led to amarked reduction of syncopal recurrence in patients with vasovagal syncope. About one-third of study subjects discontinued therapy because of side effects (Tab. 2, Fig. 4, Ref. 22). Text in PDF www.elis.sk Keywords: heophylline, adenosine, vasovagal syncope, treatment.