Treatment Of Vasovagal Syncope Research Articles

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.

Simulation training for medical emergencies: Evaluation of dentists' long-term learning skills and confidence.

As the population ages and more patients experience medical emergencies during dental treatments, dentists must competently and confidently manage these situations. We developed a simulation training course for medical emergencies in the dental setting using an inexpensive vital sign simulation app for smartphones/tablets without the need for an expensive simulator. However, the duration for which this effect is maintained is unclear. This study was performed to evaluate the long-term educational effect at 3, 6, and 12 months after taking the course. Thirty-nine dental residents participated in this course. Scenarios included vasovagal syncope, anaphylaxis, hyperventilation syndrome, and acute coronary syndrome, each of which the participants had to diagnose and treat. The participants were evaluated using a checklist for anaphylaxis diagnosis and treatment skills immediately after and 3, 6, and 12 months after the course. The participants were also surveyed about their confidence in diagnosing and treating these conditions by questionnaire before, immediately after, and 3, 6, and 12 months after the course. The checklist scores for anaphylaxis were significantly lower at 3, 6, and 12 months after the course than immediately after the course. The percentage of participants who provided a correct diagnosis and appropriate treatment for vasovagal syncope, hyperventilation syndrome, and acute coronary syndrome was lower at all reassessments than immediately after the course. Because medical emergency management skills and confidence declined within 3 months, it would be useful to introduce a refresher course approximately 3 months after the initial course to maintain skills and confidence.

Advances in Treating Vasovagal Neurocardiogenic Syndrome: A Comprehensive Review of Medical Interventions

Neurocardiogenic vasovagal syndrome (VVS) is a common clinical condition that results in a transient loss of consciousness and inability to maintain posture, with a rapid and spontaneous recovery. Considering the technological advances regarding the effectiveness of different treatments for VVS, this article aims to review the treatment options available in the medical literature to better understand the treatment options and their potential benefits. This study is a literature review of the medical literature focused on publications from 2005 to 2022 related to the therapeutic management of VVS. Digital databases such as PubMed and SciELO were searched using the descriptors “vasovagal syncope”, “neurocardiogenic syncope” and “treatment of vasovagal syncope” to identify relevant studies. Orthostatic training (or tilt training) is a non-pharmacological approach that involves postural training performed through multiple sessions of orthostasis. Tilt training (TTr) proved to be an effective therapeutic method with long-term benefits in refractory patients. Pharmacological treatment should be considered in a case-by-case scenario. Cardioneuroablation is a procedure that has been shown to eliminate or significantly reduce the vagal response, leading to symptom relief in up to 75% of patients. Results showed that implementing a definitive pacemaker reduced symptoms in at least one-third of patients. In summary, treatment strategies for VVS are evolving with advances in medical research, allowing for a thorough analysis of each modality to determine its suitability. It is crucial to emphasize that the selection of treatment options should be evaluated by a specialist individually to ensure effective management of the patient’s clinical manifestations. Thus, available interventions have the potential to improve patient’s quality of life significantly.

Ganglionated Plexus Ablation Procedures to Treat Vasovagal Syncope.

Vasovagal syncope (VVS) refers to a heterogeneous group of conditions whereby the cardiovascular reflexes normally controlling the circulation are interrupted irregularly in response to a trigger, resulting in vasodilation, bradycardia, or both. VVS affects one-third of the population at least once in their lifetime or by the age of 60, reduces the quality of life, and may cause disability affecting certain routines. It poses a considerable economic burden on society, and, despite its prevalence, there is currently no proven pharmacological treatment for preventing VVS. The novel procedure of ganglionated plexus (GP) ablation has emerged rapidly in the past two decades, and has been proven successful in treating syncope. Several parameters influence the success rate of GP ablation, including specific ablation sites, localization and surgical techniques, method of access, and the integration of other interventions. This review aims to provide an overview of the existing literature on the physiological aspects and clinical effectiveness of GP ablation in the treatment of VVS. Specifically, we explore the association between GPs and VVS and examine the impact of GP ablation procedures as reported in human clinical trials. Our objective is to shed light on the therapeutic significance of GP ablation in eliminating VVS and restoring normal sinus rhythm, particularly among young adults affected by this condition.

PO-02-232 CARDIONEURAL ABLATION IN THE MANAGEMENT OF LONG QT SYNDROME, TYPE 7

Vasovagal syncope is a complex interaction of neurologic and cardiovascular mechanisms resulting in cardiac inhibition by the parasympathetic nervous system via the vagus nerve and associated ganglionic plexi. Some types of tachycardia may be induced by bradycardia, LQT type 3 being the most common example. In these patients, a pacemaker is sometimes indicated to avoid the bradycardia trigger for tachycardia. Cardioneural ablation (CNA) is an emerging therapy that offers the potential of abolishing vagal-induced bradycardia. It is most commonly used to treat vasovagal syncope but it may also provide benefit to patients with bradycardia-induced tachyarrhythmias. We present a case of a patient with Long QT type 7 with vasovagal syncope who had an asystolic pause which induced a run of nonsustained VT. Cardioneural ablation was utilized to avoid bradycardia, with the intention of avoiding future triggering of VT. An 8-year-old female with a past-medical history of Andersen-Tawil Syndrome (Long QT Syndrome type 7). She had two syncopal events which suggested a vagal etiology. After loop monitor placement, she had a third syncopal event, which recorded a period of sinus bradycardia, culminating in a 6.3 second asystolic pause, followed by a 6 beat run of VT, with cycle length of 200-260 msec. Cardioneural ablation was considered as a means of avoiding future bradycardic events. Procedure was performed under general anesthesia. Electroanatomic mapping (Ensite Precision) was used to create 3D cardiac geometry. The same system, coupled with transthoracic ultrasound, was also used to guide transseptal puncture. Sinus bradycardia could be induced at baseline with vagal stimulation. Areas of fractionated signals were mapped to the high atrial septum between the right upper pulmonary vein and the fossa ovalis; and also in the roof of the coronary sinus. Patient was known to have a persistent left SVC to the coronary sinus. These areas were targeted for ablation. Post ablation, she had no bradycardia inducible with vagal stimulation. She tolerated the procedure well, without complication. CNA shows potential promise in the treatment of vasovagal syncope. However, there may be other clinical settings in which it finds utility. Conditions which might benefit include Andersen-Tawil syndrome, Long QT type 3, Brugada syndrome, and possibly Congenital Central Hypoventilation syndrome. Further investigation is needed to elucidate the safety and efficacy of CNA in these settings.

Catheter Ablation as a Treatment for Vasovagal Syncope: The Time has Come to Shift Towards Placebo-controlled Trials

Vasovagal syncope (VVS), a common autonomic disorder, often sees limited effectiveness with conventional treatments. Cardioneuroablation (CNA), which targets the cardiac ganglionated plexi to modulate heart rate and rhythm, has surfaced as a potential alternative. Despite positive outcomes in clinical trials, the integration of CNA into standard clinical guidelines has been impeded by the lack of placebo-controlled randomized controlled trials (RCTs) — the gold standard for the validation of new clinical interventions. This review scrutinizes the various techniques for mapping the ganglionated plexi, crucial for the efficacy of CNA, and calls for the establishment of standardized, multicentre RCTs to confirm CNA's true therapeutic value.

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.

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.

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.

Impact of supervised physical training on vasovagal syncope; a randomized controlled trial

Abstract Background Therapeutic interventions in vasovagal syncope (VVS) are centered on lifestyle modifications aimed to counteract the recognized mechanisms that precipitate syncope. In patients with recurrent VVS, supervised training might help reduce the symptomatic burden by increasing adherence to lifestyle modifications. Purpose We aimed to evaluate the effect of an integrated supervised training program versus standard care on syncopal recurrence rate among patients with VVS. Methods This randomized, controlled, 1:1 parallel-design, open-label trial was conducted between November 2019 and February 2021. Eligible patients were those aged between 18 and 70 years with newly-diagnosed medication-naïve VVS who had experienced ≥2 syncopal episodes in the prior year. All participants received education and reassurance about the benign nature of VVS, were advised to increase salt and fluid intake, and practice counter-pressure maneuvers based on 2018 European Society of Cardiology syncope guideline (standard care). Patients were randomized to standard VVS care or the training program. The intervention program consisted of thrice-weekly four-hours-long sessions during the first month after randomization; including tilt training, aerobic exercise (with rowing ergometer, recumbent biking), and standardized counter-pressure maneuvers supervised by a team of physical medicine and rehabilitation specialist and a cardiologist. After the first month, the intervention group were planned to attend a four-hours-long session every three months. The control group were followed by phone calls after the initial visit every three months. The intended follow-up duration was one year and the primary outcome was time to first syncopal episode. Results Out of 332 patients screened, 50 (mean age: 33.5 years; 64% female, figure 1) were equally randomized. Follow-up was completed for all participants. After one year, there was a significant reduction in syncope with supervised training compared to standard care (hazard ratio: 0.28; 95% confidence interval: 0.11 to 0.68; p=0.005, figure 2). Furthermore, frequency of syncope was lower in the supervised training arm versus standard of care (median [interquartile range]: 0 [0–1] versus 1 [0–3]; p=0.017). Conclusions In patients with recurrent VVS, supervised training showed promising results in reducing syncopal recurrence. Future research should focus on similar approaches to alter patients' lifestyle as an effective treatment for VVS. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Tehran University of Medical Sciences Figure 1Figure 2

Analysis of risk factors for vasovagal syncope in children

Objective To analyze the related factors of the onset of vasovagal syncope (VVS) in children, and to provide basis for the early prevention, early diagnosis and early treatment of VVS. Methods A total of 126 children with syncope admitted to Department of Pediatric Cardiology, Second Hospital of Lanzhou University from October 2018 to September 2019 were invited in the study. Totally 73 cases of children diagnosed with VVS by HUTT were selected as VVS group, and 53 HUTT-negative children were selected as control group. Related factors were retrospectively investigated, and risk factors for VVS were analyzed by univariate and multivariate regression. Results The VVS group showed statistically significant difference in age distribution with the control group (χ 2 = 19.22, P<0.05). The VVS group showed statistically significant differences of proportion in family history, syncope history, prolonged standing, electrocardiogram abnormalities, and vitamin D deficiency (43.84%, 31. 51%, 47. 95%, 34. 25%, 30.14%) compared with the control group (15.09%, 13.21%, 20.75%, 15.09%, 9.43%) (χ 2 = 11.71, 5.67, 9.79, 5.83, 7.82, P<0.05). Multivariate Logistic regression analysis showed that age and family historywere risk factors for VVS (χ 2 = 3.13, 11.06, P<0.05). Conclusion Age and family history may be risk factors for the onset of VVS. Active attention should be paid to the high-risk factors of child patient, early identification and diagnosis can prevent the occurrence and development of VVS in children. 【摘要】 目的 分析儿童血管迷走性晕厥 (VVS) 发作的相关因素, 为 VVS 早期预防、早期诊断、早期治疗提供一定的依 据。 方法 收集 2018 年 10 月至 2019 年 9 月在兰州大学第二医院小儿心血管科住院的 126 例晕厥患儿为研究对象, 经直 立倾斜试验 (HUTT) 确诊为血管迷走性晕厥 73 例儿童为 VVS 组, 另外 53 例儿童为对照组, 回顾性调査其相关因素。 结果 VVS 组与比较组在年龄分布上差异有统计学意义 (χ 2 = 12.22, P<0.05), VVS 组有家族史、有晕厥史、有持久站立诱因、心电 图异常、维生素 D 缺乏构成比 (43.84%, 31.51%, 47.95%, 34.25%, 30.14%) 与对照组 (15.09%, 13.21%, 20.75%, 15.09%, 9.43%) 比较, 差异均有统计学意义 (χ 2 值分别为 11.71, 5.67, 9.79, 5.83, 7.82, P 值均<0.05)。多因素 Logistic 回归分析显 示, 年龄、家族史与患 VVS 呈正相关 ( OR 值分别为 3.13, 11.06, P 值均<0.05)。 结论 年龄、家族史与 VVS 的发作相关。应积极关注患儿髙危因素, 早识别、早诊断, 以预防儿童 VVS 的发生发展。

Cardioneuroablation as a method of therapy in vasovagal syncope

Vasovagal syncope is the most common cause of transient loss of consciousness, may significantly impair quality of life and lead to injury. Current treatment of vasovagal syncope is based on patient education, lifestyle modification, pharmacotherapy and, in extreme cases, implantation of a pacemaker. In recent years, more and more data on cardioneuroablation have been published – a new treatment method for neurally mediated asystolic syncope. This article summarizes the current state of knowledge about this method, presents indications for this procedure and shows perspectives for its development.

Lifestyle Modification as a Method of Treatment of Vasovagal Syncope

Vasovagal syncope is the most common cause for loss of consciousness. The need for treatment of this condition is warranted by impaired quality of life and a risk of trauma due to the fall. At present, there are no medications with proven preventive effectiveness for vasovagal syncope as demonstrated by large randomized, placebo-controlled studies. At the same time, information about the pathogenesis of vasovagal reaction and provoking factors allows effective use of non-drug methods (such as patient education, physical exercise, maneuvers) in the management of patients with vasovagal syncope.

Expert consensus on the treatment of vasovagal syncope and postural tachycardia syndrome in children

Expert consensus on the treatment of vasovagal syncope and postural tachycardia syndrome in children

Intensive reading and interpretation of the expert consensus on the treatment of vasovagal syncope and postural tachycardia syndrome in children

Intensive reading and interpretation of the expert consensus on the treatment of vasovagal syncope and postural tachycardia syndrome in children

A Clinical Case Study of Vasovagal Syncope

Objectives The purpose of this clinical case report is to describe the efficacy of Korean medicine in the treatment of vasovagal syncope. Methods The patient was treated with acupuncture, pharmacopuncture, and herbal medicine. The symptoms (headache, palpitation, sweating, flushing, weakness, coldness) of the patient were observed. Results After the treatment, the patient’s symptoms improved, but more treatments were required. Conclusion This study can add to understanding of the effect of Korean medicine on vasovagal syncope Keywords: vasovagal syncope, Korean medicine, acupuncture, pharmacopuncture, herbal medicines

Catheter Ablation as a Treatment for Vasovagal Syncope: Long-Term Outcome of Endocardial Autonomic Modification of the Left Atrium.

BackgroundAutonomic modification through catheter ablation of ganglionated plexi (GPs) in the left atrium has been reported previously as a treatment for vasovagal syncope. This study aimed to observe the long‐term outcome in a larger cohort.Methods and ResultsA total of 57 consecutive patients (aged 43.2±13.4 years; 35 women) with refractory vasovagal syncope were enrolled, and high‐frequency stimulation and anatomically guided GP ablation were performed in 10 and 47 cases, respectively. A total of 127 GP sites with positive vagal response were successfully elicited and ablated, including 52 left superior, 19 left lateral, 18 left inferior, 27 right anterior, and 11 right inferior GPs. During follow‐up of 36.4±22.2 months (range 12–102 months), 52 patients (91.2%) remained free from syncope. Prodromes recurred in 16 patients. No statistical differences were found between the high‐frequency stimulation and anatomically guided ablation groups in either freedom from syncope (100% versus 89.4%, P=0.348) or recurrent prodromes (50% versus 76.6%, P=0.167). The deceleration capacity, heart rate, and heart rate variability measurements demonstrated a reduced vagal tone lasting for at least 12 months after the procedure, with improved tolerance of repeated head‐up tilt testing. No complications were observed except for transient sinus tachycardia that occurred in 1 patient.ConclusionsLeft atrial GP ablation showed excellent long‐term clinical outcomes and might be considered as a therapeutic option for patients with symptomatic vasovagal syncope.

The management of vasovagal syncope

Vasovagal syncope, or the "common faint", is the most common cause of syncope. Although it is considered a benign condition, there is a significant economic burden and significant impact on quality of life in patients with recurrent syncope, particularly in older adults. Typical vasovagal syncope usually occurs in young adults, and can often be diagnosed on the basis of history, in the absence of structural heart disease. Atypical vasovagal syncope, which is more common in older adults, can be more difficult to diagnose, however. In atypical vasovagal syncope, there is often a short or absent prodrome, and amnesia for loss of consciousness is common and it can, therefore, often be misdiagnosed, for example as falls. A more standardized approach to the diagnosis and management of patients presenting with syncope or unexplained falls is required, and it is anticipated that the number of Syncope Units will increase. Treatment of vasovagal syncope is largely conservative; however, medical or device therapy may be required when syncope is severe and refractory to conservative treatment, as there is significant impact on quality of life and it can be associated with injury. The aim of this article is to provide an overview of the diagnosis and management of vasovagal syncope.

In silico Therapeutics for Neurogenic Hypertension and Vasovagal Syncope.

Neurocardiovascular diseases (NCVD) are the leading cause of death in the developed world and will remain so till 2020. In these diseases the pathologically changed nervous control of cardiovascular system has the central role. The actual NCV syndromes are neurogenic hypertension, representing the sympathetically mediated disorder, and vasovagal syncope, which is the vagally mediated disorders. Vasovagal syncope, the disease far from its etiological treatment, could benefit from recruiting and application of antimuscarinic drugs used in other parasympathetic disorders. The informational spectrum method (ISM), a method widely applied for the characterization of protein-protein interactions in the field of immunology, endocrinology and anti HIV drug discovery, was applied for the first time in the analysis of neurogenic hypertension and vasovagal syncope therapeutic targets. In silico analysis revealed the potential involvement of apelin in neurogenic hypertension. Applying the EIIP/ISM bioinformatics concept in investigation of drugs for treatment of vasovagal syncope suggests that 78% of tested antimuscarinic drugs could have anti vasovagal syncope effect. The presented results confirm that ISM is a promissing method for investigation of molecular mechanisms underlying pathophysiological proceses of NCV syndromes and discovery of therapeutics targets for their treatment.

GW26-e2438 Efficacy and safety of low-dose β-blocker for the treatment of vasovagal syncope

GW26-e2438 Efficacy and safety of low-dose β-blocker for the treatment of vasovagal syncope