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Pacing and Clinical Electrophysiology :... Dec 2021Vasovagal syncope (VVS) (or neurocardiogenic syncope) is a common clinical condition that is challenging to both physicians and patients alike. Severe episodes of... (Review)
Review
Vasovagal syncope (VVS) (or neurocardiogenic syncope) is a common clinical condition that is challenging to both physicians and patients alike. Severe episodes of recurrent syncope can result in physical injury as well as psychological distress. This article provides a brief overview of current management strategies and a detailed overview of therapeutic modalities such as closed loop stimulation (CLS) and cardioneuroablation (CNA).
Topics: Ablation Techniques; Algorithms; Cardiac Pacing, Artificial; Diagnosis, Differential; Humans; Quality of Life; Syncope, Vasovagal
PubMed: 34748224
DOI: 10.1111/pace.14402 -
Journal of Clinical Neurophysiology :... Jul 2021This review recapitulates the head-up tilt test, which is commonly used for evaluation of orthostatic syndromes and dysautonomia. Tilt test evaluates autonomic system... (Review)
Review
This review recapitulates the head-up tilt test, which is commonly used for evaluation of orthostatic syndromes and dysautonomia. Tilt test evaluates autonomic system responses to orthostatic stress. Established tilt testing includes monitoring of heart rate and blood pressure; adding capnography and cerebral blood flow monitoring expands its diagnostic yield and allows assessing cerebral blood flow regulation. Common syndromes detectable by the tilt test are neurally mediated syncope (vasodepressor, cardiovagal, or mixed), orthostatic hypotension, postural orthostatic tachycardia syndrome, hypocapnic cerebral hypoperfusion, and orthostatic cerebral hypoperfusion syndrome. This review describes relevant physiology, tilt test protocols, diagnostic criteria for orthostatic syndromes, grading test results, diagnostic accuracy, limitations of the tilt test, and safety considerations.
Topics: Blood Pressure; Cerebrovascular Circulation; Heart Rate; Humans; Hypotension, Orthostatic; Postural Orthostatic Tachycardia Syndrome; Syncope; Syncope, Vasovagal; Tilt-Table Test
PubMed: 34009851
DOI: 10.1097/WNP.0000000000000625 -
JAMA Internal Medicine Jun 2021
Topics: Humans; Syncope, Vasovagal
PubMed: 33587095
DOI: 10.1001/jamainternmed.2020.9151 -
Journal of Cardiovascular... Oct 2022Catheter-based cardioneuroablation is increasingly being utilized to improve outcomes in patients with vasovagal syncope and atrioventricular block due to vagal... (Review)
Review
Catheter-based cardioneuroablation is increasingly being utilized to improve outcomes in patients with vasovagal syncope and atrioventricular block due to vagal hyperactivity. There is now increasing convergence among enthusiasts on its various aspects, including patient selection, technical steps, and procedural end-points. This pragmatic review aims to take the reader through a step-by-step approach to cardioneuroablation: we begin with a brief overview of the anatomy of intrinsic cardiac autonomic nervous system, before focusing on the indications, preprocedure and postprocedure management, necessary equipment, and its potential limitations.
Topics: Atrioventricular Block; Catheter Ablation; Heart; Humans; Syncope, Vasovagal; Vagus Nerve
PubMed: 35362165
DOI: 10.1111/jce.15480 -
European Journal of Internal Medicine Jun 2023Syncope is a short-term transient loss of consciousness, characterized by rapid onset and complete spontaneous recovery. According to the 2018 European Society of... (Review)
Review
Syncope is a short-term transient loss of consciousness, characterized by rapid onset and complete spontaneous recovery. According to the 2018 European Society of Cardiology guidelines, three different types of syncope have been identified. However, all forms of syncope share a common final pathophysiological event, global cerebral hypoperfusion, which results from the inability of the circulatory system to maintain blood pressure at the level required to efficiently supply blood to the brain. The vasovagal syncope (VVS) is the most common form of syncope. Although, VVS is generally harmless, its frequent occurrence can negatively affect quality of life and increase the risk of adverse events. The pathophysiological mechanisms underlying VVS remain obscure. The multifaceted nature of VVS presents a veritable challenge to understanding this condition and developing preventative strategies. Thus, the aim of this review was to discuss the factors contributing to the pathogenesis of VVS and provide guidance for future research.
Topics: Humans; Syncope, Vasovagal; Quality of Life; Syncope; Blood Pressure; Cardiology; Tilt-Table Test
PubMed: 37030995
DOI: 10.1016/j.ejim.2023.03.025 -
Practical Neurology Nov 2023Tilt testing can help to diagnose unexplained syncope, by precipitating an episode during cardiac monitoring. The Italian protocol, now most widely used, involves giving...
Tilt testing can help to diagnose unexplained syncope, by precipitating an episode during cardiac monitoring. The Italian protocol, now most widely used, involves giving sublingual nitroglycerine after 15 min, while monitoring beat-to-beat blood pressure (BP) and recording on video. Tilt testing is time-consuming but it is clinically useful and can guide therapy. Complications are rare. Syncope types include vasovagal syncope where BP falls after >3 min of tilt-up and later the heart rate falls; classic orthostatic hypotension where there is an immediate, progressive BP fall with minimal heart rate change; delayed orthostatic hypotension with a late BP fall after a stable phase but little or no heart rate rise; psychogenic pseudosyncope with apparent loss of consciousness, but no BP fall and a moderate heart rate rise; and postural orthostatic tachycardia syndrome where there is a significant heart rate rise but no BP fall.
Topics: Humans; Hypotension, Orthostatic; Tilt-Table Test; Syncope; Syncope, Vasovagal; Heart Rate; Blood Pressure
PubMed: 37726165
DOI: 10.1136/pn-2023-003749 -
Heart Rhythm Nov 2022Cardioneuroablation (CNA) has emerged as promising therapy for patients with refractory vasovagal syncope (VVS). (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cardioneuroablation (CNA) has emerged as promising therapy for patients with refractory vasovagal syncope (VVS).
OBJECTIVE
The purpose of this study was to provide a freedom from syncope estimate for CNA, including subgroup analysis by method and target of ablation.
METHODS
A systematic search was performed in MEDLINE and EMBASE according to the PRISMA guidelines until February 14, 2022. Observational studies and clinical trials reporting freedom from syncope were included. Meta-analysis was performed with a random-effects model.
RESULTS
A total of 465 patients were included across 14 studies (mean age 39.8 ± 4.0 year; 53.5% female). Different techniques were used to guide CNA: 50 patients (10.8%) by mapping fractionated electrograms, 73 (15.7%) with the spectral method, 210 (45.2%) with high-frequency stimulation, 73 (15.7%) with a purely anatomically guided method, and 59 (12.6%) with a combination. The target was biatrial in 168 patients (36.1%), left atrium only in 259 (55.7%), and right atrium only in 38 (8.2%). The freedom from syncope was 91.9% (95% confidence interval [CI] 88.1%-94.6%; I = 6.9%; P = .376). CNA limited to right atrial ablation was associated with a significant lower freedom from syncope (81.5%; 95% CI 51.9%-94.7%; P <.0001) vs left atrial ablation only (94.0%; 95% CI 88.6%--6.9%) and biatrial ablation (92.7%; 95% CI 86.8%-96.1%). Subgroup analysis according to the technique used to identify ganglionated plexi did not show any significant difference in freedom from syncope (P = .206).
CONCLUSION
This meta-analysis suggests a high freedom from syncope after CNA in VVS. Well-designed, double-blind, multicenter, sham-controlled randomized clinical trials are needed to provide evidence for future guidelines.
Topics: Humans; Female; Adult; Male; Syncope, Vasovagal; Atrial Fibrillation; Heart Atria; Atrial Appendage; Catheter Ablation; Randomized Controlled Trials as Topic; Multicenter Studies as Topic
PubMed: 35716859
DOI: 10.1016/j.hrthm.2022.06.017 -
JACC. Clinical Electrophysiology Jan 2023Treatment of cardioinhibitory vasovagal syncope (VVS) is difficult. Recently, cardioneuroablation (CNA) has emerged as a new therapeutic option. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Treatment of cardioinhibitory vasovagal syncope (VVS) is difficult. Recently, cardioneuroablation (CNA) has emerged as a new therapeutic option.
OBJECTIVES
This study sought to assess the effects of CNA on syncope recurrences in patients with VVS.
METHODS
This study was a prospective, open, randomized, controlled, investigator-initiated trial comparing CNA versus optimal nonpharmacologic therapy in patients with cardioinhibitory VVS. Patients were included if they had documented symptomatic cardioinhibitory or mixed VVS and positive atropine test. CNA was performed using radiofrequency ablation of the ganglionated plexi from the left and right atria. Follow-up lasted 2 years. Primary endpoint was time to first syncope recurrence. Secondary endpoints included changes in sinus rhythm and heart rate variability measured in Holter electrocardiography at baseline and 3, 12, and 24 months after CNA, as well as changes in quality of life at baseline and after completion of follow-up.
RESULTS
A total of 48 patients (17 male, mean age 38 ± 10 years, 24 in CNA group, 24 in control group) entered the study. The primary endpoint occurred in 2 patients (8%) from the CNA group versus 13 control patients (54%) (P = 0.0004). After CNA the mean sinus rhythm at 24-hour Holter electrocardiography was significantly faster and heart rate variability parameters significantly changed toward parasympathetic withdrawal compared with baseline values. Quality of life significantly improved in the CNA group (30 ± 10 points vs 10 ± 7 points; P = 0.0001), whereas it remained stable in control patients (31 ± 10 points vs 30 ± 10 points; P = 0.5501).
CONCLUSIONS
This is the first randomized study documenting efficacy of CNA in patients with cardioinhibitory VVS. Larger studies are needed to confirm these findings. (Cardioneuroablation for Reflex Syncope [ROMAN]; NCT03903744).
Topics: Humans; Male; Adult; Middle Aged; Heart Rate; Syncope, Vasovagal; Prospective Studies; Quality of Life; Arrhythmias, Cardiac; Reflex
PubMed: 36114133
DOI: 10.1016/j.jacep.2022.08.011 -
Heart Rhythm O2 Jun 2023Since its original description in 2005, catheter ablation techniques, commonly called cardioneuroablation, have emerged as a potential strategy for modulating autonomic...
Since its original description in 2005, catheter ablation techniques, commonly called cardioneuroablation, have emerged as a potential strategy for modulating autonomic function. Multiple investigators have provided observational data on the potential benefits of this technique in a variety of conditions associated with or exacerbated by increased vagal tone such as vasovagal syncope, functional atrioventricular block, and sinus node dysfunction. Patient selection, current techniques including the various mapping strategies, clinical experience, and limitations of cardioablation are reviewed. Finally, while cardioneuroablation has potential to be a treatment option for selected patients with symptoms mediated by hypervagotonia, the document outlines the important knowledge gaps that currently exist and the necessary next steps required before this technique can be widely implemented into clinical practice.
PubMed: 37361615
DOI: 10.1016/j.hroo.2023.02.007