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Catheter ablation of severe neurally meditated reflex (neurocardiogenic or vasovagal) syncope: cardioneuroablation long-term results
Open accessAbstract
AIMS: Neurally meditated reflex or neurocardiogenic or vasovagal syncope (NMS) is usually mediated by a massive vagal reflex. This study reports the long-term outcome of NMS therapy based on endocardial radiofrequency (RF) catheter ablation of the cardiac vagal nervous system aiming permanent attenuation or elimination of the cardioinhibitory reflex (cardioneuroablation). METHODS AND RESULTS: A total of 43 patients (18F/25M, 32.9 ± 15 years) without apparent cardiopathy (left ventricular ejection fraction=68.6 ± 5%) were included. All had recurrent NMS (4.7 ± 2 syncope/patient) with important cardioinhibition (pauses=13.5 ± 13 s) at head-up tilt test (HUT), normal electrocardiogram (ECG), and normal atropine test (AT). The patients underwent atrial endocardial RF ablation using spectral mapping to track the neurocardiac interface (AF Nest Mapping). The follow-up (FU) consisted of clinical evaluation, ECG (1 month/every 6 months/or symptoms), Holter (every 6 months/or symptoms), HUT (≥ 4 months/or symptoms), and AT (end of ablation and ≥ 6 months). A total of 44 ablations (48 ± 9 points/patient) were performed. Merely three cases of spontaneous syncope occurred in 45.1 ± 22 months (two vasodepressor, one undefined). Only four partial cardioinhibitory responses occurred in post-ablation HUT without pauses or asystole (sinus bradycardia). Long-term AT (21.7 ± 11 months post) was negative in 33 (76.7%, P < 0.01), partially positive in 7(16.3%), and normal in three patients only (6.9%) reflecting long-term vagal denervation (AT-Δ%HR pre 79.4% × 23.2% post). The post-ablation stress test and Holter showed no abnormalities. No major complications occurred. CONCLUSION: Endocardial RF catheter ablation of severe neurally meditated reflex syncope prevented pacemaker implantation and showed excellent long-term results in well selected patients. Despite no action in vasodepression it seems to cause enough long-term vagal reflex attenuation, eliminating the cardioinhibition, and keeping most patients asymptomatic. Indication was based on clinical symptoms, reproduction of severe cardioinhibitory syncope, and normal atropine response.
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“Preliminary data from cardiac ganglia plexi ablation in treating selected patients with VVS are encouraging but still insufficient to make recommendations at this time (370–372).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [372]
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Developed in collaboration with, European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), and Heart Rhythm Society (HRS), societies, E. B. T. F., European Society of Emergency Medicine (EuSEM), European Federation of Internal Medicine (EFIM), European Union Geriatric Medicine Society (EUGMS), American Geriatrics Society (AGS), European Neurological Society (ENS), et al. (2009) · European Heart Journal · doi:10.1093/eurheartj/ehp298 · Cited by 2,040
Incidence and Prognosis of Syncope
Soteriades, E. S., Evans, J. C., Larson, M. G., Chen, M. H., Chen, L., Benjamin, E. J., & Levy, D. (2002) · New England Journal of Medicine · doi:10.1056/nejmoa012407 · Cited by 1,364
Guidelines on management (diagnosis and treatment) of syncope
Brignole, M. (2001) · European Heart Journal · doi:10.1053/euhj.2001.2739 · Cited by 951
Schwartz, P. J., Priori, S. G., Cerrone, M., Spazzolini, C., Odero, A., Napolitano, C., Bloise, R., Ferrari, G. M. D., Klersy, C., Moss, A. J., et al. (2004) · Circulation · doi:10.1161/01.cir.0000125523.14403.1e · Cited by 686
Guidelines on Management (diagnosis and treatment) of syncope ? update 2004
Brignole, M., Alboni, P., Benditt, D. G., Bergfeldt, L., Blanc, J., Thomsen, P. E. B., van Dijk, J. G., Fitzpatrick, A. P., Hohnloser, S. H., Janousek, J., et al. (2004) · EP Europace · doi:10.1016/j.eupc.2004.08.008 · Cited by 650
Tilt table testing for assessing syncope
Benditt, D. G., Ferguson, D. W., Grubb, B. P., Kapoor, W. N., Kugler, J., Lerman, B. B., Maloney, J. D., Ravielle, A., Ross, B. A., Sutton, R., et al. (1996) · Journal of the American College of Cardiology · doi:10.1016/0735-1097(96)00236-7 · Cited by 574
Guidelines on management (diagnosis and treatment) of syncope-update 2004. Executive Summary.
Brignole, M., Alboni, P., Benditt, D. G., Bergfeldt, L., Blanc, J., Thomsen, P. E. B., van Dijk, J. G., Fitzpatrick, A. P., Hohnloser, S. H., Janoušek, J., et al. (2004) · European Heart Journal · doi:10.1016/j.ehj.2004.09.004 · Cited by 566
Connolly, S. J., Sheldon, R., Thorpe, K. E., Roberts, R. S., Ellenbogen, K. A., Wilkoff, B. L., Morillo, C., Gent, M., & for the VPS II Investigators (2003) · JAMA · doi:10.1001/jama.289.17.2224 · Cited by 500
Diagnostic value of history in patients with syncope with or without heart disease
Alboni, P., Brignole, M., Menozzi, C., Raviele, A., Del Rosso, A., Dinelli, M., Solano, A., & Bottoni, N. (2001) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(01)01241-4 · Cited by 444
Electrical Stimulation to Identify Neural Elements on the Heart: Their Role in Atrial Fibrillation
Scherlag, B. J., Nakagawa, H., Jackman, W. M., Yamanashi, W. S., Patterson, E. S., Po, S. S., & Lazzara, R. (2005) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-005-2492-2 · Cited by 425
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2018 ESC Guidelines for the diagnosis and management of syncope
Brignole, M., Moya, A., de Lange, F. J., Deharo, J.-C., Elliott, P. M., Fanciulli, A., Fedorowski, A., Furlan, R., Kenny, R. A., Martín, A., et al. (2018) · European Heart Journal · doi:10.1093/eurheartj/ehy037 · Cited by 1,951
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Heart Rhythm · doi:10.1016/j.hrthm.2017.03.004 · Cited by 478
2018 ESC Guidelines for the diagnosis and management of syncope
Brignole, M., Moya‐Mitjans, À., de Lange, F. J., Deharo, J., Elliot, P. M., Fanciulli, A., Fedorowski, A., Furlan, R., Kenny, R. A., Martiın, A., et al. (2018) · Kardiologia Polska · doi:10.5603/kp.2018.0161 · Cited by 475
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Circulation · doi:10.1161/cir.0000000000000499 · Cited by 463
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., et al. (2017) · Circulation · doi:10.1161/cir.0000000000000498 · Cited by 411
Metadata
- Authors
- Pachon M, J. C., Pachon M, E. I., Cunha Pachon, M. Z., Lobo, T. J., Pachon M, J. C., & Santillana P, T. G.
- ORCID
- Lobo, T. J.
- Venue
- Europace
- Publisher
- Oxford University Press (OUP)
- Published
- 2011-06-28
- Volume
- 13
- Issue
- 9
- Pages
- 1231-1242
- ISSN
- 1099-5129 (ISSN-L)
- 1532-2092
- OpenAlex
- W2327146098
- Cited by
- 230
- References
- 42
- Citations by year
- 2026: 11 · 2025: 21 · 2024: 30 · 2023: 33 · 2022: 23 · 2021: 23 · 2020: 24 · 2019: 14 · 2018: 14 · 2017: 15 · 2016: 7 · 2015: 7 · 2014: 2 · 2013: 3 · 2012: 3
- FWCI
- 2.62
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- EP Europace (publishedVersion)
- PubMed (publishedVersion)
- Scientific Electronic Library Online (São Paulo Research Foundation, Latin American and Caribbean Center on Health Sciences Information, Conselho Nacional de Desenvolvimento Científico e Tecnológico) (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Keywords
- vasovagal syncope, catheter ablation, radiofrequency ablation, vagal denervation, vagal reflex, head-up tilt, atropine test, long-term outcomes, pacemaker avoidance, syncope prevention, bradycardia, asystole, spectral mapping
- MeSH terms
- Adult, Anti-Arrhythmia Agents, Atropine, Bradycardia, Electrocardiography, Female, Heart, Humans, Male, Middle Aged, Treatment Outcome, Catheter Ablation, Tilt-Table Test, Syncope, Vasovagal, Young Adult
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