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Cited by 102Cardiovascular Syncope and Autonomic DisordersCardiac pacing and defibrillation studiesHeart Rate Variability and Autonomic Control

Cardiac pacing for severe childhood neurally mediated syncope with reflex anoxic seizures

Open access
McLeod, K A, Wilson, N, Hewitt, J, Norrie, J, Stephenson, J B P·1999·Heart
DOI 10.1136/hrt.82.6.721PMC PMC1729207
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Abstract

OBJECTIVE: To determine whether permanent cardiac pacing could prevent syncope and seizures in children with frequent severe neurally mediated syncope, and if so whether dual chamber pacing was superior to single chamber ventricular pacing. METHODS: Dual chamber pacemakers were implanted into 12 children (eight male, four female) aged 2-14 years (median 2.8 years) with frequent episodes of reflex anoxic seizures and a recorded prolonged asystole during an attack. The pacemaker was programmed to sensing only (ODO), single chamber ventricular pacing with hysteresis (VVI), and dual chamber pacing with rate drop response (DDD) for four month periods, with each patient allocated to one of the six possible sequences of these modes, according to chronological order of pacemaker implantation. The parent and patient were blinded to the pacemaker mode and asked to record all episodes of syncope or presyncope ("near miss" events). The doctor analysing the results was blinded to the patient and pacemaker mode. RESULTS: One patient was withdrawn from the study after the pacemaker was removed because of infection. In the remaining children, both dual chamber and single chamber pacing significantly reduced the number of syncopal episodes compared with sensing only (p = 0.0078 for both). VVI was as effective as DDD for preventing syncope, but DDD was superior to VVI in reducing near miss events (p = 0.016). CONCLUSIONS: Permanent pacing is an effective treatment for children with severe neurally mediated syncope and reflex anoxic seizures. VVI is as effective as DDD in preventing syncope and seizures, but DDD is superior in preventing overall symptoms.

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  • These pediatric patients were refractory to multiple medications and appeared to benefit from cardiac pacing.

    “These patients were refractory to multiple medications and appeared to benefit from cardiac pacing.”

    From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [142]

    The Recorded Events section reports fewer syncopal episodes during pacing, supporting the apparent benefit. The Conclusions recommend pacing when medical treatment has failed or been declined, but the paper does not establish that these patients were refractory to multiple medications. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • A small single-blind randomized trial reported that permanent cardiac pacing greatly reduced syncope burden in young children with frequent syncope associated with documented asystole.

    “A small, single-blind randomized trial reported that permanent cardiac pacing greatly reduced syncope burden in young children, with frequent syncope associated with documented asystole.142”

    From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [142]

    The Abstract reports a study of 12 children with frequent attacks and recorded asystole; both pacing modes significantly reduced syncope compared with sensing only. However, the Methods describe allocation by chronological order of implantation, not randomization, and say the parent, patient, and doctor analyzing results were blinded—not a single-blind design. Page numbers are unavailable in our copy. (LLM, conf=0.91)

    Experimental — accuracy not yet measured

  • A small double-blind study reported that pacing improved symptoms in very young patients with frequent vasovagal syncope.

    “Finally, a small, double-blind study reported that pacing improved symptoms in very young patients with frequent vasovagal syncope.142”

    From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [142]

    The Abstract describes a small blinded study of 12 children (median age 2.8 years) in which pacing significantly reduced syncope compared with sensing only. However, the children had frequent, severe neurally mediated syncope with reflex anoxic seizures; the paper does not describe the study population simply as having vasovagal syncope. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • VVS with prolonged asystole is a relatively transient and benign syndrome.

    “even in the presence of VVS with prolonged asystole, pacemakers should be avoided due to the relatively transient and benign nature of the syndrome.”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [402]

    The Methods say reflex anoxic seizures in most children improve with time, and the Conclusions advise limiting pacing to frequent, severe attacks after medical treatment has failed or been declined. But the paper does not characterize the syndrome as benign or recommend avoiding pacemakers altogether; it finds pacing effective for severe childhood cases. The claim also extends a childhood finding to VVS generally. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

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Cites

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Research works printed but not linked: 3

  1. [14]14. Porter CJ, McGoon MD, Espinosa RE, et al. Apparent breath-holding spells associated with life-threatening bradycardia treated by permanent pacing [abstract]. Pediatr Cardiol 1994;15:260.
  2. [22]22. Benditt DG. Cardiac pacing for the prevention of vasovagal syncope [editorial comment]. J Am Coll Cardiol 1999;33: 21-3.
  3. [24]24. Samoil D, Grubb BP, Brewster P, et al. Comparison of sin- gle and dual chamber pacing techniques in prevention of upright tilt induced vasovagal syncope. Eur J Cardiac Pacing Electrophysiol 1993;1:36-41.

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Authors
McLeod, K. A., Wilson, N., Hewitt, J., Norrie, J., & Stephenson, J. B. P.
Affiliations
Royal Hospital for Children (GB)
Corresponding author
McLeod, K A
ORCID
Venue
Heart
Publisher
BMJ
Published
1999-12-01
Volume
82
Issue
6
Pages
721-725
ISSN
1355-6037 (ISSN-L)
DOI
10.1136/hrt.82.6.721
PMC
PMC1729207
OpenAlex
W2058222956
Semantic Scholar
0ad55906e4a56954e5cb386739cc68c64512764c
Cited by
102
References
26
Citations by year
2026: 1 · 2025: 2 · 2024: 2 · 2023: 2 · 2022: 1 · 2021: 5 · 2018: 9 · 2017: 8 · 2016: 6 · 2015: 3 · 2014: 2 · 2013: 6 · 2012: 4
FWCI
4.21
Type
journal article
Language
en
Open access
Locations
  • Heart (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
Keywords
neurally mediated syncope, cardiac pacing, DDD pacing, single-chamber ventricular pacing, syncope prevention, near misses, children
MeSH terms
Adolescent, Cardiac Pacing, Artificial, Hypoxia, Brain, Child, Child, Preschool, Double-Blind Method, Electrocardiography, Female, Humans, Male, Seizures, Syncope, Vasovagal

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