Top

Journal of Interventional Cardiac Electrophysiology

Published in:

01-03-2019 | MULTIMEDIA REPORT

Electroanatomic-mapping-guided cardioneuroablation versus combined approach for vasovagal syncope: a cross-sectional observational study

Authors: Tolga Aksu, Tumer Erdem Guler, Ferit Onur Mutluer, Serdar Bozyel, Sukriye Ebru Golcuk, Kivanc Yalin

Published in: Journal of Interventional Cardiac Electrophysiology | Issue 2/2019

Abstract

Purpose

This study was designed to assess the efficacy of electroanatomic-mapping (EAM)-guided cardioneuroablation (CNA) vs combined approach for vasovagal syncope (VVS).

Methods

Twenty patients with VVS refractory to conventional treatments who underwent CNA in our institution were enrolled in the study. Twelve of these patients underwent recently introduced EAM-guided CNA using signal-based approach while 8 patients underwent combined CNA using a combination of high-frequency stimulation and spectral analysis. Both atria and coronary sinus were divided into seven segments to categorize distribution of ganglionated plexi in ablation sites. Clinical responses were evaluated and compared in terms of prodromal symptoms and syncope recurrence rates. Electrophysiological parameters and heart rate variability (HRV) analysis were used to evaluate procedural response.

Results

Procedural endpoints were achieved in all cases without any serious adverse events. Compared with the combined approach group, EAM-guided CNA was related to a shorter procedure and fluoroscopy times (p < 0.001). The mean number of ablation points in each anatomical segment was comparable between groups. The prodromal symptoms demonstrated a significant and comparable decrease after CNA. Median event-free survival was comparable between groups (χ2 = 0.03, p = 0.87). There was no new syncopal episode in any case at the end of 6-month follow-up. In the combined approach group, new syncope episodes occurred in two cases after 12-month follow-up. HRV parameters indicating parasympathetic activity were comparably decreased after ablation in both groups.

Conclusion

This pilot study shows that EAM-guided CNA strategy is feasible and safe in VVS patients resistant to conventional therapies.

Available only for authorised users

Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines, and the Heart Rhythm Society. J Am Coll Cardiol. 2017;70:e39–e110.CrossRefPubMed

Wieling W, Jardine DL, de Lange FJ, Brignole M, Nielsen HB, Stewart J, et al. Cardiac output and vasodilation in the vasovagal response: an analysis of the classic papers. Heart Rhythm. 2016;13:798–805.CrossRefPubMed

Varosy PD, Chen LY, Miller AL, Noseworthy PA, Slotwiner DJ, Thiruganasambandamoorthy V. Pacing as a treatment for Reflex-mediated (vasovagal, situational, or carotid sinus hypersensitivity) syncope: a systematic review for the 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017;136:e123–35.CrossRefPubMed

Randall WC, Milosavljevic M, Wurster RD, Geis GS, Ardell JL. Selective vagal innervation of the heart. Ann Clin Lab Sci. 1986;16:198–208.PubMed

Randall WC, Ardell JL, O’Toole MF, Wurster RD. Differential autonomic control of SAN and AVN regions of the canine heart: structure and function. Prog Clin Biol Res. 1988;275:15–31.PubMed

Chiou CW, Eble JN, Zipes DP. Efferent vagal innervation of the canine atria and sinus and atrioventricular nodes. The third fat pad. Circulation. 1997;95:2573–84.CrossRefPubMed

Soejima K, Akaishi M, Mitamura H, Ogawa S, Sakurada H, Okazaki H, et al. Increase in heart rate after radiofrequency catheter ablation is mediated by parasympathetic nervous withdrawal and related to site of ablation. J Electrocardiol. 1997;30:239–46.CrossRefPubMed

Pappone C, Stabile G, Oreto G, De Simone A, Rillo M, Mazzone P, et al. Inappropriate sinus tachycardia after radiofrequency ablation of para-Hisian accessory pathways. J Cardiovasc Electrophysiol. 1997;8:1357–65.CrossRefPubMed

Pachon JC, Pachon EI, Pachon JC, Lobo TJ, Pachon MZ, Vargas RN, et al. “Cardioneuroablation”—new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF-ablation. Europace. 2005;7:1–13.CrossRefPubMed

10.

Scanavacca M, Hachul D, Pisani C, et al. Selective vagal denervation of the sinus and atrioventricular nodes, guided by vagal reflexes induced by high frequency stimulation, to treat refractory neurally mediated syncope. J Cardiovasc Electrophysiol. 2009;20:558–63.CrossRefPubMed

11.

Yao Y, Shi R, Wong T, Zheng L, Chen W, Yang L, et al. Endocardial autonomic denervation of the left atrium to treat vasovagal syncope: an early experience in humans. Circ Arrhythm Electrophysiol. 2012;5:279–86.CrossRefPubMed

12.

Rebecchi M, de Ruvo E, Strano S, Sciarra L, Golia P, Martino A, et al. Ganglionated plexi ablation in right atrium to treat cardioinhibitory neurocardiogenic syncope. J Interv Card Electrophysiol. 2012;34:231–5.CrossRefPubMed

13.

Debruyne P. Cardio-neuromodulation with a multielectrode irrigated catheter: a potential new approach for patients with cardio-inhibitory syncope. J Cardiovasc Electrophysiol. 2016;27:1110–3.CrossRefPubMed

14.

Lellouche N, Buch E, Celigoj A, Siegerman C, Cesario D, De Diego C, et al. Functional characterization of atrial electrograms in sinus rhythm delineates sites of parasympathetic innervation in patients with paroxysmal atrial fibrillation. J Am Coll Cardiol. 2007;50:1324–31.CrossRefPubMed

15.

Rivarola E, Hardy C, Sosa E, Hachul D, Furlan V, Raimundi F, et al. Selective atrial vagal denervation guided by spectral mapping to treat advanced atrioventricular block. Europace. 2016;18:445–9.CrossRefPubMed

16.

Zhao L, Jiang W, Zhou L, et al. Atrial autonomic denervation for the treatment of long-standing symptomatic sinus bradycardia in non-elderly patients. J Interv Card Electrophysiol. 2015;43:151–9.CrossRefPubMed

17.

Aksu T, Güler TE, Bozyel S, Özcan KS, Yalın K, Mutluer FO. Cardioneuroablation in the treatment of neurally mediated reflex syncope: a review of the current literature. Turk Kardiyol Dern Ars. 2017;45:33–41.PubMed

18.

Aksu T, Golcuk E, Yalin K, Guler TE, Erden I. Simplified Cardioneuroablation in the treatment of reflex syncope, functional AV block, and sinus node dysfunction. Pacing ClinElectrophysiol. 2016;39:42–53.CrossRef

19.

Aksu T, Guler TE, Yalin K, Bozyel S. Vagal ganglia ablation: a little-known route in the treatment of vasovagal syncope. EP Lab Digest. 2017;17:26–7.

20.

Brignole M, Menozzi C, Del Rosso A, Costa S, Gaggioli G, Bottoni N, et al. New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification. Analysis of the presyncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope International Study Europace. 2000;2:66–76.PubMed

21.

Kenny RA, O'Shea D, Parry SW. The Newcastle protocols for head-up tilt table testing in the diagnosis of vasovagal syncope, carotid sinus hypersensitivity, and related disorders. Heart. 2000;83:564–9.CrossRefPubMedPubMedCentral

22.

Aksu T, Güler TE, Mutluer FO, Oto MA. Vagal denervation in atrial fibrillation ablation: a comprehensive review. Anatol J Cardiol. 2017;18:142–8.PubMedPubMedCentral

23.

Sun W, Zheng L, Qiao Y, Shi R, Hou B, Wu L, et al. Catheter ablation as a treatment for vasovagal syncope: long-term outcome of endocardial autonomic modification of the left atrium. J Am Heart Assoc. 2016;5(7):e003471.CrossRefPubMedPubMedCentral

24.

Aksu T, Guler TE, Yalin K, Mutluer FO, Calò L. Catheter ablation of bradyarrhythmia: from the beginning to the future. Am J Med Sci. 2018;355:252–65.CrossRefPubMed

25.

Pachon JC, Pachon EI, Pachon MZC, Lobo TJ, Pachon JC, Santillana TG. Catheter ablation of severe neurally meditated reflex (neurocardiogenic or vasovagal) syncope: cardioneuroablation long-term results. Europace. 2011;13:1231–42.CrossRefPubMed

26.

Rivarola EW, Hachul D, Wu T, Pisani C, Hardy C, Raimundi F, et al. Targets and end points in cardiac autonomic denervation procedures. Circ Arrhythm Electrophysiol. 2017;10(2):e004638.CrossRefPubMed

27.

Chapleau MW, Sabharwal R. Methods of assessing vagus nerve activity and reflexes. Heart Fail Rev. 2011;16:109–27.CrossRefPubMedPubMedCentral

28.

Tomaino M, Romeo C, Vitale E, Kus T, Moya A, van Dijk N, et al. Physical counter-pressure maneuvers in preventing syncopal recurrence in patients older than 40 years with recurrent neurally mediated syncope: a controlled study from the third international study on Syncope of uncertain etiology (ISSUE-3). Europace. 2014;16:1515–20.CrossRefPubMed

29.

Tanaka K, Zlochiver K, Vikstrom KL, Yamazaki M, Moreno J, Klos M, et al. Spatial distribution of fibrosis governs fibrillation wave dynamics in the posterior left atrium during heat failure. Circ Res. 2007;101:839–47.CrossRefPubMed

30.

Jadidi AS, Cochet H, Shah AJ, Kim SJ, Duncan E, Miyazaki S, et al. Inverse relationship between fractionated electrograms and atrial fibrosis in persistent atrial fibrillation: combined magnetic resonance imaging and high-density mapping. J Am Coll Cardiol. 2013;62:802–12.CrossRefPubMed

Title: Electroanatomic-mapping-guided cardioneuroablation versus combined approach for vasovagal syncope: a cross-sectional observational study
Authors: Tolga Aksu
Tumer Erdem Guler
Ferit Onur Mutluer
Serdar Bozyel
Sukriye Ebru Golcuk
Kivanc Yalin
Publication date: 01-03-2019
Publisher: Springer US
Published in: Journal of Interventional Cardiac Electrophysiology / Issue 2/2019
Print ISSN: 1383-875X
Electronic ISSN: 1572-8595
DOI: https://doi.org/10.1007/s10840-018-0421-4

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Electroanatomic-mapping-guided cardioneuroablation versus combined approach for vasovagal syncope: a cross-sectional observational study

Abstract

Purpose

Methods

Results

Conclusion

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 2/2019

Idiopathic ventricular arrhythmias arising from the posterior septum of tricuspid and mitral annuli: comparison of electrocardiographic characteristics and outcomes of catheter ablation

Noninvasive tissue adhesive for cardiac implantable electronic device pocket closure: the TAPE pilot study

Correction to: Iatrogenic atrial septal defect: reassurance or inquisitiveness

Successful pulmonary vein isolation in a patient with situs inversus abdominalis and status post interatrial Dacron patch implantation

Multipoint left ventricular pacing improves response to cardiac resynchronization therapy with and without pressure-volume loop optimization: comparison of the long-term efficacy of two different programming strategies

Parameters associated with acute morphometric lesion dimensions created by cryocatheters

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page