Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Internal Medicine Neurology Oncology Pediatrics Respiratory Medicine Surgery
Congress Coverage
2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting

Keynote Webinar | Spotlight on Diet and Diabetes

Watch on-demand

An expert-led symposium exploring the prevention and management of type 2 diabetes through dietary interventions. 
ADVANCED SEARCH
Log in
Top
Current Cardiology Reports

20-11-2023 | Vasovagal Syncope | Global Cardiovascular Health (L Sperling and D Gaita, Section Editors)

Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life

Authors: Vassil Traykov, Tchavdar Shalganov

Published in: Current Cardiology Reports

Login to get access

Abstract

Purpose of Review

Vasovagal syncope (VVS) is a common entity causing transient loss of consciousness and affecting quality of life. Guideline-recommended therapy involves conservative measures and pacing in selected patients. Cardioneuroablation (CNA) targeting the ganglionated plexi in the heart has been shown to reduce excessive vagal excitation, which plays a major role in the pathophysiology of VVS and functional bradycardia.

Recent Findings

The introduction of CNA has fueled research into its value for the treatment of VVS. Multiple observational studies and one randomized trial have demonstrated the safety and efficacy of CNA and the positive impact on quality of life. This review describes the rationale and CNA procedural techniques and outcomes. Patient selection and future directions have also been described.

Summary

Cardioneuroablation is a promising treatment for patients with recurrent VVS and functional bradycardia. Further large-scale randomized studies are needed to further verify the safety and efficacy of this approach.
Literature
1.
Serletis A, Rose S, Sheldon AG, Sheldon RS. Vasovagal syncope in medical students and their first-degree relatives. Eur Heart J. 2006;27(16):1965–70. PubMedCrossRef
2.
Torabi P, Rivasi G, Hamrefors V, Ungar A, Sutton R, Brignole M, et al. Early and late-onset syncope: insight into mechanisms. Eur Heart J. 2022;43(22):2116–23. PubMedPubMedCentralCrossRef
3.
Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883–948. PubMedCrossRef
4.
Rose MS, Koshman ML, Spreng S, Sheldon R. The relationship between health-related quality of life and frequency of spells in patients with syncope. J Clin Epidemiol. 2000;53(12):1209–16. PubMedCrossRef
5.
• Sheldon RS, Grubb BP II, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015;12(6):e41-63. A consensus paper introducing the most recent nomenclature of ganglionated plexi. PubMedPubMedCentralCrossRef
6.
Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, et al. 2021 ESC Guidelines on cardiac pacing and resynchronization therapy. Eur Heart J. 2021;42(35):3427–520. PubMedCrossRef
7.
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):1–13. PubMedCrossRef
8.
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 Clin Electrophysiol. 2016;39(1):42–53. PubMedCrossRef
9.
•• Piotrowski R, Baran J, Sikorska A, Krynski T, Kulakowski P. Cardioneuroablation for reflex syncope: efficacy and effects on autonomic cardiac regulation—a prospective randomized trial. JACC Clin Electrophysiol. 2023;9(1):85–95. The only randomized controlled trial in the field.
10.
Mosqueda-Garcia R, Furlan R, Tank J, Fernandez-Violante R. The elusive pathophysiology of neurally mediated syncope. Circulation. 2000;102(23):2898–906. PubMedCrossRef
11.
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 pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope International Study. Europace. 2000;2(1):66–76. PubMedCrossRef
12.
13.
Pauza DH, Rysevaite-Kyguoliene K, Vismantaite J, Brack KE, Inokaitis H, Pauza AG, et al. A combined acetylcholinesterase and immunohistochemical method for precise anatomical analysis of intrinsic cardiac neural structures. Ann Anat. 2014;196(6):430–40. PubMedCrossRef
14.
Pauza DH, Skripka V, Pauziene N, Stropus R. Morphology, distribution, and variability of the epicardiac neural ganglionated subplexuses in the human heart. Anat Rec. 2000;259(4):353–82. PubMedCrossRef
15.
Armour JA, Murphy DA, Yuan BX, Macdonald S, Hopkins DA. Gross and microscopic anatomy of the human intrinsic cardiac nervous system. Anat Rec. 1997;247(2):289–98. PubMedCrossRef
16.
Hou Y, Scherlag BJ, Lin J, Zhang Y, Lu Z, Truong K, et al. Ganglionated plexi modulate extrinsic cardiac autonomic nerve input: effects on sinus rate, atrioventricular conduction, refractoriness, and inducibility of atrial fibrillation. J Am Coll Cardiol. 2007;50(1):61–8. PubMedCrossRef
17.
Brignole M, Aksu T, Calò L, Debruyne P, Deharo JC, Fanciulli A, et al. Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope. Europace. 2023;25(5):euad033. PubMedPubMedCentralCrossRef
18.
Pachon JC, Pachon EI, Cunha Pachon MZ, Lobo TJ, Pachon JC, Santillana TG. Catheter ablation of severe neurally meditated reflex (neurocardiogenic or vasovagal) syncope: cardioneuroablation long-term results. Europace. 2011;13(9):1231–42. PubMedCrossRef
19.
Pachon ME, Pachon-Mateos JC, Higuti C, Santillana PT, Lobo T, Pachon C, et al. Relation of fractionated atrial potentials with the vagal innervation evaluated by extracardiac vagal stimulation during cardioneuroablation. Circ Arrhythm Electrophysiol. 2020;13(4):e007900. PubMedCrossRef
20.
Scanavacca M, Hachul D, Pisani C, Sosa E. 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(5):558–63. PubMedCrossRef
21.
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(2):279–86. PubMedCrossRef
22.
Hu F, Zheng L, Liang E, Ding L, Wu L, Chen G, et al. Right anterior ganglionated plexus: the primary target of cardioneuroablation? Heart Rhythm. 2019;16(10):1545–51. PubMedCrossRef
23.
Aksu T, Guler TE, Mutluer FO, Bozyel S, Golcuk SE, Yalin K. Electroanatomic-mapping-guided cardioneuroablation versus combined approach for vasovagal syncope: a cross-sectional observational study. J Interv Card Electrophysiol. 2019;54(2):177–88. PubMedCrossRef
24.
Debruyne P, Rossenbacker T, Collienne C, Roosen J, Ector B, Janssens L, et al. Unifocal right-sided ablation treatment for neurally mediated syncope and functional sinus node dysfunction under computed tomographic guidance. Circ Arrhythm Electrophysiol. 2018;11(9):e006604. PubMedCrossRef
25.
Francia P, Viveros D, Falasconi G, Soto-Iglesias D, Fernández-Armenta J, Penela D, et al. Computed tomography-based identification of ganglionated plexi to guide cardioneuroablation for vasovagal syncope. Europace. 2023;25(6).
26.
• Francia P, Viveros D, Falasconi G, Penela D, Soto-Iglesias D, Martí-Almor J, et al. Clinical impact of aging on outcomes of cardioneuroablation for reflex syncope or functional bradycardia: results from the cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs-The ELEGANCE multicenter study. Heart Rhythm. 2023;20(9):1279–86. A recent study demonstrating the outcomes of cardioneuroablation among different age groups. PubMedCrossRef
27.
Debruyne P, Rossenbacker T, Janssens L, Collienne C, Ector J, Haemers P, et al. Durable physiological changes and decreased syncope burden 12 months after unifocal right-sided ablation under computed tomographic guidance in patients with neurally mediated syncope or functional sinus node dysfunction. Circ Arrhythm Electrophysiol. 2021;14(6):e009747. PubMedPubMedCentralCrossRef
28.
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. PubMedCrossRef
29.
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(14):1324–31. PubMedCrossRef
30.
Aksu T, Padmanabhan D, Shenthar J, Yalin K, Gautam S, Valappil SP, et al. The benefit of cardioneuroablation to reduce syncope recurrence in vasovagal syncope patients: a case-control study. J Interv Card Electrophysiol. 2022;63(1):77–86. PubMedCrossRef
31.
Aksu T, Yalin K, Gopinathannair R. Fractionation mapping software to map ganglionated plexus sites during sinus rhythm. J Cardiovasc Electrophysiol. 2020;31(12):3326–9. PubMedCrossRef
32.
•• Vandenberk B, Lei LY, Ballantyne B, Vickers D, Liang Z, Sheldon RS, et al. Cardioneuroablation for vasovagal syncope: a systematic review and meta-analysis. Heart Rhythm. 2022;S1547–5271(22):02088–94. A meta-analysis of observational studies.
33.
Lin J, Liu Q, Jiang R, Chen S, Yu L, Jiang C. Selective anatomical catheter ablation of left atrial ganglionated plexus for vasovagal syncope: left superior and right anterior ganglionated plexus ablation. Pacing Clin Electrophysiol. 2023;46(8):1010–8. PubMedCrossRef
34.
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).
35.
Pachon MJ, Pachon ME, Santillana PT, Lobo TJ, Pachon CTC, Pachon MJ, et al. Simplified method for vagal effect evaluation in cardiac ablation and electrophysiological procedures. JACC Clin Electrophysiol. 2015;1(5):451–60. PubMedCrossRef
36.
Piotrowski R, Zuk A, Baran J, Sikorska A, Krynski T, Kulakowski P. Ultrasound-guided extracardiac vagal stimulation—new approach for visualization of the vagus nerve during cardioneuroablation. Heart Rhythm. 2022;19(8):1247–52. PubMedCrossRef
37.
Rose MS, Koshman ML, Ritchie D, Sheldon R. The development and preliminary validation of a scale measuring the impact of syncope on quality of life. Europace. 2009;11(10):1369–74. PubMedCrossRef
38.
Ng J, Sheldon RS, Ritchie D, Raj V, Raj SR. Reduced quality of life and greater psychological distress in vasovagal syncope patients compared to healthy individuals. Pacing Clin Electrophysiol. 2019;42(2):180–8. PubMedCrossRef
39.
de Barros ESRLA, Volich RM, de Barros ESPGM, da Costa Darrieux FC, Scanavacca MI, Hachul DT. Effect of psychotherapy on recurrence of events and quality of life in patients with vasovagal syncope. Sci Rep. 2022;12(1):5745. CrossRef
40.
Baysal E, Mutluer FO, Dagsali AE, Kumrulu UC, Huang HD, Aksu T. Improved health-related quality of life after cardioneuroablation in patients with vasovagal syncope. J Interv Card Electrophysiol. 2022.
41.
Brignole M, Arabia F, Ammirati F, Tomaino M, Quartieri F, Rafanelli M, et al. Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study. Europace. 2016;18(9):1427–33. PubMedCrossRef
42.
Brignole M, Donateo P, Tomaino M, Massa R, Iori M, Beiras X, et al. Benefit of pacemaker therapy in patients with presumed neurally mediated syncope and documented asystole is greater when tilt test is negative: an analysis from the third International Study on Syncope of Uncertain Etiology (ISSUE-3). Circ Arrhythm Electrophysiol. 2014;7(1):10–6. PubMedCrossRef
43.
Mandel WJ, Hayakawa H, Allen HN, Danzig R, Kermaier AI. Assessment of sinus node function in patients with the sick sinus syndrome. Circulation. 1972;46(4):761–9. PubMedCrossRef
44.
Aksu T, Erdem GT. Cardioneuroablation in the management of vasovagal syncope, sinus node dysfunction and functional atrioventricular block: patient selection based on supporting evidence. J Atr Fibrillation. 2020;13(1):2396. PubMedPubMedCentral
45.
Xhyheri B, Manfrini O, Mazzolini M, Pizzi C, Bugiardini R. Heart rate variability today. Prog Cardiovasc Dis. 2012;55(3):321–31. PubMedCrossRef
46.
Pachon MJ, Pachon ME, Pachon CTC, Santillana PT, Lobo TJ, Pachon MJ, et al. Long-term evaluation of the vagal denervation by cardioneuroablation using holter and heart rate variability. Circ Arrhythm Electrophysiol. 2020;13(12):e008703. PubMedCrossRef
47.
Bauer A, Kantelhardt JW, Barthel P, Schneider R, Mäkikallio T, Ulm K, et al. Deceleration capacity of heart rate as a predictor of mortality after myocardial infarction: cohort study. Lancet. 2006;367(9523):1674–81. PubMedCrossRef
48.
Zheng L, Sun W, Liu S, Liang E, Du Z, Guo J, et al. The diagnostic value of cardiac deceleration capacity in vasovagal syncope. Circ Arrhythm Electrophysiol. 2020;13(12):e008659. PubMedCrossRef
49.
Aksu T, Mandrola J, Raj SR. Permanent pacing for recurrent vasovagal syncope: new answers or just more questions? J Electrocardiol. 2021;65:88–90. PubMedCrossRef
50.
Chung WH, Masuyama K, Challita R, Hayase J, Mori S, Cha S, et al. Ischemia-induced ventricular proarrhythmia and cardiovascular autonomic dysreflexia after cardioneuroablation. Heart Rhythm. 2023;S1547–5271(23):02557–62.
51.
Aksu T, Turagam M, Gautam S, Futyma P, Akella K, Baysal E, et al. Effects of permanent cardiac pacing on ventricular repolarization when compared to cardioneuroablation. J Electrocardiol. 2021;67:13–8. PubMedCrossRef
52.
Aksu T, Guler TE, Bozyel S, Golcuk SE, Yalin K, Lakkireddy D, et al. Medium-term results of cardioneuroablation for clinical bradyarrhythmias and vasovagal syncope: effects on QT interval and heart rate. J Interv Card Electrophysiol. 2021;60(1):57–68. PubMedCrossRef
53.
Sakamoto S, Schuessler RB, Lee AM, Aziz A, Lall SC, Damiano RJ Jr. Vagal denervation and reinnervation after ablation of ganglionated plexi. J Thorac Cardiovasc Surg. 2010;139(2):444–52. PubMedCrossRef
54.
Thurber CJ, Sneider DR, Sauer WH, Kapur S. Recurrent vasovagal syncope following successful cardioneuroablation. Heart Rhythm Case Rep. 2022;8(7):465–8.
55.
Aksu T, Guler TE, Bozyel S, Yalin K, Gopinathannair R. Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation. Europace. 2020;22(9):1320–7. PubMedCrossRef
56.
Rivarola EWR, Hachul D, Wu TC, Pisani C, Scarioti VD, Hardy C, et al. Long-term outcome of cardiac denervation procedures: the anatomically guided septal approach. JACC Clin Electrophysiol. 2023;9(8 Pt 1):1344–53. PubMedCrossRef
57.
Scanavacca M, Rivarola EWR, Torres RVA, Hardy C, Wu TC, Darrieux F, et al. Sinus node artery occlusion during cardiac denervation procedures. JACC Case Rep. 2022;4(18):1169–75. PubMedPubMedCentralCrossRef
58.
Aksu T, Guler TE, Bozyel S, Yalin K. Vagal responses during cardioneuroablation on different ganglionated plexi: is there any role of ablation strategy? Int J Cardiol. 2020;304:50–5. PubMedCrossRef
59.
Huang X, Chen Y, Huang Y, Zhao H, He L, Tan Z, et al. Comparative effects of intensive ganglionated plexus ablation in treating paroxysmal atrial fibrillation and vasovagal syncope. Clin Cardiol. 2020;43(11):1326–33. PubMedPubMedCentralCrossRef
60.
Hu F, Zheng L, Liu S, Shen L, Liang E, Liu L, et al. The impacts of the ganglionated plexus ablation sequence on the vagal response, heart rate, and blood pressure during cardioneuroablation. Auton Neurosci. 2021;233:102812. PubMedCrossRef
61.
Calo L, Rebecchi M, Sette A, Sciarra L, Borrelli A, Scara A, et al. Catheter ablation of right atrial ganglionated plexi to treat cardioinhibitory neurocardiogenic syncope: a long-term follow-up prospective study. J Interv Card Electrophysiol. 2021;61(3):499–510. PubMedCrossRef
62.
Candemir B, Baskovski E, Beton O, Shanableh N, Akbulut İM, Kozluca V, et al. Procedural characteristics, safety, and follow-up of modified right-sided approach for cardioneuroablation. Anatol J Cardiol. 2022;26(8):629–36. PubMedPubMedCentralCrossRef
Metadata
Title
Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life
Authors
Vassil Traykov
Tchavdar Shalganov
Publication date
20-11-2023
Publisher
Springer US
Published in
Current Cardiology Reports
Print ISSN: 1523-3782
Electronic ISSN: 1534-3170
DOI
https://doi.org/10.1007/s11886-023-01997-1
Webinar | 16-05-2023 | 17:30 (CET)

Keynote Webinar | Spotlight on Cardio-Oncology

Watch now

An expert-led symposium exploring the most pertinent issues in cardio-oncology, with a focus on the new ESC guidelines. Highlights include preventative approaches in cardio-oncology, toxicity risk-stratification strategies, the clinical management of myocarditis as an adverse effect of immune checkpoint inhibitor-treatments, and the utility of biomarkers in long-term follow-up of cardiovascular disease risk in cancer patients.
Prof. Rudolf de Boer
Prof. Lorenz Lehmann
Dr. Teresa Lopéz Fernández
Image Credits