A novel strategy to treat vaso-vagal syncope: Cardiac neuromodulation by cryoballoon pulmonary vein isolation

Abstract

Background Clinical management of vaso-vagal syncope (VVS) remains challenging since no therapy has proven to completely prevent VVS recurrence. Objective The purpose of this study was to analyze the mid-term outcome of cryoballoon (CB) cardioneuroablation achieved by pulmonary vein isolation (PVI) in patients with VVS. Methods Patients who underwent CB cardioneuroablation in our centers between January 2014 to June 2018 were included. All patients had a history of VVS or pre-syncope despite therapeutic attempts with medical and/or pacing treatments. Patients were excluded in case of structural heart diseases, cerebrovascular diseases or suspected drug-related syncope. Both heart rate (HR) and atrio-ventricular (AV) interval were analyzed on the 12-lead electrocardiogram (ECG) the day before the procedure, the day after, and in the follow-up. Results In total, 26 patients (76.9% males, 37.5 ± 9.0 years old) were included. All patients underwent a successful procedure with the 28 mm second-generation Arctic Front Advance CB. No major complication occurred. At a mean follow-up of 20.1 ± 11.6 months the freedom from VVS or reflex pre-syncope was 83,7%, with 22 patients free from any clinical recurrence. Basal HR significantly increased the day after the procedure (57.2 bpm vs 78.3 bpm, p < 0.001), while at the final follow-up it stabilized at a value halfway between the 2 previous ones (69.8 bpm, p = 0.0086). The AV interval didn’t modify significantly after the procedure. Conclusion Endocardial autonomic denervation achieved by CB PVI appears to be an effective and safe treatment option for patients with refractory VVS and reflex pre-syncope.

Do we have a clear end‐point for cardioneuroablation?

“…Since then, other investigators have reported the results from smaller observational and one randomized controlled trial to use cardioneuroablation to treat vasovagal syncope, functional AV block or functional sinus node dysfunction. [15][16][17][18][19][20][21][22][23] However, there are still uncertainties with the optimal strategy for the identification of GP sites. In the original description, ablations were directed towards the highest density of the so-called AF-Nests, identified by spectral analysis of the endocardial electrograms.…”

“…Subsequent ablation at the site of inferior left GP was critical for restoring normal AV conduction. Since then, other investigators have reported the results from smaller observational and one randomized controlled trial to use cardioneuroablation to treat vasovagal syncope, functional AV block or functional sinus node dysfunction 15–23 …”