Cardioneuroablation for pediatric patients with functional sinus node dysfunction and paroxysmal atrioventricular block.

INTRODUCTION: Severe transitory episodes of bradycardia with subsequent syncope in children are common, and generally portend a benign prognosis. Rarely, patients may experience prolonged asystolic episodes secondary to significant sinus pauses (SP) or paroxysmal atrioventricular block (AVB). Cardioneuroablation (CNA) is a catheter-based intervention, used to identify and ablate the epicardial ganglionated plexi (GP), which results in disruption of the vagal-mediated parasympathetic input to the sinus and atrioventricular node. OBJECTIVE: Describe the methodology and role of CNA for treatment of pediatric patients with functional AVB or SP. METHODS: This is a single-center, case series study. Patients with SP or AVB, 21 years of age or younger, who underwent CNA between 2015 and 2021 were included. CNA was performed via anatomically guided and high-frequency stimulation methods. RESULTS: Six patients were included. The median age was 18.9 years (range 12.3-20.9 years), 33% female. Two patients had prolonged SP, two had paroxysmal AVB, and two had both SP and AVB. Four patients had prior syncope. The median longest pause was 8.9 s (range 3.9-16.8) with 11 total documented pauses (range 2-231) during the 6 months pre-CNA. Post-CNA, the median longest pause was 1.3 s (range 0.8-2.2) with one documented SP after termination of atrial tachycardia at the 3-month follow-up. At 6 months, the median longest pause was 1.1 s (0.8-1.3) with 0 documented pauses. No patients had syncope post-CNA. CONCLUSION: CNA may be an effective alternative to pacemaker implantation in pediatric patients with syncope or significant symptoms secondary to functional SP or AVB.

Incidence of and risk factors for pacemaker implantation after the modified Cryo-Maze procedure for atrial fibrillation.

OBJECTIVES: The Maze procedure is a well-established treatment for atrial fibrillation. However, it is sometimes associated with bradycardia requiring pacemaker implantation. We assessed the rates of in-hospital and late-onset pacemaker implantation after the modified Cryo-Maze procedure and explored the risk factors for pacemaker implantation. METHODS: This study enrolled a series of 751 patients who underwent the modified Cryo-Maze procedure at our institution between 2001 and 2020. Multivariable Fine-Gray regression was used to analyze the risk factors for late-onset pacemaker implantation. RESULTS: Twelve patients (1.6%) underwent in-hospital pacemaker implantation, and 55 patients (7.3%) underwent late-onset pacemaker implantation during a median follow-up of 4.5 years (interquartile range, 1.4-10.0). The most common primary indication for pacemaker implantation was sick sinus syndrome (56 patients [7.5%]), followed by complete atrioventricular block (11 patients [1.5%]). The cumulative incidence of late-onset pacemaker implantation with death as a competing risk was 2.8% at 1 year, 7.7% at 5 years, and 10.8% at 10 years. Risk factors for late-onset pacemaker implantation included a longer preoperative atrial fibrillation duration (hazard ratio, 1.14; P < .001) and an older age (hazard ratio, 1.05; P = .001). The mortality, cumulative incidence of cerebrovascular accidents, and rate of atrial fibrillation recurrence were not significantly different between patients with and without pacemaker implantation. CONCLUSIONS: Longer preoperative atrial fibrillation duration and older age are risk factors for late-onset pacemaker implantation after the modified Cryo-Maze procedure. However, the incidence of pacemaker implantation is not associated with increased morbidity or atrial fibrillation recurrence.

Sinus node dysfunction after radiofrequency catheter ablation of atrial flutter: A case report.

Atrial flutter (AFL) is the second most common atrial tachyarrhythmia after atrial fibrillation. Catheter ablation (CA) for typical AFL is well-established and has a high success rate and adequate safety. However, sick sinus syndrome (SSS) occasionally occurs when long-term, persistent AFL is terminated by ablation. Sinus node function cannot be assessed during AFL, and the preoperative prediction of underlying SSS has not yet been investigated. When this situation occurs, pacemaker implantation is often necessary. Here, we report a case of SSS after persistent AFL CA.

The future of cardioneuroablation in cardiovascular medicine.

INTRODUCTION: Cardioneuroablation is increasingly being utilized to improve outcomes in patients with vagally mediated bradyarrhythmias. However, there are still controversial issues in the field including patient selection, safety and efficacy, and procedural end-points. AREAS COVERED: In this review, the current role of cardioneuroablation is summarized, and controversial issues related to the modality are discussed. EXPERT OPINION: According to small open-label cohort studies, overall freedom from syncope recurrence was higher than 90% after cardioneuroablation in patients with vasovagal syncope (VVS). Use of the electrogram-based strategy or high-frequency stimulation demonstrate similar success rate except in procedures limited to the right atrium. Based on a recently published randomized controlled trial and metanalysis, it may be possible now to make a strong recommendation for cardioneuroablation in patients <40 years of age, and those with the cardioinhibitory or mixed type of VVS who continue to experience frequent and/or burdensome syncope recurrences. Considering patients with VVS are prone to significant placebo/expectation effect, sham-controlled trials may help to quantify the placebo effect. In well-selected patients with functional atrioventricular block and sinus bradycardia, may result in encouraging medium-term outcomes. However, functional bradycardia is identified in a minority of patients presenting with high-grade atrioventricular block or sinus node dysfunction.

Pulmonary Vein Isolation and Pacemaker Implantation in a Patient with Dextrocardia Situs Inversus.

A 70-year-old female with dextrocardia with situs inversus (DSI) totalis and inferior vena cava occlusion underwent radiofrequency catheter ablation because she had symptomatic paroxysmal atrial fibrillation (AF). Careful preoperative examination made successful pulmonary vein isolation through the left jugular vein approach. One-year later, however, AF recurred, and symptomatic sinus bradycardia or junctional bradycardia often occurred. Then, the pacemaker was implanted. We here reported a rare case of congenital abnormality, DSI with inferior vena cava occlusion who had undergone successful pulmonary vein isolation and pacemaker implantation without any complications.

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.

[Figure: see text].

Is transjugular insertion of a temporary pacemaker a safe and effective approach?

Temporary pacemakers (TPMs) are usually inserted in an emergency situation. However, there are few reports available regarding which route of access is best or what the most preferred approach is currently in tertiary hospitals. This study aimed to compare procedure times, complication rates, and indications for temporary pacing between the transjugular and transfemoral approaches to TPM placement. We analyzed consecutive patients who underwent TPM placement. Indications; procedure times; and rates of complications including localized infection, any bleeding, and pacing wire repositioning rates were analyzed. A total of 732 patients (361 treated via the transjugular approach and 371 treated via the transfemoral approach) were included. Complete atrioventricular block was the most common cause of TPM placement in both groups, but sick sinus syndrome was especially common in the transjugular approach group. Separately, procedure time was significantly shorter in the transjugular approach group (9.0 ± 8.0 minutes vs. 11.9 ± 9.7 minutes; P < 0.001). Overall complication rates were not significantly different between the two groups, and longer duration of temporary pacing was a risk factor for repositioning. The risk of reposition was significantly increased when the temporary pacing was continued more than 5 days and 3 days in the transjugular approach group and the transfemoral approach group, respectively. The transjugular approach should be considered if the TPM is required for more than 3 days.

[ECG pearl: sick sinus syndrome mimicking acute coronary syndrome - the aVR-sign]. / EKG-gyöngyszem: acut coronaria szindrómát utánzó sinuscsomó-betegség ­ az aVR-jel.

The aVR-sign can indicate left main or multivessel coronary disease, but the sign is not STEMI eqvivalent and is not a sensitive sign for coronary disese. The following case is an example of this. An 89-year-old woman was admitted with chest pain, atrial fibrillation and multiple lead ST-segment depression but ST-segment elevation in lead aVR. The aVR-sign indicated urgent angiography with negative result. A spontaneous sinus conversion was observed with repolarization normalisation. Later the ECG demonstrated SA-blocks, and sinus arrest. Sick sinus syndrome was diagnosed and the patient was treated with pacemaker and oral anticoagulant. Orv Hetil. 2020; 161(11): 434-436.

Registro Español de Marcapasos. XVI Informe Oficial de la Sección de Estimulación Cardiaca de la Sociedad Española de Cardiología (2018) / Spanish Pacemaker Registry. 16th Official Report of the Spanish Society of Cardiology Working Group on Cardiac Pacing (2018)

Introducción y objetivos: Se describe el resultado del análisis de los dispositivos de estimulación implantados y remitidos al Registro Español de Marcapasos en 2018. Métodos: Información que aporta la Tarjeta Europea del Paciente Portador de Marcapasos, así como los datos proporcionados por la industria sobre el número total de dispositivos implantados. Resultados: Se recibió información de 90 centros hospitalarios, con un total de 12.148 tarjetas, lo cual supone un 31% de la actividad total estimada. El consumo de generadores convencionales y de dispositivos de resincronización fue de 825 y 77 unidades por millón de habitantes respectivamente. La media de edad de los pacientes que recibieron un implante fue 78,3 años y un 54% de los dispositivos se implantaron en pacientes mayores de 80 años. El 77,1% de los procedimientos fueron primoimplantes y el 21,6%, recambios de generador. Aunque la estimulación secuencial bicameral sigue siendo mayoritaria, se utiliza menos en pacientes mayores de 80 años y en mujeres. Además, al 28% de los pacientes con enfermedad del nódulo sinusal y el 24,7% de aquellos con bloqueo auriculoventricular se los estimula en modo VVI/R pese a estar en ritmo sinusal. Conclusiones: El consumo total de generadores de marcapasos en España ha aumentado en un 1,2% con respecto al año 2017, fundamentalmente a expensas del aumento del consumo de generadores de terapia de resincronización cardiaca con marcapasos (8,7%). Los factores directamente relacionados con la elección del modo de estimulación son la edad y el sexo

Introduction and objectives: This report describes the result of the analysis of the implanted pacemakers reported to the Spanish Pacemaker Registry in 2018. Methods: The analysis is based on the information provided by the European Pacemaker Identification Card and supplier-reported data on the overall number of implanted pacemakers. Results: Information was received from 90 hospitals, with a total of 12 148 cards, representing 31% of the estimated activity. Use of conventional and resynchronization pacemakers was 825 and 77 units per million people, respectively. The mean age of the patients receiving an implant was 78.3 years, and 54% of the devices were implanted in people aged> 80 years. A total of 77.1% were first implants and 21.6% corresponded to generator exchanges. Bicameral sequential pacing was the most frequent pacing mode but was less frequently used in patients aged> 80 years and in women. Single chamber VVI/R pacing was used in 28% of patients with sick sinus syndrome and in 24.7% of those with atrioventricular block, despite being in sinus rhythm. Conclusions: The total consumption of pacemaker generators in Spain increased by 1.2% compared with 2017, mainly due to an 8.7% increase in cardiac resynchronization therapy with pacemaker generators. Selection of pacing mode was directly influenced by age and sex

Surgical Outcomes of Permanent Epicardial Pacing in Neonates and Young Infants Less Than 1 Year of Age.

BACKGROUND: Open surgical implantation of epicardial leads in neonates and infants remains the first option of treatment. We reviewed the long-term outcomes after epicardial pacemaker implantation in neonates and infants. METHODS: From 1989 to 2016, 48 patients (16 neonates) underwent pacemaker implantation within the first year of life. Their median age and weight were 66.5days (range: 0∼319 days), and 4.2kg (range: 1.9∼9.3kg), respectively, at the time of first pacemaker implantation. The indications for pacemaker implantation were postoperative or congenital atrioventricular block, sinus node dysfunction, and/or myocarditis-induced atrioventricular block. Forty-six (46) unipolar epicardial leads (non-steroid-eluting: 22; steroid-eluting: 24) and two bipolar leads (steroid-eluting) were inserted using a median sternotomy or subxiphoid approach. RESULTS: The mean follow-up duration was 8.5±7.9years. The most commonly used generator mode at first implantation was VVI (n=24, 50.0%). Eleven (11) generator mode changes from the initial VVI or VVIR to dual-chamber pacing were made at a mean of 7.0±6.2years after the first implantation for better inter-chamber synchrony and ventricular function. Freedom from reoperation for generator change after the first implantation was 95.3, 70.6, and 21.9% at 1, 5, and 10 years. Eighteen (18) lead malfunction events (34.1%) were detected. Freedom from reoperation for lead change was 97.8, 76.2, and 46.3% at 1, 5, and 10 years. The lead replacement rate was significantly higher in patients with non-steroid-eluting than steroid-eluting leads (p=0.045). CONCLUSIONS: Neonates and infants require more frequent changes in pacemaker generator and leads than the older population. The use of steroid-eluting leads increased lead longevity and reduced the need for surgical re-interventions.

Catheter ablation of paroxysmal atrial fibrillation in patients with sick sinus syndrome.

Sick sinus syndrome (SSS) frequently coexists with atrial fibrillation (AF). The results of AF ablation in patients with SSS have not been fully evaluated. We retrospectively investigated 65 patients with paroxysmal AF (PAF) and SSS who underwent AF ablation using either radiofrequency (n = 50) or cryoballoon ablation (n = 15) in our institute. Forty-nine (75.4%) patients had a median of 5.6 (4.8-6.0) s of documented sinus pauses prior to the procedure (42 patients on antiarrhythmic drugs), and were observed when AF terminated in 47 patients. Successful pulmonary vein isolation was achieved in all, and substrate modification was added in 3 patients. Freedom from recurrent atrial arrhythmias after single procedures was 58.7, 45.2, and 38.9% at 1, 2, and 3 years after the initial procedure. During a 23.4 (11.1-40.7) month median follow-up and after 1.4 ± 0.6 sessions, 80.6% of patients were free from arrhythmia recurrence; however, permanent pacemaker implantations were required in 9 (13.8%) patients at a median of 5.3 (2.9-21.0) months after initial procedures. The average heart rate did not significantly differ before or a median of 2.5 (1.2-5.3) months post-procedure (76.7 ± 17.4 vs. 73.5 ± 14.6 bpm, p = 0.90). Multivariate analyses revealed that larger left atrial diameters [odds ratio (OR) 1.21, 95% confidential interval (CI) 1.01-1.45, p = 0.042] were independent predictor of AF recurrence, and SSS type 1 was the sole predictor of pacemaker implantations (OR 10.30, 95% CI 1.38-76.7, p = 0.023), respectively. AF ablation obviated permanent pacemaker implantations in the majority of the patients with SSS and PAF, and SSS type 1 was a sole factor predicting pacemaker implantations.

Unifocal Right-Sided Ablation Treatment for Neurally Mediated Syncope and Functional Sinus Node Dysfunction Under Computed Tomographic Guidance.

Background Biatrial, extensive, and complex ablation strategies have been published for the treatment of neurally mediated syncope, sinus node dysfunction, and functional atrioventricular block. We have developed a less extensive and more specific approach compared with previously published cardioneuroablation strategies, called cardio-neuromodulation. It is based on tailored vagolysis of the sinoatrial node through partial ablation of the anterior right-ganglionated plexus, preferentially through a right-sided approach. Methods Patients with syncope were enrolled between December 2016 and December 2017. They were assigned to group A if they had a positive head-up tilt test and to group B if they presented with a pause ≥3 seconds. The area to target during cardio-neuromodulation was designed offline on a computed tomographic scan. Slow heart rates and pauses were compared during 24-hour rhythm registration at baseline, at 1-month follow-up, and 6-month follow-up. Syncope burden was assessed before the procedure and at 3- and 6-month follow-up. Results Twenty patients underwent cardio-neuromodulation through a right-sided approach (12 in group A, 8 in group B). The first application of radiofrequency energy led to a P-P interval shortening >120 ms in all 20 patients. After a mean±SD ablation time of 7±4 minutes and mean ablated surface area of 11±6 mm2, the P-P interval shortened by 219±160 ms ( P<0.001). The number of beats <50/min during 24-hour rhythm registration was reduced by a median of 100% at 6-month follow-up ( P<0.001). Syncope burden was reduced by 95% at 6-month follow-up ( P<0.001). Conclusions These data indicate that cardio-neuromodulation, through a right-sided and computed tomographic-guided procedure, is safe, fast, and highly reproducible in preventing inappropriate functional sinus bradycardia and syncope recurrence.

Catheter Ablation of Bradyarrhythmia: From the Beginning to the Future.

Enhanced parasympathetic tone may cause sinus bradycardia or pauses, transient or permanent atrioventricular block, with resultant vasovagal syncope. A substantial portion of these patients may be highly symptomatic and refractory to the conventional therapies and may require cardiac pacemaker implantation. Cardioneuroablation is a little known technique for management of patients with excessive vagal activation based on radiofrequency catheter ablation of main parasympathetic autonomic ganglia around the heart. Due to complicated inclusion criteria, ganglia detection methods, and ablation endpoints, routine usage of the procedure cannot be recommended at this time. In this comprehensive review, we aimed to discuss all aspects of cardioneuroablation procedure in bradyarrhythmias.

[A case of left atria subendocardial thrombus with sick sinus syndrome].

The clinical data for a patient with sick sinus syndrome was retrospectively analyzed. The patient was treated because of his heart palpitations and the increased chest pain. The patient admitted to the hospital under consideration for the left atrial tumor dependent on the echocardiography findings. After the CT scan and the dynamic ECG examination, the patient successfully underwent the left atrial tumor resection, atrial septal repair and cardiac pacing lead installation. The postoperative pathological diagnosis showed that the infective endocarditis and left atrial thrombus in left atrium was cured. The patient was discharged after postoperative anti-inflammatory therapy. By analyzing the reasons for misdignosis before or during surgery, the possible mechanisms for left atrial subendocardial thrombus have been found. This study suggests that it is necessary to combine imaging diagnosis and clinical observations to distinguish tumor from excrescence.

Impact of Catheter Ablation for Paroxysmal Atrial Fibrillation in Patients With Sick Sinus Syndrome　- Important Role of Non-Pulmonary Vein Foci.

BACKGROUND: The clinical efficacy of catheter ablation (CA) for paroxysmal atrial fibrillation (PAF) in patients with sick sinus syndrome (SSS) and the mechanism and predictors of recurrence are not yet completely elucidated. METHODS AND RESULTS: Of 963 consecutive patients who underwent PAF ablation during the study period, a total of 108 patients with SSS (SSS group) and 108 matched controls without SSS (non-SSS group) were followed up. During the follow-up period (mean, 32.8±17.5 months), the SSS group had significantly higher AF recurrence rate since the last procedure than the non-SSS group (26.9% vs. 12.0%; P=0.02). The SSS group had significantly higher prevalence of non-pulmonary vein (non-PV) foci than the non-SSS group (25.9% vs. 13.9%; P=0.027). On multivariate analysis congestive heart failure (HR, 13.7; 95% CI: 1.57-119; P=0.02) and non-PV foci (HR, 5.75; 95% CI: 1.69-19.6; P=0.005) were independent predictors of recurrence following CA in the SSS group. In the SSS group, 88 patients had bradycardia-tachycardia syndrome without prior permanent pacemaker implantation. Of these, 6 required pacemaker implantation because of AF and sinus pause recurrence. CONCLUSIONS: Patients with SSS are at higher risk of AF recurrence after CA. Non-PV foci are associated with AF recurrence following PAF with SSS.

Simplified Cardioneuroablation in the Treatment of Reflex Syncope, Functional AV Block, and Sinus Node Dysfunction.

BACKGROUND: Cardio neuroablation (CNA) is a lesser-known technique for management of patients with excessive vagal activation on the basis of radiofrequency catheter ablation (RFCA) of the areas related to the three main autonomic ganglia around the heart. We investigated the effectiveness of selective and/or stepwise RFCA of these areas via right atrium (RA) and/or left atrium (LA) in the patients with recurrent syncope due to excessive vagal activity. METHODS: Twenty-two patients presenting symptomatic functional bradyarrhythmias, neurally mediated reflex syncope (NMS), symptomatic atrioventricular (AV) block, and symptomatic sinus node dysfunction (SND; number = 8, 7, 7, respectively) were enrolled. The three main paracardiac ganglia were targeted via RA and LA in the patients with NMS and SND. The procedure was performed via RA in the patients with AV block, followed by RFCA of all ganglia via LA, if AV conduction disorder persists. The sites showing fragmented potentials were identified by electrical mapping and verified by high-frequency stimulation and ablated until atrial electrical potential was completely eliminated (<0.1 mV). RESULTS: The patients with NMS and SND were free from new syncopal episode at a mean 12.3 ± 3.4 months and 9.5 ± 3.1 months follow-up, respectively. Ablation from RA was successful in six of seven patients with AV block. Despite the increased heart rate, the resolution of AV block after the RFCA could not be achieved in one patient who had partial resolution with atropine infusion on admission. CONCLUSION: CNA may be an alternative and safe strategy to reduce NMS episodes, and to treat functional AV block and symptomatic SND, especially in young patients.