Shared Decision Making and Cardioneuroablation Allow Discontinuation of Permanent Pacing in Patients with Vagally Mediated Bradycardia

Sebastian Stec; Antoni Wileczek; Agnieszka Reichert; Janusz Śledź; Jarosław Kosior; Dariusz Jagielski; Anna Polewczyk; Magdalena Zając; Andrzej Kutarski; Dariusz Karbarz; Dorota Zyśko; Łukasz Nowarski; Edyta Stodółkiewicz-Nowarska

doi:10.3390/jcdd10090392

Shared Decision Making and Cardioneuroablation Allow Discontinuation of Permanent Pacing in Patients with Vagally Mediated Bradycardia

J Cardiovasc Dev Dis. 2023 Sep 11;10(9):392. doi: 10.3390/jcdd10090392.

Authors

Affiliations

¹ Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland.
² Department of Invasive Cardiology, County Specialistic Hospital, 37-450 Stalowa Wola, Poland.
³ El-Medica, EP-NETWORK, 26-110 Skarzysko-Kamienna, Poland.
⁴ Department of Cardiology, Masovian Specialist Hospital, 26-617 Radom, Poland.
⁵ Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, 50-981 Wroclaw, Poland.
⁶ Faculty of Medicine, Wrocław University of Science and Technology, 50-370 Wroclaw, Poland.
⁷ Department of Physiology, Pathophysiology and Clinical Immunology, Institute of Medical Sciences, Jan Kochanowski University, 25-369 Kielce, Poland.
⁸ Department of Cardiac Surgery, Świętokrzyskie Center of Cardiology, 25-736 Kielce, Poland.
⁹ Department of Special Pedagogy and Speech Therapy, Kazimierz Wielki University, 85-064 Bydgoszcz, Poland.
¹⁰ Department of Cardiology, Medical University, 20-059 Lublin, Poland.
¹¹ Department of Emergency Medicine, Wrocław Medical University, 50-367 Wroclaw, Poland.
¹² Vascular Surgery Department, The Brothers of Saint John of God Hospital, 31-061 Krakow, Poland.
¹³ Institute of Cardiovascular Science, 31-008 Krakow, Poland.

Abstract

Background: Safe discontinuation of pacemaker therapy for vagally mediated bradycardia is a dilemma. The aim of the study was to present the outcomes of a proposed diagnostic and therapeutic process aimed at discontinuing or not restoring pacemaker therapy (PPM) in patients with vagally mediated bradycardia.

Methods: The study group consisted of two subgroups of patients with suspected vagally mediated bradycardia who were considered to have PPM discontinued or not to restore their PPM if cardioneuroablation (CNA) would successfully treat their bradycardia. A group of 3 patients had just their pacemaker explanted but reimplantation was suggested, and 17 patients had preexisting pacemakers implanted. An invasive electrophysiology study was performed. If EPS was negative, extracardiac vagal nerve stimulation (ECVS) was performed. Then, patients with positive ECVS received CNA. Patients with an implanted pacemaker had it programmed to pace at the lowest possible rate. After the observational period and control EPS including ECVS, redo-CNA was performed if pauses were induced. The decision to explant the pacemaker was obtained based on shared decision making (SDM).

Results: After initial clinical and electrophysiological evaluation, 17 patients were deemed eligible for CNA (which was then performed). During the observational period after the initial CNA, all 17 patients were clinically asymptomatic. The subsequent invasive evaluation with ECVS resulted in pause induction in seven (41%) patients, and these patients underwent redo-CNA. Then, SDM resulted in the discontinuation of pacemaker therapy or a decision to not perform pacemaker reimplantation in all the patients after CAN. The pacemaker was explanted in 12 patients post-CNA, while in 2 patients explantation was postponed. During a median follow-up of 18 (IQR: 8-22) months, recurrent syncope did not occur in the CNA recipients.

Conclusions: Pacemaker therapy in patients with vagally mediated bradycardia could be discontinued safely after CNA.

Keywords: autonomic tests; bradycardia; cardioneuroablation; pacemaker; shared decision making; syncope; transvenous lead extraction.

Grants and funding

This research received an unrestricted grant from the Institute of Cardiovascular Science—CardioMedicum, Cracow, Poland.