Cardioneuroablation for the treatment of recurrent swallow syncope.

This case report describes a 62year-old male with arterial hypertension and type 2 diabetes mellitus. The patient has been suffering from multiple episodes of loss of consciousness associated with falls and many injuries for the recent 8 years. All syncopal spells were triggered by swallowing of fluid. The physical examination was unremarkable. Cardiological and neurological workup (including head-up tit test, echocardiography, electroencephalography, and barium swallow test) did not reveal any significant abnormality. Provocation test with a cold carbonated beverage (Coca-Cola) reproduced the presyncope and simultaneous electrocardiogram monitoring documented sinus arrest of 7-s duration. Patients with idiopathic deglutition (swallow) syncope can be effectively treated by dual-chamber pacemaker implant, preferentially with rate-drop-response algorithm or closed-loop stimulation function. Our patient consented for an alternative treatment method—radiofrequency catheter ablation of ganglionic plexi (cardioneuroablation)—aimed at modification of parasympathetic input to the sinus node. Right atrial anatomy was reconstructed using an electroanatomic mapping system (CARTO-3, Biosense-Webster) with tagging of sites with phrenic nerve capture and sinus nodal region. Radiofrequency energy (Navistar Thermocool, 30 W/30 s, irrigation of 20 mL/min) was delivered at the posteroseptal portion of the junction between the right atrium and superior vena cava, i.e. at the superior part of the anterior right ganglionic plexus which is empirically the most effective site for sinus nodal denervation (Figure 1). A cluster of 10 lesions (total radiofrequency time of 328 s) resulted in modest but persistent sinus rate acceleration (from 60/min to 72/min). Intraprocedural provocation test by swallowing of cold water was negative and administration of atropine (2 mg intravenously) had virtually no effect on heart rate. The total procedural time was 100 min with a radiation dose of 27 lGy.m. During the 3-year follow-up, the patient did not experience the recurrence of the syncope, did not manifest other arrhythmias on Holter and did not report any adverse effects attributable to cardioneuroablation.