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      Selection of patients with symptomatic vagal-induced sinus node dysfunction: Who will be the best candidate for cardioneuroablation?


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          Sinus node dysfunction is a multifaceted disorder with variable manifestations, the prevalence of which increases with age. In a specific group of patients, excessive vagal activity may be the sole cause for this condition. These patients are characterized as having recurrent daytime symptoms attributed to bradyarrhythmia, no evidence of organic sinus node lesions, cardiac vagal overactivation, and are non-elderly. For sinus node dysfunction patients, a permanent pacemaker implantation appears to be the ultimate solution, although it is not an etiological treatment. Cardioneuroablation is a promising emerging therapy that can fundamentally eliminate symptoms in a highly selective sub-set of sinus node dysfunction patients by cardiac vagal nerve denervation. Denervation with ablation for vagal-induced sinus node dysfunction can effectively improve sinus bradycardia and reduce syncope. To date, guidelines for selection of suitable candidates for cardioneuroablation remain lacking. The primary objective of this study was to distinguish the nature of abnormal sinus node function and to find methods for quantifying vagal tone. Clear selection criteria could help physicians in identification of patients with autonomic imbalance, thereby maximizing patient benefits and the success rate of cardioneuroablations.

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          Most cited references52

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          2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope.

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            2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy

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              Advances in heart rate variability signal analysis: joint position statement by the e-Cardiology ESC Working Group and the European Heart Rhythm Association co-endorsed by the Asia Pacific Heart Rhythm Society.

              Following the publication of the Task Force document on heart rate variability (HRV) in 1996, a number of articles have been published to describe new HRV methodologies and their application in different physiological and clinical studies. This document presents a critical review of the new methods. A particular attention has been paid to methodologies that have not been reported in the 1996 standardization document but have been more recently tested in sufficiently sized populations. The following methods were considered: Long-range correlation and fractal analysis; Short-term complexity; Entropy and regularity; and Nonlinear dynamical systems and chaotic behaviour. For each of these methods, technical aspects, clinical achievements, and suggestions for clinical application were reviewed. While the novel approaches have contributed in the technical understanding of the signal character of HRV, their success in developing new clinical tools, such as those for the identification of high-risk patients, has been rather limited. Available results obtained in selected populations of patients by specialized laboratories are nevertheless of interest but new prospective studies are needed. The investigation of new parameters, descriptive of the complex regulation mechanisms of heart rate, has to be encouraged because not all information in the HRV signal is captured by traditional methods. The new technologies thus could provide after proper validation, additional physiological, and clinical meaning. Multidisciplinary dialogue and specialized courses in the combination of clinical cardiology and complex signal processing methods seem warranted for further advances in studies of cardiac oscillations and in the understanding normal and abnormal cardiac control processes.

                Author and article information

                Front Physiol
                Front Physiol
                Front. Physiol.
                Frontiers in Physiology
                Frontiers Media S.A.
                07 February 2023
                : 14
                : 1088881
                [1] 1 Cardiac Arrhythmia Center , Heart Center , The People’s Hospital of Zhengzhou University , Henan Provincial People’s Hospital , Huazhong Fuwai Hospital , Zhengzhou, Henan, China
                [2] 2 Cardiac Arrhythmia Center , National Center for Cardiovascular Diseases , Chinese Academy of Medical Sciences and Peking Union Medical College , Fuwai Hospital , Beijing, China
                Author notes

                Edited by: Chloe E. Taylor, Western Sydney University, Australia

                Reviewed by: David G. Benditt, University of Minnesota, United States

                Piotr Kulakowski, Grochowski Hospital, Poland

                *Correspondence: Lihui Zheng, zhenglihui@ 123456263.net ; Yan Yao, ianyao@ 123456263.net.cn

                This article was submitted to Autonomic Neuroscience, a section of the journal Frontiers in Physiology

                Copyright © 2023 Cai, Zheng and Yao.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                : 03 November 2022
                : 30 January 2023
                Funded by: National Key Research and Development Program of China , doi 10.13039/501100012166;
                Award ID: 2017YFC1307800
                This work was supported by the top-level hospital clinical scientific research funds from the Chinese Academy of Medical Sciences Fuwai Hospital (2022-GSP-QZ-4), The Characteristic Clinical Application Research of Capital (Z191100006619019) and National Key Research and Development Program of China (2017YFC1307800).

                Anatomy & Physiology
                cardioneuroablation,sinus node dysfunction,selection criteria,cardiac vagal tone,deceleration capacity of heart rate


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