Cardioneuroablation Versus Pacemaker Implantation for the Treatment of Symptomatic Sinus Node Dysfunction

Not Applicable

• Conditions: Sick Sinus Syndrome; Sinus Node Dysfunction
• Interventions: Device: Permanent dual chamber pacemaker implantation; Procedure: Cardioneuroablation

• Registration Number: NCT05186220
• Lead Sponsor: Hospital Clinico Universitario de Santiago

Brief Summary

Endocardial ganglion plexus ablation (cardioneuroablation) represents a promising therapeutic technique for the treatment of vasovagal syncope (VV), functional atrioventricular block (AVB) and sinus node dysfunction (SND) with a component of vagal hypertonia. Nevertheless, there is currently a paucity of literature about the results according to the type of presentation (VV, AVB or SND). The investigators aim to assess the safety and efficacy of cardioneuroablation for the treatment of symptomatic SND.

Detailed Description

Sinus node dysfunction (SND), also known as sick sinus syndrome, comprises a wide spectrum of sinoatrial dysfunctions, ranging from sinus bradycardia, sinoatrial block, and sinus arrest to bradycardia tachycardia syndrome. An additional manifestation of SND is an inadequate chronotropic response to exercise, reported as chronotropic incompetence. Since the first cardiac denervation was reported in 2005, several registries and retrospective studies using this therapeutic approach for reflex syncope, SND and functional atrioventricular block have been published. However, due to the lack of randomized studies, current guidelines recommend permanent pacemaker implantation for patients with symptomatic SND in order to improve symptoms. Therefore, the purpose of the present study is to assess the safety and efficacy of cardioneuroablation versus permanent pacemaker implantation for the treatment of symptomatic SND.

This is a multicenter, randomized, open, interventional study. After being informed of the study and potential risks, participants will undergo a one week screening period to determine eligibility for the study entry. During this week, participants will undergo an exercise test, atropine test, and a 24 hour-holter electrocardiogram. Then, participants who meet the eligibility criteria, will be randomized 1:1 to receive permanent pacemaker implantation (control group) or cardioneuroablation (interventional group).

The primary endpoint (improve in quality of life assessed with 36-Item Short Form Survey (SF-36)) will be evaluated at six months since randomization.

Study Timeline

• Study Start: 2021-11-01
• Study First Submitted: 2021-12-16
• Status Verified: 2022-01
• Study First Submitted QC: 2022-01-06
• Last Update Submitted: 2022-01-06
• Study First Posted: 2022-01-11
• Last Update Posted: 2022-01-11
• Primary Completion: 2023-11-01
• Study Completion: 2023-11-01

Recruitment & Eligibility

• Status: UNKNOWN
• Sex: All
• Target Recruitment: 40

Inclusion Criteria

• Symptomatic sinus node dysfunction (dizziness, asthenia or syncope) clearly related to an abnormal electrocardiogram finding (sinus arrest, sinoatrial block, extreme bradycardia (<40 bpm) or chronotropic incompetence in the exercise test).
• Absence of structural cardiopathy

Exclusion Criteria

• Left ventricular ejection fraction <50%
• Severe valvular disease
• Any type of cardiomyopathy such as hypertrophic cardiomyopathy
• Previous ischemic heart disease
• QRS interval >130 ms
• Atrioventricular conduction disorder with a former indication of pacemaker implantation (atrioventricular block Mobitz II, advanced atrioventricular block, complete atrioventricular block)
• Lifetime expectance <12 months

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Permanent pacemaker implantation	Permanent dual chamber pacemaker implantation	A dual chamber pacemaker implantation will be performed. The device will be programmed in a AAI-DDDR mode to avoid unnecessary ventricular pacing.
Cardioneuroablation	Cardioneuroablation	After 3D mapping of the surface of the left and right atrium and the superior vena cava (Ensite Navx or Carto system), localization of ganglion plexus (GP) will be performed either anatomically and/or by means of high frequency stimulation (HFS). The anterior and superior right sided GP will always be ablated per protocol. Other GP will be ablated according to interventional electrophysiologist judgement. The endpoint of the ablation procedure will be 1) absence of a vagal response after HFS from the right jugular vein and 2) an increase in at least 10 bpm as compared to baseline.

Primary Outcome Measures

Name	Time	Method
Change from baseline in the SF-36 Health Survey of quality of life	Baseline and 6 months	The SF-36 Health Survey is a validated, well known generic test for assessment of the health-related quality of life of patients.

Secondary Outcome Measures

Name	Time	Method
6 month free survival from permanent pacemaker implantation in the interventional group (cardioneuroablation)	Baseline and 6 months	Percentage of patients free from pacemaker at one year in the cardioneuroablation group
Differences in complications rates between both gropus	Baseline and 6 months	Most common complications regarding the procedure. In the cardioneuroablation group; complications regarding vascular access and pericardial tamponade. In the pacemaker group, pneumothorax, device infection and vascular access.
Differences in 6 month free survival from syncope between both groups	Baseline and 6 months	Syncope will be defined as any spontaneous loss of conscious with posterior recovery.
Change in maximal heart rate and chronotropic incompetence in the exercise test	Baseline and 6 months	All patients will perform a baseline exercise test and after 6 months. Maximal heart rate and chronotropic response will be recorded.

Trial Locations

Locations (1)

Hospital Clinico Universitario de Santiago; 🇪🇸 Santiago de Compostela, A Coruña, Spain