This is a response to the Letter to the Editor ‘Regarding ‘Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope'', by J D Martínez-Alday et al., https://doi.org/10.1093/europace/euad179. ‘Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope’, by M Brignole et al., https://doi.org/10.1093/europace/euad033.
This is a response to the Letter to the Editor, EUPC-D-23-00318, ‘Regarding “Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope”’, by Martínez-Alday et al., , about the article, ‘Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope’, by Brignole et al., https://doi.org/10.1093/europace/euad033.
We thank Martínez-Alday et al.1 for their remarks to the controversy article by Brignole et al.2 Their experience in this field is welcome and adds arguments to the current debate. At this stage of knowledge, many issues concerning clinical indications, methodology, and long-term results remain unresolved and are objects of debate among experts. Carefully reading the controversy, Martínez-Alday et al. can find that their opinions are shared by some of the authors of the controversy and not shared by others. The pro and contra opinions are clearly reported in the text. Until appropriately designed trials will be performed, they remain opinions, albeit respectful.
Going into more detail, the term ‘bradyarrhythmias due to parasympathetic hypertonia (BPH)’ is not reported in the classification of reflex syncope of current 2018 ESC guidelines.3 If such BPH causes syncope, it is the cardioinhibitory form of reflex syncope. If it causes other symptoms different from syncope or it is only an electrocardiographic finding, it is synonymous with the term ‘extrinsic (functional) sinus bradycardia and atrioventricular block’ used in the controversy article. Please refer to that section of the controversy.
The extracardiac vagus nerve stimulation for guiding cardioneuroablation has not been formally investigated in studies with clinical endpoints. Thus, its usefulness remains uncertain.
The pro and contra of a sham trial have been discussed in the proper section of the controversy. Such a study is currently ongoing in Europe.
References
- 1. Martínez-Alday JD, Carazo CM, Rodriguez-Manero M. Remarks to “Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope”. EUPC-D-23-00318. [DOI] [PMC free article] [PubMed]
- 2. Brignole M, Aksu T, Calò L, Debruyne P, Deharo JC, Fanciulli A et al. Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope. Europace 2023:euad033. Epub ahead of print. PMID: 37021351 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott P, Fanciulli A et al. 2018 ESC guidelines for the diagnosis and management of syncope. Eur Heart J 2018;39:1883–948. [DOI] [PubMed] [Google Scholar]