Multiple syncope mechanisms coexisting in a Brugada syndrome patient requiring a single therapeutic approach

Abstract

We report the case of a Brugada syndrome patient with a history of syncopal and presyncopal episodes and evidence of sinus node and atrioventricular (AV) conduction abnormalities. The patient developed sinus bradycardia, sinoatrial conduction abnormalities, prolonged HV interval, early appearance of AV block, AV nodal reentrant tachycardia and polymorphic ventricular tachycardia in the electrophysiological study. He was treated with a dual-chamber pacemaker defibrillator. At the 9-year follow-up, the patient remained asymptomatic with several episodes of 1:1 AV-relationship tachycardia, interrupted with antitachycardia pacing, while the predominant pacing states of the device were AP-VS and AS-VP for most of the time.

Syncope associated with supraventricular tachycardia: Diagnostic role of implantable loop recorders

“…Our case series demonstrate clearly that mixed syncope mechanisms may coexist in some patients (Dilaveris et al., 2020; Gatzoulis, Georgopoulos, et al., 2018; Vouliotis et al., 2013). This might explain the occasional syncope recurrence in a small proportion of appropriately treated with permanent pacing bradycardia patients (Gatzoulis et al., 1999).…”

“…The identification of the precise mechanism of syncope is crucial to assess prognosis and proceed to the optimal treatment option in order to minimize the risk of recurrence. However, not uncommonly, several different syncope mechanisms may operate in the same patient as suggested by different aspects of the diagnostic approach, namely the electrophysiology study (EPS), the tilt‐table testing (TTT), and the implantable loop recorder (ILR) monitoring (Dilaveris et al., 2020; Gatzoulis, Georgopoulos, et al., 2018; Vouliotis et al., 2013)…”

“…The identification of the precise mechanism of syncope is crucial to assess prognosis and proceed to the optimal treatment option in order to minimize the risk of recurrence. However, not uncommonly, several different syncope mechanisms may operate in the same patient as suggested by different aspects of the diagnostic approach, namely the electrophysiology study (EPS), the tilt-tabletesting(TTT),andtheimplantablelooprecorder(ILR)monitoring (Dilaverisetal.,2020;Gatzoulis,Georgopoulos,etal.,2018;Vouliotis et al, 2013) Although the pathogenetic background is not totally clarified, supraventricular arrhythmias are rather infrequently recognized as the only underlying condition responsible for syncope. Typical symptoms of supraventricular tachycardia, such as sensation of palpitations, dizziness, or shortness of breath, preceding a syncopal episode, raise the suspicion for a causal link between arrhythmia and loss of consciousness, especially when no signs indicating lifethreatening ventricular tachyarrhythmias have been identified in the diagnostic workup.…”

Management of Patients With Unexplained Syncope and Bundle Branch Block: Predictive Factors of Recurrent Syncope

“…The authors of this study proposed a simple risk score with bifascicular block and HV interval which is also effective in our population. However not infrequently multiple causes of syncope are revealed during a comprehensive approach [ 11 , 18 , 19 ]. Failure to define the cause of recurrent syncope despite analytical invasive and noninvasive investigation affects not only the quality of life but also the patient’s prognosis [ 20 ].…”