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Rose Anne Kenny - One of the best experts on this subject based on the ideXlab platform.
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Carotid Sinus Syndrome—Clinical Characteristics in Elderly Patients
2016Co-Authors: Rose Anne Kenny, Gary TraynorAbstract:Carotid Sinus massage was carried out on 130 consecutive patients referred for investigation of dizziness, syncope or unexplained falls. Carotid Sinus Syndrome was diagnosed in 33 for whom no other cause of symptoms was identified. Right-sided hypersensitivity was more frequent than left-sided. Thirty per cent identified a prodrome before syncope and 30 % had retrograde amnesia for the event. In 52%, symptoms were precipitated by head movement and in 48 % by vagal stimuli. Seven described 'drop attacks ' but symptoms were reproduced with Carotid Sinus massage during head-up tilt. Injuries, including fractured neck of femur, were sustained by the majority. Carotid Sinus massage should be performed routinely on all elderly patients who have symptoms of unexplained dizziness, falls or syncope. Cardiac pacing relieves syncopal symptoms in those with a predominant cardio-inhibitory response and recurrent syncope
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cardioinhibitory Carotid Sinus Syndrome a mathematical model
International Conference of the IEEE Engineering in Medicine and Biology Society, 2015Co-Authors: Ciaran Finucane, Rose Anne Kenny, Gerard BoyleAbstract:Carotid Sinus massage (CSM) is a simple clinical test for stimulating the Carotid Sinus reflex. During CSM, firm longitudinal massage is applied at the point of maximal pulsation over the Carotid bifurcation resulting in relative bradycardia. CSM is used to diagnose Cardioinhibitory Carotid Sinus Syndrome (CICSS). CICSS is an age-related disorder, characterized by profound symptomatic cardioinhibition (> 3 seconds pause) following CSM. CICSS prevalence increases with age and is responsible for 1 to 20% of all pacemaker implantations per year. Treatment options for CSS are limited and much debate still remains around its underlying etiology. In this paper we present a first computer simulation of Carotid Sinus massage (CSM) in older adults and demonstrate its ability to simulate normal heart rate responses to CSM. Importantly we demonstrate that our mathematical model requires inclusion of model elements to simulate autonomic control of perinodal T-cell activity in order to replicate the profound cardioinhibitory response observed in CICSS. Our model findings implicate CSS as a candidate biomarker of biological aging and frailty.
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cerebral autoregulation is impaired in cardioinhibitory Carotid Sinus Syndrome
Heart, 2005Co-Authors: Steve W Parry, Mary Baptist, Nick Steen, Kathia Fiaschi, Olwen Parry, Rose Anne KennyAbstract:Objectives: To compare changes in cerebral autoregulation in response to controlled, lower body negative pressure-induced hypotension in patients with Carotid Sinus Syndrome (CSS) and case controls. Design: Prospective case controlled study. Setting: Secondary and tertiary referral falls and syncope service. Patients: 17 consecutive patients with CSS and 11 asymptomatic controls. Interventions: Hypotension insufficient to cause syncope induced by lower body negative pressure (minimum 30 mm Hg fall in systolic blood pressure (SBP)) during concomitant transcranial Doppler ultrasonography. Main outcome measures: Cerebral autoregulation (systolic, diastolic and mean middle cerebral arterial blood flow velocities and cerebrovascular resistance) with continuous end-tidal carbon dioxide and haemodynamic monitoring. Results: Cerebral autoregulatory indices differed significantly between patients with CSS and controls. Systolic, diastolic and middle cerebral arterial blood flow velocities were, respectively, 9.2 m/s (95% confidence interval (CI) 2.9 to 15.4 m/s), 4.7 m/s (95% CI 1.5 to 7.9 m/s) and 6.9 m/s (95% CI 2.5 to 11.4 m/s) slower in patients with CSS. Cerebrovascular resistance was significantly greater in patients with CSS than in controls at SBP nadir and suction release; differences were 0.9 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s) and 0.8 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s), respectively. End-tidal carbon dioxide and systemic haemodynamic variables were similar for patients and controls at baseline and during lower body negative pressure. Conclusions: Cerebral autoregulation is altered in patients with CSS. This difference may have aetiological implications in the differential presentation with falls and drop attacks rather than syncope.
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2 bradyarrhythmias sick Sinus Syndrome Carotid Sinus Syndrome
Europace, 2005Co-Authors: Rose Anne Kenny, Clive Ballard, Ruth Pearce, J Hampton, Simon Kerr, M WiddringtonAbstract:Objectives To determine the prevalence of Carotid Sinus hypersensitivity (CSH) and define heart rate (HR) and blood pressure (BP) responses to Carotid Sinus massage (CSM) in (a) an unselected community sample of older people and (b) a sub-sample with no prior history of syncope, dizziness or falls. Methods One thousand subjects were randomly sampled from a general practice database of 1517 patients over 65 years and stratified for age and gender. Consenting participants underwent detailed clinical assessment prior to supine and upright Carotid Sinus massage CSM with continuous heart rate and phasic blood pressure monitoring. CSH was defined as asystole in excess of 3 seconds and / or a drop in SBP of greater than 50mmHg. Results 272 participants had CSM. CSH was present in 107 (39%); 27% had asystole >3 seconds during CSM; 16% had symptoms (including syncope) with CSH. Previous history of syncope falls or dizziness was not predictive of CSH. Age (OR 1.05 95%CI 1.00, 1.09) and male sex (OR 1.71; 95%CI 1.04, 2.82) were the only independent predictors of CSH. In a previously asymptomatic sub-sample of 80 participants, CSH was present in 28 (35%). The 95th percentile for response was 7.3 seconds' asystole and 77mmHg drop in systolic blood pressure (7.1 seconds and 74mmHg when supine; 5.6 seconds and 76mmHg when erect). Conclusion CSH is common in older persons, even those with no prior history of syncope, dizziness, or falls. Derived normal thresholds for heart rate and blood pressure responses are larger than previously reported in symptomatic groups. When present, CSH cannot be assumed to be the attributable cause in those presenting with syncope and further work is required to determine the factors which transform CSH into a symptomatic state.
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amnesia for loss of consciousness in Carotid Sinus Syndrome implications for presentation with falls
Journal of the American College of Cardiology, 2005Co-Authors: Steve W Parry, Nick I Steen, Mary Baptist, Rose Anne KennyAbstract:OBJECTIVES The goal of this study was to compare the clinical characteristics of patients with Carotid Sinus Syndrome who presented with falls with those who presented with syncope. BACKGROUND Carotid Sinus Syndrome presents with both falls and syncope. The reasons for this differential presentation are unknown, but amnesia for loss of consciousness may be the underlying cause. METHODS Two groups of 34 consecutive patients with Carotid Sinus Syndrome as the sole cause of falls and syncope were recruited. Cognitive function and clinical characteristics were compared between the two groups. RESULTS Syncopal subjects with Carotid Sinus Syndrome were more likely to be older males (18 [53%] vs. 7 [21%] years; p = 0.006) with a longer duration of symptoms (27.9 vs. 13.3 months; p = 0.009) and more soft tissue injuries (19 [56%] vs. 9 [26%]; p = 0.03). Duration of asystole during Carotid Sinus massage was similar in both groups (5.1 vs. 5.4 s; p = 0.42), but witnessed amnesia for loss of consciousness was more frequent in fallers than those with syncope (21 [95%] vs. 4 [12%]; p < 0.001). Clinical characteristics and cognitive function were otherwise similar in both groups. CONCLUSIONS Patients with Carotid Sinus Syndrome have similar rates of witnessed loss of consciousness during laboratory testing regardless of symptoms. However, those presenting with falls are far less likely to perceive any disturbance of consciousness than those with syncope, showing for the first time the manner in which such patients manifest symptoms. Cognitive impairment does not explain the amnesia for loss of consciousness seen in fallers with Carotid Sinus Syndrome.
Michele Brignole - One of the best experts on this subject based on the ideXlab platform.
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incidence and predictors of syncope recurrence after cardiac pacing in patients with Carotid Sinus Syndrome
International Journal of Cardiology, 2018Co-Authors: Giulia Rivasi, Michele Brignole, R Sutton, Martina Rafanelli, Francesca Tesi, Alice Ceccofiglio, Diana Solari, Andrea UngarAbstract:Abstract Background Cardiac pacing is the treatment of choice for cardioinhibitory Carotid Sinus Syndrome (CSS), but syncope recurrence occurs in up to 20% of patients within 3 years. The present study aims at assessing incidence and identifying predictors of syncope recurrence in patients receiving pacing therapy for CSS. Methods The Syncope Clinics of two large regional hospitals in Northern Italy, both following European Syncope Guidelines, combined to perform this study. Retrospective analysis of 3127 consecutive patients undergoing Carotid Sinus massage (CSM) was performed 2004–2014. Ten-second supine and standing CSM was systematically assessed in patients aged >40 years with suspected reflex syncope as part of the initial evaluation. Syncope recurrence was investigated in those paced for CSS having >6 months' available follow-up. Data were collected from clinical records and patient interviews. Results CSS was diagnosed in 261 patients (8.3%). Pacemakers were implanted in 158, with follow-up data available in 112: 19 (17%) experienced 73 syncope recurrences during a mean follow-up of 89 ± 42 months, yielding an incidence of 0.5 episodes per patient/year. Prodrome, predisposing situations preceding syncope and chronic nitrate therapy were more frequent in patients reporting recurrence. Prodrome and predisposing situations remained independent predictors of post-implantation recurrence on multivariable analysis. Conclusions CSS is a frequent cause of syncope, if CSM is performed during the initial evaluation. Most patients treated by pacing remain asymptomatic during long-term follow-up. In those who have recurrence, its incidence is very low. Prodrome and predisposing situations are predictors of post-implantation recurrence, suggesting presence of hypotensive susceptibility.
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073_16760 predictors of syncopal recurrence after cardiac pacing in patients with Carotid Sinus Syndrome
JACC: Clinical Electrophysiology, 2017Co-Authors: Martina Rafanelli, Michele Brignole, Giulia Rivasi, D Solari, Francesca Tesi, Alice Ceccofiglio, F C Sacco, S Venzo, I Giannini, Andrea UngarAbstract:In cardio-inhibitory Carotid Sinus Syndrome (CI-CSS), syncopal recurrence is expected to occur in up to the 20% of patients after pacing therapy. The present study analyzes post-implantation syncopal recurrence in CI-CSS, to identify predictors of recurrence. We retrieved electronic records
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assessment of the vasodepressor reflex in Carotid Sinus Syndrome
Circulation-arrhythmia and Electrophysiology, 2014Co-Authors: Diana Solari, Daniele Oddone, Roberto Maggi, Alberto Solano, Francesco Croci, Paolo Donateo, Wouter Wieling, Michele BrignoleAbstract:Background— Assessment of the vasodepressor reflex in Carotid Sinus Syndrome is influenced by the method of execution of the Carotid Sinus massage and the coexistence of the cardioinhibitory reflex. Methods and Results— Carotid Sinus massage reproduced spontaneous symptoms in 164 patients in the presence of hypotension or bradycardia (method of symptoms). When an asystolic pause was induced, the vasodepressor reflex was reassessed after suppression of the asystolic reflex by means of 0.02 mg/kg IV atropine. An isolated vasodepressor form was found in 32 (20%) patients, who had lowest systolic blood pressure (SBP) of 65±15 mm Hg. Of these, only 21 (66%) patients had an SBP fall ≥50 mm Hg, which is the universally accepted cut-off value for the diagnosis of the vasodepressor form. Conversely, a lowest SBP value of ≤85 mm Hg (corresponding to the fifth percentile) detected 97% of vasodepressor patients, but was also present in 84% of the 132 patients with an asystolic reflex. These latter patients had both asystole ≥3 s (mean 7.6±2.2 s) and SBP fall to 63±22 mm Hg: in 46 (28%) patients, symptoms persisted after atropine (mixed form), in the remaining 86 (52%) patients, symptoms did not (cardioinhibitory form) persist. Conclusions— The current definition of ≥50 mm Hg SBP fall failed to identify one third of patients with isolated vasodepressor form. A cut-off value of symptomatic SBP of ≤85 mm Hg seems more appropriate, but it is unable to identify cardioinhibitory forms. In asystolic forms, atropine testing is able to distinguish a cardioinhibitory form from a mixed form.
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clinical context and outcome of Carotid Sinus Syndrome diagnosed by means of the method of symptoms
Europace, 2014Co-Authors: Diana Solari, Daniele Oddone, Roberto Maggi, Alberto Solano, Francesco Croci, Paolo Donateo, Michele BrignoleAbstract:Aims The prevalence and outcome of Carotid Sinus Syndrome (CSS) reported in the literature vary owing to differences in indications and methods of Carotid Sinus massage (CSM). Methods and results We performed CSM on all patients aged 40 years and above with unexplained syncope after the initial evaluation. Carotid Sinus massage was performed in the supine and standing positions on both sides for 10 s during continuous electrocardiogram and blood pressure monitoring; CSS was diagnosed in the event of an abnormal response to CSM in association with reproduction of spontaneous symptoms (‘method of symptoms’). From July 2005 to July 2012, CSS was found in 164 (8.8%) of 1855 patients (mean age 77 ± 9 years, 73% males): 81% had an asystolic reflex (mean pause 7.6 ± 2.2 s) and 19% a vasodepressor reflex (mean lowest systolic blood pressure 65 ± 15 mmHg). Potential multifactorial causes of syncope (orthostatic hypotension, bundle branch block, bradycardia, tachyarrhythmias) were found in 74% of patients. One hundred forty-one patients received the proper care [advice on lifestyle measures in all, discontinuation (#40) or reduction (#17) of antihypertensive drugs, pacemaker implantation (#57)] and were followed up for 39 ± 25 months. Syncope recurred in 23 patients; the actuarial syncopal recurrence rate was 7% at 1 year and 26% at 5 years. Total syncopal episodes decreased from 91 per year during the 2 years before evaluation to 21 episodes per year during follow-up ( P = 0.001). On Cox proportional-hazards regression, a mixed or vasodepressor response to tilt testing was the only independent predictor of syncopal recurrence (hazard ratio = 1.8; P = 0.01). Conclusion Carotid Sinus massage by means of the ‘method of symptoms’ indentifies a clinical Syndrome with definite features and outcome. A treatment strategy involving lifestyle measures, reduction of antihypertensive drugs and cardiac pacing when appropriate is effective in reducing the syncopal recurrence rate.
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A positive response to head-up tilt testing predicts syncopal recurrence in Carotid Sinus Syndrome patients with permanent pacemakers
American Journal of Cardiology, 1995Co-Authors: Germano Gaggioli, Michele Brignole, Carlo Menozzi, Nicola Bottoni, Lorella Gianfranchi, Daniele Oddone, Gianluigi Devoto, Enrico Gostoli, Gino LolliAbstract:Abstract In conclusion, most of the Carotid Sinus Syndrome patients who have syncopal recurrence despite pacing therapy have a positive response to head-up tilt testing, which suggests the presence of a more complex neurogenic disease.
R S Bexton - One of the best experts on this subject based on the ideXlab platform.
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Carotid Sinus Syndrome a modifiable risk factor for nonaccidental falls in older adults safe pace
Journal of the American College of Cardiology, 2001Co-Authors: Rose Anne Kenny, D A Richardson, R S Bexton, Nick Steen, F E Shaw, John BondAbstract:Abstract OBJECTIVES The aim of the study was to determine whether cardiac pacing reduces falls in older adults with cardioinhibitory Carotid Sinus hypersensitivity (CSH). BACKGROUND Cardioinhibitory Carotid Sinus Syndrome causes syncope, and symptoms respond to cardiac pacing. There is circumstantial evidence for an association between falls and the Syndrome. METHODS A randomized controlled trial was done of consecutive older patients (>50 years) attending an accident and emergency facility because of a non-accidental fall. Patients were randomized to dual-chamber pacemaker implant (paced patients) or standard treatment (controls). The primary outcome was the number of falls during one year of follow-up. RESULTS One hundred seventy-five eligible patients (mean age 73 ± 10 years; 60% women) were randomized to the trial: pacemaker 87; controls 88. Falls (without loss of consciousness) were reduced by two-thirds: controls reported 669 falls (mean 9.3; range 0 to 89), and paced patients 216 falls (mean 4.1; range 0 to 29). Thus, paced patients were significantly less likely to fall (odds ratio 0.42; 95% confidence interval: 0.23, 0.75) than were controls. Syncopal events were also reduced during the follow-up period, but there were much fewer syncopal events than falls—28 episodes in paced patients and 47 in controls. Injurious events were reduced by 70% (202 in controls compared to 61 in paced patients). CONCLUSIONS There is a strong association between non-accidental falls and cardioinhibitory CSH. These patients would not usually be referred for cardiovascular assessment. Carotid Sinus hypersensitivity should be considered in all older adults who have non-accidental falls.
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clinical experience of a new rate drop response algorithm in the treatment of vasovagal and Carotid Sinus syncope
Europace, 2000Co-Authors: J B Johansen, R S Bexton, Toby Markowitz, E H Simonsen, M K EricksonAbstract:Dual chamber pacing has proven beneficial in patients with sudden drops in heart rate as seen in vasovagal syncope and Carotid Sinus Syndrome. Newer algorithms for faster detection of an insidious drop in heart rate and short lasting intervention pacing at a high rate, as in the rate drop response algorithm in the Medtronic Kappa series of pacemakers, might improve the effect of pacing. Two case reports, that demonstrate the use of these rate drop response algorithms, are presented. A 24-year-old woman with recurrent episodes of syncope and repeated tilt-table tests with vasovagal cardioinhibitory outcomes had a Medtronic Kappa 400 pacemaker implanted. Syncope was abolished during repeat tilt-table testing following pacemaker implantation and proper functioning of the rate drop response algorithm. The patient has been free of syncope during follow-up apart from a single episode that occurred due to neglect of vasovagal warning symptoms. A 52-year-old man with coronary artery disease developed recurrent blackouts. Carotid Sinus massage resulted in 5·5 s of asystole and presyncope. A Medtronic Kappa 700 pacemaker with a rate drop response algorithm was implanted and the patient became asymptomatic. The rate drop response algorithm is discussed in detail based upon the case reports, and recommendations are given for the use of this algorithm in patients with vasovagal syncope and Carotid Sinus Syndrome. (Europace 2000; 2: 245–250)
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a study comparing vvi and ddi pacing in elderly patients with Carotid Sinus Syndrome
Heart, 1997Co-Authors: S J Mcintosh, J Lawson, R S Bexton, R G Gold, M Tynan, Rose Anne KennyAbstract:OBJECTIVE: To determine whether single chamber ventricular demand (VVI) pacing is adequate for elderly patients with Carotid Sinus Syndrome. DESIGN: Prospective double blind randomised cross over study. SETTING: Tertiary referral centre. PATIENTS: 30 consecutive patients aged over 60 years with Carotid Sinus Syndrome referred for cardiac pacing. INTERVENTION: Patients underwent dual chamber pacemaker implantation and were then randomised to two three-month periods of VVI and DDI pacing. MAIN OUTCOME MEASURES: Responses to cardiovascular tests (vasodepression during Carotid Sinus massage, pacemaker effect, postural blood pressure measurements, and response to head up tilt), and symptoms. RESULTS: 11 patients developed profound hypotension during upright Carotid Sinus massage while pacing VVI compared with only two while pacing DDI. The upright pacemaker effect was greater in VVI (VVI, -31 (SD 19) mm Hg v DDI, -4 (12) mm Hg; P < 0.001). Postural blood pressure measurements and responses to head up tilt did not vary. Eleven patients were unable to tolerate VVI pacing and had to be withdrawn early from this limb of the study (group A). Fourteen of the remainder completed diary cards and did not express a preference (group B). No patient preferred VVI. Group A patients were older (group A, 78 (6) years v group B, 70 (9) years; P < 0.05), were more likely to be female (group A, 73% v group B, 14%; P < 0.01), and were more likely to have orthostatic hypotension while pacing DDI (group A, 46% v group B, 0%; P < 0.01). Group A and B patients could not be differentiated by other prepacing clinical or haemodynamic variables. CONCLUSIONS: Elderly patients with Carotid Sinus Syndrome are likely to develop symptomatic hypotension following VVI pacing. The optimum pacing mode for individual patients cannot be predicted by simple cardiovascular tests before pacing.
R J Toorop - One of the best experts on this subject based on the ideXlab platform.
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long term safety and efficacy of internal Carotid artery adventitial stripping in Carotid Sinus Syndrome
Current Hypertension Reviews, 2014Co-Authors: R J Toorop, Frans L Moll, R F Visser, Marc R ScheltingaAbstract:Background: To investigate the long term efficacy of Carotid denervation by adventitial stripping of the internal Carotid artery (ICA) for Carotid Sinus Syndrome (CSS). Secondly, the long term safety of this technique is investigated with emphasis on the effects on blood pressure (BP), heart rate (HR) and Carotid artery diameter. Methods: Characteristics of patients that were operated for CSS in a single institute between 1980-2007 were studied by a retrospective chart review. Alive and fit patients additionally received a standardized interview investigating symptoms of residual CSS or baroreflex failure. They underwent a test panel consisting of office BP measurement, Carotid Sinus massage (CSM), table tilt testing, 24-hour ECG and ambulatory BP measurement (ABPM) and Carotid duplex. Unoperated, age- and sex- matched individuals without CSS served as controls. Results: After a total follow up of 91±34 months, 22 of 26 patients (85%) were asymptomatic and 20 of them (77%) without a pacemaker. Of the 7 surviving and fit patients, six were free of CSS symptoms (follow up 114 ± 81 months). Recurrence of CSS after an initial successful Carotid denervation was not observed. BP level, BP variability and Carotid diameters were not different compared to controls. Conclusion: Carotid denervation by adventitial stripping of the ICA for CSS seems effective and safe on the long term. A randomized controlled trial comparing the efficacy and safety of Carotid denervation, pacing and medical treatment is needed for optimal future treatment of patients suffering from CSS.
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clinical results of Carotid denervation by adventitial stripping in Carotid Sinus Syndrome
European Journal of Vascular and Endovascular Surgery, 2010Co-Authors: R J Toorop, Marc R Scheltinga, M C Huige, Frans L MollAbstract:Abstract Aims Older patients with spells of syncope may suffer from a Carotid Sinus Syndrome (CSS). Patients with invalidating CSS routinely receive pacemaker treatment. This study evaluated the safety and early outcome of a surgical technique termed Carotid denervation by adventitial stripping for CSS treatment. Methods Carotid Sinus massage (CSM) during cardiovascular monitoring confirmed CSS in patients with a history of repeated syncope and dizziness. The internal Carotid artery was surgically denervated by adventitial stripping over a minimum distance of 3cm via a standard open approach. Patient characteristics, perioperative complications and 30-day success rate were analyzed. Results A total of 39 Carotid denervation procedures was performed in 27 individuals (23 males, mean age 70±3 years) between 1980 and 2007 in a single institution. Eleven patients had a bilateral hypersensitive Carotid Sinus. Procedure related complications included wound hematoma ( n =4), neuropraxia of the marginal mandibular branch of the facial nerve ( n =2) and dysrhythmia responding to conservative treatment ( n =3). Significant alterations in systolic and diastolic blood pressure and heart rate were not observed. One patient developed a cerebral ischaemic vascular accident on the 24th postoperative day. One patient with residual disease had a successful redenervation within 1 month after the initial operation. Two patients with persistent symptoms received a pacemaker but also to no avail. At 30-day follow up 25 of 27 patients (93%) were free of syncope, and 24 free of a pacemaker (89%). Conclusion Carotid denervation by adventitial stripping of the proximal Carotid internal artery is effective and safe and may offer a valid alternative for pacemaker treatment in patients with Carotid Sinus Syndrome.
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adventitial stripping for Carotid Sinus Syndrome
Annals of Vascular Surgery, 2009Co-Authors: R J Toorop, Marc R Scheltinga, Frans L MollAbstract:Patients with a Carotid Sinus Syndrome (CSS) suffer from spells of dizziness and loss of conscience due to an exaggerated Carotid baroreflex response. Three types of the Syndrome are described: cardioinhibitory, vasodepressor and a mixed form. The gold standard for treatment is insertion of a pacemaker, but this therapy may be effective only in a pure cardioinhibitory type. In contrast, surgically interrupting afferent nerves at the origin may offer relief of symptoms in all three types. The present review analyzes the results of a surgical technique termed "adventitial stripping" of the Carotid Sinus. Data from 130 procedures demonstrate that Carotid denervation is effective in 85% of CSS cases with low complication rates. Postoperative monitoring is mandatory as transient alterations in blood pressure and heart rate may occur.
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anatomy of the Carotid Sinus nerve and surgical implications in Carotid Sinus Syndrome
Journal of Vascular Surgery, 2009Co-Authors: R J Toorop, Marc R Scheltinga, Frans L Moll, Ronald L A W BleysAbstract:Background The Carotid Sinus Syndrome (CSS) is characterized by syncope and hypotension due to a hypersensitive Carotid Sinus located in the Carotid bifurcation. Some patients ultimately require surgical Sinus denervation, possibly by transection of its afferent nerve (Carotid Sinus nerve [CSN]). The aim of this study was to investigate the anatomy of the CSN and its branches. Methods Twelve human Carotid bifurcations were microdissected. Acetylcholinesterase (ACHE) staining was used to identify location, side branches, and connections of the CSN. Results A distinct CSN originating from the glossopharyngeal (IX) nerve was identified in all specimens. A duplicate CSN was incidentally present (2/12). Mean CSN length measured from the hypoglossal (XII) nerve to the Carotid Sinus was 29 ± 4 mm (range, 15-50 mm). The CSN was frequently located on anterior portions of the internal Carotid artery, either laterally (5/12) or medially (6/12). Separate connections to pharyngeal branches of the vagus (X) nerve (6/12), vagus nerve itself (3/12), sympathetic trunk (2/12), as well as the superior cervical ganglion (2/12) were commonly observed. The CSN always ended in a network of small separate branches innervating both Carotid Sinus and Carotid body. Conclusion Anatomical position of the CSN and its side branches and communications is diverse. From a microanatomical standpoint, CSN transection as a single treatment option for patients with CSS is suboptimal. Surgical denervation at the Carotid Sinus level is probably more effective in CSS.
Frans L Moll - One of the best experts on this subject based on the ideXlab platform.
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long term safety and efficacy of internal Carotid artery adventitial stripping in Carotid Sinus Syndrome
Current Hypertension Reviews, 2014Co-Authors: R J Toorop, Frans L Moll, R F Visser, Marc R ScheltingaAbstract:Background: To investigate the long term efficacy of Carotid denervation by adventitial stripping of the internal Carotid artery (ICA) for Carotid Sinus Syndrome (CSS). Secondly, the long term safety of this technique is investigated with emphasis on the effects on blood pressure (BP), heart rate (HR) and Carotid artery diameter. Methods: Characteristics of patients that were operated for CSS in a single institute between 1980-2007 were studied by a retrospective chart review. Alive and fit patients additionally received a standardized interview investigating symptoms of residual CSS or baroreflex failure. They underwent a test panel consisting of office BP measurement, Carotid Sinus massage (CSM), table tilt testing, 24-hour ECG and ambulatory BP measurement (ABPM) and Carotid duplex. Unoperated, age- and sex- matched individuals without CSS served as controls. Results: After a total follow up of 91±34 months, 22 of 26 patients (85%) were asymptomatic and 20 of them (77%) without a pacemaker. Of the 7 surviving and fit patients, six were free of CSS symptoms (follow up 114 ± 81 months). Recurrence of CSS after an initial successful Carotid denervation was not observed. BP level, BP variability and Carotid diameters were not different compared to controls. Conclusion: Carotid denervation by adventitial stripping of the ICA for CSS seems effective and safe on the long term. A randomized controlled trial comparing the efficacy and safety of Carotid denervation, pacing and medical treatment is needed for optimal future treatment of patients suffering from CSS.
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clinical results of Carotid denervation by adventitial stripping in Carotid Sinus Syndrome
European Journal of Vascular and Endovascular Surgery, 2010Co-Authors: R J Toorop, Marc R Scheltinga, M C Huige, Frans L MollAbstract:Abstract Aims Older patients with spells of syncope may suffer from a Carotid Sinus Syndrome (CSS). Patients with invalidating CSS routinely receive pacemaker treatment. This study evaluated the safety and early outcome of a surgical technique termed Carotid denervation by adventitial stripping for CSS treatment. Methods Carotid Sinus massage (CSM) during cardiovascular monitoring confirmed CSS in patients with a history of repeated syncope and dizziness. The internal Carotid artery was surgically denervated by adventitial stripping over a minimum distance of 3cm via a standard open approach. Patient characteristics, perioperative complications and 30-day success rate were analyzed. Results A total of 39 Carotid denervation procedures was performed in 27 individuals (23 males, mean age 70±3 years) between 1980 and 2007 in a single institution. Eleven patients had a bilateral hypersensitive Carotid Sinus. Procedure related complications included wound hematoma ( n =4), neuropraxia of the marginal mandibular branch of the facial nerve ( n =2) and dysrhythmia responding to conservative treatment ( n =3). Significant alterations in systolic and diastolic blood pressure and heart rate were not observed. One patient developed a cerebral ischaemic vascular accident on the 24th postoperative day. One patient with residual disease had a successful redenervation within 1 month after the initial operation. Two patients with persistent symptoms received a pacemaker but also to no avail. At 30-day follow up 25 of 27 patients (93%) were free of syncope, and 24 free of a pacemaker (89%). Conclusion Carotid denervation by adventitial stripping of the proximal Carotid internal artery is effective and safe and may offer a valid alternative for pacemaker treatment in patients with Carotid Sinus Syndrome.
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adventitial stripping for Carotid Sinus Syndrome
Annals of Vascular Surgery, 2009Co-Authors: R J Toorop, Marc R Scheltinga, Frans L MollAbstract:Patients with a Carotid Sinus Syndrome (CSS) suffer from spells of dizziness and loss of conscience due to an exaggerated Carotid baroreflex response. Three types of the Syndrome are described: cardioinhibitory, vasodepressor and a mixed form. The gold standard for treatment is insertion of a pacemaker, but this therapy may be effective only in a pure cardioinhibitory type. In contrast, surgically interrupting afferent nerves at the origin may offer relief of symptoms in all three types. The present review analyzes the results of a surgical technique termed "adventitial stripping" of the Carotid Sinus. Data from 130 procedures demonstrate that Carotid denervation is effective in 85% of CSS cases with low complication rates. Postoperative monitoring is mandatory as transient alterations in blood pressure and heart rate may occur.
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anatomy of the Carotid Sinus nerve and surgical implications in Carotid Sinus Syndrome
Journal of Vascular Surgery, 2009Co-Authors: R J Toorop, Marc R Scheltinga, Frans L Moll, Ronald L A W BleysAbstract:Background The Carotid Sinus Syndrome (CSS) is characterized by syncope and hypotension due to a hypersensitive Carotid Sinus located in the Carotid bifurcation. Some patients ultimately require surgical Sinus denervation, possibly by transection of its afferent nerve (Carotid Sinus nerve [CSN]). The aim of this study was to investigate the anatomy of the CSN and its branches. Methods Twelve human Carotid bifurcations were microdissected. Acetylcholinesterase (ACHE) staining was used to identify location, side branches, and connections of the CSN. Results A distinct CSN originating from the glossopharyngeal (IX) nerve was identified in all specimens. A duplicate CSN was incidentally present (2/12). Mean CSN length measured from the hypoglossal (XII) nerve to the Carotid Sinus was 29 ± 4 mm (range, 15-50 mm). The CSN was frequently located on anterior portions of the internal Carotid artery, either laterally (5/12) or medially (6/12). Separate connections to pharyngeal branches of the vagus (X) nerve (6/12), vagus nerve itself (3/12), sympathetic trunk (2/12), as well as the superior cervical ganglion (2/12) were commonly observed. The CSN always ended in a network of small separate branches innervating both Carotid Sinus and Carotid body. Conclusion Anatomical position of the CSN and its side branches and communications is diverse. From a microanatomical standpoint, CSN transection as a single treatment option for patients with CSS is suboptimal. Surgical denervation at the Carotid Sinus level is probably more effective in CSS.