CNA Conference - Dr. Yan Yao - CNA for vasodepressor syncope: who is a good candidate?

Um, I wanna introduce our first speaker, Doctor Yan Yao from Fei Hospital in Beijing. He is halfway around the world and staying up late tonight, uh, with us to speak. And he has a difficult subject because he has the most controversial topic in cardio neuroablation, and that is vasodepressor syncope. Uh, so, looking forward to what he has to say. And now let's hear from Yan Ya with CNA for vasodepressor syncope, who is a good candidate. One, greetings from Beijing. I'm Doctor Yan Yao from Beijing Huai Hospital. Uh, it's my honor to attend this, uh, or, uh, world symposium and, uh, card illusion ablation. I'm assigned to give a speech and I think probably, uh, the most, uh, controversial, uh, topic, talking about the cardiolu ablation for treatment. Uh, of the laser or depressure syncope, how to identify the suitable candidates. Uh, as we all know, during the past 10 years, the cardio ablation, uh, has become more and more acceptable and popular, and the previous, uh, publication confirmed the effectiveness and the, uh, safety, uh, on the treatment for the video fecal syncope. And uh there are 4 major uh clinical results indicate it's uh highly effective with either CDR uh cardio inhibitory plus mixed PVS. And uh our data started from year 2005. The first two cases were both uh middle-aged women with the frequent, that we are talking about uh about 100 times uh syncope for over 20 years until they got uh parsal HFF. Uh, come to my hospital for air fibrillation, and we noticed once we destroy the ganglion plexus, their syncope also has gone. And uh we published our 1st 10, that, uh, you know, you can see their improvement is significant and uh our also nearly 6010 case, uh, 60 cases results, uh, get a similar. Uh results as previous, uh, in the slides as other three, trials. Uh, you can see the success rate is above 90% for mixed or cardio inhibitory radio vacate syncope in during the 3 years follow-up. And at that time, we basically uh rely on uh anatomy, targeting, and the high frequency stimulation. Uh, as we all know, we use their head up test test to classify the basal syncope into three types, mixed, cardio inhibitory and the vaso depressor. Uh, this is what we're talking about. Uh, the limitation for the adaptive test is the low reproducibility range from 31 to 92% as reported, and, uh, that's the reason the current guidelines by the uh HRS uh deleted as their uh diagnosis tools. However, without such a uh uh test, Uh, we cannot classify patients to be either, uh, in a fixed or cardioc inhibitory or, you know, uh, very depressive type. So we still need this test to classify our patients, to guide our, uh, treatment, especially if we're talking about the, uh, intervention, either pacemaker or cardio ablations. Uh, there might be also a challenge for both the patients and the medical personnel to encourage patients to do this test, because, um, some of them are just scared by these long poles or syncope in the testing rooms. And can we use the cardiourin ablation to treat uh the big syncope? Uh, these are possible mechanisms, uh, explained by Doctor Paon I would like to quote. So their parasympthetic derivation, uh, their ganglion plexus contain the cell body of the vagus nerve and the axons of the sympatic nerve. The cell body and the nerve cannot be regenerated after being destroyed, but the destruction of simple axons can. Therefore, the lead effect of ganglia plexus ablation or card illusion ablation, uh, is the removal of the vigorous nerve. Uh, this has been confirmed by thousands of cases, not only for cardio illusion ablation, but uh also join AFib ablation. I, I believe all our colleagues have seen that many times. So, currently, uh, this is a typical, uh, strategy for, uh, recurrent or refractory radio weak syncope. After consecutive or non-pharmacological therapies, we may try uh head up test uh test, and then also based on the uh recorded evidence or somehow exclusive, you know, diagnosis process, we classify them into three types, for cardio inhibitory. Who is younger than 40 years old, we may recommend them to do the cardio ablation. For those aged uh above 40 years old, they may have more choices, but based on the current clinical evidence, we believe dual chamber pacemaker with closed loop function provide a more promoting. Uh, you know, results than the normal DTD or pacemaker. Definitely, we also can try cardiodin ablation. For mixed, uh, our previous results indicate cardiodin ablation also works. For visual depression, uh, it seems like And medogen or other medication should be the primary choice. And uh it's quite uh doubtful if the cardioluron application alone can really affect uh this subtype. Anyway, we're trying to understand the rationale for such application on this subtype. Uh, we know they, uh, Atomic nervous system consists of the central and intrinsic, uh, autonomous nerve systems. And uh there is a collection in mostly we believe in the right anterior uh ganglia plexus. Uh, however, uh, some believe instead of simply, uh, derivating the effect there, cardio neutron ablation also elevated the afferent nerves which prevented the stimuli from introducing the central nerve system. That's the trigger cannot reach central system. So the effort there to cause a secondary radio dilation through cardiac red flags. That's probably the most widely accepted experimentation. So, we also may gather some inspiration from other uh diseases like the uh renal elevation and, uh, you know, anti uh hypertension, uh, uh, you know, treatment, as we know, there are many uh either controversial or, or, or in affirmative. Uh, clinical trials, and I believe the majority of them that confirmed the value. And my hospital just uh finished, uh, uh SHA trials and compared with the re elevation with SHAM, you know, ablation confirmed the, uh, provide a solid evidence confirmed such effects. Also, the data is, uh, uh, you know, Kind of like a potentially uh improved heart failure also. And we all know, uh, some doctors, especially in UCLA, they use very diversion to manage the refractory ventricular arrhythmias. So compared with the uh visual depressive uh video syncope, I think linear derivation prevent ventricular tachycardia is much more uh acceptable, but the truth is this uh Greek evidence just to confirm uh the results. So I think that only indicate we have more work to do to really understand, explain the underlying mechanisms. Also, we also need to uh establish the uh missiles and the, the, you know, all this process. Of course, we need to find out the right uh the, the, the Other candidates, and uh we definitely also need more research to exclude the possible, uh, you know, uh compensant effects or even the placebo effects. So our unpublished data with 20 visual depression patients indicate uh the success rate may reach to 55%. It's not clear enough, but to compare with others seems like uh we cannot exclude the placebo effects, but uh it is same as uh their effects in some patients. And uh how to find out the right candidates. We believe the DC can be used as a uh uh tools and then we all know this DC uh declared uh in uh capacity were used uh to predict the certain type of death in patients with uh uh The myocardial infarction history and uh we have been using that to evaluate the ablation effect of cardiolu ablation. You can see post the cardio ablation, the GC dropped from above 10 to uh below 7 mostly and can last long uh to as long as 1 year, even longer. So we also found with these 20 cases, their lower DC value, uh, you know, uh, with a higher uh syncope recurrence. And uh we also found for any type of the uh bigger, bigger syncope, the higher, which means above 10 DC value, especially during the light. Previ uh, uh, before, uh, Cali ablation, uh, predicted, uh, better ablation, you know, effects. So there are definitely uh limitation to either uh use a DC or use a cardio ablation to treat uh radio differential uh syncope. However, the uh this uh initial evidence indicate there is a potential, you know, research we should to do. So currently, we are Uh, conducting a clinical trial, we call it comparing trials. Uh, this is to compare a cardioluron ablation versus megagen. And uh this is not specifically for visual depression. However, uh, this is what we have been talking about for a long time. We need this kind of the har trial to exclude the placebo effects. But I think to make comparison between the cardio illusion ablation versus drug. Might be a good uh choice to answer the placebo effects, whether it's, uh, if there is or to how much uh extent it existed. Uh, thank you. Sure. Thank you. Thank you, Doctor Yao, for that lecture. Doctor Yao is having difficulty joining us today, unfortunately, um, but we, uh, appreciate his, his time and that information, um. You know, I, I liked his, his graph and that 45% of CNA patients with vasodepressor had a favorable response. And it's interesting to ponder uh whether or not that is placebo effect, whether or not that is due to afferent effects on the vagus, or whether or not that is due to baseline heart rates. And I think the campaign trial is gonna be very interesting to see. What comes out of that to find out. If there is going to be true benefit to patients with purely vas vasodepressive syncope, um. Any thoughts, Jose, on Yes, I would like to thank Professor Yao. Uh, he is one of the first investigators that, uh, begin to, to do the cardio regulation and to get achievements in the treatment. Uh, in this kind of, uh, treatment. There is something very interesting because obviously in the first uh trial you did the, the vasodepressor uh type of uh syncope was not included in, in the indication. And I think the vasodepressor is not a good indication for cardio neration but there are several things. Uh, I have to take in mind that it's possible to weaken the, the, the receptors, uh, by ablating the ganglia, and it's possible to reduce the sensibility of the reflex. So it's possible to improve the patient. Doctor Yao was the first to, uh, found that it's possible to treat the, uh, or to get improvement of the patients that present vasodepressor syncope. I think it is a possibility, but it is not a main indication. It is not a clear indication yet. We have a lot of trials ongoing, and I, I think in a short time, we, we will have a good answer for this. Yeah, it's, it seems intuitively like it wouldn't help if the, if the heart rate is not slowing, and primarily what's happening with CNA is you're obliterating that heart rate slowing effect, um. That CNA for vasodepressor isn't gonna be useful, but, you know, is there a part of the feedback loop that gets modified that may benefit or as you said, if raising the basal heart rate somewhat, does that improve things? Um, you know, would there be a, a role for implantable loop monitor? Um, and is there a number in the, the DC number that can you ferret through that data and say, you know, 80% of these patients are really not good candidates, but there is a subset that you could predict and uh it'd be very interesting over time to see what comes out of that. There is a very interesting, uh, electrophysiological phenomenon that is, obviously, the, the, uh, the, uh, the body of the cells that are, uh, afferent cells are uh uh far from the heart. However, they are not eliminated by radiofrequency. However, if If you, if we eliminate the fibers of these cells, it's possible to get a retrogradive degeneration of these cells, and by this, it's possible to get a weakening of the reflex and by weakened the reflex, we improve the vision. So,