{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T17:20:04Z","timestamp":1786123204298,"version":"build-2736575974"},"reference-count":12,"publisher":"Oxford University Press (OUP)","issue":"8","license":[{"start":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T00:00:00Z","timestamp":1784592000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,7,31]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Asystole caused by vagal activity with prolonged sinus arrest and absent escape rhythm is rare and may overlap with intrinsic conduction system vulnerability. Cardioneuroablation (CNA) is an emerging option for cardioinhibitory syncope, but its role after pacemaker implantation has been rarely reported.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case summary<\/jats:title>\n                    <jats:p>A 43-year-old man presented with recurrent syncope due to abrupt, prolonged sinus arrest of up to 25\u2005s without escape rhythm. Cardiological evaluation, including tilt-table testing, echocardiography, Holter monitoring, and positron emission tomography, revealed no structural or inflammatory substrate. A dual-chamber pacemaker with left bundle branch area pacing was implanted, preventing further syncope. However, after implantation, the patient reported severe sleep fragmentation and debilitating daytime somnolence. Device diagnostics showed 1704 nocturnal rate-drop response activations since pacemaker implantation, despite normal polygraphy. Given the exceptional burden of presumed vagally mediated nocturnal events and marked functional impairment, CNA was performed, resulting in substantial suppression of nocturnal vagal episodes and marked symptomatic improvement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>This case demonstrates an unusual combination of profound vagally mediated asystole and possible intrinsic conduction vulnerability. Pacemaker therapy eliminated cardioinhibitory vasovagal syncope but unmasked severe nocturnal vagal hyperreactivity, leading to frequent symptomatic rate-drop responses by the pacemaker. CNA successfully restored autonomic balance, reduced pacemaker rate-drop responses and resolved symptoms. This case highlights the utility of CNA in patients with vagal hyperreactivity and cardioinhibitory vasovagal syncope on top of pacemaker implantation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ehjcr\/ytag526","type":"journal-article","created":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T11:22:25Z","timestamp":1784546545000},"source":"Crossref","is-referenced-by-count":0,"title":["Profound vagal hyperreactivity unmasked after pacemaker implantation: a rare indication for cardioneuroablation\u2014a case report"],"prefix":"10.1093","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-6550-3681","authenticated-orcid":false,"given":"Muhemin","family":"Mohammed","sequence":"first","affiliation":[{"name":"Department of Nuclear Medicine, University Hospital Zurich , RAE A 12 Raemistrasse 100, Zurich 8091 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4024-2974","authenticated-orcid":false,"given":"Gonca","family":"Suna","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich , Raemistrasse 100, Zurich 8091 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8847-2154","authenticated-orcid":false,"given":"Aju P","family":"Pazhenkottil","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine, University Hospital Zurich , RAE A 12 Raemistrasse 100, Zurich 8091 ,","place":["Switzerland"]},{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich , Raemistrasse 100, Zurich 8091 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1896-0803","authenticated-orcid":false,"given":"Ardan M","family":"Saguner","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich , Raemistrasse 100, Zurich 8091 ,","place":["Switzerland"]},{"name":"Center for Translational and Experimental Cardiology (CTEC), University of Zurich , Wagistrasse 12, Schlieren 8952 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,7,21]]},"reference":[{"key":"2026080710062399400_ytag526-B1","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1097\/HCO.0000000000000134","article-title":"Inherited progressive cardiac conduction disorders","volume":"30","author":"Baruteau","year":"2015","journal-title":"Curr Opin Cardiol"},{"key":"2026080710062399400_ytag526-B2","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1093\/europace\/euz109","article-title":"Molecular and genetic insights into progressive cardiac conduction disease","volume":"21","author":"Asatryan","year":"2019","journal-title":"Europace"},{"key":"2026080710062399400_ytag526-B3","first-page":"630","article-title":"Genetic determinants of hereditary bradyarrhythmias","volume":"33","author":"Rezazadeh","year":"2017","journal-title":"Can J Cardiol"},{"key":"2026080710062399400_ytag526-B4","doi-asserted-by":"crossref","first-page":"1932","DOI":"10.1016\/j.hrthm.2013.05.014","article-title":"HRS\/EHRA\/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes","volume":"10","author":"Priori","year":"2013","journal-title":"Heart Rhythm"},{"key":"2026080710062399400_ytag526-B5","doi-asserted-by":"crossref","first-page":"985","DOI":"10.1016\/j.amjcard.2003.12.052","article-title":"Autonomic responses to single- and dual-chamber pacing","volume":"93","author":"Chiladakis","year":"2004","journal-title":"Am J Cardiol"},{"key":"2026080710062399400_ytag526-B6","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1111\/j.1540-8159.2006.00306.x","article-title":"Sleep parameters in patients using pacemakers with sleep rate function","volume":"29","author":"Greco","year":"2006","journal-title":"Pacing Clin Electrophysiol"},{"key":"2026080710062399400_ytag526-B7","doi-asserted-by":"crossref","DOI":"10.1093\/europace\/euae206","article-title":"Cardioneuroablation for the treatment of reflex syncope and functional bradyarrhythmias: a scientific statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS) and the Latin American Heart Rhythm Society (LAHRS)","volume":"26","author":"Aksu","year":"2024","journal-title":"Europace"},{"key":"2026080710062399400_ytag526-B8","first-page":"1708","article-title":"Long-term evaluation of vagal denervation by cardioneuroablation using Holter and heart rate variability","volume":"8","author":"Pach\u00f3n","year":"2011","journal-title":"Heart Rhythm"},{"key":"2026080710062399400_ytag526-B9","doi-asserted-by":"crossref","DOI":"10.1016\/j.hrthm.2023.03.1423","article-title":"Cardioneuroablation in patients with a prior pacemaker implant","volume":"20","author":"Jansov\u00e1","year":"2023","journal-title":"Heart Rhythm"},{"key":"2026080710062399400_ytag526-B10","doi-asserted-by":"crossref","first-page":"2205","DOI":"10.1111\/jce.15480","article-title":"Cardioneuroablation for vasovagal syncope and atrioventricular block: a step-by-step guide","volume":"33","author":"Aksu","year":"2022","journal-title":"J Cardiovasc Electrophysiol"},{"key":"2026080710062399400_ytag526-B11","first-page":"1458","article-title":"Cardioneuroablation as a therapeutic approach for functional AV block presenting late after AVNRT ablation","volume":"34","author":"San Antonio","year":"2023","journal-title":"J Cardiovasc Electrophysiol"},{"key":"2026080710062399400_ytag526-B12","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1016\/j.hrthm.2023.11.022","article-title":"Cardioneuroablation for reflex asystolic syncope: mid-term safety, efficacy and patient's acceptance","volume":"21","author":"Kulakowski","year":"2024","journal-title":"Heart Rhythm"}],"container-title":["European Heart Journal - Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/ehjcr\/advance-article-pdf\/doi\/10.1093\/ehjcr\/ytag526\/69696144\/ytag526.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ehjcr\/article-pdf\/10\/8\/ytag526\/69696144\/ytag526.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ehjcr\/article-pdf\/10\/8\/ytag526\/69696144\/ytag526.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T14:06:31Z","timestamp":1786111591000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ehjcr\/article\/doi\/10.1093\/ehjcr\/ytag526\/8739182"}},"subtitle":[],"editor":[{"given":"Felix","family":"Wiedmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]},{"given":"Armen","family":"Kocharian","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]},{"given":"Ugur","family":"Canpolat","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]},{"given":"Deepti","family":"Ranganathan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,7,21]]},"references-count":12,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2026,7,31]]}},"URL":"https:\/\/doi.org\/10.1093\/ehjcr\/ytag526","relation":{},"ISSN":["2514-2119"],"issn-type":[{"value":"2514-2119","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,8]]},"published":{"date-parts":[[2026,7,21]]},"article-number":"ytag526"}}