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Erschienen in: BMC Cardiovascular Disorders 1/2019

Open Access 01.12.2019 | Case report

Swallow syncope: a case report and review of literature

verfasst von: Kelvin Shenq Woei Siew, Maw Pin Tan, Ida Normiha Hilmi, Alexander Loch

Erschienen in: BMC Cardiovascular Disorders | Ausgabe 1/2019

Abstract

Background

Swallow or deglutition syncope is an unusual type of neurally-mediated syncope associated with life-threatening bradyarrhythmia and hypotension. It is a difficult condition to diagnose with commonly delayed diagnosis and management. There is lack of review articles that elucidate the basic demographics, clinical characteristics and management of this rare condition. This publication systematically reviews the 101 case reports published since 1793 on swallow syncope.

Case presentation

A 59-year-old man presented with the complaint of recurrent dizziness associated with meals. A 24-h ambulatory ECG recording confirmed an episode of p-wave asystole at the time of food intake. Oesophagogastroduodenoscopy with balloon inflation in the mid to lower oesophagus resulted in a 5.6 s sinus pause. The patient’s symptoms resolved completely following insertion of a permanent dual chamber pacemaker.

Conclusions

Swallow syncope is extremely rare, but still needs to be considered during diagnostic workup. It is commonly associated with gastro-intestinal disease. Permanent pacemaker implantation is the first line treatment.
Hinweise

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Abkürzungen
AV block
Atrioventricular block
ECG
Electrocardiogram
OGD
Oesophagogastroduodenoscopy
PPM
Permanent pacemaker

Background

Swallow syncope is a rare cause of a neurally mediated syncope that is frequently associated with life-threatening bradyarrhythmia [1]. The underlying mechanism is believed to be an exaggerated vagal stimulation during swallowing resulting in suppression of the cardiac conduction system. Swallow syncope has been reported in all age groups and occurs with or without underlying esophageal or cardiac pathology. A diagnosis of swallow syncope is frequently missed by physicians, often resulting in delayed diagnosis and treatment. The first case of swallow syncope was reported by Spens in 1793 [2]. Since then, another 117 cases have been reported in the literature.
We present a case of recurrent swallow syncope with a review and summary of the entire literature available regarding this rare condition.

Case presentation

A 59-year-old Chinese male presented with a 6-month history of intermittent dizziness. The dizziness occurred exclusively at meal times and was worst when swallowing large quantities of solid food, such as rice or bread. He initially was symptom free when consuming smaller quantities of solids or fluids, but his condition worsened progressively with presyncopal events occurring even while eating smaller quantities of solid food. The patient described a sensation of increasing difficulty in swallowing despite reducing the size of his meals. He denied any associated syncope or seizures. His past medical history and physical examination were unremarkable and blood investigations were within normal limits. Echocardiography revealed a structurally normal heart with normal systolic and diastolic function. 24-h electrocardiogram (ECG) monitoring recorded a sinus pause of 4.5 s at the time the patient had his meal (Fig. 1). A provisional diagnosis of swallow syncope was made and a permanent pacemaker (PPM) implantation was scheduled.
Tilt table testing prior to pacemaker insertion resulted in a hypotensive response 5 min after provocation with 400 micrograms of sublingual glycerin trinitrate administered sublingually, with reproduction of symptoms of syncope. The minimal blood pressure was 32.9/29.2 mmHg and the heart rate 75.3 bpm. No asystole was observed during tilt table testing (Fig. 2).
The patient’s symptoms resolved completely after implantation of a dual chamber PPM. A diagnostic workup to exclude gastrointestinal disease was performed. A barium swallow test was normal and effectively ruled out achalasia. The oesophagus appeared healthy with no structural disease on oesophagogastroduodenoscopy (OGD). The pacemaker was continuously interrogated during the OGD. Increased pacing requirements were noted when the endoscope was advanced into the esophagus (Fig. 3b). Subsequently, a 20 mm diameter TTS (through-the-scope), CRE™ (controlled radial expansion) balloon (Boston scientific) was sequentially inflated in the proximal, mid and distal esophagus while the pacemaker was programmed “OFF” to assess the physiologic response. Inflation in both distal and mid oesophagus resulted in significant sinus pauses of up to 5.6 s (Fig. 3c) confirming the cardio-inhibitory response to oesophageal distension as the underlying pathophysiological mechanism of this patient’s syncopal events.

Discussion

Swallow syncope is more common in males (59.4%, n = 60), and in the older age group (55.4%, n = 56, more than 60 years old). The mean age at presentation was 57.5 years with the youngest patient described in the literature being 5 years old [3] and the eldest 89 years old [4]. All of the patient presented with either presyncope or syncope. Only one patient was diagnosed incidentally, when a high degree atrioventricular (AV) block associated with meal times was found during a diagnostic workup for lung carcinoma [5]. Swallow syncope is strongly associated with gastrointestinal diseases (32.7%, n = 33). Hiatal hernia (18.8%, n = 19), oesophageal stricture (3%, n = 3), achalasia (3%, n = 3) and oesophageal carcinoma are the most common associated gastrointestinal disorders. Thirty-three patients (32.7%) had underlying cardiac diseases including coronary artery diseases (13.9%, n = 14), atrial fibrillation (5%, n = 5), sick sinus syndrome (3%, n = 3), aortic aneurysm, rheumatic heart disease and digitalis toxicity. Twenty-eight patients (27.7%) had metabolic diseases like hypertension, diabetes mellitus, dyslipidaemia or obesity.
In most patients (54.5%, n = 55), any type of food – be it liquids or solids - triggered syncope. Atrioventricular conduction blocks (34.7%, n = 35) including first, second and third-degree AV blocks are the most common electrophysiological problems, followed closely by sinus node dysfunctions (33.7%, n = 34) including sinus bradycardia, sinus arrest and asystole. Second degree AV block, complete heart block (=3rd degree AV block) and asystole were the most frequently reported bradyarrhythmia in the literature. However, there are several cases where both sinus and atrioventricular dysfunction concurred. Paroxysmal atrial fibrillation and atrial tachycardia were rare causes of syncope. Table 1.
Table 1
Literature review of 101 cases of Swallow Syncope from 1949 to 2018
Author/ Reference
Age/ Gender
Presenting Symptom
Underlying Diseases
Trigger Factor
Type of arrhythmia
Management
Effectiveness
Padalia et al. 2018/ [6]
65/ F
Presyncope, Dysphagia, Odynophagia/
Candida Esophagitis, Metabolic Diseases
Solid and Liquid
Sinus bradycardia, Sinus arrest
Micafugin
Yes
Sammy et al. 2018/ [7]
67/M
Syncope
End Stage Renal Failure
Ascension of Hyoid bone irritate carotid sinus
Yamaguchi et al. 2018/ [8]
76/M
Syncope
No
Solid and Liquid (Citrus based)
Sinus arrest, AV block
PPM
Yes
Lipar et al. 2018/ [9]
49/F
Syncope
Post whiplash neck injury
Solid and Liquid
PPM
Yes
Van Damme et al. 2017/ [10]
39/M
Syncope
No
Solid and Liquid
3rd degree AV block
PPM
Aydogdu et al. 2017/ [11]
51/F
Presyncope, Syncope
No
Solid food
AV block
Rejected PPM
65/F
Syncope
Liquid (Carbonated)
Sinus arrest, 3rd degree AV block
PPM
Yes
39/F
Presyncope, Syncope
No
Solid food
3rd degree AV block
PPM
Yes
53/F
Presyncope, Syncope
No
Solid food
Asystole
Diet modification
68/M
Presyncope, Syncope
Atrial Fibrillation
Liquids
Asystole
PPM
Yes
Patel et al. 2017/ [12]
48/M
Syncope, Nausea, Tunnel vision
Hiatus Hernia
Solid and Liquid
Sinus arrest
Hiatus hernia repair surgery
Yes
Zaid et al. 2017/ [13]
71/M
Syncope
Achalasia
Solid food
AV block
Bhogal et al. 2017/ [14]
68/F
Presyncope
Hiatus Hernia, Metabolic Diseases
Solid food
Sinus Bradycardia, 1st degree AV block
Discontinuation of metoprolol + Proton Pump Inhibitor
No
59/M
Pre-syncope & Syncope
No
Liquid diet
Premature atrial complexes & Asystole
PPM
Yes
Trinco et al. 2016/ [15]
83/ M
Syncope
Carotid endarterectomy, Metabolic diseases
Solid and Liquid
Sinus bradycardia, 3rd degree AV block
PPM
Yes
Islam et al. 2016/ [16]
60/ F
Presyncope, Syncope
No
Solid food (Large chunk of bread)
AV block
Avoidance of trigger
Yes
Chhetri et al. 2016/ [17]
71/M
Syncope
Fundoplication for GERD
Solid and Liquid (Fizzy drink)
Sinus arrest
PPM
NM
Tiffany et al. 2016/ [18]
80/F
Syncope, palpation, facial flushing
Metabolic diseases, Hypothyrodism
Solid and Liquid
Atrial Tachycardia
Catheter ablation
Yes
Manu et al. 2016/ [19]
13/F
Syncope
Superior sinus atrial septal defect
Solid and Liquid
3rd degree AV block
PPM
Yes
Aaberg et al. 2015/ [20]
62/M
Pre-syncope, Syncope
No
Solid and Liquid
2nd and 3rd degree AV block
PPM
Yes
Kahn et al. 2015/ [4]
89/M
Syncope
Transient Oesophageal dysmotility, Coronary artery diseases
Solid and Liquid (Carbonated)
1st and 2nd degree AV block
PPM
Yes
Saitoh et al. 2015/ [21]
70/M
Syncope
No
Solid food
Asystole
PPM
Yes
Erdogan et al. 2015/ [22]
47/M
Syncope
Achalasia
Solid and Liquid
AV block, Asystole
Pneumatic dilation
Yes
Shashank et al. 2014/ [23]
31/F
Presyncope & Syncope
No
Liquid (Carbonated)
Sinus bradycardia, Asystole
PPM
Yes
78/ M
Presyncope
Sick sinus syndrome, Metabolic diseases
Solid food
PPM + Coffee before meals
Yes
80/M
Presyncope, Syncope
Hiatus Hernia AF, various cardiac comorbid
Solid food (Sticky food)
Avoidance of trigger
Yes
Shah et al. 2014/ [24]
57/M
Presyncope, Syncope
No
Swallow +Cold drink
Advanced heart block for 3–4 s
PPM
Yes
Witcik et al. 2014/ [25]
70/M
Syncope, Weakness, Flushing
Mild AV regurgitation
Liquid (Carbonated)
Atrial Fibrillation with ventricular pause
PPM
Yes
Arihide et al. 2014/ [26]
79/M
Syncope
Coronary artery disease, Metabolic diseases
Solid and Liquid
Sinus arrest
PPM
Yes
Moore et al. 2013/ [27]
65/F
Presyncope, Syncope
No
Solid food
AV block
PPM
Yes
Lambiris et al. 2013/ [28]
54/M
Presyncope, Shortness of breath
No
Solid and Liquid
1st degree AV block
PPM
Yes
Rezvani et al. 2013/ [29]
51/F
Syncope
Post Laparoscopic gastrectomy
Solid and Liquid
AV block
Atropine
Yes
Kim eat al. 2012/ [30]
39/M
Syncope, Chest tightness
No
Liquid (Cold)
3rd degree AV block
Avoidance of trigger
Yes
Knopke et al. 2012/ [31]
49/F
Syncope, Dysphagia, Regurgitation
Hiatus hernia, Diffuse oesophageal spasm
Solid food
3rd degree AV block
PPM
Yes
Foreman et al. 2011/ [32]
52/F
Presyncope, Chest pain
No
Solid food
2nd degree AV block
PPM
Yes
Vanerio et at. 2011/ [33]
84/F
Syncope
Hiatus Hernia
Solid and Liquid (Carbonated)
Nissen’s Fundoplication
Yes
Mitra et al. 2011/ [34]
60/F
Presyncope, Syncope
Metabolic Diseases
Solid food
Sinus Bradycardia, 3rd degree AV block
PPM
Yes
Marina et al. 2010/ [35]
37/M
Syncope
Megaoesophagus, Extra Cardiac mass compressing left atrium
Solid and Liquid
Deflation of gastric band
GY Lee et al. 2010/ [36]
62/M
Syncope, Dysphagia
Atrial Fibrillation, Metabolic diseases
Liquid
Asystole
PPM
Yes
Endean et al. 2010/ [37]
61/ M
Syncope, Chest pain, Vision lost
Post Carotid entaterectomy
Solid food
Glycopyrrolate
Yes
Casella et al. 2009/ [38]
66/ M
Syncope
Oesophageal dysmotility, Sick sinus syndrome
Liquid only
AV block
PPM
Yes
Karamitsos et al. 2009/ [39]
82/F
Syncope
Hiatus hernia
Large meal
NM
Favaretto et al. 2008/ [40]
63/M
Syncope, Odynophagia
Hiatus hernia
Solid and Liquid
Asystole
PPM
Yes
Bajwa et al. 2008/ [41]
51/M
Presyncope, Syncope
Metabolic diseases, Inflammatory bowel diseases
Solid food
Atrial & Ventricular atopic beat
PPM
Yes
Christopher et al. 2008/ [42]
25/F
Syncope
No
Solid and Liquid
3rd degree AV block
PPM
Yes
Fahrner et al. 2008/ [43]
75/M
Syncope
No
Solid and Liquid
AV block
Patsilinakos et al. 2007/ [44]
86/F
Syncope
Oesophageal stenosis, Ascending aorta aneurysm, Hypothyroidism
Solid and Liquid
Sinus arrest
Avoidance of trigger
Yes
Tuzcu et al. 2007/ [45]
16/F
Syncope, Visual disturbance
No
Solid food
3rd degree AV block, Asystole
PPM
Yes
Omni et al. 2006/ [2]
66/F
Syncope
Metabolic Diseases
Liquid
AV block
PPM
Yes
Gawrieh et al. 2005/ [46]
63/M
Presyncope, Syncope, Dysphagia
Hiatus Hernia
Solid food
AV block, Asystole
PPM
Yes
63/M
Presyncope, Syncope
Hiatus hernia, Coronary artery diseases, Metabolic diseases
Solid and Liquid
Refuse treatment
62/F
Presyncope, Syncope, Dysphagia
Nutcracker oesophagus, Coronary artery diseases
Solid and Liquid
Sinus bradycardia, Sinus arrest
PPM
Yes
Turan et al. 2005/ [47], Kang et al. 2005/ [48]
48/M
Syncope, Dysphagia
Achalasia
Solid food
Sinus bradycardia
PPM
Yes
59/ M
Syncope
Metabolic diseases
Solid and Liquid
Sinus bradycardia
PPM
59/M
Syncope, Dysphagia
Compression fracture thoracic spine, Graves diseases
Solid food
Sinus bradycardia
Diet habit modification
Sreekant et al. 2004/ [49]
85/M
Syncope
Coronary artery diseases, Peripheral vascular diseases
Solid and liquid
Asystole
PPM
Yes
61/ F
Presyncope
Metabolic diseases
Liquid (Carbonated)
Sinus Bradycardia
Yoshifumi et al. 2004/ [50]
76/F
Syncope
Hiatus hernia
Solid food
Srivathsan et al. 2003/ [51]
26/M
Presyncope
No
Solid food
Systole
PPM
Yes
Mekawa et al. 2002/ [52]
76/ F
Syncope
Hiatus hernia
Solid and liquid
Hernia repair surgery
Yes
Gordon et al. 2002/ [53]
26/F
Syncope, Central chest discomfort
Hiatus hernia
Solid and liquid
Paroxysmal Atrial fibrillation, Ventricle atopic beat
Diet habit modification
Yes
Takeshi et al. 2002 [54]
69/F
Presyncope, Syncope
Metabolic diseases
Solid food
Sinus arrest
Rasmi et al. 2001/ [55]
16/M
Syncope
No
Liquid (Carbonated)
Asystole
PPM
Yes
Haumer et al. 2000/ [56]
67/ M
Syncope
Coronary artery disease
Liquid
Sinus arrest
Temporary Pacemaker
Yes
Kakuchi et al. 2000/ [57]
21/M
Syncope
Vasovagal syncope
Solid and liquid
AV block
PPM
Kazushi et al. 1999/ [58]
69/M
Syncope, Facial flushing, Profuse diarrhoea
Metabolic disease, Stroke
Solid food
Cessation of Enalapril
Yes
Olshasky et al. 1999/ [59]
72/M
Presyncope, Syncope
Liquid (Cold carbonated)
Sinus bradycardia
PPM
Dante et al. 1997/ [60]
78/M
Syncope
Oesophageal carcinoma
Solid food
AV block, Asystole
PPM
Yes
Bellori et al. 1992/ [61]
69/M
Syncope
Liquid
Sinus arrest
SY AO et al. 1991/ [5]
70/M
Incidental
Lung carcinoma
Solid and Liquid
High grade AV block
Atropine before meal
Yes
Shapira et al. 1991/ [62]
63/M
Presyncope, Syncope
Hiatus hernia, Coronary artery disease
Solid and Liquid
2nd degree AV block
PPM
Yes
Kunimoto et al. 1990/ [63]
65/M
Presyncope, Syncope
No
Liquid (Cold)
2nd degree AV block, Asystole
PPM
Yes
Elam et al. 1989/ [64]
44/M
Syncope
No
Solid and Liquid
3rd degree AV block
PPM
Yes
Engelharbt et al. 1986/ [3]
5/F
Syncope
No
Solid and Liquid/ Brush teeth
3rd degree AV block
Close Observation
Yes
Ausubel et al. 1987/ [65]
26/M
Syncope
Heart murmur
Solid food
Sinus bradycardia, AV block
PPM
Yes
Nakano et al. 1987/ [66]
67/M
Syncope, Retrosternal discomfort
Aneurysm descending thoracic aorta
Solid and Liquid
Sinus bradycardia, Sinus arrest
Atropine before meal
Yes
Nakagawa et al. 1987/ [67], Guberman et al.1986/ [68]
48/M
Syncope
No
Solid and Liquid
AV block
Atropine
62/F
Syncope
No
Oesophageal balloon inflation
2nd degree heart block
Propanthelene bromide
No
62/M
Syncope
Congestive heart failure
Solid food
2nd degree heart block
Discontinuation of digoxin
Yes
Alan et al. 1986/ [69]
56/M
Syncope
Inferior myocardial infarction
Liquid
1st degree heart block
PPM
Yes
Golf et al. 1986/ [70]
15/ F
Syncope
No
Solid and Liquid
SA node blockade with junctional escape rhythm
Armstrong et al. 1985/ [71]
53/F
Syncope, Dyspnoea, Retrosternal discomfort
Hiatus hernia
Liquid
Sinus bradycardia
PPM
Yes
58/F
Syncope, Pulseless, Apnoea
Myocardial infarction, Atrial Fibrillation, Stroke
Solid and Liquid
Sinus bradycardia and Asystole
PPM
No
58/F
Presyncope
No
Solid and Liquid
3rd degree AV block and Asystole
PPM
Yes
81/F
Syncope
Hiatus hernia, Metabolic disease
Liquid (Hot)
Sinus bradycardia
PPM
Yes
53/M
Syncope
Myocardial infarction
Liquid (Cold)
2nd degree AV block
PPM
Yes
Kunis et al. 1985/ [72]
60/M
Presyncope, Syncope, Chest pain
Metabolic diseases
Solid food (Hot)
3rd degree AV block, Asystole
PPM
Yes
Drake et al. 1985/ [73]
76/F
Syncope
Myocardial infarction, Metabolic disease
Sight of food
3rd degree AV block
PPM
Yes
Mauro et al. 1985/ [74]
65/ F
Presyncope, syncope
Myocardial ischemia
Solid and Liquid
2nd degree AV block
Atropine
No
Golf et al. 1977 [75]
−/ M
Syncope, Convulsion
No
Solid and Liquid
2nd degree AV block
PPM
Yes
Weaddington et al. 1975/ [76]
71/M
Syncope
Hiatus hernia, Oesophagus carcinoma, Atrial Fibrillation
Solid food
Sinus bradycardia and Asystole
Surgical removal of Oesophageal Carcinoma
Yes
B Wik et al. 1975/ [77]
43/ M
Syncope, Retrosternal chest pain
Rheumatic heart diseases
Liquid (Carbonated)
AV block
PPM
Poul et al. 1973/ [78]
64/ F
Syncope
Hiatus hernia, Abnormal oesophageal motility
Solid and Liquid
Sinus bradycardia, AV block
Hernia Repair
Yes
Edgar et al. 1972/ [79]
84/M
Syncope
Hiatus hernia, Metabolic diseases
Solid and Liquid
2nd degree AV block
Atropine
Yes
Keith et al. 1971/ [80]
45/M
Syncope, Dysphagia, Heart burn
Hiatus hernia, Oesophageal stricture
Solid and Liquid
Sinus bradycardia
Dilation of oesophageal stricture
Yes
Rajendra et al. 1971/ [81]
29/ F
Syncope
No
Solid and Liquid
Asystole
Surgical cauterization vagal nerve
Yes
Edgardo et al. 1970/ [82]
73/M
Syncope, Chest pain
Myocardial infarction, Metabolic disease
Solid and Liquid
AV block, Asystole
Atropine
Yes
R P Sapru et al.1968/ [83]
29/F
Presyncope
No
Solid and Liquid
AV block, Asystole
Atropine
Yes
George et al. 1958/ [84]
−/−
Syncope
No
Liquid
Discontinuation of digitalis
Yes
Correll et al. 1949/ [85]
67/M
Syncope, Chocking sensation
Oesophageal diverticulum, Digitalis medication
Solid and Liquid
3rd degree AV block
Atropine
Yes
F Female, M Male, (−) Not Stated, AV Atrioventricular, PPM Permanent Pacemaker
Pacemaker implantation is the most popular treatment modality. More than half of the patients (55.5%, n = 56) were treated with a permanent pacemaker. Almost all (98.1%, n = 52) of the patients treated with pacemakers reported resolution of syncopal symptoms. One patient passed away shortly following a PPM implant due to asystole despite a reportedly normal functioning pacemaker [71]. Treatment of an underlying causative factor (15.8%, n = 16) was the second most common treatment modality. Treatment of an underlying gastrointestinal disorder has been shown to carry a good likelihood of resolving the swallow syncope. For example, all four cases of hiatal hernia that were corrected surgically had a complete resolution of the swallow syncope. Likewise, dilatation of an oesophageal stricture and an achalasia resulted in complete resolution of swallow syncope. Other reported successful treatments of underlying gastrointestinal diseases included surgical cauterisation of the vagal nerve, long term proton pump inhibitors and surgical excision of an oesophageal carcinoma. Pharmacological management was the preferred treatment option in the 19th and early twentieth century prior to the era of pacemakers. From the limited numbers, atropine was the most widely used, with about 90% efficacy. Table 2.
Table 2
Characteristics of 101 reviewed cases of swallow syncope
 
Frequency (n=)
Percentage (%)
Age Group (n = 101)
 Childhood/Adolescent [0–19 years]
6
5.9
 Younger adults [20–59 years]
37
36.6
 Older adults [60 years and above]
56
55.4
 Not stated
2
2.0
Gender (n = 101)
 Male
60
59.4
 Female
40
39.6
 Not Stated
1
1.0
Clinical Presentation (n = 101)
 Syncope
100
99.0
 Dysphagia
12
11.9
 Asymptomatic (incidental diagnosis)
1
1.0
Underlying Diseases (n = 100)
 Gastrointestinal Diseases
34
33.7
 Hiatal Hernia
19
18.8
 Achalasia
3
3.0
 Esophageal stricture
3
3.0
 Cardiac Diseases
33
32.7
 Coronary artery diseases
14
13.9
 Atrial Fibrillation
5
5.0
 Sick Sinus Syndrome
3
3.0
 Comorbiditiesa
28
27.7
Trigger Factor (n = 101)
 Any (Solid and Liquid)
55
54.5
 Solid only
23
22.8
 Liquid only
23
22.8
Type of Arrhythmia (n = 101)
 Sinus Dysfunctionb
34
33.7
 Atrioventricular Dysfunctionc
35
34.7
 Combination Sinus and AV Dysfunction
16
15.8
 Not Stated
13
12.9
 Othersd
3
3.0
Management (n = 101)
 Pacemaker Implantation
56
55.5
 Pharmacotherapy
11
10.9
 Atropine
9
8.9
 Treatment of Underlying causative factor
16
15.8
 Surgical correction of hiatal hernia
4
4.0
 Dilation of achalasia
1
1.0
 Dilation of esophageal stricture
1
1.0
 Conservative Management
9
8.9
 Avoidance trigger/ diet modification
7
6.9
 Close observation/ refused treatment
2
2.0
 Not Stated
9
8.9
 Documented efficacy of resp. treatment
Effective (n=)
Efficacy rate (%)
 Pacemaker (n = 53)
52
98.1
 Atropine treatment (n = 8)
7
87.5
 Surgical correction of Hiatal hernia (n = 4)
4
100
 Dilation of Achalasia (n = 1)
1
100
 Dilation of esophageal stricture (n = 1)
1
100
 Avoidance trigger/ diet modification (n = 5)
5
100
aComorbidities defined as hypertension or diabetes mellitus or dyslipidemia or obesity or chronic kidney disease
b Sinus Bradycardia, Sinus Arrest, Asystole; c First, Second, Third degree Atrioventricular block; d Atrial Tachycardia, Atrial Fibrillation and others
Various mechanisms regarding the pathogenesis of swallow syncope have been postulated.
The most common postulated mechanism is increased and excessive vagal reflex activation during swallowing causing cardio inhibition [86]. During swallowing, the afferent impulses from the oesophageal plexus travel via the vagus nerve to the nucleus solitarius tract in the medulla oblongata. Subsequently, a corresponding signal that regulates involuntary peristalsis will travel down the parasympathetic efferent fibers through the oesophageal branch of the vagus nerve [87]. The presence of reflex arcs between afferent sensory fibers and efferent parasympathetic fibers of the cardiac branch results in inappropriate vagal activation with bradycardia, disturbance to the conduction system and hypotension secondary to vasodilation [27, 88]. The exact mechanism remains to be elucidated, however, excessive parasympathetic stimulation to the heart seems to be the central mechanism. The fact that atropine, a potent anticholinergic agent, prevents bradyarrhythmia effectively in cases of swallow syncope supports the theory of excessive vagal stimulations [5, 29, 66, 79].
Abnormal oesophageal mechanoreceptors have been postulated to be the primary cause of swallow syncope in individuals with underlying structural and functional disorders of the gastrointestinal system. We demonstrated a reproducible cardio-inhibition with balloon inflation in the mid to lower oesophagus in our patient [48, 89]. The bradyarrhythmia was terminated upon deflation of the balloon suggesting that mechanoreceptors in the mid-lower oesophagus may play a role in the pathogenesis of swallow syncope.
Investigations of neurally-mediated syncope should be tailored based on actual precipitants. While a tilt-table test confirmed the presence of a vasovagal response with reproduction of syncope, it did not demonstrate any periods of asystole. The diagnosis in this case was confirmed during OGD with cardiac monitoring and hence investigation with an OGD with haemodynamic monitoring should be considered for individuals with suspected swallow syncope. A diagram depicting a proposed approach to the diagnostic work-up and management of patients with symptoms suggestive of swallow syncope is depicted in (Fig. 4).

Conclusions

Swallow syncope is a rare cause for syncopal events and should be considered as part of the diagnostic workup. Pacemakers are a safe and efficacious therapeutic option for all patients with that condition. In patients with associated gastrointestinal disease, specific treatment of the underlying disease has a high likelihood of resolving the swallow syncope without the need for permanent pacing.

Acknowledgments

This publication was presented as an abstract at the European Society of Cardiology, Heart Failure 2019 and the World Congress on Acute Heart Failure, 25th – 28th May 2019, Athens, Greece.
Not applicable.
Written informed consent was obtained from the patient for publication of this case report.

Competing interests

The authors declare that they have no competing interests.
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Metadaten
Titel
Swallow syncope: a case report and review of literature
verfasst von
Kelvin Shenq Woei Siew
Maw Pin Tan
Ida Normiha Hilmi
Alexander Loch
Publikationsdatum
01.12.2019
Verlag
BioMed Central
Erschienen in
BMC Cardiovascular Disorders / Ausgabe 1/2019
Elektronische ISSN: 1471-2261
DOI
https://doi.org/10.1186/s12872-019-1174-4

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