Oculocardiac Reflex in a Patient With Maxillofacial Trauma: A Case Study and Literature Review.

Oculocardiac reflex (OCR), presenting as bradycardia and asystole, is a potential intraoperative complication that may occur during maxillofacial trauma surgery. Bradycardia is the most common symptom of this phenomenon. Surgeons should be aware of its long-term effects, such as arrhythmias and even cardiac arrest. We report the case of a 40-year-old male patient with a fracture of the floor of the orbit. During a surgical exploration of the orbital floor, the patient exhibited sudden symptoms of OCR. It was managed by withholding the surgery and administering atropine. The article also highlights the mechanism, types, incidence, and management of OCR in patients with maxillofacial trauma.

Unconventional diagnosis of bradyarrhythmic syncope in Brugada syndrome: a case report.

Background: The Brugada syndrome (BrS) is an inherited disorder associated with the risk of ventricular fibrillation and sudden cardiac death (SCD). The current main therapy is an implantable cardioverter-defibrillator (ICD). However, the risk stratification and management of patients remain challenging. Here, we present a case of BrS representative of the pitfalls that clinicians may encounter in the management of Brugada patients in routine clinical practice. Case summary: A 39-year-old man with BrS and recurring syncope was implanted with a subcutaneous ICD (S-ICD) (EMBLEM MRI S-ICD, Boston Scientific). Syncope recurred some months later. Subcutaneous ICD interrogation showed no arrhythmic events, but SMART Pass (high-pass filter) deactivation was noted. A query was sent to Boston Scientific clinical service, unveiling an extremely long asystolic pause as syncope determinant. Subcutaneous ICD was explanted and replaced by conventional single chamber ICD in the pre-pectoral region. Discussion: Brugada syndrome patients with high-risk features are candidates for ICD implantation to prevent SCD. Recent evidence highlighted that symptomatic patients carry a substantially higher risk compared with asymptomatic ones. Syncope may represent a pivotal symptom in BrS patients, but young patients with Type 1 Brugada pattern may experience syncope other than from tachyarrhythmias. Subcutaneous ICD is an advisable option in young ICD recipients to avoid lifetime complication related to standard transvenous systems. However, S-ICD lacks pacing capabilities and, therefore, is not indicated when an anti-bradycardia system is needed. The diagnostic workup of syncope in Brugada patients may be ineffective in elucidating the underlying aetiology whose understanding is essential to offer a personalized therapeutic approach.

Third-Degree Atrioventricular Block And Asystole After Lung Resection: A Rare Complication.

Surgical resection remains the optimal therapeutic option for early-stage operable NSCLC. Despite significant advances in recent years related to anesthetic and surgical techniques, cardiopulmonary complications remain major causes for postoperative morbimortality. In this paper we present a case of a patient who developed complete AV block followed by asystole after lung resection surgery. The patient underwent surgery via right VATS and the procedure was uneventful.  On the first post-operative day patient developed a third-degree atrioventricular block followed by 6 seconds asystole. Pharmacological treatment was instituted and implementation of a permanent pacemaker occurred on the third post-operative day, without complications. The remaining postoperative course was uneventful and the patient was discharged home on the sixth post-operative day. It is the objective of the authors to report and highlight this rare and potencial fatal complication of lung resection.

Syncope or seizure: that is the question-case report of a young patient with convulsive cardioinhibitory syncope treated with cardioneuroablation.

Background: Differentiation of syncope from seizure is challenging and has therapeutic implications. Cardioinhibitory reflex syncope typically affects young patients where permanent pacing should be avoided whenever possible. Cardioneuroablation may obviate the need for a pacemaker in well-selected patients. Case summary: A previously healthy 24-year-old woman was referred to the emergency department after recurrent episodes of transient loss of consciousness (TLOC). The electrocardiogram (ECG) and the echocardiogram were normal. An electroencephalogram (EEG) showed intermittent, generalized pathological activity. During EEG under photostimulation, the patient developed a short-term TLOC followed by brachial myocloni, while the concurrent ECG registered a progressive bradycardia, which turned into a complete atrioventricular block and sinus arrest with asystole for 14 s. Immediately after, the patient regained consciousness without sequelae. The episode was interpreted as cardioinhibitory convulsive syncope. However, due to the pathological EEG findings, an underlying epilepsy with ictal asystole could not be fully excluded. Therefore, an antiseizure therapy was also started. After discussing the consequences of pacemaker implantation, the patient agreed to undergo a cardioneuroablation and after 72 h without complications, she was discharged home. At 10 months, the patient autonomously discontinued the antiepileptics. The follow-up EEG displayed unspecific activities without clinical correlations. An implantable loop recorder didn't show any relevant bradyarrhythmia. At 1-year follow-up, the patient remained asymptomatic and without syncopal episodes. Discussion: Reflex syncope must be considered in the differential diagnosis of seizures. The cardioneuroablation obviated the need for a pacemaker and allowed for the withdrawal of anticonvulsants, originally started on the premise of seizure.

Asystole in a young child with tetrahydrocannabinol overdose: a case report and review of literature.

Introduction: The association between Δ8-tetrahydrocannabinol (THC) and cardiac dysrhythmia has not been well described in children. Asystole, while consistent with reports of severe bradycardia and apnea in children, is uncommonly described in the current literature. We present the first pediatric case of asystole and apnea following THC ingestion. Case: A 7-year-old male presented to the emergency department (ED) after his mother noticed he was lethargic 3-4 h after accidental ingestion of five 15 mg (total of 75 mg) Δ8-THC gummies. Upon arrival, he was vitally stable and well-appearing. He received maintenance intravenous fluids. Approximately 7 h after initial ingestion, he experienced a >15-s episode of asystole and apnea on telemetry requiring sternal rub to awaken. This was followed by bradycardia (60 beats per minute range) which resolved with 0.1 mg glycopyrrolate. He was admitted to the PICU, drowsy but arousable with stable vitals. After an uneventful 24-h (post-ingestion) PICU observation, he was discharged home in stable condition. Discussion: To our knowledge, this is the first reported pediatric case of THC-induced asystole. The etiology of asystole may be attributed to direct vagal stimulation of THC or respiratory depression. The typical recommended observation time after potential toxicity is 3-6 h after children have returned to their physiological and behavioral baseline. Our patient was clinically stable with no concern for respiratory depression or cardiac dysrhythmia yet experienced an asystolic pause with apnea 7 h after initial ingestion. Conclusion: Our case demonstrates that asystole and apnea may occur in pediatric patients following large THC ingestions and those symptoms can appear late outside of the currently recommended observation period.

Complete Heart Block and Ventricular Asystole Caused by Vagus Nerve Stimulation Therapy.

Left vagus nerve stimulation (VNS) is an advanced therapeutic option for refractory, drug-resistant epilepsy. A 45-year-old woman with a history of refractory catamenial focal epilepsy since age 16, treated with a five-drug antiepileptic regimen and VNS (implanted eight and one-half years prior), presented with dyspnea, chest discomfort, and lightheadedness. During observation, symptoms recurred and were associated with bradycardia (<20 bpm) and a complete atrioventricular node (AVN) block. Following admission, she continued to experience recurrent symptomatic AVN block and transient ventricular asystole, temporally correlated with her baseline seizure activity and resultant activation of her VNS. Deactivation of VNS resolved her bradyarrhythmia, and she experienced no recurrence over 14 months of follow-up. This case highlights a therapeutic dilemma in cases of refractory epilepsy, with limited therapeutic options if seizure activity requires VNS to be controlled.

Lettre to editor: Case report of an ictal asystole as debut in new onset epilepsy.

The case report describes a 65-year-old man with arterial hypertension and a metallic aortic valve who presented to the emergency room for a loss of consciousness event and memory impairment. The electroencephalographic recording showed right temporal epileptiform activity followed by a 9 s asystole with quick consciousness recovery. The patient was diagnosed with right temporal epilepsy with asystole and was prescribed levetiracetam to prevent new events. A pacemaker was indicated in the follow-up for the long duration of the asystole, preventing major morbidity. Ictal asystole (IA) is a rare phenomenon of epilepsy that leads to syncope. It is observed in focal epilepsy, especially in left temporal epilepsy. Underlying cardiac pathology may facilitate IA, especially when the onset of the epilepsy is new. Knowledge of focal temporal semiology is key, concerning our case report, the memory impairment points to temporal pathology, and ictal vomiting in the non-dominant hemisphere. Anti-seizures drugs must be initiated in all patients, and there is a recommendation to avoid those with negative inotropic and arrhythmogenic effects (such as phenytoin, carbamazepine, and lacosamide). There is a discussion about pacemaker indication, however, it is highly recommended in non-controlled epilepsy and in ictal asystoles that last for more than 6 s to reduce morbidity.

Predicting time to asystole following withdrawal of life-sustaining treatment: a systematic review.

The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.

Asystole on loop recorder in patients with unexplained syncope and negative tilt testing: age distribution and clinical predictors.

BACKGROUND: Approximately 50% of patients with unexplained syncope and negative head-up tilt test (HUTT) who have an electrocardiogram (ECG) documentation of spontaneous syncope during implantable loop recorder (ILR) show an asystolic pause at the time of the event. OBJECTIVE: The aim of the study was to evaluate the age distribution and clinical predictors of asystolic syncope detected by ILR in patients with unexplained syncope and negative HUTT. METHODS: This research employed a retrospective, single-center study of consecutive patients. The ILR-documented spontaneous syncope was classified according to the International Study on Syncope of Uncertain Etiology (ISSUE) classification. RESULTS: Among 113 patients (54.0 ± 19.6 years; 46% male), 49 had an ECG-documented recurrence of syncope during the observation period and 28 of these later (24.8%, corresponding to 57.1% of the patients with a diagnostic event) had a diagnosis of asystolic syncope at ILR: type 1A was present in 24 (85.7%), type 1B in 1 (3.6%), and type 1C in 3 (10.7%) patients. The age distribution of asystolic syncope was bimodal, with a peak at age < 19 years and a second peak at the age of 60-79 years. At Cox multivariable analysis, syncope without prodromes (OR 3.7; p = 0.0008) and use of beta blockers (OR 3.2; p = 0.002) were independently associated to ILR-detected asystole. CONCLUSIONS: In patients with unexplained syncope and negative HUTT, the age distribution of asystolic syncope detected by ILR is bimodal, suggesting a different mechanism responsible for asystole in both younger and older patients. The absence of prodromes and the use of beta blockers are independent predictors of ILR-detected asystole.

Ictal Asystole During Focal Seizures Due to Left Occipital Glioneuronal Tumor: A Report of Case Treated With Cardiac Neuromodulation.

Ictal asystole (IA) is a rare but potentially life-threatening complication of focal epilepsy. The sudden onset of loss of consciousness and drop attacks in a patient with chronic epilepsy should suggest the possibility of this complication. Once the diagnosis is established, rapid management should be considered, especially in high-risk cases. The approach does not differ between temporal and extratemporal lobe epilepsies. Strategies can be aimed at preventing the emergence of cortical epileptic activity from the beginning (surgery, antiseizure therapy), neutralizing negative chronotropic effects on the heart (cardiac neuromodulation), or restarting the heart rhythm with a pacemaker. Pacemaker implantation is not a completely complication-free treatment, and living with a device that requires care and follow-up throughout life makes alternative treatment methods more valid for young patients with many years to live or cases that could benefit from surgery. In this article, we present a patient with a left occipital glioneuronal tumor and drug-resistant occipital lobe epilepsy. IA was documented by long-term video EEG monitoring (VEM). During about 2 years of follow-up after a cardiac neuromodulation procedure, there were no drop attacks or asystole with seizures, confirmed by long-term VEM.

Sudden unexpected death in epilepsy and ictal asystole in patients with autoimmune encephalitis: a systematic review.

OBJECTIVE: As autoimmune encephalitis (AE) often involves the mesial temporal structures which are known to be involved in both sudden unexpected death in epilepsy (SUDEP) and ictal asystole (IA), it may represent a good model to study the physiopathology of these phenomena. Herein, we systematically reviewed the occurrence of SUDEP and IA in AE. METHODS: We searched 4 databases (MEDLINE, Scopus, Embase, and Web of Science) for studies published between database inception and December 20, 2022, according to the PRISMA guidelines. We selected articles reporting cases of definite/probable/possible/near-SUDEP or IA in patients with possible/definite AE, or with histopathological signs of AE. RESULTS: Of 230 records assessed, we included 11 cases: 7 SUDEP/near-SUDEP and 4 IA. All patients with IA were female. The median age at AE onset was 30 years (range: 15-65), and the median delay between AE onset and SUDEP was 11 months; 0.9 months for IA. All the patients presented new-onset seizures, and 10/11 also manifested psychiatric, cognitive, or amnesic disorders. In patients with SUDEP, 2/7 were antibody-positive (1 anti-LGI1, 1 anti-GABABR); all IA cases were antibody-positive (3 anti-NMDAR, 1 anti-GAD65). Six patients received steroid bolus, 3 intravenous immunoglobulin, and 3 plasmapheresis. A pacemaker was implanted in 3 patients with IA. The 6 survivors improved after treatment. DISCUSSION: SUDEP and IA can be linked to AE, suggesting a role of the limbic system in their pathogenesis. IA tends to manifest in female patients with temporal lobe seizures early in AE, highlighting the importance of early diagnosis and treatment.

Cardioneuroablation for the treatment of ictal-associated cardiac asystole: case report and literature review.

Background: Ictal-associated bradyarrhythmia or asystole can be a manifestation of malignant seizure syndromes. In patients with ictal-associated hypervagotonia and asystole, cardioneuroablation may provide a promising alternative to permanent pacemaker implantation. Case summary: We present a case of a 47-year-old female with a 1.5-year history of ongoing uncontrolled seizures with multiple semiologies despite multiple antiepileptic drugs who had episodes of symptomatic severe sinus bradycardia (15-30 b.p.m.) and sinus pauses (15-16 s). She underwent a successful cardioneuroablation for ictal-induced asystole with complete resolution of bradyarrhythmias. Discussion: This case highlights the utility of cardioneuroablation in patient with ictal-induced cardiac bradyarrhythmia and asystole. Cardioneuroablation may be an approach to avoid permanent pacemakers in this population.

Syncope and Cannabis: hypervagotonia from chronic abuse? A case report and literature review.

BACKGROUND: Cannabis is the most consumed drug worldwide and number of users is increasing, particularly among youth. Moreover, cannabis potential therapeutic properties have renewed interest to make it available as a treatment for a variety of conditions. Albeit rarely, cannabis consumption has been associated with cardiovascular diseases such as arrhythmias, myocardial infarction (MI) and potentially sudden death. CASE PRESENTATION: A 24-year-old woman presented to the emergency department sent by her cardiologist because of a recent finding of a 16 seconds asystole on the implantable loop recorder (ILR) she implanted 7 months before for recurrent syncopes. She declared that she is a heavy cannabis user (at least 5 cannabis-cigarette per day, not mixed up with tobacco, for no less than 12 years) and all syncopes occurred shortly after cannabis consumption. After a collective discussion with the heart team, syncope unit, electrophysiologists and toxicologist, we decided to implant a dual chamber pacemaker with a rate response algorithm due to the high risk of trauma of the syncopal episodes. 24 months follow-up period was uneventful. CONCLUSIONS: Cannabis cardiovascular effects are not well known and, although rare, among these we find ischemic episodes, tachyarrhythmias, symptomatic sinus bradycardia, sinus arrest, ventricular asystole and possibly death. Because of cannabis growing consumption both for medical and recreational purpose, cardiovascular diseases associated with cannabis use may become more and more frequent. In the light of the poor literature, we believe that cannabis may produce opposite adverse effects depending on the duration of the habit. Acute administration increases sympathetic tone and reduces parasympathetic tone; conversely, with chronic intake an opposite effect is observed: repetitive dosing decreases sympathetic activity and increases parasympathetic activity. Clinicians should be aware of the increased risk of cardiovascular complications associated with cannabis use and should investigate its consumption especially in young patients presenting with cardiac dysrhythmias.

[When the Brain Dictates the Rhythm].

INTRODUCTION: In rare cases, an HSV-Encephalitis can lead to sinus node dysfunction, as was the case in this 70-year old woman who suffered from recurrent syncopes. Diagnostic work-up showed sinus bradycardias and short-lasting sinus arrests, primarily consider-ed to be of cardiac etiology. After development of fever and neurological alteration, an HSV1 encephalitis was diagnosed. As our research of the current literature showed, the connection between the two is not completely clear. The HSVtypical infestation of the insular cortex, which influences the autonomic nervous system, should be discussed by all means. However, due to cessation of arrhythmia after seizure-suppressing therapy, we suspected an epileptic cause in this case. This shows the importance of a thorough differential diagnostic evaluation.

Application of the TiPS65 score for out-of-hospital cardiac arrest patients with initial non-shockable rhythm treated with ECPR.

Background: The TiPS65 score is a validated scoring system used to predict neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients with shockable rhythm treated with extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to assess the predictive performance of the TiPS65 score in OHCA patients with initial non-shockable rhythm treated with ECPR. Methods: This was a secondary analysis using the JAAM-OHCA registry, a multicenter prospective cohort study. The study included adult OHCA patients with initial non-shockable rhythm who underwent ECPR. The TiPS65 score assigned one point to each of four variables: time to hospital ≤25 minutes, pH value ≥7.0 on initial blood gas assessment, shockable on hospital arrival, and age younger than 65 years. Based on the sum score, the predictive performance for 1-month survival and favorable neurological outcomes, defined as the Cerebral Performance Category 1 or 2, was evaluated. Results: Among 57,754 patients in the registry, 370 were included in the analysis. The overall one-month survival and favorable neurological outcome were 11.1% (41/370) and 4.2% (15/370), respectively. The 1-month survival rates based on the TiPS65 score were as follows: 11.2% (12/107) for 0 points, 9.3% (14/150) for 1 point, 10.0% (9/90) for 2 points, and 26.1% (6/23) for ≥3 points. Similarly, the 1-month favorable neurological outcomes were: 5.6% (6/107) for 0 points, 2.7% (4/150) for 1 point, 4.4% (4/90) for 2 points, and 4.3% (1/23) for ≥3 points. The area under the curve was 0.535 (95% CI: 0.437-0.630) for 1-month survival and 0.530 (95% CI: 0.372-0.683) for 1-month neurological outcome. Conclusion: This study demonstrates that the TiPS65 score has limited prognostic performance among OHCA patients with initial non-shockable rhythm treated with ECPR. Further research is warranted to develop a predictive tool specifically focused on OHCA with initial non-shockable rhythm to aid in determining candidates for ECPR.

Air pollution and out-of-hospital cardiac arrest risk: a 7-year study from a highly polluted area.

AIMS: Globally, nearly 20% of cardiovascular disease deaths were attributable to air pollution. Out-of-hospital cardiac arrest (OHCA) represents a major public health problem; therefore, the identification of novel OHCA triggers is of crucial relevance. The aim of the study was to evaluate the association between air pollution (short-, mid-, and long-term exposures) and OHCA risk, during a 7-year period in a highly polluted urban area in northern Italy, with a high density of automated external defibrillators (AEDs). METHODS AND RESULTS: Out-of-hospital cardiac arrests were prospectively collected from the 'Progetto Vita Database' between 1 January 2010 and 31 December 2017; day-by-day air pollution levels were extracted from the Environmental Protection Agency stations. Electrocardiograms of OHCA interventions were collected from the AED data cards. Day-by-day particulate matter (PM) 2.5 and 10, ozone (O3), carbon monoxide (CO), and nitrogen dioxide (NO2) levels were measured. A total of 880 OHCAs occurred in 748 days. A significant increase in OHCA risk with a progressive increase in PM2.5, PM10, CO, and NO2 levels was found. After adjustment for temperature and seasons, a 9% and 12% increase in OHCA risk for each 10 µg/m3 increase in PM10 (P < 0.0001) and PM2.5 (P < 0.0001) levels was found. Air pollutant levels were associated with both asystole and shockable rhythm risk, while no correlation was found with pulseless electrical activity. CONCLUSION: Short- and mid-term exposures to PM2.5 and PM10 are independently associated with the risk of OHCA due to asystole or shockable rhythm.

The Heart and Seizures: Friends or Enemies?

The heart and seizures are closely linked by an indissoluble relationship that finds its basis in the cerebral limbic circuit whose mechanisms remain largely obscure. The differential diagnosis between seizures and syncopes has always been a cornerstone of the collaboration between cardiologists and neurologists and is renewed as a field of great interest for multidisciplinary collaboration in the era of the diffusion of prolonged telemonitoring units. The occurrence of ictal or post-ictal arrhythmias is currently a cause of great scientific debate with respect to the role and risks that these complications can generate (including sudden unexpected death in epilepsy). Furthermore, the study of epileptic seizures and the arrhythmological complications they cause (during and after seizures) also allows us to unravel the mechanisms that link them. Finally, intercritical arrhythmias may represent great potential in terms of the prevention of cardiological risk in epileptic patients as well as in the possible prediction of the seizures themselves. In this paper, we review the pertaining literature on this subject and propose a scheme of classification of the cases of arrhythmia temporally connected to seizures.

Bioética en donantes en asistolia controlada

Las campañas de prevención y promoción de salud, así como los avances en las medidas terapéuticas destinadas a los pacientes neurocríticos, han logrado reducir la incidencia de pacientes con injuria encefálica aguda (IEA) que evolucionan a la muerte encefálica (ME). Sin embargo, en la mayoría de los países de América Latina, los órganos perfusibles aptos para trasplante (TX) provienen de donantes fallecidos en ME. La donación en asistolia (DA), y en particular la donación en asistolia controlada (DAC), constituye una opción aceptada y válida para la obtención de órganos que contribuiría a la disminución de las listas de espera para trasplante. Durante el proceso de DAC, se aplican conceptos con fuerte impronta bioética cuya aplicación resulta fundamental en el momento de la toma de decisiones. El presente artículo tiene el objetivo de analizar dichos conceptos con la finalidad de otorgar herramientas válidas al equipo asistencial para aquellos procesos en los que existe deliberación moral, como ocurre en la donación de órganos en asistolia controlada, considerada parte integral de los cuidados al final de la vida.

Campaigns for health prevention and promotion, along with advancements in therapeutic measures for neurocritical patients, have succeeded in reducing the incidence of patients with acute brain injury (ABI) progressing to brain death (BD). However, in most Latin American countries, suitable perfusable organs for transplantation (TX) come from deceased donors in brain death (BD). Donation after circulatory death (DCD), particularly controlled donation after circulatory death (cDCD), represents an accepted and valid option for organ procurement that would contribute to reducing transplant waiting lists. During the cDCD process, strong bioethical principles are applied, and their implementation is crucial when making decisions. The purpose of this article is to analyze these concepts, aiming to provide valid tools to the healthcare team for processes involving moral deliberation, such as controlled circulatory death organ donation, considered an integral part of end-of-life care.

As campanhas de prevenção e promoção da saúde, bem como os avanços na medidas terapêuticas voltadas para pacientes neurocríticos conseguiram reduzir a incidência de pacientes com lesão cerebral aguda que evoluem para morte encefálica (ME). No entanto, na maioria dos países latino-americanos, os órgãos que podem ser perfundidos adequados para transplante (TX) vêm de doadores falecidos em ME. A doação em assistolia e em particular a doação em assistolia controlada (DAC),é uma opção aceita e válida para a obtenção de órgãos, o que contribuiria para a redução das listas de espera para transplantes. Durante o processo DAC, são aplicados conceitos com forte cunho bioético, que são fundamentais na o momento da tomada de decisão. Este artigo tem como objetivo analisar esses conceitos, com o objetivo de oferecer ferramentas válidas à equipe de saúde, para os processos em que há deliberação moral como ocorre na doação de órgãos em assistolia controlada considerada parte integrante dos cuidados de fim de vida.

Cardioneuroablation for neurally-mediated syncope: Initial experience.

Cardioneuroablation is an emerging alternative therapeutic modality for young patients with severe neurally-mediated syncope. We present two images of cardioneuroablation performed in young patients who suffered from recurrent neurally-mediated syncope with asystole and functional atrioventricular block. The patients remain syncope-free during follow-ups.