Ground vasovagal presyncopes and fighter pilot fitness: aeromedical concerns.

BACKGROUND: Vasovagal episodes are common events but may have consequences for flight safety, particularly in high-performance aircrafts, where the autonomic nervous system is impacted during +G(z) accelerations. However, the risk is difficult to assess in the case of ground presyncopes. CASE REPORT: A 27-yr-old fighter pilot experienced a feeling of faintness at a daily briefing. He had previously shown no medical history except for a single episode. The initial physical examination was normal. During vagal maneuvers, the pilot developed a cardiac pause and a tilt-table test was positive. Other investigations were normal.The pilot lost consciousness twice in centrifuge testing while previous tests had shown a good cardiovascular tolerance. He was declared unfit to fly fast jets but fit as a multicrew transport pilot with a waiver. DISCUSSION: The epidemiology of vasovagal reactions is difficult to estimate in aircrew. A late occurrence in the career can be explained by either a newly acquired hypervagotonia, or an old predisposition with specific triggering factors in which psychosocial aspects are important. In such circumstances three steps are necessary to assess fitness: 1) to check for other etiologies; 2) to look for vasovagal predisposition; and 3) to check psychiatric condition. The studies about the predictive value of the tilt-test must be taken into account. CONCLUSION: In the case of vasovagal presyncope in a fighter pilot, the aeromedical decision should consider the medical history of the pilot, the results of investigations, and the experience and motivation of the individual under review. Centrifuge testing may be useful in difficult situations.

LBBB in aircrew with low cardiac risk: diagnostic application of multislice CT.

INTRODUCTION: Because of its excellent negative predictive value for diagnosing coronary stenoses, multislice computed tomography (MSCT) may be a way to assess the absence of significant coronary stenosis. We discussed its place in aeromedical decision-making for aircrew members with a low level of cardiovascular risk factors and acquired left bundle branch block (LBBB). METHODS AND RESULTS: During the period 2002-2004, 12 male aircrew members (mean age: 42.9 yr) with acquired LBBB were admitted to our cardiovascular and aeronautical department. The exploration of LBBB was classical, including an electrophysiological study, the usual coronary angiography, and MSCT. All the morphological explorations of the coronary tree were normal. DISCUSSION: In addition to complex electrophysiological mechanisms, coronary artery disease (CAD) is suspected, but remains infrequent in some EKG findings such as acquired LBBB, especially for patients with low cardiovascular risk factors as demonstrated with our aircrew members. However, in aerospace medicine the expert needs to prove the absence of CAD. The use of standard examinations (exercise stress test, stress myocardial scintigraphy, etc.) is controversial because of artifacts and a conventional coronary angiography is necessary. According to previous studies, including using a validated technique in our department (with 16-slice computed tomography), the excellent negative predictive value of MSCT (97 to 99%) may be a way to avoid invasive exploration during the investigation of a newly acquired LBBB in aviators with low cardiovascular risk.