Eur J Cardiothorac Surg 2002;21:587-590
© 2002 Elsevier Science NL
Swallow syncope associated with paroxysmal atrial fibrillation
Jackie Gordon,
Syed M. Saleem,
Dumbor L. Ngaage,
James A.C. Thorpe*
Department of Cardio Thoracic Surgery, Yorkshire Heart Centre, Jubilee Wing, D-Floor, The General Infirmary, Leeds LS1 3EX, UK
Received 28 April 2001;
received in revised form 14 December 2001;
accepted 18 December 2001.
* Corresponding author. Tel.: +44-113-392-5736; fax: +44-113-392-8436
e-mail: thorpyat{at}aol.com
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Abstract
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Swallow or deglutition syncope is a very unusual potentially lethal but treatable disorder. We report the case of a 26-year-old woman, who presented with a history of recurrent, multiple fainting episodes precipitated by swallowing. Twenty-four-hour manometry and pH recording together with continuous 24-h ECG monitoring revealed multiple episodes of symptomatic and asymptomatic paroxysmal atrial fibrillation, and significant gastro-oesophageal reflux associated with swallowing. Oesophageal function tests and continuous electrocardiographic evaluation is important in the diagnosis of this rare condition.
Key Words: Swallow syncope • Syncopal syndromes • Paroxysmal atrial fibrillation • Esophageal function tests • Gastroesophageal reflux
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1. Introduction
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Swallow or deglutition syncope is a very unusual potentially lethal but treatable disorder. Apart from a possible case reported by Spans in 1793, the earliest report of oesophageal syncope was by McKenzie in 1906. Most reported cases of swallow syncope are due to bradyarrhythmia [1,2]. The diagnosis and successful management of this condition can pose a clinical dilemma. We discuss the management of a 26-year-old woman with a clinical rarity of swallow syncope associated with paroxysmal atrial fibrillation.
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2. Case report
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A 26-year-old woman presented with multiple episodes of fainting, central chest discomfort, heartburn and excessive salivation induced by swallowing. She smoked 20 cigarettes, and drank 6 units of alcohol and 3 mugs of caffeinated drinks daily. She was not taking any medication and had no significant past medical history. She was referred for evaluation and management.
On admission, she was in sinus rhythm at a rate of 72 beats/min with a systemic blood pressure of 110/80 mmHg. Physical examination revealed no abnormality. Barium studies and oesophago-gastroscopy confirmed a small hiatus hernia without oesophagitis. Multiple episodes of symptomatic and asymptomatic paroxysmal atrial fibrillation and ventricular ectopic beats were recorded repeatedly during meals or while drinking water on elecrocardiographic monitoring, as shown in Fig. 1
. Oesophageal manometry revealed a hypotensive lower oesophageal sphincter with a mean mid-expiratory pressure of 13 mmHg. The sphincter appeared to relax completely. The ambulatory pH study showed upright gastro-esophageal reflux. The fraction of time when the pH was less than 4 in the upright position was 7%, supine 1.4% and total 4.9% (Fig. 2)
. She complained of distressing symptoms during the test, which coincided with the episodes of significant gastro-oesophageal reflux and arrhythmia. She was successfully treated conservatively with dietary control and a proton pump inhibitor.
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Fig. 1. The relevant part of a 24-h electrocardiograph showing normal sinus rhythm between meals and periods of paroxysmal atrial fibrillation with ventricular ectopics recorded during meal times.
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Fig. 2. A portion of the recording obtained from an ambulatory pH monitoring study showing upright gastro-oesophageal reflux.
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3. Discussion
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The neurally mediated syncopal syndromes encompass a number of apparently related disturbances of reflex cardiovascular control. Some of these syndromes, such as carotid sinus syndrome and post-micturition syncope, are encountered occasionally in clinical practice, whereas others like swallow syncope are quite rare. Syncope due to atrioventricular heart block induced by swallowing or pneumatic dilatation of the oesophagus has been reported [3,4]. Tachyarrhythmia associated with swallowing has been observed very rarely and not usually associated with syncope [5,6].
The mechanism of swallow syncope is probably related to the innervation of the oesophagus. Both motor and sensory innervation of the oesophagus is by the vagus. The neurones subserving sensory function from the esophagus and motor function to the heart are in close relationship to each other in the dorsal nucleus of the vagus. Therefore, it seems most likely that swallow syncope is mediated by a central reflex involving an unusual, if not abnormal, connection in this nucleus. Furthermore, acid stimulation of the lower oesophagus leads to a significant reduction in coronary blood flow in patients with coronary artery disease, but not in patients with heart transplant when the heart is denervated, suggesting a cardio-oesophageal reflex [7]. The physiological inter-relationship between the upper gastrointestinal tract and heart is well known [8]. Dysrhythmias are common during any procedure that involves manipulation of the upper gastrointestinal tract, such as endoscopy of the oesophagus or stomach. Oesophageal syncope represents an extreme form of this phenomenon [1].
The diagnosis of the rare condition should depend on a demonstration of the direct relationship between swallowing and syncope, as in this patient (Fig. 1). Some primary oesophageal diseases that have been associated with this condition include hiatal hernia, carcinoma, achalasia and diffuse spasm [1,9,10]. This case also highlights the importance of investigating patients with swallow syncope for underlying pathological conditions and instituting the appropriate treatment. The discontinuation or reduction of aggravating medications such as digoxin, ß-blockers or calcium channel antagonists may be necessary. Several drugs including atropine, adrenaline, ephedrine and isoprenaline have been tried with inconsistent results. Bilateral splanchnic nerve block and bilateral vagal block with various local anaesthetics have been unreliable in controlling symptoms. When syncope is not associated with an oesophageal abnormality that requires correction, the treatment of choice is the insertion of a cardiac demand pacemaker.
Swallow syncope is a rare clinical condition that can be difficult to diagnose and treat successfully. Patients with suggestive symptoms should be have a full oesophageal physiological work-up with a 24-h electrocardiographic monitoring to document the relationship between swallowing and adverse cardiac events, and also to identify underlying oesophageal pathologies. A successful treatment of this condition can be achieved by treating the associated oesophageal disease.
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References
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Abstract
1. Introduction
