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Swallowing-Induced Paroxysmal Atrial Fibrillation Associated with Neurocardiogenic Syncope – a Case Report

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Swallowing-Induced Paroxysmal Atrial Fibrillation Associated with Neurocardiogenic Syncope – a Case Report DOI：10.6314/JIMT.201902_30(1).08 內科學誌 2019：30：42-46 Swallowing-induced Paroxysmal Atrial Fibrillation Associated with Neurocardiogenic Syncope – A Case Report Yu-Shien Kao1, Ye-Hsu Lu1, Meng-Chi Chang2, Wei-Chung Tsai1,3, and Chee-Siong Lee1,3 1Department of Internal Medicine, 2Department of Nursing, Kaohsiung Medical University Hospital; 3School of Medicine, College of Medicine, Kaohsiung Medical University Abstract Swallowing-induced tachyarrhythmias is a rare phenomenon, with only over 50 cases reported in the literature. We reported a unique case of swallowing-induced paroxysmal atrial fibrillation(AF) associated with Type IIB neurocardiogenic syncope. A 71-year-old woman presented with intermittent palpitation happening mostly at night time and during meal when she swallowed food. The symptom of palpitation could be relieved by walking exercise. Paroxysmal atrial fibrillation was documented during palpitation. She also had an episode of syncope. Brief episodes of AF could be easily induced by drinking water in room temperature. Tilting table test results showed a very short duration of repetitive premature atrial contractions (PACs) followed by cardiac asystole up to 4.86 seconds after provocation with sublingual nitroglycerin. Under the diagnosis of swallowing- induced AF and Type IIB neurocardiogenic syncope, she was successfully treated with a DDDR pacemaker and oral propafenone 150mg three times a day. The clinical symptoms were under well control and there was no more syncope after treatment. (J Intern Med Taiwan 2019; 30: 42-46) Key Words: Swallowing, Tachyarrhythmias, Atrial fibrillation Introduction They typically manifest as transient atrioventric- ular block in the presence of either an esophageal Atrial fibrillation (AF) is the most common abnormality or known coronary artery disease, and sustained tachyarrhythmia encountered clinically. its mechanism has been considered mainly due to The etiology of AF is complicated and it might be vagotonic reflex. Swallowing-induced tachyar- associated with autonomic nervous system activa- rhythmias are less frequent with unclear etiology, tion, renin-angiotensin-aldosterone system activa- and usually not associated with cardiac or esoph- tion, genetic variants or other extracardiac factors, ageal abnormalities2,3. We report a case of swal- such as hypertension, hyperthyroidism, or alcohol lowing-induced paroxysmal AF (SIAF) associated consumption1. Swallowing-induced dysrhythmias with neurocardiogenic syncope which has not been can be classified into tachyarrhythmias and brady- reported before. arrhythmias, with the latter being more common. Reprint requests and correspondence：Dr. Chee-Siong Lee Address：Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Shih-Chuan 1st Road, San Min District, Kaohsiung City, Taiwan Swallowing-induced Atrial Fibrillation 43 Case Report table test was arranged in order to understand the possible mechanism of her syncope. A very short A 71-year-old woman, who had been suffer- duration of repetitive PACs followed by cardiac ing from intermittent palpitation for over 10 years, asystole up to 4.86 seconds was induced during the was referred to us because of recent syncope. Parox- test after provocation with sublingual nitroglycerin ysmal AF had been documented during her previ- (Figure 2). Frequent paroxysmal AF episodes were ous palpitation episodes. Detailed history revealed recorded immediately after tilting table test. Under that her palpitation happened mostly either at night the diagnosis of swallowing-induced AF and Type time period or during meal, and could be relieved by IIB neurocardiogenic syncope, she was successfully exercise. She had no dysphagia or dyspepsia. Esoph- treated with a DDDR pacemaker and oral propafe- agogastroduodenoscopy did not find any pathologi- none 150mg three times a day. The clinical symp- cal change in her esophagus and stomach. She was a toms were under well control and there was no more nonsmoker and did not consume alcohol or caffein- syncope after treatment. ated beverages. Her family history was negative for Discussion cardiac dysrhythmias or other heart diseases. On physical examination, there was no remark- The first case of a swallowing-induced tachyar- able finding except anxious personality. Her resting rhythmia was reported back in 1926 by Sakai and 12-lead ECG and thyroid function were normal. Mori4, approximately over 50 cases have been Echocardiography revealed normal left and right reported since then. The prevalence of swallowing- ventricular function with no regional wall motion induced tachyarrhythmia was reported to be 0.6% abnormality. 24-hour Holter ECG showed several among patients presented with symptomatic atrial episodes of paroxysmal AF, with asystole up to 6 arrhythmias. The clinical characteristics were: (1) seconds following one of the AF episodes. Brief males predominated 9:1 over females, (2) most cases episodes of AF could be easily induced by drink- occurred over 35 years of age, (3) tachyarrhythmias ing water in room temperature (Figure 1). A tilting occurred consistently and reproducibly shortly after Figure 1. Paroxysmal atrial fibrillation easily induced by water swallowing. 44 Y. S. Kao, Y. H. Lu, M. C. Chang, W. C. Tsai, and C. S. Lee Figure 2. Cardiac asystole up to 4.86 seconds was induced during tilt table test after provocation with sublingual nitroglycerin. each swallow, (4) 90% of the patients had prema- ducibly demonstrated. This theory was also not able ture atrial contractions (PACs) and/or atrial tachy- to explain cases in which the focus of tachyarrhyth- cardia (AT) as the manifesting arrhythmia, (5) the mias was not in the left atrium, such as pulmonary PACs provoked by swallowing usually had the same veins, right atrium and superior vena cava3,11,12 . P-wave morphology as the first beat of the AT and Gastroendoscopy and image study in our patient did AF5. Moreover, atrioventricular (AV) nodal reentrant not suggest any evidence of direct contact between tachycardia and AV reciprocating tachycardia as well esophagus and left atrium. as AF can be induced by swallowing6,7,8. There were Autonomic nervous system activation can few cases about the SIAF. Our patient was relatively induce significant and heterogeneous changes of older in comparison with previous cases, and pre- atrial electrophysiology and induce atrial tachyar- sented with SIAF which was rarely reported. rhythmias. Lindsay et al proposed a vagal nerve- The true mechanism of swallowing-induced mediated neural reflex as the initiating mechanism tachyarrhythmias is unclear. Several mechanisms of swallowing-induced atrial tachyarrhythmias. have been postulated in previous studies but with The increased intra-esophageal pressure associ- inconsistent suggestions. Cohen et al first reported ated with swallowing activated the afferent and atrial fibrillation triggered by balloon dilatation of efferent branches of the vagus nerve. Atrial ectopy the esophagus at the level of left atrium, thus sug- may result from preferential vagal discharge to the gested that mechanical stimulation of left atrium by atrial myocardium, which in turn may produce distended esophagus was the mechanism9 . Burton AT or AF13. In a case report by Morady et al, an et al even reported a case in which the patient needed esophageal manometric study demonstrated that the surgery to reposition the esophagus to cure swallow- swallowing tachycardia was coincident with relax- ing arrhythmia10. However, this has not been repro- ation of the upper esophageal sphincter and pre- Swallowing-induced Atrial Fibrillation 45 ceded the peristaltic activity in the esophageal body. to 4.86 seconds was induced. This also indicated They also described that the most possible mecha- clearly that our patient had an exaggerated vagal- nism was a vagally mediated neural reflex involv- mediated response. There has no known previous ing a neurotransmitter other than acetylcholine case report of this exact condition like ours dem- because atropine and bethanechol did not affect the onstrating the combination of swallowing-induced swallowing-induced AT14. Results from Heart rate AF and cardioinhibitory neurocardiogenic syncope. variability evaluation also suggested an increase Management of swallowing-induced tachyar- of parasympathetic nerve activity with suppres- rhythmias can be difficult. Given the variations in sion of sympathetic nerve activity when swallow- the trigger and type of the arrhythmias, different ing-induced AT occurred. The high frequency (HF) mechanisms may apply to each individual patient. component was suppressed after ablation with sup- There is no universally successful treatment for pression of PACs, suggesting that parasympathetic swallowing-induced tachyarrhythmias. There were nerve activity was strongly involved in the cause of a variety of medication including verapamil, beta- this arrhythmia rather than the sympathetic nerve blockers, class Ia, Ic antiarrhythmic drugs, and ami- system11. However, this hypothesis does not explain odarone has been reported to achieved satisfactory the poor effectiveness of vagolytic medications symptoms control2,3,4. Newer techniques of radio- such as atropine in these patients. Recently, epi- frequency catheter ablation of the arrhythmogenic cardial adipose tissue (EAT) which contains auto- source have also been attempted successfully on nomic ganglionated plexus with both adrenergic and swallowing-induced tachyarrhythmias refractory to cholinergic
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