S4276 Deglutition Syncope Without Esophageal Abnormalities Successfully Treated With Dual-Chamber Pacemaker Implantation: A Case Report

Introduction: Deglutition syncope is a rare, vagally mediated reflex syncope triggered by swallowing, causing bradyarrhythmia and cerebral hypoperfusion. Diagnosis is challenging and may require electrocardiogram (ECG) monitoring during meals. Management includes dietary changes, medications, and pacemaker implantation. Dual-chamber pacing is effective, especially in recurrent cases. This report presents a rare case successfully treated with a pacemaker despite no esophageal abnormalities. Case Description/Methods: A 65-year-old man presented with a 1-year history of recurrent syncope and presyncope triggered by eating or drinking, especially when eating rapidly. Symptoms included lightheadedness, nausea, and near-fainting, without dysphagia. His history included controlled diabetes, hyperlipidemia, gastroesophageal reflux disease, and a myeloproliferative disorder. Workup revealed a small sliding hiatal hernia and gastroesophageal reflux disease, with normal ECG, echocardiogram, and myocardial perfusion imaging. A 30-day Holter monitor showed sinus pauses up to 3.7 seconds, linked to swallowing. A dual-chamber pacemaker was implanted. At 1-month follow-up, all symptoms had resolved. Discussion: Deglutition syncope is a rare, reflex-mediated condition characterized by swallowing-induced bradyarrhythmia, most often affecting older adults with a slight male predominance. It may be triggered by both solids and liquids, especially when consumed rapidly, and frequently lacks prodromal symptoms. The pathophysiology involves an exaggerated vagal reflex via esophageal mechanoreceptors leading to cardioinhibition—manifesting as sinus pauses, atrioventricular block, or even asystole. Diagnosis hinges on clinical suspicion and documentation of swallowing-associated arrhythmias using Holter monitoring or event recorders, as routine ECG and imaging are typically normal. A significant subset of patients has structural esophageal or cardiac abnormalities, though many remain idiopathic. Management includes lifestyle modification, avoiding triggers, and in persistent or high-risk cases, dual-chamber pacemaker implantation, which has shown high success rates. Evaluation for treatable esophageal causes, such as hiatal hernia or achalasia, is essential, as their correction may resolve symptoms. For younger or pacemaker-averse patients, emerging therapies like cardioneuroablation offer promising, device-free alternatives.