Current best medical practices survey in vagus nerve stimulation programming

Vagal Nerve Stimulator Therapy (VNS) uses programmable duty cycle (DC) and three modes of stimulation: normal mode (NM), heart-rate responsive automatic stimulation mode (AS), and on-demand magnet mode (MM). VNS therapy guidelines exist however; they may not represent real-world best clinical practices. This study aims to identify current best medical practices in VNS programming. Epilepsy VNS practitioners received an anonymous, deidentified IRB-approved online survey at the American Epilepsy Society Meeting (12/3/2023, Orlando Florida). The majority of respondents were US-practicing (n = 45, 78%) epileptologists (n = 43, 74%) programming VNS devices in 50 patients or less in the preceding two years prior to the creation of the survey (n = 39, 67%). Most programmed VNS independently and trained others how to program VNS devices (n = 49, 84%). Large variations in programming of NM, AS, and DC occurred. The median initial and maximum target NM output was 1-1.25 mA (n = 18, 31%) and 2-2.5 mA (n = 23, 40%) respectively. Most (n = 37, 64%) programmed AS current higher than NM. A third subset programmed initial and final AS heart-rate increase thresholds at 40% and 20% respectively (n = 19, 33%). The median anticipated final DC target was 35%. Most achieved final VNS settings at or before 40 weeks (n = 47, 81%) and declared VNS non-responders at 13-36 months after initial programming (n = 37, 64%). Our study identifies variability in VNS programming practices amongst epilepsy practitioners highlighting gaps between guideline recommendations and their clinical application. This study offers critical insights into optimal VNS therapy settings and optimization of VNS therapy outcomes for patients with DRE.