Atrioventricular BlockTELE-SPACERNCT05774262
Pacemaker Implantation Versus Cardioneuroablation for Functional Atrioventricular Block
A study testing Pacemaker implantation and Cardioneuroablation (CNA) in people with Atrioventricular Block, run by American Heart of Poland at 2 sites in Poland.
Trial summary
The TELE-SPACER study is a multicenter, noncommercial, physician-initiated, proof-of-concept, prospective, randomized, controlled, unblinded clinical trial and registry designed to compare two methods of treatment of patients with functional Atrio-Ventricular Block (AVB): the guidelines-recommended elective pacemaker… Read more about this study
- Who is it for?
- Ages 18 to 75 years
- Conditions the study is for
- Atrioventricular Block
- What is being tested?
- Pacemaker implantation and Cardioneuroablation (CNA)
- Type of treatment
- Surgery or procedure
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 300 participants
- Where
- 2 sitesPoland
- Study dates
- 1 Sep 2023to 31 Dec 2026
- Phase
- Interventional
- Are there results?
- Not yet: the study is under way
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 to 75 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Written informed consent to participate in the study
- Age 18-75
- Indication (at least one) of the European Society of Cardiology (ESC) for elective pacemaker implantation due to isolated (without sinus node dysfunction and bundle branch block) paroxysmal, persistent or reflex atrioventricular block:
- Symptomatic first degree AVB (above 300 msec). Class IIaC
- Symptomatic Mobitz type I second degree AVB. Class IIaC
- AVB 2:1, even asymptomatic, but not during sleep. Class IIaC
Show all 11Show fewer
- Mobitz II type advanced 2nd degree AVB or complete block (3rd degree AVB). Class IC
- Advanced AVB during AF regardless of symptoms, but not during sleep. Class IC
- Reflex syncope in patients over 40 years of age with documented pauses within the AVB mechanism, symptomatic (>3 sec) or asymptomatic >6 sec. Class IC
- Reflex syncope in patients over 40 years of age with documented pauses within AVB mechanism in the course of sick sinus syndrome (CSS). Class IC
- Reflex syncope in patients over 40 years of age with documented pauses within AVB mechanism during tilt test. Class IC
Who cannot join
- Implanted pacemaker/ICD/CRT
- Sinus node dysfunction with indication for pacemaker implantation
- Planned ablation of the atrioventricular junction
- Severe prolonged bradycardia in advanced AVB requiring intravenous drugs and temporary pacing
- Status post cardiac surgery
- Acute myocardial infarction and heart failure (not related to bradycardia)
Show all 17Show fewer
- Status post percutaneous valvular intervention or ablation
- Acute infection or any other accompanying disease which is contraindication to percutaneous procedures and/or implantation of a pacemaker
- Pregnancy, nursing or planned pregnancy within 12 months
- Decompensated chronic diseases (endocrine disorders, electrolyte disorders, etc.)
- Advanced cardiomyopathies with indication for ICD implantation in primary or secondary prevention of sudden cardiac death (SCD)
- Advanced ventricular arrhythmias with indication for ICD implantation in primary or secondary prevention of SCD
- Persistent right or left bundle branch block
- Musculoskeletal diseases with separate indications for pacemaker implantation
- Contraindications to the procedures used in the study
- The presence of a mental illness or limitation of cognitive functions that prevent independent participation in the study, including the use of telemedicine services
- Any abnormality found that is considered by the Principal Investigator a contraindication to participate in the stidy due to data interpretation or safety issue
Trial locations and contacts
2 sites in 1 country. Contact the study team or a site near you to ask about taking part.
Poland2 sites, 2 recruiting
- Recruiting
American Heart of Poland
Dąbrowa Górnicza, 41-300
Sebastian Stec, MD, PhD, +48 600 298 022, smstec@wp.pl
- Recruiting
American Heart of Poland
Mielec, 39-300
Sebastian Stec, MD, PhD, +48 600 298 022, smstec@wp.pl
About this study
Official title: TELE-monitoring for Standard Pacemaker Implantation or Delayed Pacemaker Implantation After Autonomic/Electrophysiologic Evaluation and Cardioneuroablation for managEment of Functional atrioventriculaR Block - Randomized Controlled Study
The TELE-SPACER study is a multicenter, noncommercial, physician-initiated, proof-of-concept, prospective, randomized, controlled, unblinded clinical trial and registry designed to compare two methods of treatment of patients with functional Atrio-Ventricular Block (AVB): the guidelines-recommended elective pacemaker (PM) therapy vs cardiovascular autonomic tests (CAT), electrophysiologic assessment (EPS) with referral to cardioneuroablation (CNA) and reevaluation of indications for PM therapy.
The main questions TELE-SPACER aims to answer are:
Read more
- Can the investigators successfully treat functional AVB without implantable device (PM)?
- Can the investigators prove the feasibility and safety and demonstrate non-inferiority of CNA procedure in patients with functional AVB, avoiding long-term permanent pacing, its limitations, complications and costs ?
The TELE-SPACER trial will validate the European Society of Cardiology (ESC) recommendations (level C of evidence: expert opinion) for elective PM implantation and will introduce CNA as effective treatment in the functional AVB patient population.
Functional AVB - defined as a persistent or paroxysmal AVB with a positive results of atropine test
Read the detailed description
TELE-SPACER trial will enroll a minimum of 100 participants, males and females, 18-75 years old: 1) with indications for elective PM implantation due to atrioventricular block (AVB) according to 2021 ESC guidelines on cardiac pacing; 2) who had positive atropine tests. Participants will be randomized into two groups - either optimized guideline-recommended PM therapy (group A, n=50) or reevaluation for PM therapy after CAT/EPS and experimental procedure CNA (group B, n=50). Participants who will choose to opt-out of randomization will be included in the registry (group C) and will undergo patient-tailored intervention through shared decision-making with a possibility of either PM implantation, CNA or observation only. The registry is expected to include up to 200 participants.
Patient enrollment time is anticipated to last 2 years. Recruitment will take place in four study sites, in two distinct phases. First, the investigators will identify potential participants with AVB and a positive atropine test, confirming significant dependence of heart rhythm and conduction on the vagus nerve (hyperactivity of vagus nerve). Their medical records will be analyzed by the Scientific Committee (symptoms evaluation, physical examination, documentation of AVB). In the second phase eligible participants will be invited by the investigator to participate in the trial during medical consultation. After explanations describing the study protocol, including the risk and benefits, they will sign the written informed consent to participate in the study or will choose to opt-out of randomization to be included in the registry only (group C). Informed consent will be obtained only if it is clear that the patient truly understands the nature of the study. Alternatively, the patient will be encouraged to take a copy of the consent form home to contemplate enrolment in the study. Only participants who voluntarily consent will be included. Participants will be able to withdraw at any time without compromising their medical care.
Paricipants will be randomized in 1:1 allocation to either group A or group B. Randomization will be performed centrally and assigned automatically to each patient via internet. The randomization list will be blocked per center, with randomly varying block sizes of 2 and 4. The centers will not be aware of the block sizes. The PM implantation and treatment allocation will not be blinded to the patient or follow-up physician. Participants in either arm of the study will be followed-up at regular intervals for a minimum of 12 months. During the 12-month study duration, the use of effective contraception will be recommended for women of child-bearing age.
The period of the screening and randomization visit will last from 0 to 7 days, and the qualification for elective PM implantation (group A) or elective loop recorder monitoring/CAT/EPS (group B) and subsequent therapeutic decisions (CNA, DDDR, other treatment based on the test result) from 0 to 4 weeks. Parameter analysis baseline, including ECG telemonitoring, QOL and symptoms, will take place at randomization (0 months), 3, 6 and 12 months. Participants will be assessed using cardiovascular autonomic testing (CAT) with telemedical registration at 6 and 12 months. All measured parameters, as well as demographic and clinical data will be recorded in the study database.
Participants in group A (PM, n = 50) will receive care on the basis of the 2021 ESC Guidelines on Cardiac Pacing Recommendations. They will be implanted with PM (DDD pacemaker or its modification as HBP/LBBAP - His-Purkinje or left bundle branch area pacing) and will be monitored with external ECG recorder (certified medical devices of at least class IIa) with telemonitoring. Group B participants (CNA, n = 50) will be implanted with implantable loop recorder (ILR) device (Biotronik, Biomonitor 3m), also with remote tele-monitoring, with the same thresholds for automatic episode recording. As part of telemonitoring system, all participants will receive in the period before the procedure a dedicated telemonitoring kit consisting of a portable ECG device and a tablet with a sim card for network connection. This telemonitoring kit will enable regular self-testing, symptom reporting and interactive, objective telemedicine consultations. Participants will be provided with 24/7 contact with medical staff in the telemonitoring center specialized in cardiac arrhythmias and implantable device monitoring. The major reason for ECG recording is to provide ECG documentation of clinical AVB, as well as monitoring of participants before and after CNA (or PM implantation, if accepted). In case of severe AVB, the emergency system will always be called.
Participants in group B will be referred for EPS and ECVS (extracardiac vagal nerve stimulation) with the possibility of simultaneous CNA after exclusion of advanced and occult distal AVBs. Once the effectiveness of the CNA is confirmed, the patient will be further monitored. If CNA is not succesful and/or its immediate effectiveness is not confirmed (meeting the ESC criteria for pacemaker implantation after CNA), the patient will be referred for pacemaker implantation and will cross-over into group A.
CNA will be performed in group B under general anesthesia by experienced operators (at least 25 CNA procedures preformed). After EPS, a biatral, binodal, anatomically guided CNA will be performed under ECVS guidance, with a demonstration of the vagal reflex (complete asystole or AVB with atrial pacing) at the onset of the CNA and its complete disappearance after a successful CNA. Additional ablation substrates will also be allowed and performed.
Participants included in the registry (group C) will undergo an individually tailored intervention through shared decision making (SDM) with the option of implantation of PM (subgroup CA), CNA (subgroup CB) or observation only (subgroup C0).
All participants participating in the study and registry will be asked to complete questionnaires on health-related quality of life (EQ-5D-5L, SF-36), symptoms of bradycardia (VAS), fatigue (MFIS), depression (HADS-M) and sleep (ESS, AIS-8) at 0, 6, 12 months.
The safety of the interventions will be assessed on a monthly basis (telemedicine and standard follow-up visits), with monitoring of major adverse cardiovascular events (MACE). All events will be resolved by the Central Investigation Safety Committee, which does not include members of the Investigation Steering Committee.
- Conditions
- Atrioventricular Block
- Being tested
- Pacemaker implantation, Cardioneuroablation (CNA)
- Keywords
- AVB, Pacemaker implantation, Cardioneuroablation, Cardiovascular autonomic testing (CAT), Telemedicine
- Medical subject headings
- Atrioventricular Block
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Pacemaker implantationProcedure or surgery
Elective pacemaker implantation (DDDR) for functional AVB according to the 2021 ESC Guidelines for Cardiac Pacing
Cardioneuroablation (CNA)Procedure or surgery
Experimental method; elective implantable loop recorder (ILR) and biatrial, binodal, atomically and electroanatomically guided CNA with extracardiac vagal nerve stimulation (ECVS) prior and after procedure monitoring (disappearance of ECVS-induced AVB with the goal of achieving post-procedure and maintaining a target heart rate > 50 beats per minute). CNA procedure is performed with radio-frequency generators and irrigated catheters and with support of 3D-electroanatomic mapping system.
CNA group will receive external ECG recorders. The major reason for external ECG recorders is to provide documentation of clinical AVB, as well as monitoring of patients before and after CNA (or PM implantation, if accepted). In case of severe AVB symptoms always the emergency system will be called.
| Study group | Role | What they receive |
|---|---|---|
| Group A - PACEMAKER | Active comparator | Group A, n=50 patients aged 18-75 years with indications for elective PM implantation according to the 2021 ESC guidelines for cardiac pacing due to paroxysmal or persistent AVB with a positive results of atropine test.
Group A is early elective pacemaker implantation (PM) strategy in functional AVB. Receives: Procedure: Pacemaker implantation |
| Group B - CARDIONEUROABLATION | Active comparator | Group B, n=50 patients aged 18-75 years with indications for elective PM implantation according to the 2021 ESC guidelines for cardiac pacing due to paroxysmal or persistent AVB with a positive results of atropine test.
Group B will undergo strategy of postponed/deferred PM implantation in functional AVB. Patients wil be implanted and monitored with ILR (in case of severe symptomatic AVB always the emergency system will be called). After cardiovascular autonomic testing (CAT), electrophysiological study (EPS), extra cardiac vagal nerve stimulation (ECVS) and cardioneuroablation will be performed. If CNA is succesful, pacemaker implantation will be cancelled. If CNA is unsuccessful, second session of CNA will be planned. In case of inefficient second attempt, patients will be referred for PM implantation. They will cross-over to PACEMAKER arm. Receives: Procedure: Cardioneuroablation (CNA) |
What is being measured
The primary outcome is the main question the study is designed to answer.
To determine the efficacy of CNA in the treatment of AVB in comparison to PM therapy within 12 months of PM implantation/CNA procedure.
This is objective endpoint examining the onset of AVB episodes after PM/CNA. It will specify the number of pauses > 3.0 s in the ECG external recorder for group B (occurrence of > 1 pause or the need for earlier (0-12 months) PM implantation will be an indicator of the failure of the CNA procedure), assuming the presence of PM stimulation in group A at the level between 93-100% (equates to the continued duration of the AVB treated with PM).
Measured: 12 months
Secondary outcomes (8)
Occurrence of MACE (major advers cardiac events)
MACE are defined as peri-procedural and long-term complications: death, stroke, myocardial infarction, pericardial effusion requiring drainage, AVB, venous thrombosis, infection, hemorrhage, hematoma, fistula, pseudoaneurysm, surgical intervention
Measured: at 0, 3, 6, 12 months
Assessment of the effect of CNA and PM implantation on AVB symptoms based on based on VAS (Visual Analog Scale)
VAS (Visual Analog Scale) indicates the general health status with100 indicating the best health, 0 indicating the worst health status.
Measured: 0, 3, 6, 12 months
Assessment of the effect of CNA and PM implantation on health-related quality of life (QOL) based on questionaire EQ-5D-5L
EQ-5D-5L comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension is scored on a scale of 1-5 ponts, that describes the patient's health state. The maximum score of 1 indicates the best health state, higher scores indicate more severe or frequent problems.
Measured: 0, 6, 12 months
Assessment of the effect of CNA and PM implantation on health-related quality of life (QOL) based on questionaire SF-36
SF-36 questionnaire consists of 36 questions that are distributed across eight scales. Each scale is directly transformed into 0-100 scale. The lower the score the more disability, the higher the score the less disability.
Measured: 0, 6, 12 months
Assessment of the effect of CNA and PM implantation on fatique based on Modified Fatigue Impact Scale (MFIS)
MFIS is a validated, standardized, 21-item questionnaire, which provides an assessment of the effects of fatigue in terms of physical, cognitive, and psychosocial functioning. Total scores range from 0-84. The lower the score the less fatigue, the higher the score the more fatigue impairs physical, cognitive, and psychosocial functioning.
Measured: 0, 6, 12 moths
Assessment of the effect of CNA and PM implantation on depression/anxiety based on Modified Hospital Anxiety and Depression Scale (HADS-M)
HADS-M is a validated, standardized 16-item questionnaire to evaluate the association between anxiety and depression and the degree of illness acceptance in patients. Total scores range from 0-64. Higher scores indicate a greater degree of anxiety or depression.
Measured: 0, 6, 12 months
Assessment of the effect of CNA and PM implantation on sleep disorders based on questionaire Epworth Sleep Scale (ESS)
The ESS score is a standardized, validated 8-item questionnaire (with scores 0-3 each). The total score can range from 0 to 24. The higher the ESS score, the higher that person's average sleep propensity in daily life.
Measured: 0, 6, 12 months
Assessment of the effect of CNA and PM implantation on sleep disorders based on Athens Insomnia Scale-8 (AIS-8)
AIS-8 is a standardized, validated questionnaire assessing 8 factors related to nocturnal sleep and daytime dysfunction, which are rated on a 0-3 scale. The sleep is evaluated from the cumulative score of all factors and reported as an individual's sleep outcome. Higher score indicates more sleep disturbances.
Measured: 0, 6, 12 months
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted17 Mar 2023
- Study start1 Sep 2023
- Primary completion31 Aug 2026 (estimated)
- Study completion31 Dec 2026 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (21)Papers the sponsor has linked to this study.
- Other trials for Atrioventricular BlockStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Model description
- multicenter, noncommercial, physician-initiated, proof-of-concept, prospective, randomized, controlled trial and registry
- Masking
- Single blind
- Who is masked
- Outcomes assessor
- Enrolment
- 300 participants (estimated)
Sponsor and investigators
- Lead sponsor
- American Heart of Poland
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Sebastian Stec, American Heart of Poland
- Investigators
- Sebastian M Stec, MD, PhD, Principal investigator, American Heart of PolandEdyta Stodolkiewicz-Nowarska, MD, PhD, Study director, American Heart of PolandKrzysztof Milewski, MD, PhD, Study chair, American Heart of Poland
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT05774262
- Sponsor's protocol ID
- 2022/ABM/03/00035
- Acronym
- TELE-SPACER
- Status last verified
- Mar 2024
- First submitted
- 17 Feb 2023
- Last updated
- 18 Mar 2024
- Results posted
- No
- Data monitoring committee
- Yes
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- Yes: Time Frame: Requests can be submitted starting 9 months after article publication and the data will be made accessible for up to 24 months. Extensions will be considered on a case-by-case basis. Access Criteria: Access to trial IPD can be requested by qualified researchers engaging in independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). For more information or to submit a request, please contact PI smstec@wp.pl
Publications
Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martin A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG; ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 Jun 1;39(21):1883-1948. doi: 10.1093/eurheartj/ehy037. No abstract available.
PubMed 29562304Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabes JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylen I, Tolosana JM; ESC Scientific Document Group. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021 Sep 14;42(35):3427-3520. doi: 10.1093/eurheartj/ehab364. No abstract available.
PubMed 34455430Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e60-e122. doi: 10.1161/CIR.0000000000000499. Epub 2017 Mar 9. No abstract available.
PubMed 28280231Klank-Szafran M, Stec S, Sledz J, Janion M. [Radiofrequency ablation and cardioneuroablation for AVNRT and atrioventricular block]. Kardiol Pol. 2010 Jun;68(6):720-4. Polish.
PubMed 20806214Aksu T, Guler TE, Bozyel S, Ozcan KS, Yalin K, Mutluer FO. Cardioneuroablation in the treatment of neurally mediated reflex syncope: a review of the current literature. Turk Kardiyol Dern Ars. 2017 Dec;45(1):33-41. doi: 10.5543/tkda.2016.55250.
PubMed 28106018Baysal E, Guler TE, Gopinathannair R, Bozyel S, Yalin K, Aksu T. Catheter Ablation of Atrioventricular Block: From Diagnosis to Selection of Proper Treatment. JACC Case Rep. 2020 Sep 15;2(11):1793-1801. doi: 10.1016/j.jaccas.2020.07.050. eCollection 2020 Sep.
PubMed 34317058Aksu T, Gopinathannair R, Bozyel S, Yalin K, Gupta D. Cardioneuroablation for Treatment of Atrioventricular Block. Circ Arrhythm Electrophysiol. 2021 Sep;14(9):e010018. doi: 10.1161/CIRCEP.121.010018. Epub 2021 Sep 1.
PubMed 34465122Wileczek A, Polewczyk A, Kluk M, Kutarski A, Stec S. Ultrasound-guided imaging for vagus nerve stimulation to facilitate cardioneuroablation for the treatment of functional advanced atrioventricular block. Indian Pacing Electrophysiol J. 2021 Nov-Dec;21(6):403-406. doi: 10.1016/j.ipej.2021.06.008. Epub 2021 Jun 26.
PubMed 34186197Josiak K, Stec S, Zysko D, Skonieczny B, Kosior J, Sledz J, Wilczek A, Stodolkiewicz-Nowarska E, Biel B, Szymkiewicz P, Skoczynski P, Karbarz D, Ludwik B, Banasiak W, Jagielski D. Safety and efficacy of His bundle pacing validated by extracardiac vagal nerve stimulation (HIS-STORY). Cardiol J. 2022;29(4):698-701. doi: 10.5603/CJ.a2022.0053. Epub 2022 Jun 15. No abstract available.
PubMed 35703044Reichert A, Wileczek A, Stec S. Cardioneuroablation for the effective treatment of recurrent vasovagal syncope to restore driving abilities. Kardiol Pol. 2022;80(11):1158-1160. doi: 10.33963/KP.a2022.0189. Epub 2022 Aug 10. No abstract available.
PubMed 35946179Gajda R, Knechtle B, Gebska-Kuczerowska A, Gajda J, Stec S, Krych M, Kwasniewska M, Drygas W. Amateur Athlete with Sinus Arrest and Severe Bradycardia Diagnosed through a Heart Rate Monitor: A Six-Year Observation-The Necessity of Shared Decision-Making in Heart Rhythm Therapy Management. Int J Environ Res Public Health. 2022 Aug 19;19(16):10367. doi: 10.3390/ijerph191610367.
PubMed 36012002Pachon JC, Pachon EI, Pachon JC, Lobo TJ, Pachon MZ, Vargas RN, Jatene AD. "Cardioneuroablation"--new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF-ablation. Europace. 2005 Jan;7(1):1-13. doi: 10.1016/j.eupc.2004.10.003.
PubMed 15670960Pachon JC, Pachon EI, Cunha Pachon MZ, Lobo TJ, Pachon JC, Santillana TG. Catheter ablation of severe neurally meditated reflex (neurocardiogenic or vasovagal) syncope: cardioneuroablation long-term results. Europace. 2011 Sep;13(9):1231-42. doi: 10.1093/europace/eur163. Epub 2011 Jun 28.
PubMed 21712276Pachon M JC, Pachon M EI, Santillana P TG, Lobo TJ, Pachon CTC, Pachon M JC, Albornoz V RN, Zerpa A JC. Simplified Method for Vagal Effect Evaluation in Cardiac Ablation and Electrophysiological Procedures. JACC Clin Electrophysiol. 2015 Oct;1(5):451-460. doi: 10.1016/j.jacep.2015.06.008. Epub 2015 Aug 21.
PubMed 29759475Yao Y, Shi R, Wong T, Zheng L, Chen W, Yang L, Huang W, Bao J, Zhang S. Endocardial autonomic denervation of the left atrium to treat vasovagal syncope: an early experience in humans. Circ Arrhythm Electrophysiol. 2012 Apr;5(2):279-86. doi: 10.1161/CIRCEP.111.966465. Epub 2012 Jan 24.
PubMed 22275485
Study at a glance
From the registry record, last updated by the sponsor on 18 Mar 2024. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- TELE-monitoring for Standard Pacemaker Implantation or Delayed Pacemaker Implantation After Autonomic/Electrophysiologic Evaluation and Cardioneuroablation for managEment of Functional atrioventriculaR Block - Randomized Controlled Study
- ClinicalTrials.gov ID
- NCT05774262
- Acronym / sponsor ID
- TELE-SPACER / 2022/ABM/03/00035
- Conditions
- Atrioventricular Block
- Keywords
- AVB, Pacemaker implantation, Cardioneuroablation, Cardiovascular autonomic testing (CAT), Telemedicine
- Study type
- Interventional
- Recruitment status
- Recruiting
- Enrolment
- 300 participants (estimated)
- Lead sponsor
- American Heart of PolandUniversity, hospital or other
- Study start
- 1 Sep 2023 (actual)
- Primary completion
- 31 Aug 2026 (estimated)
- Study completion
- 31 Dec 2026 (estimated)
- First posted
- 17 Mar 2023 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The TELE-SPACER study is a multicenter, noncommercial, physician-initiated, proof-of-concept, prospective, randomized, controlled, unblinded clinical trial and registry designed to compare two methods of treatment of patients with functional Atrio-Ventricular Block (AVB): the guidelines-recommended elective pacemaker (PM) therapy vs cardiovascular autonomic tests (CAT), electrophysiologic assessment (EPS) with referral to cardioneuroablation (CNA) and reevaluation of indications for PM therapy.
The main questions TELE-SPACER aims to answer are:
- Can the investigators successfully treat functional AVB without implantable device (PM)?
- Can the investigators prove the feasibility and safety and demonstrate non-inferiority of CNA procedure in patients with functional AVB, avoiding long-term permanent pacing, its limitations, complications and costs ?
The TELE-SPACER trial will validate the European Society of Cardiology (ESC) recommendations (level C of evidence: expert opinion) for elective PM implantation and will introduce CNA as effective treatment in the functional AVB patient population.
Functional AVB - defined as a persistent or paroxysmal AVB with a positive results of atropine test
Detailed description
TELE-SPACER trial will enroll a minimum of 100 participants, males and females, 18-75 years old: 1) with indications for elective PM implantation due to atrioventricular block (AVB) according to 2021 ESC guidelines on cardiac pacing; 2) who had positive atropine tests. Participants will be randomized into two groups - either optimized guideline-recommended PM therapy (group A, n=50) or reevaluation for PM therapy after CAT/EPS and experimental procedure CNA (group B, n=50). Participants who will choose to opt-out of randomization will be included in the registry (group C) and will undergo patient-tailored intervention through shared decision-making with a possibility of either PM implantation, CNA or observation only. The registry is expected to include up to 200 participants.
Patient enrollment time is anticipated to last 2 years. Recruitment will take place in four study sites, in two distinct phases. First, the investigators will identify potential participants with AVB and a positive atropine test, confirming significant dependence of heart rhythm and conduction on the vagus nerve (hyperactivity of vagus nerve). Their medical records will be analyzed by the Scientific Committee (symptoms evaluation, physical examination, documentation of AVB). In the second phase eligible participants will be invited by the investigator to participate in the trial during medical consultation. After explanations describing the study protocol, including the risk and benefits, they will sign the written informed consent to participate in the study or will choose to opt-out of randomization to be included in the registry only (group C). Informed consent will be obtained only if it is clear that the patient truly understands the nature of the study. Alternatively, the patient will be encouraged to take a copy of the consent form home to contemplate enrolment in the study. Only participants who voluntarily consent will be included. Participants will be able to withdraw at any time without compromising their medical care.
Paricipants will be randomized in 1:1 allocation to either group A or group B. Randomization will be performed centrally and assigned automatically to each patient via internet. The randomization list will be blocked per center, with randomly varying block sizes of 2 and 4. The centers will not be aware of the block sizes. The PM implantation and treatment allocation will not be blinded to the patient or follow-up physician. Participants in either arm of the study will be followed-up at regular intervals for a minimum of 12 months. During the 12-month study duration, the use of effective contraception will be recommended for women of child-bearing age.
The period of the screening and randomization visit will last from 0 to 7 days, and the qualification for elective PM implantation (group A) or elective loop recorder monitoring/CAT/EPS (group B) and subsequent therapeutic decisions (CNA, DDDR, other treatment based on the test result) from 0 to 4 weeks. Parameter analysis baseline, including ECG telemonitoring, QOL and symptoms, will take place at randomization (0 months), 3, 6 and 12 months. Participants will be assessed using cardiovascular autonomic testing (CAT) with telemedical registration at 6 and 12 months. All measured parameters, as well as demographic and clinical data will be recorded in the study database.
Participants in group A (PM, n = 50) will receive care on the basis of the 2021 ESC Guidelines on Cardiac Pacing Recommendations. They will be implanted with PM (DDD pacemaker or its modification as HBP/LBBAP - His-Purkinje or left bundle branch area pacing) and will be monitored with external ECG recorder (certified medical devices of at least class IIa) with telemonitoring. Group B participants (CNA, n = 50) will be implanted with implantable loop recorder (ILR) device (Biotronik, Biomonitor 3m), also with remote tele-monitoring, with the same thresholds for automatic episode recording. As part of telemonitoring system, all participants will receive in the period before the procedure a dedicated telemonitoring kit consisting of a portable ECG device and a tablet with a sim card for network connection. This telemonitoring kit will enable regular self-testing, symptom reporting and interactive, objective telemedicine consultations. Participants will be provided with 24/7 contact with medical staff in the telemonitoring center specialized in cardiac arrhythmias and implantable device monitoring. The major reason for ECG recording is to provide ECG documentation of clinical AVB, as well as monitoring of participants before and after CNA (or PM implantation, if accepted). In case of severe AVB, the emergency system will always be called.
Participants in group B will be referred for EPS and ECVS (extracardiac vagal nerve stimulation) with the possibility of simultaneous CNA after exclusion of advanced and occult distal AVBs. Once the effectiveness of the CNA is confirmed, the patient will be further monitored. If CNA is not succesful and/or its immediate effectiveness is not confirmed (meeting the ESC criteria for pacemaker implantation after CNA), the patient will be referred for pacemaker implantation and will cross-over into group A.
CNA will be performed in group B under general anesthesia by experienced operators (at least 25 CNA procedures preformed). After EPS, a biatral, binodal, anatomically guided CNA will be performed under ECVS guidance, with a demonstration of the vagal reflex (complete asystole or AVB with atrial pacing) at the onset of the CNA and its complete disappearance after a successful CNA. Additional ablation substrates will also be allowed and performed.
Participants included in the registry (group C) will undergo an individually tailored intervention through shared decision making (SDM) with the option of implantation of PM (subgroup CA), CNA (subgroup CB) or observation only (subgroup C0).
All participants participating in the study and registry will be asked to complete questionnaires on health-related quality of life (EQ-5D-5L, SF-36), symptoms of bradycardia (VAS), fatigue (MFIS), depression (HADS-M) and sleep (ESS, AIS-8) at 0, 6, 12 months.
The safety of the interventions will be assessed on a monthly basis (telemedicine and standard follow-up visits), with monitoring of major adverse cardiovascular events (MACE). All events will be resolved by the Central Investigation Safety Committee, which does not include members of the Investigation Steering Committee.
Study design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Single blind (outcomes assessor)
- Number of arms
- 2
- Model description
- multicenter, noncommercial, physician-initiated, proof-of-concept, prospective, randomized, controlled trial and registry
| Arm | Type | Receives |
|---|---|---|
| Group A - PACEMAKER | Active comparator | Procedure: Pacemaker implantationGroup A, n=50 patients aged 18-75 years with indications for elective PM implantation according to the 2021 ESC guidelines for cardiac pacing due to paroxysmal or persistent AVB with a positive results of atropine test. Group A is early elective pacemaker implantation (PM) strategy in functional AVB. |
| Group B - CARDIONEUROABLATION | Active comparator | Procedure: Cardioneuroablation (CNA)Group B, n=50 patients aged 18-75 years with indications for elective PM implantation according to the 2021 ESC guidelines for cardiac pacing due to paroxysmal or persistent AVB with a positive results of atropine test. Group B will undergo strategy of postponed/deferred PM implantation in functional AVB. Patients wil be implanted and monitored with ILR (in case of severe symptomatic AVB always the emergency system will be called). After cardiovascular autonomic testing (CAT), electrophysiological study (EPS), extra cardiac vagal nerve stimulation (ECVS) and cardioneuroablation will be performed. If CNA is succesful, pacemaker implantation will be cancelled. If CNA is unsuccessful, second session of CNA will be planned. In case of inefficient second attempt, patients will be referred for PM implantation. They will cross-over to PACEMAKER arm. |
Who may qualify
- Ages
- 18 to 75 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (11 listed)
- Written informed consent to participate in the study
- Age 18-75
- Indication (at least one) of the European Society of Cardiology (ESC) for elective pacemaker implantation due to isolated (without sinus node dysfunction and bundle branch block) paroxysmal, persistent or reflex atrioventricular block:
Key exclusion criteria (17 listed)
- Implanted pacemaker/ICD/CRT
- Sinus node dysfunction with indication for pacemaker implantation
- Planned ablation of the atrioventricular junction
- Severe prolonged bradycardia in advanced AVB requiring intravenous drugs and temporary pacing
- Status post cardiac surgery
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Pacemaker implantationElective pacemaker implantation (DDDR) for functional AVB according to the 2021 ESC Guidelines for Cardiac Pacing | Procedure or surgery | Group A - PACEMAKER |
| Cardioneuroablation (CNA)Experimental method; elective implantable loop recorder (ILR) and biatrial, binodal, atomically and electroanatomically guided CNA with extracardiac vagal nerve stimulation (ECVS) prior and after procedure monitoring (disappearance of ECVS-induced AVB with the goal of achieving post-procedure and maintaining a target heart rate > 50 beats per minute). CNA procedure is performed with radio-frequency generators and irrigated catheters and with support of 3D-electroanatomic mapping system. CNA group will receive external ECG recorders. The major reason for external ECG recorders is to provide documentation of clinical AVB, as well as monitoring of patients before and after CNA (or PM implantation, if accepted). In case of severe AVB symptoms always the emergency system will be called. | Procedure or surgery | Group B - CARDIONEUROABLATION |
Primary outcome
To determine the efficacy of CNA in the treatment of AVB in comparison to PM therapy within 12 months of PM implantation/CNA procedure.
Time frame: 12 months
This is objective endpoint examining the onset of AVB episodes after PM/CNA. It will specify the number of pauses > 3.0 s in the ECG external recorder for group B (occurrence of > 1 pause or the need for earlier (0-12 months) PM implantation will be an indicator of the failure of the CNA procedure), assuming the presence of PM stimulation in group A at the level between 93-100% (equates to the continued duration of the AVB treated with PM).
8 secondary outcomes
Occurrence of MACE (major advers cardiac events)
Time frame: at 0, 3, 6, 12 months
Assessment of the effect of CNA and PM implantation on AVB symptoms based on based on VAS (Visual Analog Scale)
Time frame: 0, 3, 6, 12 months
Assessment of the effect of CNA and PM implantation on health-related quality of life (QOL) based on questionaire EQ-5D-5L
Time frame: 0, 6, 12 months
Assessment of the effect of CNA and PM implantation on health-related quality of life (QOL) based on questionaire SF-36
Time frame: 0, 6, 12 months
Assessment of the effect of CNA and PM implantation on fatique based on Modified Fatigue Impact Scale (MFIS)
Time frame: 0, 6, 12 moths
Assessment of the effect of CNA and PM implantation on depression/anxiety based on Modified Hospital Anxiety and Depression Scale (HADS-M)
Time frame: 0, 6, 12 months
Assessment of the effect of CNA and PM implantation on sleep disorders based on questionaire Epworth Sleep Scale (ESS)
Time frame: 0, 6, 12 months
Assessment of the effect of CNA and PM implantation on sleep disorders based on Athens Insomnia Scale-8 (AIS-8)
Time frame: 0, 6, 12 months
Results and safety
This study is still under way. Results are not available in the source record yet.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 18 Mar 2024.
- Background: PubMed 29562304Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martin A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG; ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 Jun 1;39(21):1883-1948. doi: 10.1093/eurheartj/ehy037. No abstract available.
- Background: PubMed 34455430Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabes JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylen I, Tolosana JM; ESC Scientific Document Group. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021 Sep 14;42(35):3427-3520. doi: 10.1093/eurheartj/ehab364. No abstract available.
- Background: PubMed 28280231Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e60-e122. doi: 10.1161/CIR.0000000000000499. Epub 2017 Mar 9. No abstract available.
- Background: PubMed 20806214Klank-Szafran M, Stec S, Sledz J, Janion M. [Radiofrequency ablation and cardioneuroablation for AVNRT and atrioventricular block]. Kardiol Pol. 2010 Jun;68(6):720-4. Polish.
- Background: PubMed 28106018Aksu T, Guler TE, Bozyel S, Ozcan KS, Yalin K, Mutluer FO. Cardioneuroablation in the treatment of neurally mediated reflex syncope: a review of the current literature. Turk Kardiyol Dern Ars. 2017 Dec;45(1):33-41. doi: 10.5543/tkda.2016.55250.
- Background: PubMed 34317058Baysal E, Guler TE, Gopinathannair R, Bozyel S, Yalin K, Aksu T. Catheter Ablation of Atrioventricular Block: From Diagnosis to Selection of Proper Treatment. JACC Case Rep. 2020 Sep 15;2(11):1793-1801. doi: 10.1016/j.jaccas.2020.07.050. eCollection 2020 Sep.
- Background: PubMed 34465122Aksu T, Gopinathannair R, Bozyel S, Yalin K, Gupta D. Cardioneuroablation for Treatment of Atrioventricular Block. Circ Arrhythm Electrophysiol. 2021 Sep;14(9):e010018. doi: 10.1161/CIRCEP.121.010018. Epub 2021 Sep 1.
- Background: PubMed 34186197Wileczek A, Polewczyk A, Kluk M, Kutarski A, Stec S. Ultrasound-guided imaging for vagus nerve stimulation to facilitate cardioneuroablation for the treatment of functional advanced atrioventricular block. Indian Pacing Electrophysiol J. 2021 Nov-Dec;21(6):403-406. doi: 10.1016/j.ipej.2021.06.008. Epub 2021 Jun 26.
- Background: PubMed 35703044Josiak K, Stec S, Zysko D, Skonieczny B, Kosior J, Sledz J, Wilczek A, Stodolkiewicz-Nowarska E, Biel B, Szymkiewicz P, Skoczynski P, Karbarz D, Ludwik B, Banasiak W, Jagielski D. Safety and efficacy of His bundle pacing validated by extracardiac vagal nerve stimulation (HIS-STORY). Cardiol J. 2022;29(4):698-701. doi: 10.5603/CJ.a2022.0053. Epub 2022 Jun 15. No abstract available.
- Background: PubMed 35946179Reichert A, Wileczek A, Stec S. Cardioneuroablation for the effective treatment of recurrent vasovagal syncope to restore driving abilities. Kardiol Pol. 2022;80(11):1158-1160. doi: 10.33963/KP.a2022.0189. Epub 2022 Aug 10. No abstract available.
- Background: PubMed 36012002Gajda R, Knechtle B, Gebska-Kuczerowska A, Gajda J, Stec S, Krych M, Kwasniewska M, Drygas W. Amateur Athlete with Sinus Arrest and Severe Bradycardia Diagnosed through a Heart Rate Monitor: A Six-Year Observation-The Necessity of Shared Decision-Making in Heart Rhythm Therapy Management. Int J Environ Res Public Health. 2022 Aug 19;19(16):10367. doi: 10.3390/ijerph191610367.
- Results publication: PubMed 15670960Pachon JC, Pachon EI, Pachon JC, Lobo TJ, Pachon MZ, Vargas RN, Jatene AD. "Cardioneuroablation"--new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF-ablation. Europace. 2005 Jan;7(1):1-13. doi: 10.1016/j.eupc.2004.10.003.
- Individual participant dataSharing planned: Yes. Time Frame: Requests can be submitted starting 9 months after article publication and the data will be made accessible for up to 24 months. Extensions will be considered on a case-by-case basis. Access Criteria: Access to trial IPD can be requested by qualified researchers engaging in independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). For more information or to submit a request, please contact PI smstec@wp.pl
Related trials for Atrioventricular Block
Active, not recruitingObservational study
Safety, Performance, and Clinical Benefit of Pacing the Left Bundle Branch Area - Post-Market Clinical Follow-up
Bradycardia, Atrioventricular Block
Recruiting
SPIKE FLOW Endocardial Lead Safety and Performance Study
Acute Myocardial Infarction (AMI), Asystole
Not yet recruiting
Belgo-Luxembourg Leadless PM Registry
Bradyarrhythmias, AV Block Complete
Recruiting
Novel Approach to Conduction System Pacing With Use of Ultrasound
Conduction Block, Atrioventricular, Bundle-Branch Block
Not yet recruiting
Head-to-Head (H2H) Comparison of Ambulatory Cardiac ECG Monitors in Japan
Atrial Fibrillation (AF), Atrial Flutter
Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part.
Sebastian M Stec, MD, PhD principal investigator
American Heart of Poland
Edyta Stodolkiewicz-Nowarska, MD, PhD study director
American Heart of Poland
Krzysztof Milewski, MD, PhD study chair
American Heart of Poland
2 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Pacemaker implantation and Cardioneuroablation (CNA) in people with Atrioventricular Block, run by American Heart of Poland at 2 sites in Poland.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 11 inclusion and 17 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: looking for participants now, as of the sponsor's last update on 18 Mar 2024. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 2 sites in Poland. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
This study is still under way. Results are not available in the source record yet.
How can a doctor refer a patient or contact the research team?
Contact Sebastian M Stec, MD, PhD (+48 600-298-022, smstec@wp.pl), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
To determine the efficacy of CNA in the treatment of AVB in comparison to PM therapy within 12 months of PM implantation/CNA procedure. (time frame: 12 months). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT05774262, which also lists 21 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 18 Mar 2024.