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To the Editor:
I read with interest the article by Tatum et al. that described four patients with intraoperative ventricular asystole during left vagus nerve stimulation (VNS) for epilepsy in humans.1 In their discussion, the authors noted that asystole may occur with tetanic stimulation of the accessory nerve, but vagally mediated ventricular asystole (often with syncope and anoxic seizures) has been more frequently reported in patients with glossopharyngeal neuralgia,2 trigeminal neuralgia,3 and swallow syncope.4 In particular, swallow syncope is produced by a vagovagal reflex with afferent vagal impulses resulting from esophageal distention.4 Vagally mediated ventricular asystole may be prevented in some cases with atropine,2,4,5 with procaine block of the vagus nerve in the neck,4 with section of afferent cranial nerves or vagal branches,2,4 or with pacemakers.2,3,5 Vagovagal reflexes may be responsible for ventricular asystole in other circumstances as well,5 as is likely in the following case.
In 1985, a 35-year-old woman with severe myasthenia gravis presented with pneumonia and respiratory failure. Her myasthenia began at age 15, and a thymectomy at age 16 showed thymic hyperplasia. She was subsequently treated with high dose pyridostigmine and prednisone, but suffered numerous exacerbations, usually associated with upper respiratory infections or pneumonia. Her medical history was otherwise significant for a generalized seizure disorder with adolescent onset. In the hospital she had several seizures reported by the nurses following tracheal suctioning, despite “therapeutic” anticonvulsant levels. Because of worsening respiratory function she was transferred to the intensive care unit and intubated. Cardiac monitoring demonstrated several episodes of severe bradycardia, second degree A-V block, or ventricular asystole lasting from 10 to 40 seconds (figure) and accompanied by syncope and sometimes seizures. All of the episodes were precipitated …
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