1. VASODEPRESSIVE SYNDROME OF FIGHTER PILOT: A CASE REPORT
TUOMO K. LEINO, M.D., Ph.D., JUHA HARTIKAINEN, M.D., PhD
and ROOPE SOVELIUS, M.D., Ph.D.
Air Force Command Finland
Kuopio University Hospital, Finland
Centre for Military Medicine, Finnish Defence Forces
FINLAND

2. Disclosure Information 87th Annual Scientific Meeting of ASMA Tuomo Leino, MD, PhD
I have the following financial relationships to disclose:
- Employee of: Air Force Command Finland
I will not discuss off-label use and/or investigational use in my presentation.

3. INTRODUCTION
Vasodepressive syndrome (neurocardiogenic syndrome) is an cardiac autonomic reflex leading to bradycardia or aystole and vasodilatation causing syncope. No trigger causing the reflex can be identified.
Differential diagnosis: vasovagal syncope, vasodepressive syndrome, sick sinus syndrome, carotis hypersensitivity, glossofaryngeal neuralgia, Bezold-Jarisch reflex, physical activity triggered vasodepressive reaction
Vasodepressive syndrome will lead to unconsiousness without any warning symptoms

4. CASE REPORT
40-yr-old male F/A-18 C Hornet fighter pilot of the Finnish Air Force (FINAF)
Fainted for during morning shover in December 2009
Pilot is a top level soccer player (exellent fittness)
First degree AV-block (PR 236 ms) in all flight physical ECGs
Otherwise his clinical examination was normal
Not on any medication
No family history of arrhtyhmias

5. CASE REPORT 12-lead ECG
PR 236 ms

6. CASE REPORT
January 2010 during 24 h-Holter monitoring he fainted again after wake-up
ECG-recording revealed 25 sec asystole with spontaneous recovery
Clinical history shows no evidence of coronary artery disease
Transthoracic echocardiography reveals normal heart structures and function

7. CASE REPORT HOLTER MONITORING
25 sec asystole

8. WAIVER GUIDELINES EASA PART MED
AMC1 MED.B.010 Cardiovascular system
(i) Syncope
(1) Applicants with a history of recurrent vasovagal syncope should be assessed as unfit.
A fit assessment may be considered by the licensing authority after a 6-month period without recurrence provided cardiological evaluation is satisfactory. Such evaluation should include:
(i) a satisfactory symptom limited 12 lead exercise ECG to Bruce Stage IV or equivalent. If the exercise ECG is abnormal, myocardial perfusion imaging/stress echocardiography should be required;
(ii) a 2D Doppler echocardiogram showing neither significant selective chamber enlargement nor structural or functional abnormality of the heart, valves or myocardium;
(iii) a 24-hour ambulatory ECG recording showing no conduction disturbance, complex or sustained rhythm disturbance or evidence of myocardial ischaemia.

9. WAIVER GUIDELINES EASA PART MED
AMC1 MED.B.010 Cardiovascular system
(l) Rhythm and conduction disturbances
(4) Supraventricular arrhythmias
Applicants with significant disturbance of supraventricular rhythm, including sinoatrial dysfunction, whether intermittent or established, should be assessed as unfit.
A fit assessment may be considered by the licensing authority if cardiological evaluation is satisfactory.
(9) Pacemaker
Applicants with a subendocardial pacemaker should be assessed as unfit. A fit assessment may be considered at revalidation by the licensing authority no sooner than 3 months after insertion and should require:
(i) no other disqualifying condition;
(ii) a bipolar lead system, programmed in bipolar mode without automatic mode change of the device;
(iii) that the applicant is not pacemaker dependent;
(iv) regular follow-up, including a pacemaker check; and
(v) a multi-pilot limitation.

10. CASE REPORT PACEMAKER THERAPY
A bipolar dual chamber pacemaker was implanted after the second vasodepressive syndrome episode
Pacing mode: AAI-DDD bpm, AV delay 270 ms
atrial pacing if sinusbradycardia < 45 bpm and
ventricular pacing if atrioventricular delay > 270 ms up to
heart rate 135 bpm
1 sec

11. CASE REPORT PACEMAKER THERAPY
Atrial electrode
(right atrium)
Ventricular electrode
(right venticle)

12. CASE REPORT FOLLOW-UP
Flight physical: RR 102/77, BMI 23 (172 cm, 68 kg), non-smoker, max bicycle test Vo2 54,6 ml/kg/min, PEF 570 ml/sec, ECG: sinus rythm and grade 1 AV-block (PR interval > 200 ms)
No vasodepressive episodes after DDD pacemaker
Neurological evaluation normal (EEG normal)
Glucose tolerance test normal
No other arrytmias were observed during 24-h Holter

13. CASE REPORT FOLLOW-UP DDD pacemaker (setting 45 -135) analysis:
99,6 % of time spontaneous sinus rythm,
artial pacing 0,4 % of time and
ventricul pacing 0,0 % of time
Ventricular electrode resistance increased year 2015, but was considered not to be indication for pacemaker or wire replacement
No syncope or pre-syncope symptoms during 5 years of follow-up after DDD pacemaker implantation

14. CASE REPORT FOLLOW-UP
Sept 20, 2012 centrifuge run up to + 5 Gz was normal and DDD pacemaker function was normal after centrifuge run
Rapid decompression test up to ft was normal and pacemaker function was normal after chamber test
Test flight with two-seated F/A-18D was normal (no electromagnetic interference)
Sept 24, 2015 centrifuge run (radip on-set profile to + 8 Gz normal and DDD pacemaker function was normal after centrifuge run

15. CONCLUSIONS Vasodepressive syndrome can lead to asystole and syncope
Pacemaker implantation is indicated if vasodepressive syndrome results in repeated episodes of syncope
During 5 –years of follow-up pilot had NOT experienced any syncopes or pre-syncope symptoms
Flight safety vs. operational need (CO level fighter pilot)
proven safety in centrifuge, chamber and test flight
Waiver was granted for fighter pilot operation with OML restriction year Year 2015 after 5 years follow-up waiver was granted for single seated fighter pilot operation