Prolonged ventricular asystole, sinus arrest, and paroxysmal atrial flutter-fibrillation: an uncommon presentation of vasovagal syncope.

We described a 55-year-old woman with recurrent syncope, complete atrioventricular (AV) block, sparsely scattered idioventricular beats lasting for 56 seconds, and long sinus arrest recorded during the syncopal episode. Paroxysmal atrial flutter-fibrillation was also presented during Holter electrocardiograph (ECG) monitoring without clinical symptom. During tilt test, atrial flutter with variable AV block was induced and the patient suddenly passed out. The vasovagal syncope was successfully treated with a DDD permanent pacemaker with a rate drop response algorithm. Vasovagal syncope with concomitant ventricular asystole and sinus arrest is rare. Aggressive management with permanent pacemaker is strongly advocated in malignant vasovagal syncope.