Usefulness of invasive electrophysiologic testing to stratify the risk of arrhythmic events in asymptomatic patients with Wolff-Parkinson-White pattern (original) (raw)
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The Asymptomatic Patient with the Wolff-Parkinson-White Electrocardiogram
Pace-pacing and Clinical Electrophysiology, 1997
Sudden death can be the first manifestation of the Wolff-Parkinson-White (WPW) syndrome. The underlying mechanism being atrial fibrillation with a very high ventricular rate, because of a short anterograde refractory period of the accessory atrioventricular pathway (AP), deteriorating into ventricular fibrillation. Information on the anterograde refractory period of the AP is therefore important to recognize asymptomatic people with the WPW ECG at risk for dying suddenly. Several noninvasive tests are available to identify the low risk patient. Decision making when to interrupt the AP in asymptomatic WPW patients not at low risk requires an invasive study to document the electrophysiological properties of the AP and to determine its exact location.
Clinical and Demographic Characteristics of WPW Syndrome Attending Arrhythmia Clinic of NICVD
Bangladesh Medical Journal, 2014
Wolff-Parkinson-White syndrome is a disorder characterized by presence of an accessory pathway which predisposes patients to tachyarrhythmias and sudden death. Among patients with WPW syndrome, atrioventricular reentrant tachycardia (AVRT) is the most common arrhythmia, accounting for 95% of re-entrant tachycardias. It has been estimated that one-third of patients with WPW syndrome have atrial fibrillation (AF). AF is a potentially life-threatening arrhythmia. If an accessory pathway has a short anterograde refractory period, then rapid repetitive conduction to the ventricles during AF can result in a rapid ventricular response with subsequent degeneration to ventricular fibrillation (VF). The study population included a total of 255 patients in whom 175 (68.62%) were men and 80 (31.38%) were women. Demographic data and clinical characteristics are depicted in Table 1. Left and right WPW syndrome were existing in 70.59% and 29.41% of patients respectively. Documented narrow QRS SVT ...
The American Journal of Cardiology, 1983
Twenty patients with the Wolff-Parkinson-White (WPW) syndrome and 1 or more episodes of symptomatic atrial fibrillation (AF) due to rapid anterograde bypass tract conduction underwent electrophysiologic testing. The mean ventricular rate during spontaneous AF was 242 f 56 beats/min (f standard deviation) and the shortest preexcited R-R interval was 194 f 40 ms. Six patients underwent surgical bypass tract ablation and 14 were treated medically, based on the results of electropharmacologic testing. Over a mean follow-up period of 35 f 19 months (f standard deviation), only 1 patient treated medically had a recurrence of minimally symptomatic AF. The successful chemoprophylaxis of symptomatic AF was associated with the inability to induce AF and atrioventricular reciprocating tachycardia during drug testing (7 patients) or with the induction of AF with a ventricular rate <200 beats/min and a shortest preexcited R-R interval of >250 ms (7 patients). Electrophysiologic testing can identify a subgroup of patients with WPW and AF in whom medical therapy is a suitable alternative to bypass tract ablation. Patients with the Wolff-Parkinson-White syndrome (WPW) who have an episode of atria1 fibrillation (AF) may have an extremely rapid ventricular rate due to rapid conduction through an atrioventricular bypass tract. In addition to causing symptoms due to hemodynamic compromise, such as syncope or weakness, the rapid ventricular rate that occurs during AF may also result in ventricular fibrillation.'p2 One option available for the treatment of patients with WPW who have had an episode of AF associated with an extremely rapid ventricular rate is surgical ablation of the bypass tract." This therapeutic option exposes the patient to the potential risks of open-heart surgery. Few data are available regarding the long-term results of medical therapy in patients with WPW and AF. We therefore examined the role of electrophysiologic testing in selecting patients with WPW and AF who may be appropriate candidates for medical therapy and in designing a drug regimen effective in preventing life-threatening episodes of AF.
Relation Between clinical presentation and induced arrhythmias in the Wolff-Parkinson-White syndrome
American Journal of Cardiology, 1987
Electrophysiologic testing is warranted in patients with the Wolff-Parkinson-White (WPW) syndrome presenting with rapid atrial fibrillation (AF) or ventricular fibrillation. Indications are less clear in patients presenting only with atrioventricular reentrant tachycardia (ART). A knowledge of propensity of this latter group to show a rapid ventricular response in the event of AF and the ability of electrophysiologic testing to reproduce the type and rate of clinical arrhythmias are relevant to this decision. The records of 126 symptomatic patients with manifest WPW syndrome were reviewed and separated into 4 groups according to presentation: group l-AF; group P-ART; group 3-palpitations suggesting ART; and group 4-AF and ART. All patients except those in group 3 had electrocardiographically documented clinical arrhythmias, and these arrhythmias were compared with those induced during electrophysiologic testing. The shortest RR interval during induced AF and the cycle length of induced ART correlated well with those occurring clinically (r = 0.72, p <O.OOOOl), as did the cycle length of induced ART (r = 0.79, p <O.OOOOl). Patients presenting with AF (65% ) had a higher incidence of atrial vulnerability (46%) and sustained AF at electrophysiologic testing than those presenting with ART (16 % and 5 % ) or undocumented palpitations (27 % and 21% ). Forty-one percent of patients with ART and 51% with undocumented palpitations had potentially lethal rates (shortest RR interval <250 ms) during induced AF. The ability to reproduce clinical arrhythmias and the frequency of rapid rates during AF induced in patients presenting with only ART or undocumented palpitations supports the recommendation for electrophysiologic testing in symptomatic patients with WPW. (Am J Cardiol 1967;60:576-579) T here is general agreement that therapy guided by electrophysiologic testing is indicated in patients with Wolff-Parkinson-White (WPW] syndrome who present with atria1 fibrillation (AF] and a rapid ventricular response over the accessory pathway.1 It is less clear whether electrophysiologic testing is necessary in patients with anterograde preexcitation presenting with well tolerated atrioventricular reentrant tachycardia (ART] or undocumented palpitations suggestive of ART. Knowledge of the propensity of the latter groups to have a rapid ventricular response to AF may be helpful in addressing this issue. We compared the electrophysiologic properties of the accessory pathway in patients presenting with ART or with undocument-
Pacing and Clinical Electrophysiology, 2008
Wolff-Parkinson-White (WPW) syndrome but atrial flutter/fibrillation (AF) with rapid ventricular response (RVR) is rare. Although AF occurs in 18% of adult WPW pts, its incidence in children is unknown. We sought to determine risk factors for AVRT spontaneously degenerating to AF during electrophysiologic studies (EPS) in children with WPW. Methods: This was a retrospective study of children with WPW referred for accessory pathway (AP) ablation without clinical AF. Standard electrophysiologic protocols were performed to induce AVRT. To determine if AF degeneration was associated with patient characteristics, 2-sample t-tests, Chi-square, and Fisher's exact were used. Results: There were 53 (31 males) WPW pts studied. During EPS, AVRT degenerated to AF in 27/53 (51%). RVR was seen in 18/27 (67%) patients. The ventricular cycle length (CL) during AF was shorter with RVR (211 + 24 ms) than without (313 + 65 ms) (P = 0.01). AF occurred more commonly among patients with right anterior AP (P = 0.05). Patient gender, age, height, weight, body surface area, persistence of preexcitation on exercise testing, baseline CL, AVRT conduction, and AP number were not significant AF determinants. The AVRT CL was significantly shorter in patients with (265.2 + 41.5 ms) versus those without (308 + 59 ms) AF (P = 0.01). Preliminary data suggest that AP location may be related to patient ethnicity. Conclusion: AF with RVR occurred following AVRT induction during EPS in 34% of our WPW patients, typically associated with right-sided AP locations. Time intervals for RVR to degenerate into ventricular fibrillation and lead to SCD are yet to be determined. (PACE 2008; 31:1307-1312 atrial flutter, Wolff-Parkinson-White, supraventricular tachycardia, pediatrics, demographics
Europace, 2013
The aims of this survey was to provide insight into treatment activity, the strategy of treatment, and risk stratification of patients with asymptomatic and symptomatic ventricular pre-excitation across Europe. Fifty-eight centres, members of the European Heart Rhythm Association EP research network, covering 20 countries answered the survey questions. All centres were high-volume ablation centres. A younger person with asymptomatic Wolff-Parkinson-White (WPW) pattern has a higher likelihood of being risk-stratified or receiving ablation therapy compared with an older subject. Two-thirds of centres report that they have observed a decline in the number of patients ablated for an accessory pathway during the last 10 years. Pre-excited atrial fibrillation is rarely seen. Discontinuation of a scheduled WPW ablation due to close vicinity of the accessory pathway to the AV node happens very rarely. Patients with a first episode of preexcited atrial fibrillation would immediately be referred for catheter ablation to be performed within weeks by 80.4% of the centres. A significant proportion of responders (50.9%) would use electrical cardioversion to restore sinus rhythm in a patient with pre-excited atrial fibrillation. With respect to the choice of antiarrhythmic medication for a patient with pre-excited AF, the majority (80.0%) would choose class 1C antiarrhytmic drugs while waiting for a catheter ablation. A patient seen in the emergency room with a second episode of orthodromic atrioventricular reentry tachycardia would be referred for immediate ablation by 79.2-90.6% of centres depending on the presence of pre-excitation. The volume of paediatric ablations performed on children younger than 12 years was low (46.4%: 0 patients per year; 46.4%: 1-9 patients per year). The majority of responding centres (61-69%) report that their country lack national guidelines dealing with clinical strategies related to WPW. There is a need for national guidelines dealing with clinical strategy in patients with WPW syndrome. Older individuals with asymptomatic WPW pattern have a higher risk of not receiving risk stratification or curative therapy with ablation compared with younger patients, despite the higher risk of developing atrial fibrillation.
Pacing and Clinical Electrophysiology, 2003
KALARUS, Z., ET AL.: Electrophysiological Features of Orthodromic Atrioventricular Reentry Tachycardia in Patients with Wolff-Parkinson-White Syndrome and Atrial Fibrillation. The aim of this study was to compare the electrophysiological features of tachycardia between WPW patients with and without AF. The study population consisted of 114 patients with WPW syndrome and reciprocating tachycardia during electrophysiological study. Two groups were selected: group I with AF during the procedure (n = 42) and the control group n = 72 without AF (group II). Cycle length (V-V interval), antero A-V, retrograde V-A conduction time during tachycardia and indexes V-A/V-V were analyzed. In addition, the relation between antero-, retrograde conduction time, and V-V was evaluated. Selection of the most predictive factor for AF presence was performed using regression analysis. Significant differences between the two groups were observed. These included a higher rate of tachycardia, shorter anterograde conduction time,
Circulation-arrhythmia and Electrophysiology, 2014
A lthough infrequently, asymptomatic patients with a Wolff-Parkinson-White (WPW) electrocardiographic pattern experience sudden cardiac death because of life-threatening arrhythmias (typically atrial fibrillation with rapid antegrade conduction through an atrioventricular [AV] accessory pathway [AP], resulting in ventricular fibrillation). 1-3 The risk of such an event has been reported to be ≈0.1% per patient-year. 4 Attempts have been made to identify patients at high risk but specific guidelines for risk stratification in the asymptomatic young patients with WPW, including recommendation for the invasive electrophysiological (EP) evaluation and prophylactic catheter ablation of the AP, have not been published until recently. 5 The aim of the present study was to evaluate retrospectively the electrophysiological profile of asymptomatic children and adolescents with a WPW electrocardiographic pattern and to assess the results of an invasive risk stratification strategy applying currently consented risk criteria. 5 Editorial see p 187 Clinical Perspective on p 223 Methods Patients The study population was identified retrospectively from the clinical databases of 2 tertiary care centers providing invasive pediatric EP evaluation and radiofrequency (RF) catheter ablation for the whole territory of the Czech Republic (10.5 million inhabitants). Between October 2000 and August 2011, 85 consecutive patients (51 boys, 34 girls) under the age of 18 years with an asymptomatic WPW pattern underwent an invasive EP study for risk stratification. The patients had no antiarrhythmic medication and showed persistent preexcitation up to the maximum achieved heart rate during exercise stress testing before the EP study. The median age at EP evaluation was 14.9 (first-third quartile [Q1-Q3]=12.5-16.6) years. Owing to the purely retrospective study design, the use of available institutional clinical records, absence of effect on
Risk of atrial fibrillation according to the initial presentation of a preexcitation syndrome
International Journal of Cardiology
Background: Atrioventricular reentrant tachycardia (AVRT) is frequent in Wolff-Parkinson-White syndrome (WPW). Atrial fibrillation (AF) is rare. The purpose of the study was to determine the factors of spontaneous AF in WPW according to the initial presentation. Methods and results: Electrophysiological study (EPS) was performed among 709 patients with a preexcitation syndrome. First event was AF in 44 patients. Remaining patients were studied for AVRT (314), syncope (94), adverse presentation without AF (9) or systematically (248 asymptomatic patients). Patients with AF were older than other patients (44 ± 16 years vs 34.5 ± 17) (0.0003); maximal rate conducted over accessory pathway (AP) was higher in patients with AF than in other patients except in adverse presentation (0.0002); AVRT was induced more frequently in patients with AF than in asymptomatic patients (57% vs 14.5%) but less than in patients with AVRT (89%). AF was induced more frequently in patients with AF than in other patients except in adverse presentation (b 0.0001). During follow-up AF occurred more frequently in patients with AF (5; 11%) than in patients with AVRT (7; 2%), with syncope (1%) and asymptomatic patients (4; 1.6%). Older age predicted recurrence (54 ± 16 vs 40 ± 17). Conclusions: AF was the first event in only 6% of patients with WPW and was a rare event in other patients. They are older but 10% are less than 18 years and have a more rapid conduction over AP than other patients.
Atrial and Ventricular Vulnerability in a Patient with the Wolff-Parkinson-White Syndrome
Pacing and Clinical Electrophysiology, 1981
vulnerability in a palient with the Woljj-Parkinson-W'hile syndrome. An electrophysjoiogic study was carried out in a patient with the Woljj-Parkinson-White syndrome and a history of sponfuneous atrial fibrillafion but with no evidence oj organic cardiac disease. A singJe induced premature ventricular depoiarizalion resulted in ventricular tachycardia joUowed by ventricular fibrillation. Similarly, airial pacing or premature atrial siimulation resulted in frequent episodes of airial fibrillation or flutter. The atrial and ventricular effective refractory periods were 180 ms and < 160 ms. respectively, al a driven cycle length of 480 ms. Intravenous adminislralion of procainamide resulted in lengthening of the refractory periods and failure to induce either atriai or venlricular arrhythmias with pacing. In most patients with enhanced atrioventricular nodal or accessory atrioventricular nodal bypass, Ihe mechanism of ventricular tachycardia is related to an inordinately rapid ventricular response during supraventricular arrhythmias. In our patient, a unique mechonism was apparent; atrial and venlricular vulnerability to fibrillation was associated with extremely short myocardial effective refraclory periods. The relationship of this finding to sudden cardiac death bears further study. (PACE. Vol. 4, January-February, 1981} atrial vulnerability, ventricular vulnerability, Wolff-ParJiinson-White syndrome. ventricular fibrillation, atrial fibrillation, atrial flutter Atrial fibrillation is a well-documenled complication in palients with the Wolff-Parkinson-White syndrome and its occurrence has been related to increased citrial vulnerability during reciprocating atrioventricular tachycardia or to delayed atrial conduction.'"^ Less clear, however, is the relationship between ventricular arrhythmias and preexcitation. This uncer
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European Journal of Cardiovascular Prevention & Rehabilitation, 2006
This consensus paper on behalf of the Study Group on Sports Cardiology of the European Society of Cardiology follows a previous one on guidelines for sports participation in competitive and recreational athletes with supraventricular arrhythmias and pacemakers. The question of imminent life-threatening arrhythmias is especially relevant when some form of ventricular rhythm disorder is documented, or when the patient is diagnosed to have inherited a pro-arrhythmogenic disorder. Frequent ventricular premature beats or nonsustained ventricular tachycardia may be a hallmark of underlying pathology and increased risk. Their finding should prompt a thorough cardiac evaluation, including both imaging modalities and electrophysiological techniques. This should allow distinguishing idiopathic rhythm disorders from underlying disease that carries a more ominous prognosis. Recommendations on sports participation in inherited arrhythmogenic conditions and asymptomatic gene carriers are also discussed: congenital and acquired long QT syndrome, short QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular cardiomyopathy and other familial electrical disease of unknown origin. If an implantable cardioverter defibrillator is indicated, it is no substitute for the guidelines relating to the underlying pathology. Moreover, some particular recommendations for patients/ athletes with an implantable cardioverter defibrillator are to be observed. Eur J Cardiovasc Prev Rehabil 13:676-686
Medico-legal perspectives on sudden cardiac death in young athletes
International Journal of Legal Medicine, 2016
Sudden cardiac death (SCD) in a young athlete represents a dramatic event, and an increasing number of medicolegal cases have addressed this topic. In addition to representing an ethical and medico-legal responsibility, prevention of SCD is directly correlated with accurate eligibility/ disqualification decisions, with an inappropriate pronouncement in either direction potentially leading to legal controversy. This review summarizes the common causes of SCD in young athletes, divided into structural (hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, congenital coronary artery anomalies, etc.), electrical (Brugada, congenital LQT, Wolf-Parkinson-White syndrome, etc.), and acquired cardiac abnormalities (myocarditis, etc.). In addition, the roles of hereditary cardiac anomalies in SCD in athletes and the effects of a positive result on them and their families are discussed. The medico-legal relevance of pre-participation screening is analyzed, and recommendations from the American Heart Association and European Society of Cardiology are compared. Finally, the main issues concerning the differentiation between physiologic cardiac adaptation in athletes and pathologic findings and, thereby, definition of the so-called gray zone, which is based on exact knowledge of the mechanism of cardiac remodeling including structural or functional adaptions, will be addressed.
Wolff-Parkinson-White Syndrome and Adenosine Response in Pediatric Patients
Pacing and Clinical Electrophysiology, 2013
Background: Adenosine administration to patients with Wolff-Parkinson-White (WPW) usually increases preexcitation and therefore may be diagnostic for WPW syndrome when the electrocardiogram (ECG) is questionable. We aimed to determine the adenosine response in pediatric patients with WPW pattern on ECG and whether blocked accessory pathway (AP) conduction with adenosine correlated with nonrapid AP conduction measured by invasive electrophysiology study (EPS). Methods: All patients with WPW ≤18 years of age who underwent EPS over a 5-year period were identified. The adenosine response during atrial pacing was characterized as blocked or continued AP conduction. Invasive data were obtained during atrial pacing and atrial fibrillation. Conduction through the AP to a cycle length ≤250 ms was considered rapid; otherwise patients were nonrapid. The sensitivity, specificity, and positive (PPV) and negative predictive value were calculated for blocked AP conduction to identify nonrapid baseline AP conduction during EPS. Results: There were 59 patients included and nine (15%) had blocked AP conduction with adenosine. Five of these nine had WPW syndrome and four had fasciculoventricular APs. All nine patients had nonrapid conduction on baseline EPS. Blocked AP conduction with adenosine as a marker of nonrapid baseline AP conduction had a specificity of 100%, a PPV of 100%. Conclusions: In these pediatric patients with WPW pattern on ECG, a significant minority blocked AP conduction with adenosine and this finding had 100% specificity and PPV for nonrapid baseline antegrade AP conduction. The finding of blocked AP conduction with adenosine may aid in risk stratification. (PACE 2013; 36:491-496) pediatrics, clinical electrophysiology, Wolff-Parkinson-White syndrome, adenosine, risk stratification Background Wolff-Parkinson-White (WPW) syndrome is characterized by the presence of one or more accessory pathways (AP) which bypass normal atrioventricular (AV) nodal conduction. Administration of intravenous adenosine to patients with WPW may result in increased preexcitation primarily due to AV nodal block. 1-3 Therefore administration of adenosine may aid in making the diagnosis of WPW syndrome in patients with questionable or subtle ventricular preexcitation on a surface electrocardiogram (ECG). However, adenosine administration has been shown to have variable effects on antegrade conduction of APs in adults with preexcitation on surface ECG, making this technique for diagnosing WPW syndrome Disclosures: None.
Pacing and Clinical Electrophysiology, 2012
Background: In Wolff-Parkinson-White (WPW) syndrome, rapid antegrade conduction of atrial tachyarrhythmias can result in ventricular fibrillation and sudden death. Antegrade conduction can be assessed through noninvasive testing or invasive electrophysiology study (EPS). We aimed to determine the correlation between noninvasive testing and EPS in a pediatric WPW population. Methods: All WPW patients <21 years who underwent EPS over a 10-year period were identified. Noninvasive testing reviewed included electrocardiogram, Holter, and exercise stress test (EST). Patients were classified as low-risk if preexcitation was lost during any test. EPS data reviewed included antegrade conduction during atrial pacing and atrial fibrillation. Conduction through the accessory pathway (AP) to a cycle length ≤250 ms was considered rapid, otherwise patients were nonrapid. Sensitivity, specificity, positive (PPV), and negative predictive value (NPV) of noninvasive testing to correctly identify nonrapid conduction was calculated. Results: There were 135 EPS. Twenty-four patients (18%) were classified low-risk noninvasively. Two of the 24 (8%) had rapid conduction at baseline EPS. The sensitivity, specificity, PPV, and NPV of low-risk noninvasive testing to predict nonrapid conduction was 22%, 94%, 92%, and 31%, respectively. Sixteen of the 24 had low-risk EST and none had rapid conduction at baseline EPS. The specificity and PPV of low-risk EST were 100%. Conclusion: Loss of preexcitation during noninvasive testing had high specificity and PPV for nonrapid antegrade conduction during baseline EPS. Abrupt loss of preexcitation during EST was a highly reliable noninvasive marker of nonrapid AP conduction at baseline in our pediatric WPW patients.
Pacing and Clinical Electrophysiology, 2017
Background Risk stratification for Wolff-Parkinson-White (WPW) pattern either by non-invasive or invasive tests is important to determine whether an ablation is necessary or not. The aim was to compare noninvasive tests and invasive studies in a pediatric WPW population. Methods A total of 71 WPW patients [median age 14 years (IQR 11-16 years); 43 male] underwent Holter monitoring, exercise stress test (EST), and transesophageal electrophysiological study (TEEPS). In the case of a ≤ 270 ms effective refractory period of accessory pathway (APERP) or induction of supraventricular tachycardia using TEEPS, patients were classified as high-risk and underwent invasive electrophysiological study (EPS).
Accessory pathway properties are similar in symptomatic and asymptomatic preexcitation
Journal of Interventional Cardiac Electrophysiology
Purpose Patients with WPW syndrome have an increased mortality rate compared to the general population. Although asymptomatic preexcitation has previously been considered benign, recent studies have found that also asymptomatic patients have clinical and electrophysiological factors associated with increased risk of sudden cardiac death. This study compares the baseline electrophysiological characteristics of accessory pathways in symptomatic and asymptomatic patients with preexcitation. We hypothesized that a significant proportion of asymptomatic patients has inducible orthodromic tachycardia during programmed electrical stimulation. Methods This retrospective study includes 1853 patients with preexcitation who underwent invasive electrophysiological testing in two Swedish University Hospitals between 1991 and 2018. The mean age was 36 ± 17 years with a range of 3–89 years. Thirty-nine percent was women. A total of 269 patients (15%) were children younger than 18 years. Electrophy...