Change of Paradigm in the Management of Patients with Accessory Pathways over the Last Forty Years: Wolff-Parkinson-White Syndrome as an Electrophysiological Marvel at Risk of Extinction.

Over the last decades, the approach to the Wolff-Parkinson-White syndrome, as well as its treatment, has substantially changed, leading to improvement in the prognosis and quality of life of these patients. From the first diagnostic electrophysiologic studies to the most recent evaluations, important data on pathophysiologic and clinical aspects have been gathered, and this learning journey is still not concluded. This body of knowledge is a fundamental part of any cardiologists' armamentarium despite the fact that this syndrome is rarely observed in adult patients.

Automated external defibrillator documented degeneration of pre-excited atrial fibrillation into ventricular fibrillation.

Wolff-Parkinson-White (WPW) syndrome can be the cause of syncope or sudden cardiac death, which results from ventricular fibrillation (VF) degenerated from rapid anterograde conduction of atrial fibrillation (AF) to the ventricles through the accessory pathway. We present a case of WPW syndrome in which recording the actual moment of onset of the degeneration of pre-excited AF into VF. This was fortuitous and also lucky for this patient.

When and how to assess an asymptomatic ventricular pre-excitation syndrome?

Sudden cardiac death may be the first event in the history of Wolff-Parkinson White syndrome: this is a very rare event although as ablation of the accessory pathway avoids this risk a potentially malignant form of the disease needs to be detected. Electrophysiological studies are the most reliable method. These may be performed by a trans-oesophageal or endocavity approach from the age of six to seven years onwards. Whilst it is rare to detect a potentially malignant form the results of these studies more often enable the person to play sports or continue their job without offering radio-frequency ablation. The former however is indicated when tachycardia is induced in children over 12 years old and in adults.

[Preventive efficacy of propafenone, its effect on functional state of the heart during long-term treatment of patients with paroxysmal atrioventricular arrhythmias].

Efficacy and tolerability of propafenone were studied in the process of long-term treatment of patients with various forms of paroxysmal atrioventricular arrhythmias. It was established that propafenone appears to be highly effective remedy for prophylaxis of paroxysms of atrioventricular reciprocal nodal tachycardia and atrioventricular tachycardia in Wolf-Parkinson-White syndrome. The preparation did not exert negative influence on functional state of the heart. Side reactions requiring withdrawal of propafenone were observed in 12.7% of cases.

Risk stratification in the asymptomatic child with Wolff-Parkinson-White syndrome.

PURPOSE OF REVIEW: As the safety and efficacy of invasive electrophysiologic studies and ablation therapy in pediatrics improves, there has been a greater interest in developing adequate risk stratification criteria for the asymptomatic pediatric patient with Wolff-Parkinson-White syndrome. This review will discuss the recent literature regarding this debate. RECENT FINDINGS: Recent retrospective and prospective studies of Wolff-Parkinson-White syndrome in asymptomatic pediatric patients have shown that the well established adult criteria for risk stratification may not be applicable in children. Both symptomatic and asymptomatic children had similar accessory pathway effective refractory periods and supraventricular tachycardia inducibility in recent invasive electrophysiologic studies. The first attempt at prospective evaluation of the use of ablation therapy in asymptomatic adult and pediatric patients with the condition has sparked a debate as to the definition of a high-risk patient and the utility of ablation in the asymptomatic patient. SUMMARY: It is still controversial whether the established criteria for risk stratification in adults can be confidently applied to the pediatric patient. The majority of pediatric electrophysiologists use invasive electrophysiologic studies for risk stratification and selection of appropriate therapy. This clinical practice reflects the increasing prevalence and safety of electrophysiologic study and ablation. Further studies to better define indications for study and ablation are still necessary, however, to define accurate criteria for risk stratification in this difficult pediatric problem.

Risk of sudden death after successful accessory atrioventricular pathway ablation in resuscitated patients with Wolff-Parkinson-White syndrome.

INTRODUCTION: Cardiac arrest in patients with Wolff-Parkinson-White (WPW) syndrome can be due to ventricular fibrillation mediated by fast conduction over the accessory pathway during atrial fibrillation. However, if primary ventricular fibrillation is the reason for resuscitation, placement of an implantable cardioverter defibrillator (ICD) would be indicated. The aim of this study was to test the hypothesis that in resuscitated patients with WPW syndrome, recurrences can be prevented by sole ablation of their accessory pathways. METHODS AND RESULTS: We performed a long-term follow-up study of 48 resuscitated patients with WPW syndrome who underwent successful accessory pathway ablation as their sole primary treatment. Cardiac arrest had occurred either spontaneously in 32 patients (group A) or after intravenous administration of antiarrhythmic drugs in 16 patients (group B) and was never associated with an acute myocardial infarction or other concomitant factors. All patients had normal left ventricular function at echocardiography. A total of 56 accessory AV pathways were ablated successfully with radiofrequency current (n = 55) or during surgery (n = 1) and were located at the left free wall (n = 35), right free wall (n = 8), or septal-paraseptal region (n = 13). Follow-up 5.0+/-1.9 years after ablation (range 0.2 to 7.9) was obtained in all 48 patients. All of the patients were alive, and none had a life-threatening arrhythmia or syncope after successful ablation of their accessory pathways. CONCLUSION: In resuscitated patients with WPW syndrome who have normal left ventricular function at echocardiography and no ECG abnormalities suggesting additional electrical disease, ablation of their overt accessory pathways prevented cardiac arrest recurrences; therefore, ICD placement is generally not indicated.

Catheter ablation in a patient with a congenital giant right atrial diverticulum presented as Wolff-Parkinson-White syndrome.

A young woman symptomatic for tachycardia showed right ventricular preexcitation on the surface ECG with a pattern during induced atrial fibrillation suggestive of multiple APs. Noninvasive imaging techniques performed prior to catheter ablation demonstrated the presence of a giant right atrial diverticulum confirmed by hemodynamic procedure. This structure functioned as an enormous accessory AP. We performed catheter ablation of this pathway using a special 4-mm multipolar catheter inside the diverticulum. This is the first case of such as anomaly being successfully treated with catheter ablation.

[Therapeutic management of the Wolff-Parkinson-White syndrome]. / Stratégie thérapeutique du syndrome de Wolff-Parkinson-White.

Reentry tachycardia and atrial fibrillation occur in 12 to 36 per cent of patients with Wolff-Parkinson-White (WPW) syndrome. The severity of the arrhythmia depends on the frequency of attacks, on the heart rate in tachycardia and on the condition of the underlying myocardium. Moreover, ventricular fibrillation has been observed in some cases of atrial fibrillation with a fast ventricular response due to accessory pathways with very short refractory periods. This is the mechanism of sudden death in WPW syndrome. The prognosis can be assessed by atrial pacing, now often performed by the transoesophageal method. pacing makes it possible to measure the atrial vulnerability and the value of the shortest interval conducted through the accessory pathway. Indirect methods, such as exercise electrocardiogram or ajmaline injection, are less specific in predicting the characteristics of the accessory pathway. The therapeutic approach depends on the symptoms. Asymptomatic patients or those who present with only rare episodes of reciprocal tachycardia can be left untreated, but a preventive medical treatment is necessary in patients with atrial fibrillation or frequent attacks of tachycardia. When this treatment is ineffective or complicated by side-effects, a more radical therapy must be proposed. For the last 20 years this has been surgery, but nowadays catheter ablation of the accessory pathway gives similar results in skilled hands and tends to replace surgery.