Pre-excited Atrial Fibrillation Research Articles

Expanded application of wearable cardioverter defibrillators beyond current guidelines: proposal for a European register explained through single clinical scenarios

The wearable cardioverter defibrillator (WCD) is becoming a more and more widely used instrument for the prevention of sudden cardiac death of patients either with a secondary prevention implantable cardioverter...

Wolf–Parkinson–White Syndrome: Diagnosis, Risk Assessment, and Therapy—An Update

Wolf–Parkinson–White (WPW) syndrome is a disorder characterized by the presence of at least one accessory pathway (AP) that can predispose people to atrial/ventricular tachyarrhythmias and even sudden cardiac death. It is the second most common cause of paroxysmal supraventricular tachycardia in most parts of the world, affecting about 0.1–0.3% of the general population. Most patients with WPW syndrome have normal anatomy, but it may be associated with concomitant congenital heart disease or systemic diseases. Although many individuals are asymptomatic, during supraventricular arrhythmia episodes, they may experience severe symptoms, including syncope or even sudden cardiac death (mainly due to pre-excited atrial fibrillation over rapidly conducting AP). In addition to arrhythmia-related symptoms, for some specific locations of the APs with overt anterograde conduction, there might be a reduction in exercise capacity mediated by a reduction in LV systolic performance due to anomalous LV depolarization. Although it is typically diagnosed through electrocardiography (ECG), additional tests are necessary for risk assessment. Management of WPW syndrome may be quite challenging and can vary from only acknowledging the presence of the accessory pathway to pharmacological treatment or radiofrequency ablation. Early diagnosis, risk assessment, and appropriate treatment are critical steps in the management of WPW syndrome, aiming to improve the quality of life and reduce the risk of life-threatening arrhythmias.

An Episode of Paroxysmal Atrial Fibrillation Revealing Wolff-Parkinson-White Syndrome, a Case Report

Wolff-Parkinson-White syndrome involves abnormal electrical conduction in the heart through accessory pathways. Pre-excited atrial fibrillation arises from the non-decremental conduction of atrial fibrillation to the ventricles via these pathways, resulting in supraventricular tachycardias and, albeit rarely, sudden cardiac death due to ventricular fibrillation. Our case report aims to elucidate the specific characteristics of this condition and explore different methods of managing it.

Unresponsive to Cardioversion Pre-excited Irregular Rhythm

Highlights: 1. Atrial fibrillation in the presence of an accessory pathway may present with confounding electrocardiographic signs. 2. The clinical recognition of WPW may be hindered by the presence of pre-excited AF. - Case Summary: A 46-year-old man without known past medical history was referred to the tertiary hospital emergency department after being found collapsed at home. There are no any complaints of any headache, nausea, chest pain, or paralysis of extremities before losing consciousness. His chest examination to bilateral auscultation was clear. Chest X-ray, routine blood work, and transthoracic echocardiography did not reveal any abnormalities. The initial heart rate before referral was 250-300/min and the ECG shows irregular wide QRS complex tachycardia. The ECG after cardioversions shows sinus rhythm 86 bpm with WPW type A pattern. The patient got intravenous amiodarone and intravenous lidocaine during the transfer. And the ECG on arrival at the emergency department, the heart rate was 50-150 bpm irregularly and the ECG shows atrial fibrillation with a narrow QRS complex. Discussion: Rapid anterograde accessory pathway conduction during atrial fibrillation (AF) can result in sudden cardiac death. During pre-excited AF, delta waves as the key feature of Wolff-Parkinson-White (WPW) syndrome might be obscured. We should keep in mind the diagnosis of pre-excited AF in patients presenting with irregular and wide complex tachycardia.

Intermittent ventricular pre-excitation in symptomatic adults: Always a marker of low risk?

Intermittent ventricular pre-excitation was considered a low-risk marker for sudden death. However, to date, some studies do not exclude the existence of accessory pathways (APs) with high-risk intermittent antegrade conductive properties. According to current European Guidelines, high-risk features of APs are antegrade pathway conduction ≤250 ms in baseline or during the adrenergic stimulus, inducibility of atrioventricular reciprocating tachycardias (AVRT), inducibility of pre-excited atrial fibrillation (AF), and presence of multiple APs. For all of these transcatheter ablation is recommended. The aim of our study was to evaluate the existence of differences in risk characteristics between patients with intermittent pre-excitation (IPX) and those with persistent pre-excitation (PPX), from a sample of adults with ventricular pre-excitation and symptoms like palpitations. 293 adults [IPX: 51 (17.4%); PPX: 242 (82.6%)] underwent electrophysiological study and then catheter ablation of their APs if arrhythmia inducibility (AVRT/AF) was noted, or, conversely, if it was appreciated a fast AP antegrade conduction, in baseline or during intravenous isoproterenol infusion, or if multiple APs were detected. There were no statistically significant differences in demographic characteristics (age and gender), AVRT/AF inducibility, antegrade conductive properties, the prevalence of multiple APs, and APs locations between IPX and PPX patients. In our study, patients with IPX did not show significant differences in clinical and electrophysiological features versus PPX patients.

Symptomatic intermittent ventricular pre-excitation in adult: a monocentric retrospective study

Abstract Funding Acknowledgements Type of funding sources: None. Backgorund: Intermittent ventricular pre-excitation was considered a low-risk marker for sudden death. However, to date some studies do not exclude the existence of accessory pathways (APs) with high-risk intermittent antegrade conductive properties. High-risk features of APs are: ERP/SPERRI ≤250 msec (in basal or during adrenergic stimulus), inducibility of atrioventricular reciprocating tachycardias (AVRT), inducibility of pre-excited atrial fibrillation (AF), multiple APs. For these catheter ablation is recommended. Purpose The aim of this retrospective study was to evaluate the existence of a statistically significant difference in the risk characteristics between patients with intermittent pre-excitation (IPX) and with persistent pre-excitation (PPX), from a sample of adults with symptomatic ventricular pre-excitation (Wolff-Parkinson-White Syndrome). Methods Between August 2005 and December 2015, 293 adults (age ≥18 years) [males: 183 (62.5%)], without structural heart disease, with signs of ventricular pre-excitation and symptomatic for palpitations underwent an EP study [IPX: 51 (17.4%), males: 31 (60.8%); PPX: 242 (82.6%), males: 152 (62.8%)]. The APs were submitted to catheter ablation if EP study showed inducibility of arrhythmias (AVRT/AF) and, in case of non-inducibility of arrhythmias, if ERP ≤250 msec, in basal or during intravenous infusion of isoproterenol. Additionally, the presence of multiple accessory pathways was assessed during the test. Results The 2 groups of patients did not show statistically significant differences in age at the time of EP study [IPX: mean age 37.23±16.89 years Vs PPX: mean age 39.03±16.19 (P-value>0.05)] and gender (IPX male: 60.8% Vs PPX male: 62.8%; P-value>0.05). When measured, there were no statistically significant differences regarding ERP [IPX: mean ERP 260±45.8msec Vs PPX: mean ERP 267.7±59.6msec; P-value>0.05]. The inducibility of arrhythmias (AVRT/AF) was 59.3% in the IPX group (27 patients) vs 38% in the PPX group (92 patients), showing statistically significant differences (P-value<0.05). Multiple accessory pathways were found in 2 patients of the IPX group (3.9%), both females (100%), and in 6 patients of the PPX group (2.5%), of which 2 females (33.3%), not showing statistically significant differences (P-value>0.05). Conclusion In our study, patients with IPX did not shown statical significant differences in clinical and electrophysiological features Vs PPX partients. Thus, intermittent ventricular pre-excitation could not absolutely be considered a marker of lower arrhythmic risk.

Pre-excited atrial fibrillation revealed at a very delayed age: case report

BackgroundWolff-Parkinson-White (WPW) syndrome is a condition characterized by the persistence of an accessory pathway responsible for ventricular pre-excitation that can lead to symptomatic and potentially severe arrhythmias. Coexistence with atrial fibrillation is well known and not uncommon, exposing to potential degenerescence into ventricular fibrillation when atrial impulses are transmitted along the accessory pathway. WPW syndrome is most prevalent in younger patients and cases revealed after an advanced age have rarely been described in the literature.Case presentationHere, we report a case of atrial pre-excitation first diagnosed at the age of 72 years that required external electrical cardioversion with a favorable outcome. The diagnosis was based on clinical and electrographic findings.ConclusionsWPW syndrome is a relatively rare cardiac disorder that can be a cause of sudden death, especially when combined with atrial fibrillation. Therefore, cardiologists have to consider this diagnosis in patients presenting clinical signs of arrhythmia with an electrical pattern of WPW.

Not Just a One-Way: Mahaim Accessory Pathway Concomitantly Supporting Orthodromic Atrioventricular Re-Entrant Tachycardia

We report the case of a 41-year-old female with documented narrow QRS tachycardia. During electrophysiological study, both orthodromic and antidromic atrioventricular reentry tachycardia (AVRT) were demonstrated as well as short episodes of pre-excited atrial fibrillation. Programmed atrial stimulation resulted in decremental anterograde conduction on the AP, thus confirming an unexpected Mahaim accessory pathway (AP) diagnosis. Limited 3D activation maps of the right atrium during orthoAVRT, respectively, and the right ventricle (RV) during antiAVRT were constructed and helped accurately describe the atrial and ventricular insertion points, which were superposed on the tricuspid ring, confirming the existence of a single short atrio-ventricular right free wall AP. Short atrioventricular APs with anterograde Mahaim-type conduction concomitantly sustaining orthodromic AVRT are extremely rare. Electroanatomical 3D mapping may help both to clarify the diagnosis and increase the success rate by accurately describing the insertion points of complex accessory pathways.

Pre-excited atrial fibrillation: A lower threshold for electrical cardioversion

Pre-excited atrial fibrillation: A lower threshold for electrical cardioversion

Para-Hisian pacing: The eyes see what the mind knows.

A young male presented with pre-excited atrial fibrillation. During an electrophysiology study, preexcitation suggestive of a pathway in posteroseptal location was confirmed but no tachycardia was inducible. Para-Hisian pacing was done during sinus rhythm. Is there retrograde conduction through the accessory pathway?

The Risk of Sudden Death Associated with Symptomatic and Asymptomatic Ventricular Pre-excitation in Athletes

Abstract Sudden death (SD) in athletes is a potential avoidable dramatic scenario. When done regularly, cardiological evaluation increases the chances of diagnosing ventricular pre-excitation. Consequently, the following question arises: what is the real incidence of SD risk in athletes with Wolff-Parkinson-White (WPW) syndrome/pattern? This study included 84 consecutive patients diagnosed with WPW and was designed as a retrospective analysis of data acquired between 2011 and 2021 to answer this question. The patients were evaluated using a 12-lead electrocardiogram (ECG), echocardiography, stress test, and electrophysiological study (EPS). The SD risk linked to WPW was defined as ≥ 1 of the following: the anterograde effective refractory period (AERP) of the accessory pathway (AP) ≤ 250 ms, atrial fibrillation (AF) with the shortest RR pre-excited interval ≤ 250 ms, syncope during AF or atrioventricular reentry tachycardia. The athletes with WPW pattern (n=25) or syndrome (n=59) at risk of SD were identified and treated with radiofrequency ablation (RFA). The mean age was 19.83 (10–29) years; 66.6% were men. Seventeen athletes (n=17; 20.23%) were found with SD risk: 15 (n=15; 17.85%) in the WPW syndrome group and 2 (n=2; 2.38%) in the WPW pattern group. During the EPS, n=4 developed syncope: 1 during antidromic tachycardia and 3 during pre-excited AF. RFA was curative in 96.42% of cases. The EPS is mandatory to identify athletes with short AERP APs linked to an increased risk of SD. RFA is the intervention that settles the patients into a risk-free area, allowing resumption of sports shortly afterward.

Atrial Fibrillation with Ventricular Pre-Excitation: A Diagnosis That Must Not Be Missed

Wolff-Parkinson-White (WPW) syndrome is caused by an accessory pathway that communicates between the atria and ventricles known as the Bundle of Kent. The development of atrial fibrillation, can result in the atrial impulses all being conducted via the accessory pathway and result in a sinister, board complex, irregular tachycardia, with varying QRS morphology (known as pre-excited atrial fibrillation) Adenosine is a potent atrioventricular node blocker, which can be used in the treatment of supraventricular tachycardias, but also has diagnostic utility, particularly in differentiating between supraventricular tachycardia with aberrant conduction (which would often terminate) and a ventricular tachycardia (which would not respond to adenosine). However, the administration of adenosine in pre-excited atrial fibrillation can precipitate 1:1 atrial to ventricular conduction, which can degenerate into life-threatening ventricular arrythmias. This case describes a patient who presented with pre-excited atrial fibrillation and received intravenous adenosine that resulted in development of broad complex tachycardia with haemodynamic compromise. In patients with pre-exited atrial fibrillation, AV nodal blocking agents should be avoided and direct current cardioversion should be utilised.

Emergency catheter ablation: A feasible option for acute treatments of patients with unstable pre-excited atrial fibrillation.

Pre-excited atrial fibrillation (AF) is associated with increased risk of life-threatening events. However, at times, patients with pre-excited AF still repetitively suffer from hemodynamic disturbance, with resistance to acute treatments of antiarrhythmic therapy and cardioversion. To evaluate the feasibility in correcting hemodynamic disturbance, patients with pre-excited AF who underwent catheter ablation of accessory pathway as an emergency procedure, were retrospectively collected from two centers of China. The medical records of patients were analyzed and summarized in this case series. Five patients with pre-excited AF who received emergency catheter ablation of accessory pathway, were collected from two contributor centers and reported in this case series. All collected patients still repetitively suffered from hemodynamic disturbance induced by rapid anterograde conduction of AF via pathway, even guideline recommended acute interventions of intravenous antiarrhythmic therapy and cardioversion had been performed. Finally, as an emergency procedure, catheter ablation of accessory pathway was performed in collected patients. Correspondingly, the hemodynamic unstable status was greatly relieved. Meanwhile, all collected patients with high risk of pre-excited AF were combined with left-sided accessory pathway, with shortest RR interval of widened pre-excited QRS complex less than 250 ms. Thus, combination with left-sided pathway is proposed as an indicator for the increased risk of life-threatening events in patients with high risk of pre-excited AF. Emergency catheter ablation of accessory pathway is an effective option for the acute managements of patients with high risk of pre-excited AF in unstable hemodynamics, which is resistant to antiarrhythmic therapy and cardioversion.

Electrophysiological and therapeutic effects of amiodarone in patients with preexcited atrial fibrillation.

Atrial fibrillation (AF) with fast ventricular response over an overt accessory pathway (AP) (preexcited AF) with a short anterograde refractory period is a potentially malignant arrhythmia. This study aimed to evaluate the safety and efficacy of amiodarone for preexcited AF management. This study enrolled 103 patients with evidence of AP in electrocardiography. Patients with preexcited AF were included in the study. Intravenous amiodarone (300 mg) was infused for 30 min for all patients in the AF rhythm. Electrophysiological parameters were evaluated before amiodarone injection and 2 h after pharmacological or electrical cardioversion. Antegrade and retrograde refractory periods of the atrioventricular node (AVN) and AP, as well as antegrade and retrograde Wenckebach points of AVN, were increased significantly after amiodarone infusion. Furthermore, the mean of the shortest preexcited RR interval was increased during the monitoring period. Comparing the preexcited index at the beginning of the study and before cardioversion (2 h later) revealed that the QRS complexes changed to a wider pattern as the preexcitation index changed from 80.61 to 92.26 (P < 0.001). Nineteen (18.4%) patients converted to the sinus rhythm with amiodarone infusion. No ventricular arrhythmia was detected during monitoring. Amiodarone could be considered a safe drug in patients with preexcited AF for rate control despite its relatively low efficacy in conversion to the sinus rhythm.

Case Report: Pre-excited atrial fibrillation as the initial manifestation of Wolff Parkinson White Syndrome

BACKGROUND: Atrial fibrillation is the second most common arrhythmia associated with Wolf Parkinson White syndrome. It usually presents itself with high ventricular rates, and its importance lies in the increased risk of turning into ventricular fibrillation and sudden death, which is why an accurate diagnosis is necessary to implement the correct treatment for the acute event and subsequently its definitive resolution. CASE REPORT: A 41-year-old male patient attended the emergency department with a 12-hour evolution clinical course of palpitations and syncope. On arrival, he was hemodynamically stable: an electrocardiogram was performed; with the finding of an irregular rhythm, absence of P waves, wide QRS complexes of variable duration, with the initial phase of the QRS complex wider than the final phase, a heart rate of 160 to 170 beats per minute, with an RR interval of 200 milliseconds, all of this compatible with AF with pre-excitation. CLINICAL COURSE: Due to the high risk of ventricular fibrillation and sudden death, synchronized electrical cardioversion was performed, with which it was possible to revert the sinus rhythm, with the presence of delta waves, compatible with left anterolateral preexcitation. The patient presented a favorable evolution, he was hospitalized and subsequently underwent electrophysiological studies that confirmed the diagnosis of Wolf Parkinson White syndrome, with a left anterolateral Bundle of Kent, which was resolved by radiofrequency ablation. CONCLUSION: A case of atrial fibrillation with pre-excitation as the first manifestation of Wolf Parkinson White syndrome was presented. The treatment of choice in the acute episode is synchronized electrical cardioversion, avoiding the use of drugs that block conduction of the atrioventricular node, due to the increased risk of turning into ventricular fibrillation and sudden death. The definitive treatment in these patients is radiofrequency ablation, it is an effective and safe method.

A Case Report of Pre-excited Atrial Fibrillation Encounters Ebstein's Anomaly: Is Amiodarone a Good Alternative Choice?

This is a case report of a 39-year-old man who presented to the emergency room with atrial fibrillation (AF), pre-excitation, and Ebstein's anomaly (EA). Currently, there was no suggestion of pharmacologic management if the patient declines surgical or catheter ablation therapy. A review of the literature concluded that amiodarone may be a suitable therapy for the pharmacological management of this patient.

Ebstein Anomaly Focusing on Pre-excited Atrial Fibrillation Management

Introduction: Ebstein’s anomaly is a rare abnormality of the heart associated with atrialization right ventricle and apical (downward) displacement of the tricuspid valve functional annulus. Twenty percents of patients with Ebstein’s anomaly accompanied with accessory pathway. The dilatation of atrium and aging process may develop atrial fibrillation (AF).Case Description: A 35 years old patient with recurrency palpitation, accompanied with dizziness and epigastric discomfort. He had history of taking propafenone 3 x 150 mg for long time while the palpitation recurrent. He was hospitalization due to propafenone could not suppress the palpitation. During monitor in hospital revealed haemodynamic stable with heart rate 160-180 beats/minute irregularly irregular. The electrocardiography showed atrial fibrillation with pre-excitation WPW syndrome. We performed electrical cardioversion 100 joule. Then the atrial fibrillation was convert to sinus rhythm with WPW pattern. The propafenone 3 x 150mg was continued. The patient was performed catheter radiofrequency ablation of the accessory pathway. Electrophysiology showed AV fusion at right anteroseptal pathway and preexcited atrial fibrillation with shortest RR interval 220 ms that converted by cardioversion. The ablation was successfully performed. Discussion: The accessory pathway is a complication of ebstein anomaly. Digoxin, beta-blockers, diltiazem, verapamil, and amiodarone are potentially harmful in pre-excited atrial fibrillation. Propafenone reduces fast inward potential by sodium channels, reduces spontaneous automaticity and prolongs the effective refractory periode so could be used in this case. Catheter ablation of accessory pathway in Ebstein anomaly with WPW syndrome was class I recommendation. In our case, the accessory pathway was successfully ablated.

B-AB20-04 PROSPECTIVE ASSESSMENT OF CHILDREN WITH WOLFF-PARKINSON-WHITE SYNDROME: HOW RARE ARE EVENTS, REALLY?

Wolff-Parkinson-White Syndrome (WPW) is associated with sudden death. Previous retrospective studies have challenged dogma that risk stratification strategies predict risk. There have been calls for validation with multicenter prospective data that we provide here. Using data collected at diagnosis we sought to better understand children with WPW comparing those with and without a life-threatening event (LTE). Patients were enrolled from 19 participating centers in the US, Canada and India. Demographic, clinical and electrophysiology study (EPS) data were compared between children with and without LTE. LTE was defined as aborted sudden death or pre-excited atrial fibrillation (AF) with: SPERRI ≤ 250, syncope or hemodynamic instability. Among 720 subjects (56% M) mean age at diagnosis was 9.8+/-6.4 y (0-21.8 y), 8% had congenital heart disease (CHD). A LTE occurred in 16 (2.2%), palpitations in 266 (37%), documented SVT in 216 (30%), and as an incidental finding on ECG 223 (31%). The LTE was aborted sudden death in 10/16 (62%) and pre-excited AF in 6/16 (38%). Age at LTE was 10.9 +/-7y (0.2 mo -18 y) and 63% were male. The LTE was the sentinel symptom in 60%, whereas 27% had previous SVT and 20% a previous WPW evaluation. Activity at the time of LTE was competitive 20% or noncompetitive 20% athletics, rest/sleep 13%, routine daily activities 40% or unknown 7%. Preexcitation was intermittent in 8% and 7% of the LTE groups had CHD. The outcome of the event was full recovery in 79%, recovery with neurological deficit 7% and death 14%. Comparing those with and without a LTE there was no difference in age, sex or presence of intermittent preexcitation. EPS performed in 69% of those with LTE and 74% of those without identified only APERP as significantly different (263+/-82 vs 312+/-67, p 0.01). In this prospectively enrolled population of children with WPW, 2.2% suffered a LTE, higher than previously reported. Children were similar in age and sex to those without a LTE. The LTE was often the sentinel symptom and occurred during rest or activities of daily life more often than with exercise. The only EPS derived value that differed was APERP. Although the most common LTE type was aborted sudden death, the most frequent outcome was full recovery.

Loss of ventricular preexcitation during noninvasive testing does not exclude high-risk accessory pathways: A multicenter study of WPW in children

Abrupt loss of ventricular preexcitation on noninvasive evaluation, or nonpersistent preexcitation, in Wolff-Parkinson-White syndrome (WPW) is thought to indicate a low risk of life-threatening events. The purpose of this study was to compare accessory pathway (AP) characteristics and occurrences of sudden cardiac arrest (SCA) and rapidly conducted preexcited atrial fibrillation (RC-AF) in patients with nonpersistent and persistent preexcitation. Patients 21 years or younger with WPW and invasive electrophysiology study (EPS) data, SCA, or RC-AF were identified from multicenter databases. Nonpersistent preexcitation was defined as absence/sudden loss of preexcitation on electrocardiogram, Holter monitoring, or exercise stress test. RC-AF was defined as clinical preexcited atrial fibrillation with shortest preexcited R-R interval (SPERRI) ≤ 250 ms. AP effective refractory period (APERP), SPERRI at EPS , and shortest preexcited paced cycle length (SPPCL) were collected. High-risk APs were defined as APERP, SPERRI, or SPPCL ≤ 250 ms. Of 1589 patients, 244 (15%) had nonpersistent preexcitation and 1345 (85%) had persistent preexcitation. There were no differences in sex (58% vs 60% male; P=.49) or age (13.3±3.6 years vs 13.1±3.9 years; P=.43) between groups. Although APERP (344±76 ms vs 312±61 ms; P<.001) and SPPCL (394±123 ms vs 317±82 ms; P<.001) were longer in nonpersistent vs persistent preexcitation, there was no difference in SPERRI at EPS (331±71 ms vs 316±73 ms; P=.15). Nonpersistent preexcitation was associated with fewer high-risk APs (13% vs 23%; P<.001) than persistent preexcitation. Of 61 patients with SCA or RC-AF, 6 (10%) had nonpersistent preexcitation (3 SCA, 3 RC-AF). Nonpersistent preexcitation was associated with fewer high-risk APs, though it did not exclude the risk of SCA or RC-AF in children with WPW.

The “Better” Answer

The “Better” Answer