Symptomatic Wolff-Parkinson-White Syndrome Research Articles

“Appearances can be deceptive” symptomatic Wolff–Parkinson–White syndrome in Ebstein’s anomaly

ABSTRACT Ablation in Ebstein’s anomaly with Wolff–Parkinson–White (WPW) syndrome is very challenging due to complex anatomy and multiple arrhythmias associated with it. We expect atrioventricular reciprocating tachycardia which is the most common arrhythmia associated with WPW. As appearances can be deceptive, although in our case report, this 22-year-old female had preexcitation, she had typical atrial flutter, preexcited atrial fibrillation in addition to atrioventricular reciprocating tachycardia. She needed cavo-tricuspid isthmus ablation in addition to accessory pathway ablation to render the aforementioned arrhythmias noninducible. This case affirms the fact that a detailed and meticulous electrophysiologic study is to be done to diagnose all arrhythmias associated with this congenital heart disease.

Tp-e interval and Tp-e/JT ratio before and after catheter ablation in patients with Wolff Parkinson White syndrome

Aim: Tp-e and Tp-e/QT are novel markers of ventricular repolarization. However, preexcitation in Wolff Parkinson White (WPW) syndrome may preclude accurate measurement of repolarization as assessed by the QT. We aimed to research the assessment of Tp-e and Tp-e/JT before and after ablation in WPW.
 Material and Method: We enrolled 50 consecutive patients with symptomatic WPW syndrome who underwent catheter ablation of their accessory pathways for treatment. All of the patients were successfully ablated. ECGs were performed before the procedure and repeated after the ablation procedure.
 Results: Tp-e (86.6±16.2 vs 80.6±12.5; p=0.021) and Tp-e(c) (96.7±18.9 vs 88.3±11.2; p=0,005) showed a significant decrease after the procedure. Tp-e/JT (0.307±0.053 vs 0.279±0.040; p=0.001) and Tp-e/JT(c) (0.276±0.048 vs 0.255±0.045; p=0.009) showed a significant decrease after the procedure. There was a significant association between ERP and before procedure Tp-e (c) (r=- 0.370, p=0.008) and Tp-e/JT (r=- 0.371, p=0.008).
 Conclusion: This study demonstrated that Tp-e and Tp-e/JT were significantly diminished in WPW after the ablation.

Clinical characteristics of challenging catheter ablation procedures in patients with WPW syndrome: A 10 year single-center experience

BackgroundCatheter ablation is the established treatment for patients with symptomatic Wolff–Parkinson–White syndrome (WPW). However, some patients undergo a challenging ablation or have recurrences during the early post-ablation phase. The aim of this study was to evaluate the clinical factors associated with an unsuccessful ablation outcome or repeated sessions. MethodsFour hundred seventy-five symptomatic consecutive WPW patients (38.2±16.2 years old, 61% men, 69% with pre-excitation) who underwent an accessory pathway (AP) ablation from August 2005 to December 2015 were enrolled. When APs recurred, a redo ablation procedure was performed according to the patients’ desire. ResultsFour hundred thirty-nine patients (92.4%) were cured by ablation, but it failed in 36 (7.6%) after the first procedure. Seventeen patients had AP recurrences during the acute phase within 36h post-ablation. On the other hand, 4 were identified after more than one year. In a multivariate logistic regression analysis, multiple, parahisian, and broad APs were significant independent predictors of recurrences after the 1st procedure, with odds ratios of 14.88 (p<0.001), 10.14 (p<0.001), and 6.88 (p<0.001), respectively. Finally, 468 patients (98.5%) received a successful ablation during a mean follow-up of 8.3±3.0 years. However, after the final procedure no significant predictors were recognized. Out of 508 total procedures, three major (0.6%) complications occurred. ConclusionsSymptomatic WPW patients with multiple, parahisian, and broad APs had a significantly higher risk of recurrence. In half of the recurrence patients, AP recurrences were confirmed during the acute phase, but were rarely recorded in the very late phase.

A Novel and Simple Algorithm Using Surface Electrocardiogram That Localizes Accessory Conduction Pathway in Wolff-Parkinson-White Syndrome in Pediatric Patients.

The location of the accessory pathway (AP) can be precisely identified on surface electrocardiography (ECG) in adults with Wolff-Parkinson-White (WPW) syndrome. However, current algorithms to locate the AP in pediatric patients with WPW syndrome are limited. To propose an optimal algorithm that localizes the AP in pediatric patients with WPW syndrome. From 1992 to 2016, 180 consecutive patients aged below 18 years with symptomatic WPW syndrome were included. After the exclusion of patients with non-descriptive electrocardiography (ECG), multiple APs, congenital heart diseases, non-inducible tachycardia, and those who received a second ablation, 104 patients were analyzed retrospectively. Surface ECG was obtained before ablation and evaluated by using previously documented algorithms, from which a new pediatric algorithm was developed. Previous algorithms were not highly accurate when used in pediatric patients with WPW syndrome. In the new algorithm, the R/S ratio of V1 and the polarity of the delta wave in lead I could distinguish right from the left side AP with 100% accuracy. The polarity of the delta wave of lead V1 could distinguish free wall AP from septal AP with an accuracy of 100% in left-side AP, compared to 88.6% in leads III and V1 for right-side AP. The overall accuracy was 92.3%. This simple, novel algorithm could differentiate left from right AP and septal from free wall AP in pediatric patients with WPW syndrome.

PRKAG3 polymorphisms associated with sporadic Wolff–Parkinson–White syndrome among a Taiwanese population

BackgroundThe aim of this study was to investigate whether mutation in AMP-activated protein kinase (AMPK) subunit genes (PRKAG3-230) is associated with sporadic, isolated Wolff–Parkinson–White (WPW) syndrome. MethodsThis study consisted of 87 patients with symptomatic WPW syndrome and 93 healthy controls. PRKAG3-230 genotypes were determined using real-time polymerase chain reaction assay. Genotype and allele frequencies of PRKAG3-230 between patients with WPW syndrome and healthy controls were ascertained using chi-square test or Fisher exact test when appropriate. ResultsPRKAG3-230 were genotyped in 87 patients (53 men and 34 women; age=24.4±18.0 years) with WPW syndrome and 93 healthy controls (57 men and 36 women; age=16.8±4.2 years). There were no significant differences between the two groups in terms of age and sex. The patients with CG and CG+CC genotypes had a significantly increased risk of WPW syndrome compared with those with GG genotype [odds ratio (OR)=1.99, 95% confidence interval (CI)=1.01–3.89, p=0.045; OR=1.99, 95% CI=1.04–3.78, p=0.037, respectively]. The allelic types were not associated with the risk of WPW syndrome. The patients with manifest type with CG and CG+CC genotypes had a significantly increased risk of WPW syndrome compared with those with GG genotype (OR=2.86, 95% CI=1.16–7.05, p=0.022; OR=2.84, 95% CI=1.19–6.80, p=0.019, respectively). The patients with right-side accessory pathways with CG and CG+CC genotypes had a significantly increased risk of WPW syndrome compared with those with GG genotype (OR=3.07, 95% CI=1.25–7.51, p=0.014; OR=2.84, 95% CI=1.19–6.80, p=0.019, respectively). The allelic types were not associated with the risk of WPW types and locations. ConclusionThis study shows that PRKAG3-230 may be associated with sporadic WPW syndrome among a Taiwanese population. Further studies are warranted to elucidate the role of mutations in AMPK subunit genes other than PRKAG3-230 in sporadic WPW syndrome.

Utility of unipolar recordings for complex Wolff–Parkinson–White ablation

Radiofrequency ablation has been shown to be a safe and effective treatment strategy for the management of symptomatic patients with Wolff–Parkinson–White syndrome. It is supported by a success rate of 95% and a recurrence rate of less than 5%. However, ablation of accessory pathways can be challenging at times. The causes for failure can be grouped into three categories – unusual location of the pathway, technical difficulties in delivering the ablation and localization error [1]. In this case report we are reporting a case of a young male who presented to us with symptomatic Wolff–Parkinson–White syndrome with two failed prior ablations at another institution. This case illustrates the importance of knowing accurate localization and course of the accessory pathway by utilizing the unipolar and bipolar electrograms simultaneously during radiofrequency ablation.

Mitochondrial disease in pregnancy: a systematic review.

Mitochondrial diseases are heterogeneous in clinical presentation and genotype. The incidence of known pathogenic mitochondrial DNA mutations in the general population is 1 in 500. Little is known about the implications of pregnancy for women with mitochondrial disease. We undertook a systematic review of the literature on mitochondrial disease in pregnancy. Ten case reports were identified. The most common complications were threatened preterm labour (5 women) and preeclampsia (4 women). Two women experienced magnesium sulphate toxicity. Pregnancy had a varied effect on mitochondrial disease with some women being asymptomatic; others developing mild symptoms such as exercise intolerance or muscle weakness which resolved postnatally; and others developed more serious, persistent symptoms such as symptomatic Wolff-Parkinson-White syndrome, persistent paraesthesia and focal segmental glomerulosclerosis. Women with mitochondrial disease appear to be at increased risk of complications during pregnancy and labour but further prospective cohort studies are needed.

Safety and Efficacy of Flecainide in the Treatment of Symptomatic Children With Wolff-Parkinson-White Syndrome

Sudden cardiac death may occur in children with symptomatic and asymptomatic Wolff-Parkinson-White syndrome (WPWS). Symptomatic patients are usually treated with antiarrhythmic drugs until ablation of an accessory pathway (AP) could be performed. The objective of this study was to review the safety and efficacy of flecainide in the treatment of children with symptomatic WPWS. Twenty-two children (14 male) with WPWS and without structural heart disease were studied. AP location was achieved by electrophysiological testing or 12-lead electrocardiogram tracing. Symptomatic children (i.e., those frequent palpitations or supraventricular tachycardia episodes) received flecainide. Patients were followed-up for an average of 3.4years until ablation of AP. Eighteen children reported clinical symptoms when first diagnosed, but only 13 initiated treatment during 16.23months (range 1-55). Flecainide was effective in all patients: Seven became asymptomatic, and six experimented isolated episodes of palpitations. One child experienced hair loss as a side effect. AP location was as follows: left free wall (n=7), right free wall (n=4), posteroseptal (n=8), and anteroseptal (n=4). Ablation was performed without complications in 13 children. Symptomatic WPWS in children can be treated safely and efficiently with flecainide. It represents a good alternative therapy until AP ablation can be performed.

When should we recommend catheter ablation for patients with the Wolff–Parkinson–White syndrome?

Catheter ablation has been proven as very effective and safe therapy for patients with symptomatic Wolff-Parkinson-White (WPW) syndrome. Its application in asymptomatic individuals with WPW pattern remains controversial. This review will elaborate on the role of catheter ablation in symptomatic and asymptomatic patients with WPW pattern on ECG. Several recent prospective studies evaluated invasive risk stratification followed by prophylactic catheter ablation in asymptomatic patients with WPW pattern. Inducibility of arrhythmias in these patients during invasive electrophysiological study was shown to predict the development of future symptomatic arrhythmias. Although ablation of accessory pathways performed in 'inducible' patients decreased the incidence of subsequent symptomatic arrhythmias, the studies were not powered to detect a reduction in life-threatening arrhythmias. Radiofrequency catheter ablation remains the first-line therapy for patients with symptomatic WPW syndrome. Invasive electrophysiological study and possible ablation of accessory pathway may be offered to well informed asymptomatic individuals with WPW if they are willing to trade the very small risk of subsequent sudden death or incapacity for a small immediate procedural risk of serious complications or death. Asymptomatic patients may require invasive risk stratification and possible catheter ablation for important social or professional reasons.

Accessory atrioventricular pathways with only antegrade conduction in patients with symptomatic Wolff-Parkinson-White syndrome. Clinical features, electrophysiological characteristics and response to radiofrequency catheter ablation.

Information about accessory pathways conducting only in the antegrade direction is limited. The purposes of the present study were to prospectively investigate the clinical features, electrophysiological characteristics, effects of radiofrequency catheter ablation and recurrent atrial fibrillation after successful ablation in patients with accessory pathways conducting only in the antegrade direction, and to compare them with those who had pathways capable of bidirectional conduction in a consecutive series of 759 patients. Electrophysiological studies and radiofrequency catheter ablation were performed in 33 study patients with antegrade-only accessory pathways and in 377 patients with bidirectional accessory pathways for comparison. The patients with accessory pathways conducting only in the antegrade direction were older (47 +/- 16 vs 40 +/- 16 years, P = 0.037) and had a higher incidence of atrial fibrillation (100% vs 27.1%, P < 0.001) as well as related syncope (33.3% vs 10.1%, P = 0.001). The study patients also had more accessory pathways located in the posterior septum and a higher incidence of retrograde atrioventricular nodal conduction. The biophysical variables, success and complication rates of radiofrequency ablation were similar in both groups. During the follow-up period of 32 +/- 12 months, symptomatic atrial fibrillation after successful ablation did not recur in 79% and 81% of patients with unidirectional and bidirectional accessory pathways, respectively. Furthermore, old age and cardiovascular diseases were independent predictors of recurrent atrial fibrillation after radiofrequency ablation. In conclusion, this study showed that atrial fibrillation with preexcitation was the usual presentation in patients who had symptomatic Wolff-Parkinson White syndrome with an antegrade-only accessory pathway, and might be related to antegrade conduction of the accessory pathway. Therefore elimination of antegrade-only and bidirectional pathways by radiofrequency ablation could prevent the recurrence of symptomatic atrial fibrillation in younger patients without cardiac disease.

Catheter ablation of the accessory pathways of the Solff-Parkinson-White syndrome and its variants

The basis of arrhythmias in the Wolff-Parkinson-White (WPW) syndrome and its variants is the presence of accessory atrioventricular connections. Those variants include the concealed form of the WPW syndrome, the permanent form of junctional reciprocating tachycardia, and Mahaim preexcitation. In all forms of symptomatic WPW syndrome, catheter ablation of the accessory atrioventricular connections using radiofrequency current has become the treatment of choice. This review traces the development of this therapy, outlines the basics of the technique, summarizes the results reported in the largest series, indicates remaining areas of controversy, and discusses the indications and limitations of radiofrequency ablation therapy.

Radiofrequency catheter ablation of accessory atrioventricular pathway in Wolff-Parkinson-White syndrome.

Eighty patients with manifest or concealed Wolff-Parkinson-White (WPW) syndrome underwent catheter ablation of 86 accessory pathways (AP) using radiofrequency current. There are 65 AP located on the left side and 21 on the right side of the heart. The atrioventricular reciprocating tachycardia was previously documented in 77 patients and atrial fibrillation with a rapid ventricular response in 21 patients. Ablation was attempted via a catheter positioned at the atrial aspect of the tricuspid annulus in patients with a right-sided AP and via a catheter positioned in the left ventricle directly below the mitral annulus in patients with a left-sided AP. AP conduction was permanently abolished in 82 of the 86 pathways (95%). The number of radiofrequency current applications for these 82 successfully ablated AP was 7.6 +/- 0.9. Of the 65 left-sided and 21 right-sided AP, 62 (95%) and 20 AP (95%) were successfully ablated, respectively. The current application to the right-sided AP was 16.7 +/- 2.2, which was greater than that to the left-sided one (4.7 +/- 0.6, p < 0.001). No serious complication was observed in any case. Catheter ablation of AP using radiofrequency current is an effective and safe therapeutic modality for patients with symptomatic WPW syndrome.