News from the Heart Rhythm SocietyPACES/HRS Expert Consensus Statement on the Management of the Asymptomatic Young Patient with a Wolff-Parkinson-White (WPW, Ventricular Preexcitation) Electrocardiographic Pattern: Developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS)
Section snippets
Preamble
The purpose of this consensus statement is to provide up-to-date clinical practice guidelines on the evaluation and management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW) electrocardiographic (ECG) pattern.1 The terminology WPW was first used to describe a “bundle-branch pattern” with a short PR interval in healthy young people prone to paroxysmal tachycardia and/or atrial fibrillation. Although isolated case reports preceded the 1930 landmark manuscript, history
Methods and evidence
The recommendations listed in this document are, whenever possible, evidence-based. An extensive literature search was performed. The committee also reviewed documents related to the subject matter as previously published by HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), and the European Heart Rhythm Association (EHRA). The committee reviewed and ranked evidence supporting current recommendations based on a standard process as previously described and
Document review and approval
This document was reviewed by the executive committee within PACES, none of whom were on the writing committee, as well as by additional members of HRS. All writing members approved the final version. The writing committee thanks all reviewers for their comments and suggestions, many of which were incorporated into this manuscript. Disclosures for writing members and reviewers are in the Appendix.
Mitchell I. Cohen, MD, FACC, FHRS
Chair, Guideline Development Committee, PACES
Table of Contents
- 1
Introduction
- 2
Natural history and presentation of WPW
- 3
Risk stratification in WPW
- 4
Noninvasive evaluation of WPW patients
- 5
Rationale, definition, and techniques for an invasive EP study
- 6
EP risk stratification of WPW
- 6.1
Symptomatic patients
- 6.2
Asymptomatic patients
- 6.3
Risks of invasive EP study
- 6.1
- 7
Catheter ablation: success rates, risks, and other considerations
- 7.1
Efficacy of catheter ablation
- 7.2
Cryoablation
- 7.2
Risks and complications
- 7.1
- 8
Special issues
- 8.1
WPW and CHD
- 8.2
WPW and ADHD
- 8.3
WPW and sports participation
- 8.1
- 9
Recommendations for young
Natural history and presentation of WPW
The natural history of the asymptomatic patient with WPW is extrapolated from data on symptomatic patients and from asymptomatic patients discovered by fortuitous ECG testing. In large-scale general population studies involving children and adults, the prevalence of WPW is estimated to be 1–3 in 1000 individuals.7, 8, 9, 10, 11, 12, 13 Familial studies have shown an incidence of 5.5 in 1000 among first-degree relatives following an index case of WPW.14 Identification of the truly asymptomatic
Risk stratification in WPW
In current practice the intent of risk stratification in asymptomatic children with a WPW ECG pattern is to identify which individuals are at risk for a lethal cardiac arrhythmia. In its simplest form, risk stratification utilizes noninvasive testing (eg, Holter or exercise stress test) to ascertain true loss of preexcitation at physiological heart rates. Inability to clearly demonstrate absolute loss of manifest preexcitation warrants consideration for more invasive EP testing. The critical
ECG
The ECG during preexcited AF affords a “true” assessment of the anterograde characteristics of the accessory pathway. The measurement of the Shortest Pre-Excited R-R Interval (SPERRI) has been used to determine accessory pathway properties; however, much of the literature is based on invasive studies. A SPERRI of 220–250 ms and especially less than 220 ms is more commonly seen in patients with WPW who have experienced cardiac arrest.29, 37 Conversely, intermittent loss of preexcitation during
Rationale, definition, and techniques for an invasive EP study
In the absence of a clear understanding of the accessory pathway anterograde characteristics by noninvasive testing, invasive testing should be considered. The purpose of such an invasive EP study in asymptomatic patients with a WPW ECG pattern is to identify a potential subgroup of patients who may be at increased risk for lethal cardiac arrhythmias and in whom the risk-to-benefit ratio favors ablation. In adults with asymptomatic preexcitation, 70% of electrophysiologists recently surveyed
Symptomatic patients
In clinical studies of adult WPW patients, a SPERRI ≤220–250 ms during AF has been shown to be the best discriminator of those at risk of VF.3, 4, 55 Based on combined pediatric and adult studies (age range 5–68 years; mean 28 years), the APERP is less useful because it (1) is less predictive of life-threatening events (range 180–310 ms) than the SPERRI in AF and (2) is similar between patients with WPW and VF and those with WPW and AV reentrant SVT, but without VF.3, 4 In symptomatic patients
Catheter ablation: success rates, risks, and other considerations
Since it was first introduced for WPW in the pediatric population in 1990, RFA has offered a potential definitive cure for arrhythmias that could previously be treated only with medications, DC ablation, or surgery. RFA is now widely accepted as a therapy for WPW and is frequently considered to be first-line therapy. This is due to high success rates and a low-risk profile, particularly when the use of cryoablation is included for septal accessory pathways and those near small coronary
WPW and CHD
The association of ventricular preexcitation and WPW with CHD is well known. In a study of infants with WPW, 20% had CHD.15 Ventricular preexcitation is most often associated with Ebstein anomaly,15, 104, 135, 136, 137 seen in as many as 44%,136 but has also been described in patients with d-TGA,137 l-TGA,15 pulmonary atresia/intact ventricular septum,104 patent ductus arteriosus,15 parachute mitral valve,104 tetralogy of Fallot,137 total anomalous pulmonary venous return,137 and a ventricular
Recommendations for young asymptomatic patients (8–21 years) with WPW ECG patternϒ,2
- 1
An exercise stress test, when the child is old enough to comply, is a reasonable component of the evaluation if the ambulatory ECG exhibits persistent preexcitation (Class IIA, Levels of Evidence B/C). In patients with clear and abrupt loss of preexcitation at physiological heart rates, the accessory pathway properties pose a lower risk of sudden death. In children with subtle preexcitation the ECG and exercise test may be difficult to interpret.
- 2
Utilization of invasive risk stratification
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- ⁎
Member of Pediatric and Congenital Electrophysiology Society (PACES).
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Member of Heart Rhythm Society (HRS).