Atrial Fibrillation with a Very Rapid Ventricular Response as the First Clinical Arrhythmia in a 76‐Year‐Old Man

Abstract

The interest of electrohysiological study for the prognostic evaluation of asymptomatic Wolff-Parkinson-White (WPW) syndrome remains controversial. We report the case of an asymptomatic 67-year-old man without heart disease in whom a type A WPW syndrome was noted. Because the WPW was unchanged during exercise testing, transesophageal EPS was performed. In basal state, 1/1 conduction through the Kent bundle was noted up to a rate of 210 beats/min. After infusion of 30 microg of isoproterenol, atrial pacing was associated with a 1/1 conduction throughout the Kent bundle at a rate at 300 beats/min and induced rapid atrial fibrillation which was stopped by flecainide. No treatment was indicated. Nine years later, at age 76, the patient developed syncope related to rapid atrial fibrillation requiring cardioversion. In conclusion, the occurrence of a potentially lethal supraventricular tachyarrhythmia in a previously asymptomatic patient with WPW syndrome might be encountered in elderly patients. Transesophageal electrophysiological evaluation is a useful means to predict this risk.

Atrial Fibrillation Induction by Transesophageal Electrophysiology Studies in Patients with Asymptomatic Ventricular Preexcitation

“…Sudden death may occur even in previously asymptomatic patients with VPE. [6][7][8][9][10] Although catheter ablation of the AP offers curative treatment, this procedure is not without risk. [22][23][24] Effective screening for risk of sudden death may be useful in avoiding the potential complications of TVEPS and AP ablation for patients previously identified as having no risk of sudden death.…”

“…Because of the known risk of sudden death associated with VPE, risk assessment is important in all pediatric patients with evidence of VPE on ECG. [6][7][8][9][10] Measurement of the shortest preexcited RR interval during AFib can assess this risk. 6 Thus, the efficacy of this risk stratification strategy for patients with VPE depends on the ability to induce AFib.…”

“…6 Cardiac arrest may be the first manifestation of VPE and can occur at any age. [6][7][8][9][10] Although the incidence of sudden death with VPE is rare (~0.0015 per patient-year), the catastrophic nature This research was funded solely through departmental sources. of this manifestation suggests an important role for risk stratification and treatment of those at risk.…”

Risk of atrial fibrillation according to the initial presentation of a preexcitation syndrome

“…Data of the second electrophysiological study were unchanged. These 4 patients developed a spontaneous AF with adverse presentation, between 3 and 14 years after initial evaluation [15]. AP ablation was performed after the occurrence of AF and the patients had no recurrences after ablation.…”

Induction of Atrial Fibrillation with Adenosine during a Transesophageal Electrophysiology Study to Risk Stratify a Patient with Asymptomatic Ventricular Preexcitation

“…1 Any patient with an AP with short refractoriness is capable of rapid ventricular response during atrial fibrillation (AFib) and is at risk of sudden death, which may be the first manifestation ventricular preexcitation. [2][3][4][5][6] As absence of symptomatic arrhythmias alone cannot reliably rule out risk of sudden death, other methods of risk stratification must be used in patients with asymptomatic ventricular preexcitation (aVPE). 7 Sudden disappearance of preexcitation on electrocardiogram (ECG), observed as single-beat loss of the delta wave, during exercise testing correlates to a long anterograde AP effective refractory period (ERP) and low risk of sudden death.…”