Electrophysiologic Profile and Results of Invasive Risk Stratification in Asymptomatic Children and Adolescents With the Wolff–Parkinson–White Electrocardiographic Pattern

Abstract

Background-Data on the results and clinical effect of an invasive risk stratification strategy in asymptomatic young patients with the Wolff-Parkinson-White electrocardiographic pattern are scarce. Methods and Results-Eighty-five consecutive patients aged <18 years with a Wolff-Parkinson-White pattern and persistent preexcitation at maximum exercise undergoing invasive risk stratification were retrospectively studied. Adverse accessory pathway (AP) properties were defined according to currently consented criteria as any of the following: shortest preexcited RR interval during atrial fibrillation/rapid atrial pacing ≤250 ms (or antegrade effective refractory period ≤250 ms if shortest preexcited RR interval was not available) or inducible atrioventricular re-entrant tachycardia. Age at evaluation was median 14.9 years. Eighty-two patients had a structurally normal heart and 3 had hypertrophic cardiomyopathy. A single manifest AP was present in 80, 1 manifest and 1 concealed AP in 4, and 2 manifest APs in 1 patient. Adverse AP properties were present in 32 of 85 patients (37.6%) at baseline and in additional 16 of 44 (36.4%) after isoproterenol. Ablation was performed in 41 of these 48 patients. Ablation was deferred in the remaining 7 for pathway proximity to the atrioventricular node. In addition, 18 of the low-risk patients were ablated based on patient/parental decision. Conclusions-Adverse AP properties at baseline were exhibited by 37.6% of the evaluated patients with an asymptomatic Wolff-Parkinson-White preexcitation persisting at peak exercise. Isoproterenol challenge yielded additional 36.4% of those tested at higher risk. Ablation was performed in a total of 69.4% of patients subjected to invasive risk stratification. (Circ Arrhythm Electrophysiol. 2014;7:218-223.)

Wolff–Parkinson–White syndrome (WPW) and athletes: Darwin at play?

“…This may change pathway properties and our ability to interpret the conduction velocity of an accessory pathway in the anesthetized state is not clear. Multiple studies in adults and children have demonstrated that isoproterenol can enhance accessory pathway conduction [4,[20][21][22]. In the pediatric population, Moore et al [20] demonstrated that the addition of isoproterenol increased the percentage of children deemed "high risk" at EPS from 5% to 25%.…”

“…With complication rates at ablation now far less than 1% and success rates with ablation for WPW approaching 97%, many practitioners and families have concluded that the risk/benefit ratio has tilted toward the side of invasive testing, risk assessment, and ablation [21,23,24]. The identifiable and notably small risk of invasive EP testing can then be weighed against the unknown but likely small, B) Baseline Exercise Fig.…”

Guidelines for Management of Asymptomatic Ventricular Pre-excitation

“…Kubuš and colleagues 13 from Prague and Leipzig have examined for the first time in the accompanying report the consequences of following the published guidelines. They have retrospectively evaluated the electrophysiological profile of 85 asymptomatic children (median age ≈15 years) with a ventricular pre-excitation pattern on their ECG, to assess the outcomes of invasive risk stratification applying current guidelines.…”

“…Although ablation would seem to be indicated in the great majority of patients reported in Kubuš' article, catheter ablation was actually performed in only ≈70% of patients. 13 It was deferred in ≈15% of subjects with an adverse pathway secondary to a perinodal location. The authors have in this way explicitly identified a valuable additional concept in the risk assessment of these patients, one that is only clearly definable with EP study.…”

“…21,22 Achieving that balance can be difficult, and the current work of Kubuš et al 13 highlights some of the practical issues that we now must address. During the past 15 years, catheter ablation has altered the natural history of the asymptomatic child with isolated ventricular pre-excitation, whose only risk factor for a life-threatening arrhythmia was a measurement of antegrade conduction obtained on isoproterenol.…”