Abstract

Literature Review

A Wolff-Parkinson-White (WPW) Electrocardiographic Pattern in Asymptomatic Patient – State-of-the-Art-Review

Vijay Yadav*, Sanjeev Thapa, Ratna Mani Gajurel, Chandra Mani Poudel, Bhawani Manandhar, Manju Sharma, Suman Adhikari and Suraj Shrestha

Published: 07 June, 2022 | Volume 7 - Issue 2 | Pages: 046-053

A comprehensive approach to asymptomatic adults with Wolff-Parkinson-White (WPW) pattern discovered incidentally on routine electrocardiography (ECG) is debatable. The objective of this review article is to update the most recent evidence on the management of young patients with asymptomatic WPW patterns. A substantial proportion of adults with WPW patterns on ECG may remain asymptomatic but the lifetime risk for fatal arrhythmias still exists. The inherent properties of the accessory pathway determine the risk of sudden cardiac death. A low-risk pathway is considered when the pre-excitation is intermittent on ambulatory monitoring or when it disappears completely or abruptly during exercise testing. On the other hand, a high-risk pathway in EP study is suggested by the presence of the shortest pre-excited RR interval (SPERRI) during atrial fibrillation of ≤ 250 ms or accessory pathway effective refractory period (APERP) ≤ 240 ms. The cardiac evaluation may thus be considered in asymptomatic patients with WPW to determine the individual risk for future symptomatic arrhythmia. A shared-decision making must be performed before offering catheter ablation whose procedural success rate is high.

Read Full Article HTML DOI: 10.29328/journal.jccm.1001132 Cite this Article Read Full Article PDF

Keywords:

WPW pattern; Electrophysiology study; Catheter ablation

References

  1. WEDD AM. Paroxysmal tachycardia: With reference to nomotopic tachycardia and the role of the extrinsic cardiac nerves. Archives of Internal Medicine. 1921;27(5):571-5
  2. Wolff L. Bundle branch block with short PR interval in healthy young people prone to paroxysmal tachycardia. Am Heart J. 1930;5:685-704.
  3. Kulig J, Koplan BA. Wolff-Parkinson-White syndrome and accessory pathways. Circulation. 2010;122(15):e480-e48
  4. Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, Estes NAM 3rd, Field ME, Goldberger ZD, Hammill SC, Indik JH, Lindsay BD, Olshansky B, Russo AM, Shen WK, Tracy CM, Al-Khatib SM. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016 Apr 5;67(13):e27-e115. doi: 10.1016/j.jacc.2015.08.856. Epub 2015 Sep 24. Erratum in: J Am Coll Cardiol. 2016 Dec 27;68(25):2922-2923. PMID: 26409259.
  5. Pediatric and Congenital Electrophysiology Society (PACES); Heart Rhythm Society (HRS); American College of Cardiology Foundation (ACCF); American Heart Association (AHA); American Academy of Pediatrics (AAP); Canadian Heart Rhythm Society (CHRS), Cohen MI, Triedman JK, Cannon BC, Davis AM, Drago F, Janousek J, Klein GJ, Law IH, Morady FJ, Paul T, Perry JC, Sanatani S, Tanel RE. PACES/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). Heart Rhythm. 2012 Jun;9(6):1006-24. doi: 10.1016/j.hrthm.2012.03.050. Epub 2012 May 10. PMID: 22579340.
  6. Kashou A WP, Kowlgi GNN. Asymptomatic Ventricular Preexcitation (Wolff-Parkinson-White Pattern): When to Be Concerned. American College of Cardiology. 2022.
  7. Cox JL, Gallagher JJ, Cain ME. Experience with 118 consecutive patients undergoing operation for the Wolff-Parkinson-White syndrome. J Thorac Cardiovasc Surg. 1985 Oct;90(4):490-501. PMID: 4046618.
  8. Cain ME, Luke RA, Lindsay BD. Diagnosis and localization of accessory pathways. Pacing Clin Electrophysiol. 1992 May;15(5):801-24. doi: 10.1111/j.1540-8159.1992.tb06847.x. PMID: 1382283.
  9. Ferguson T. Anatomic and electrophysiologic principles in the surgical treatment of cardiac arrhythmias. Cardiac arrhythmia surgery Philadelphia: Hanley and Belfus, Inc. 1990:19-51.
  10. Bardy GH, Packer DL, German LD, Gallagher JJ. Preexcited reciprocating tachycardia in patients with Wolff-Parkinson-White syndrome: incidence and mechanisms. Circulation. 1984 Sep;70(3):377-91. doi: 10.1161/01.cir.70.3.377. PMID: 6744541.
  11. Gallagher JJ, Pritchett EL, Sealy WC, Kasell J, Wallace AG. The preexcitation syndromes. Prog Cardiovasc Dis. 1978 Jan-Feb;20(4):285-327. doi: 10.1016/0033-0620(78)90015-4. PMID: 146210.
  12. Macedo PG, Patel SM, Bisco SE, Asirvatham SJ. Septal accessory pathway: anatomy, causes for difficulty, and an approach to ablation. Indian Pacing Electrophysiol J. 2010 Jul 20;10(7):292-309. PMID: 20680108; PMCID: PMC2907089.
  13. Jose Jalife WGS. Zipes and Jafile's Cardiac Electrophysiology-From Cell to Bedside. 2022(8th edition);
  14. Hluchy J. Mahaim fibers: electrophysiologic characteristics and radiofrequency ablation. Z Kardiol. 2000;89 Suppl 3:136-43. doi: 10.1007/s003920050023. PMID: 10810796.
  15. Soares Correa F, Lokhandwala Y, Cruz Filho F, Sánchez-Quintana D, Mori S, Anderson RH, Wellens HJJ, Back Sternick E. Part II-Clinical presentation, electrophysiologic characteristics, and when and how to ablate atriofascicular pathways and long and short decrementally conducting accessory pathways. J Cardiovasc Electrophysiol. 2019 Dec;30(12):3079-3096. doi: 10.1111/jce.14203. Epub 2019 Oct 16. PMID: 31588593.
  16. Gupta A, Lokhandwala Y, Rai N, Malviya A. Adenosine-A drug with myriad utility in the diagnosis and treatment of arrhythmias. J Arrhythm. 2020 Dec 18;37(1):103-112. doi: 10.1002/joa3.12453. PMID: 33664892; PMCID: PMC7896475.
  17. Sethi KK, Dhall A, Chadha DS, Garg S, Malani SK, Mathew OP. WPW and preexcitation syndromes. J Assoc Physicians India. 2007 Apr;55 Suppl:10-5. PMID: 18368860.
  18. Boersma L, García-Moran E, Mont L, Brugada J. Accessory pathway localization by QRS polarity in children with Wolff-Parkinson-White syndrome. J Cardiovasc Electrophysiol. 2002 Dec;13(12):1222-6. doi: 10.1046/j.1540-8167.2002.01222.x. PMID: 12521337.
  19. Narasimhan JFC. LeoSchamroth An Introduction to Electrocardiography. 2015(8th Edition); 194-196.
  20. Bhattad PB, Jain V. Revisiting Electrocardiographic Wolff-Parkinson-White Pattern. The Journal of Medical Research. 2020;6(4):114-11
  21. Guize L, Soria R, Chaouat JC, Chrétien JM, Houe D, Le Heuzey JY. Prévalence et évolution du syndrome de Wolff-Parkinson-White dans une population de 138 048 sujets [Prevalence and course of Wolf-Parkinson-White syndrome in a population of 138,048 subjects]. Ann Med Interne (Paris). 1985;136(6):474-8. French. PMID: 4083638.
  22. Vidaillet HJ Jr, Pressley JC, Henke E, Harrell FE Jr, German LD. Familial occurrence of accessory atrioventricular pathways (preexcitation syndrome). N Engl J Med. 1987 Jul 9;317(2):65-9. doi: 10.1056/NEJM198707093170201. PMID: 3587328.
  23. Munger TM, Packer DL, Hammill SC, Feldman BJ, Bailey KR, Ballard DJ, Holmes DR Jr, Gersh BJ. A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989. Circulation. 1993 Mar;87(3):866-73. doi: 10.1161/01.cir.87.3.866. PMID: 8443907.
  24. Klein GJ, Bashore TM, Sellers TD, Pritchett EL, Smith WM, Gallagher JJ. Ventricular fibrillation in the Wolff-Parkinson-White syndrome. N Engl J Med. 1979 Nov 15;301(20):1080-5. doi: 10.1056/NEJM197911153012003. PMID: 492252.
  25. Obeyesekere MN, Leong-Sit P, Massel D, Manlucu J, Modi S, Krahn AD, Skanes AC, Yee R, Gula LJ, Klein GJ. Risk of arrhythmia and sudden death in patients with asymptomatic preexcitation: a meta-analysis. Circulation. 2012 May 15;125(19):2308-15. doi: 10.1161/CIRCULATIONAHA.111.055350. Epub 2012 Apr 24. PMID: 22532593.
  26. Etheridge SP, Escudero CA, Blaufox AD, Law IH, Dechert-Crooks BE, Stephenson EA, Dubin AM, Ceresnak SR, Motonaga KS, Skinner JR, Marcondes LD, Perry JC, Collins KK, Seslar SP, Cabrera M, Uzun O, Cannon BC, Aziz PF, Kubuš P, Tanel RE, Valdes SO, Sami S, Kertesz NJ, Maldonado J, Erickson C, Moore JP, Asakai H, Mill L, Abcede M, Spector ZZ, Menon S, Shwayder M, Bradley DJ, Cohen MI, Sanatani S. Life-Threatening Event Risk in Children With Wolff-Parkinson-White Syndrome: A Multicenter International Study. JACC Clin Electrophysiol. 2018 Apr;4(4):433-444. doi: 10.1016/j.jacep.2017.10.009. Epub 2017 Nov 15. PMID: 30067481.
  27. Chubb H, Ceresnak SR. A proposed approach to the asymptomatic pediatric patient with Wolff-Parkinson-White pattern. HeartRhythm Case Rep. 2020 Jan 15;6(1):2-7. doi: 10.1016/j.hrcr.2019.09.003. PMID: 31956492; PMCID: PMC6962761.
  28. Todd DM, Klein GJ, Krahn AD, Skanes AC, Yee R. Asymptomatic Wolff-Parkinson-White syndrome: is it time to revisit guidelines? J Am Coll Cardiol. 2003 Jan 15;41(2):245-8. doi: 10.1016/s0735-1097(02)02707-9. PMID: 12535817.
  29. Klein GJ, Gulamhusein SS. Intermittent preexcitation in the Wolff-Parkinson-White syndrome. Am J Cardiol. 1983 Aug;52(3):292-6. doi: 10.1016/0002-9149(83)90125-x. PMID: 6869275.
  30. Hindman MC, Last JH, Rosen KM. Wolff-Parkinson-White syndrome observed by portable monitoring. Ann Intern Med. 1973 Nov;79(5):654-63. doi: 10.7326/0003-4819-79-5-654. PMID: 4751741.
  31. Fitzsimmons PJ, McWhirter PD, Peterson DW, Kruyer WB. The natural history of Wolff-Parkinson-White syndrome in 228 military aviators: a long-term follow-up of 22 years. Am Heart J. 2001 Sep;142(3):530-6. doi: 10.1067/mhj.2001.117779. PMID: 11526369.
  32. Weng KP, Wolff GS, Young ML. Multiple accessory pathways in pediatric patients with Wolff-Parkinson-White syndrome. Am J Cardiol. 2003 May 15;91(10):1178-83. doi: 10.1016/s0002-9149(03)00263-7. PMID: 12745099.
  33. Santinelli V, Radinovic A, Manguso F, Vicedomini G, Gulletta S, Paglino G, Mazzone P, Ciconte G, Sacchi S, Sala S, Pappone C. The natural history of asymptomatic ventricular pre-excitation a long-term prospective follow-up study of 184 asymptomatic children. J Am Coll Cardiol. 2009 Jan 20;53(3):275-80. doi: 10.1016/j.jacc.2008.09.037. PMID: 19147045.
  34. Escudero CA, Ceresnak SR, Collins KK, Pass RH, Aziz PF, Blaufox AD, Ortega MC, Cannon BC, Cohen MI, Dechert BE, Dubin AM, Motonaga KS, Epstein MR, Erickson CC, Fishberger SB, Gates GJ, Capone CA, Nappo L, Kertesz NJ, Kim JJ, Valdes SO, Kubuš P, Law IH, Maldonado J, Moore JP, Perry JC, Sanatani S, Seslar SP, Shetty I, Zimmerman FJ, Skinner JR, Marcondes L, Stephenson EA, Asakai H, Tanel RE, Uzun O, Etheridge SP, Janson CM. Loss of ventricular preexcitation during noninvasive testing does not exclude high-risk accessory pathways: A multicenter study of WPW in children. Heart Rhythm. 2020 Oct;17(10):1729-1737. doi: 10.1016/j.hrthm.2020.05.035. Epub 2020 Jun 1. PMID: 32497761.
  35. Bricker JT, Porter CJ, Garson A Jr, Gillette PC, McVey P, Traweek M, McNamara DG. Exercise testing in children with Wolff-Parkinson-White syndrome. Am J Cardiol. 1985 Apr 1;55(8):1001-4. doi: 10.1016/0002-9149(85)90734-9. PMID: 3984857.
  36. Gaita F, Giustetto C, Riccardi R, Mangiardi L, Brusca A. Stress and pharmacologic tests as methods to identify patients with Wolff-Parkinson-White syndrome at risk of sudden death. The American journal of cardiology. 1989;64(8):487-90.
  37. Wellens HJ, Bär FW, Gorgels AP, Vanagt EJ. Use of ajmaline in patients with the Wolff-Parkinson-White syndrome to disclose short refractory period of the accessory pathway. Am J Cardiol. 1980 Jan;45(1):130-3. doi: 10.1016/0002-9149(80)90230-1. PMID: 7350760.
  38. Wellens HJ, Braat S, Brugada P, Gorgels AP, Bär FW. Use of procainamide in patients with the Wolff-Parkinson-White syndrome to disclose a short refractory period of the accessory pathway. Am J Cardiol. 1982 Nov;50(5):1087-9. doi: 10.1016/0002-9149(82)90422-2. PMID: 7137035.
  39. Pappone C, Santinelli V, Rosanio S, Vicedomini G, Nardi S, Pappone A, Tortoriello V, Manguso F, Mazzone P, Gulletta S, Oreto G, Alfieri O. Usefulness of invasive electrophysiologic testing to stratify the risk of arrhythmic events in asymptomatic patients with Wolff-Parkinson-White pattern: results from a large prospective long-term follow-up study. J Am Coll Cardiol. 2003 Jan 15;41(2):239-44. doi: 10.1016/s0735-1097(02)02706-7. PMID: 12535816.
  40. Leitch JW, Klein GJ, Yee R, Murdock C. Prognostic value of electrophysiology testing in asymptomatic patients with Wolff-Parkinson-White pattern. Circulation. 1990 Nov;82(5):1718-23. doi: 10.1161/01.cir.82.5.1718. Erratum in: Circulation 1991 Mar;83(3):1124. PMID: 2225373.
  41. Brembilla-Perrot B, Ghawi R. Electrophysiological characteristics of asymptomatic Wolff-Parkinson-White syndrome. Eur Heart J. 1993 Apr;14(4):511-5. doi: 10.1093/eurheartj/14.4.511. PMID: 8472715.
  42. Sharma AD, Yee R, Guiraudon G, Klein GJ. Sensitivity and specificity of invasive and noninvasive testing for risk of sudden death in Wolff-Parkinson-White syndrome. J Am Coll Cardiol. 1987 Aug;10(2):373-81. doi: 10.1016/s0735-1097(87)80021-9. PMID: 3598007.
  43. Moore JP, Kannankeril PJ, Fish FA. Isoproterenol administration during general anesthesia for the evaluation of children with ventricular preexcitation. Circ Arrhythm Electrophysiol. 2011 Feb;4(1):73-8. doi: 10.1161/CIRCEP.110.958660. Epub 2010 Dec 14. PMID: 21156771.
  44. Szabo TS, Klein GJ, Sharma AD, Yee R, Milstein S. Usefulness of isoproterenol during atrial fibrillation in evaluation of asymptomatic Wolff-Parkinson-White pattern. Am J Cardiol. 1989 Jan 15;63(3):187-92. doi: 10.1016/0002-9149(89)90283-x. PMID: 2909998.
  45. Willis P, Tabibiazar MR, Dave MR, Mazar M. Asymptomatic Patient with EKG showing Wolff-Parkinson-White Pattern. Proceedings of UCLA Healthcare. 2011;
  46. Pappone C, Santinelli V, Manguso F, Augello G, Santinelli O, Vicedomini G, Gulletta S, Mazzone P, Tortoriello V, Pappone A, Dicandia C, Rosanio S. A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-Parkinson-White syndrome. N Engl J Med. 2003 Nov 6;349(19):1803-11. doi: 10.1056/NEJMoa035345. PMID: 14602878.
  47. Bigelow AM, Smith G, Clark JM. Catheter Ablation Without Fluoroscopy: Current Techniques And Future Direction. J Atr Fibrillation. 2014 Apr 30;6(6):1066. doi: 10.4022/jafib.1066. PMID: 27957068; PMCID: PMC5135245.
  48. Alvarez M, Tercedor L, Almansa I, Ros N, Galdeano RS, Burillo F, Santiago P, Peñas R. Safety and feasibility of catheter ablation for atrioventricular nodal re-entrant tachycardia without fluoroscopic guidance. Heart Rhythm. 2009 Dec;6(12):1714-20. doi: 10.1016/j.hrthm.2009.08.037. Epub 2009 Sep 3. PMID: 19959117.

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