Management of Asymptomatic Wolff-Parkinson-White Pattern in Young Patients: Has Anything Changed?

Wolf-Parkinson-White Syndrome: Diagnosis, Risk Assessment, and Therapy-An Update

Wolf-Parkinson-White (WPW) syndrome is a disorder characterized by the presence of at least one accessory pathway (AP) that can predispose people to atrial/ventricular tachyarrhythmias and even sudden cardiac death. It is the second most common cause of paroxysmal supraventricular tachycardia in most parts of the world, affecting about 0.1-0.3% of the general population. Most patients with WPW syndrome have normal anatomy, but it may be associated with concomitant congenital heart disease or systemic diseases. Although many individuals are asymptomatic, during supraventricular arrhythmia episodes, they may experience severe symptoms, including syncope or even sudden cardiac death (mainly due to pre-excited atrial fibrillation over rapidly conducting AP). In addition to arrhythmia-related symptoms, for some specific locations of the APs with overt anterograde conduction, there might be a reduction in exercise capacity mediated by a reduction in LV systolic performance due to anomalous LV depolarization. Although it is typically diagnosed through electrocardiography (ECG), additional tests are necessary for risk assessment. Management of WPW syndrome may be quite challenging and can vary from only acknowledging the presence of the accessory pathway to pharmacological treatment or radiofrequency ablation. Early diagnosis, risk assessment, and appropriate treatment are critical steps in the management of WPW syndrome, aiming to improve the quality of life and reduce the risk of life-threatening arrhythmias.

Routine Interictal EEG Recording Should be Performed Together with Simultaneous Two-Lead ECG Recording

We aimed to evaluate the contribution of simultaneous electrocardiography (ECG) recording during routine interictal electroencephalography (EEG) recording in patients with seizures or epilepsy and therefore to provide evidence-based data on this subject. Patients with interictal cardiac arrhythmia on routine EEG-ECG recordings were determined and evaluated based on cardiologic and neurologic findings. Out of 1,078 patients aged between 5 and 16 years (mean: 10.2 ± 3.2), 9 (0.08%) patients were found to have an arrhythmia. Six patients had both epilepsy and cardiac arrhythmia (premature ventricular contractions [PVCs] in 5; Wolff-Parkinson-White [WPW] in 1 patient) and the remaining three patients had nonepileptic paroxysmal events (NPEs) and arrhythmia (PVC in 2; WPW in 1). Three patients had other diseases (neurofibromatosis type 1, tuberous sclerosis, and congenital heart disease status postsurgery). Cardiac arrhythmia required radiofrequency ablation or antiarrhythmic drug treatment in two patients with epilepsy and also two patients with NPE; however, it improved with no specific treatment in the remaining five patients. NPE was not related to arrhythmia in one of three patients with NPE. Our study suggests that routine interictal EEG-ECG recording provides a valuable and feasible opportunity to reveal unnoticed or new-onset cardiac arrhythmias. Therefore, ECG should be recorded simultaneously during routine interictal EEG recordings. Cardiac arrhythmias detected by routine interictal EEG-ECG recordings would require arrhythmia treatment in nearly half of the patients.

Characteristics of antegrade-only accessory pathways in children and adolescents

There is minimal data regarding antegrade-only accessory pathways in young patients. Given evolving recommendations and treatments, retrospective analysis of the clinical and electrophysiologic properties of antegrade-only pathways in patients <21 years old was performed, with subsequent comparison of electrophysiology properties to age-matched controls with bidirectional pathways. Of 522 consecutive young patients with ventricular pre-excitation referred for electrophysiology study, 33 (6.3%) had antegrade-only accessory pathways. Indications included palpitations (47%), chest pain (25%), and syncope (22%). The shortest value for either the accessory pathway effective refractory period or the pre-excited R-R interval was taken for each patient, with the median of the antegrade-only group significantly greater than shortest values for the bidirectional group (310 [280-360] ms versus 270 [240-302] ms, p < 0.001). However, the prevalence of pathways with high-risk properties (effective refractory period or shortest pre-excited R-R interval <250 ms) was similar in both study patients and controls (13% versus 21%) (p = 0.55). Sixteen patients had a single antegrade-only accessory pathway and no inducible arrhythmia. Six patients had Mahaim fibres, all right anterolateral with inducible antidromic reciprocating tachycardia. However, 11 patients with antegrade-only accessory pathways and 3 with Mahaim fibres had inducible tachycardia due to a second substrate recognised at electrophysiology study. These included concealed accessory pathways (7), bidirectional accessory pathways (5), and atrioventricular node re-entry (2). Antegrade-only accessory pathways require comprehensive electrophysiology evaluation as confounding factors such as high-risk conduction properties or inducible Supraventricular Tachycardia (SVT) due to a second substrate of tachycardia are often present.

Review paper on WPW and athletes: Let sleeping dogs lie?

Accessory pathways are present in 1 in 300 young individuals. They are often asymptomatic and potentially lethal arrhythmias may be the first presentation. During long-term follow-up, up to 20% of asymptomatic individuals with pre-excitation go on to develop an arrhythmia and the absence of traditional clinical and electrophysiological high-risk markers does not guarantee the "safe" nature of an accessory pathway. The widespread availability of permanent cure for the condition at low risk by catheter ablation, creates an incentive to screen for accessory pathways with a 12-lead ECG, particularly in individuals who are perceived to be at increased risk, such as athletes and high-risk professions. We review the existing literature on the assessment and management of accessory pathways (Wolff-Parkinson-White [WPW] syndrome) and discuss its implications for the young athletic population.