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Christmyer Z, Pisupati M, Shah MJ, Srinivasan C, Vetter VL, Iyer VR, Triguba M, Janson CM. Risk Stratification in Pediatric Wolff-Parkinson-White: Practice Variation Among Pediatric Cardiologists and Electrophysiologists. Pediatr Cardiol 2024; 45:1668-1675. [PMID: 37544951 DOI: 10.1007/s00246-023-03247-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Published guidelines provide recommendations for risk stratification in pediatric Wolff-Parkinson-White (WPW). There are no data on provider concordance with these guidelines. We hypothesized that significant practice variation exists between pediatric cardiologists (PC) and electrophysiologists (EP). METHOD The records of all patients, age 8 to 21 years, with a new ECG diagnosis of WPW between 1/1/2013 and 12/31/2018, from a single center, were retrospectively reviewed. Subjects were categorized on the basis of symptoms and resting ECG findings as one of the following: asymptomatic intermittent WPW, asymptomatic persistent WPW, or symptomatic WPW. The performance and results of diagnostic testing, including Holter monitor, event monitor, exercise stress test (EST), and electrophysiology study (EPS), were recorded. The primary outcome was concordance with published guidelines. A secondary outcome was documentation of a discussion of sudden cardiac death (SCD) risk. RESULTS 615 patient encounters were analyzed in 231 patients with newly diagnosed WPW pattern on ECG (56% male; mean age at diagnosis 13.9 ± 2.5 years). EP were observed to have a significantly higher rate of guideline concordance than PC (95% vs. 71%, p < 0.001). There was significant practice variation between PC and EP in the documentation of a discussion of SCD risk: 96% in EP vs. 39% in PC (p < 0.001). CONCLUSION Significant practice variation exists in the non-invasive and invasive risk stratification of pediatric WPW, with lower concordance to published guidelines amongst PC, when compared to EP. This report highlights the need to promote awareness of current WPW guidelines in the pediatric cardiology community at large.
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Affiliation(s)
- Zane Christmyer
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Meghana Pisupati
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Maully J Shah
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Chandra Srinivasan
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Victoria L Vetter
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - V Ramesh Iyer
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Mary Triguba
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Christopher M Janson
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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Lampert R, Chung EH, Ackerman MJ, Arroyo AR, Darden D, Deo R, Dolan J, Etheridge SP, Gray BR, Harmon KG, James CA, Kim JH, Krahn AD, La Gerche A, Link MS, MacIntyre C, Mont L, Salerno JC, Shah MJ. 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play. Heart Rhythm 2024; 21:e151-e252. [PMID: 38763377 DOI: 10.1016/j.hrthm.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/09/2024] [Indexed: 05/21/2024]
Abstract
Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.
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Affiliation(s)
- Rachel Lampert
- Yale University School of Medicine, New Haven, Connecticut
| | - Eugene H Chung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Rajat Deo
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joe Dolan
- University of Utah, Salt Lake City, Utah
| | | | - Belinda R Gray
- University of Sydney, Camperdown, New South Wales, Australia
| | | | | | | | - Andrew D Krahn
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Andre La Gerche
- Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | | | - Lluis Mont
- Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Jack C Salerno
- University of Washington School of Medicine, Seattle, Washington
| | - Maully J Shah
- Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania
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Moore JP, Aboulhosn JA, Zeppenfeld K, Waldmann V, Bessière F, Blom NA, Combes N, Fish FA, McLeod CJ, Kanter RJ, Tan W, Patel N, von Alvensleben JC, Kamp A, Lloyd MS, Anderson CC, Tan RB, Mariucci E, Levi DS, Salem M, Shivkumar K, Khairy P. Rationale and Design of the Multicenter Catheter Ablation of Ventricular Tachycardia Before Transcatheter Pulmonary Valve Replacement in Repaired Tetralogy of Fallot Study. Am J Cardiol 2023; 204:14-21. [PMID: 37536198 DOI: 10.1016/j.amjcard.2023.07.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/08/2023] [Accepted: 07/13/2023] [Indexed: 08/05/2023]
Abstract
Patients with repaired tetralogy of Fallot are at elevated risk for ventricular arrhythmia and sudden cardiac death. Over the past decade, the pathogenesis and natural history of ventricular tachycardia has become increasingly understood, and catheter ablation has emerged as an effective treatment modality. Concurrently, there has been great progress in the development of a versatile array of transcatheter valves that can be placed in the native right ventricular outflow tract for the treatment of long-standing pulmonary regurgitation. Although such valve platforms may eliminate the need for repeat cardiac operations, they may also impede catheter access to the myocardial substrates responsible for sustained macro-reentrant ventricular tachycardia. This manuscript provides the rationale and design of a recently devised multicenter study that will examine the clinical outcomes of a uniform, preemptive strategy to eliminate ventricular tachycardia substrates before transcatheter pulmonary valve implantation in patients with tetralogy of Fallot.
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Affiliation(s)
- Jeremy P Moore
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California.
| | - Jamil A Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California
| | - Katja Zeppenfeld
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - Victor Waldmann
- Paris Cardiovascular Research Center (PARCC), Institut national de la santé et de la recherche médicale (Inserm), Université Paris Cité, Paris, France; Adult Congenital Heart Disease Medico-Surgical Unit; M3C-Necker, Hôpital Universitaire Necker-Enfants malades, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Francis Bessière
- Cardiac Electrophysiology Unit, European Georges Pompidou Hospital, Paris, France; Louis Pradel Hospital, Hospices Civils de Lyon, Université Lyon 1 Claude Bernard, Lyon, France
| | - Nico A Blom
- Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pediatric Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicolas Combes
- Department of Congenital Heart Diseases, Centre de Référence Malformations Cardiaques Congénitales Complexes M3C, Hôpital Marie Lannelongue, Groupe Hospitalier Paris-Saint Joseph, Plessis-Robinson, Paris, France; University of Versailles Saint-Quentin-en-Yvelines (UVSQ), Institut national de la santé et de la recherche médicale (Inserm), CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Frank A Fish
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Ronald J Kanter
- Nicklaus Children's Hospital, Miami, Florida; Duke University School of Medicine, Durham, North Carolina
| | - Weiyi Tan
- Adult Congenital Heart Disease, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nimesh Patel
- Adult Congenital Heart Disease, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Anna Kamp
- The Heart Center, Nationwide Children's Hospital, the Ohio State University, Columbus, Ohio
| | - Michael S Lloyd
- Department of Cardiac Electrophysiology, Emory University, Atlanta, Georgia
| | - Charles C Anderson
- Center for Congenital Heart Disease, Providence Sacred Heart Children's Hospital, Spokane, Washington
| | - Reina B Tan
- Division of Cardiology, Hassenfeld Children's Hospital, NYU Langone Health, New York, New York
| | - Elisabetta Mariucci
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Daniel S Levi
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Morris Salem
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California; Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Que, Canada
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Paul T, Krause U, Sanatani S, Etheridge SP. Advancing the science of management of arrhythmic disease in children and adult congenital heart disease patients within the last 25 years. Europace 2023; 25:euad155. [PMID: 37622573 PMCID: PMC10450816 DOI: 10.1093/europace/euad155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 08/26/2023] Open
Abstract
This review article reflects how publications in EP Europace have contributed to advancing the science of management of arrhythmic disease in children and adult patients with congenital heart disease within the last 25 years. A special focus is directed to congenital atrioventricular (AV) block, the use of pacemakers, cardiac resynchronization therapy devices, and implantable cardioverter defibrillators in the young with and without congenital heart disease, Wolff-Parkinson-White syndrome, mapping and ablation technology, and understanding of cardiac genomics to untangle arrhythmic sudden death in the young.
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Affiliation(s)
- Thomas Paul
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Pediatric Heart Center, Georg-August-University Medical Center, Robert-Koch-Str, 40, Göttingen D-37075, Germany
| | - Ulrich Krause
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Pediatric Heart Center, Georg-August-University Medical Center, Robert-Koch-Str, 40, Göttingen D-37075, Germany
| | - Shubhayan Sanatani
- Children’s Heart Centre, British Columbia Children’s Hospital, Vancouver, BC, Canada
| | - Susan P Etheridge
- Pediatric Cardiology, University of Utah School of Medicine and Primary Children’s Medical Center, Salt Lake City, UT
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Sim HSS, Imran SS, Teoh CS. Progression of Wolff-Parkinson-White pattern 12-lead electrocardiogram changes in an asymptomatic athlete. Singapore Med J 2023; 64:449-453. [PMID: 37459000 PMCID: PMC10395805 DOI: 10.4103/singaporemedj.smj-2021-151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 01/05/2022] [Indexed: 07/20/2023]
Affiliation(s)
- Hwei Sian Shauna Sim
- Department of Orthopaedic Surgery, Sports Medicine Centre, Khoo Teck Puat Hospital, Singapore
| | | | - Chin Sim Teoh
- Department of Orthopaedic Surgery, Sports Medicine Centre, Khoo Teck Puat Hospital, Singapore
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Di Pino A, Oreto L, Di Pino A. Electrophysiological guided accessory-pathway ablation strategy in children with asymptomatic WPW: it may not be enough to prevent sudden cardiac death. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01409-4. [DOI: 10.1007/s10840-022-01409-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022]
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Abstract
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.
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Clinical Approach to Symptomatic and Asymptomatic Patients with Ventricular Pre-excitation. Card Electrophysiol Clin 2020; 12:527-539. [PMID: 33162001 DOI: 10.1016/j.ccep.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Despite extensive knowledge of the physiopathology of ventricular pre-excitation, management of asymptomatic patients with this condition remains controversial.
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Książczyk TM, Pietrzak R, Werner B. Management of Young Athletes with Asymptomatic Preexcitation-A Review of the Literature. Diagnostics (Basel) 2020; 10:E824. [PMID: 33076240 PMCID: PMC7602380 DOI: 10.3390/diagnostics10100824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION The management of young athletes with asymptomatic preexcitation remains a challenge, regardless of the progress we have made in understanding the basis of condition and developing catheter ablation procedures. The risk of sudden death, however small, yet definite, being the first symptom is determining our approach. The aim of the study was to establish the current state of knowledge regarding the management of young athletes diagnosed with asymptomatic preexcitation, by conducting a literature review. MATERIAL AND METHODS A comprehensive literature review was completed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was limited to English language publications using the following search terms: "asymptomatic" or "incidental" and "pre-excitation" or "Wolff-Parkinson-White" or "delta wave" and "athlete" or "sport". The search was supplemented by hand review of the bibliographies of previous relevant systematic reviews. RESULTS The search resulted in 85 of abstracts, and the manual search of the bibliographies resulted in 24 additional papers. After careful analysis 10 publications were included in the review. In all but one of the presented papers, the authors used non-invasive methods and then either trans-esophageal or invasive EPS as a way to risk stratify asymptomatic patients. Evidence of rapid conduction through the accessory pathway was considered high risk and prompted sport disqualification. In the analysed reports there were combined: 142 episodes of the life-threatening events (LTE)/sudden death (SCD), of which 56 were reported to occur at rest, 61 during activity and no data were available for 25. CONCLUSIONS athletic activity may impose an increased risk of life-threatening arrhythmias in patients with asymptomatic preexcitation; hence, a separate approach could be considered, especially in patients willing to engage in high-intensity, endurance and competitive sports.
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Affiliation(s)
| | | | - Bożena Werner
- Department of Paediatric Cardiology and General Paediatrics, Medical University of Warsaw, 02–091 Warsaw, Poland; (T.M.K.); (R.P.)
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Pieles GE, Stuart AG. The adolescent athlete's heart; A miniature adult or grown-up child? Clin Cardiol 2020; 43:852-862. [PMID: 32643161 PMCID: PMC7403711 DOI: 10.1002/clc.23417] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 06/16/2020] [Accepted: 06/26/2020] [Indexed: 12/18/2022] Open
Abstract
The systematic development of early age talent in sports academies has led to the professionalization of pediatric sport and the sports physician need to be aware of pediatric cardiological problems. Research into the medical cardiac care and assessment of the pediatric athlete are accumulating, but specific pediatric international guidelines are not available yet and reference data for ECG and echocardiography are incomplete, in particular for the age group <12 years of age. This article is an introduction to the physiological and diagnostics specifics of the pediatric athlete. The focus lies in the differences in presentation and diagnosis between pediatric and adult athletes for the most common pathologies. Reference data for electrical and structural adaptations to intensive exercise are sparse particularly in athletes aged below 12 years old. Training related changes include decrease of resting heart rate, increase of cardiac output, ventricular cavity size, and wall thickness. Cardiac hypertrophy is less pronounced in pediatric athletes, as HR mediated cardiac output increase to endurance exercise is the dominant mechanism in peripubertal children. As in adults, the most pronounced cardiovascular adaptations appear in classical endurance sports like rowing, triathlon, and swimming, but the specifics of pediatric ECG and echocardiographic changes need to be considered.
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Affiliation(s)
- Guido E Pieles
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Congenital Heart Unit, Bristol Heart Institute, Bristol, UK.,Institute of Sport, Exercise and Health, University College London, London, UK
| | - A Graham Stuart
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Congenital Heart Unit, Bristol Heart Institute, Bristol, UK
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Whitehill R, Campbell R. The "Great Debate" continues. Heart Rhythm 2020; 17:1656-1657. [PMID: 32470626 DOI: 10.1016/j.hrthm.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/19/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Robert Whitehill
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
| | - Robert Campbell
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
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Chubb H, Ceresnak SR. A proposed approach to the asymptomatic pediatric patient with Wolff-Parkinson-White pattern. HeartRhythm Case Rep 2020; 6:2-7. [PMID: 31956492 PMCID: PMC6962761 DOI: 10.1016/j.hrcr.2019.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 01/02/2023] Open
Affiliation(s)
| | - Scott R. Ceresnak
- Address reprint requests and correspondence: Dr Scott R. Ceresnak, Department of Pediatrics - Division of Pediatric Cardiology, 750 Welch Rd, Suite 305, Palo Alto, CA 94304.
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