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Jemtrén A, Saygi S, Åkerström F, Asaad F, Bourke T, Braunschweig F, Carnlöf C, Drca N, Insulander P, Kennebäck G, Nordin AP, Sadigh B, Rickenlund A, Saluveer O, Schwieler J, Svennberg E, Tapanainen J, Turkmen Y, Bastani H, Jensen-Urstad M. Risk assessment in patients with symptomatic and asymptomatic pre-excitation. Europace 2024; 26:euae036. [PMID: 38363996 PMCID: PMC10873488 DOI: 10.1093/europace/euae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/23/2024] [Indexed: 02/18/2024] Open
Abstract
AIMS Controversy remains as to whether the exercise stress test (EST) is sufficient for risk evaluation in patients with pre-excitation. This study aims to clarify the usefulness of EST in risk stratification in both asymptomatic and symptomatic patients presenting with pre-excitation. METHODS AND RESULTS This prospective study includes consecutive asymptomatic and symptomatic patients with pre-excitation referred for risk assessment. All participants performed an incremental EST (bicycle) prior to an electrophysiology study (EPS). Primary data from the EST included loss of pre-excitation during exercise, and primary data from the EPS included the measurement of accessory pathway effective refractory period (APERP), shortest pre-excited RR interval (SPERRI), and inducible arrhythmia with the use of a beta-adrenergic receptor agonist if deemed necessary. One hundred and sixty-four patients (59 asymptomatic, 105 symptomatic) completed an EST and EPS. Forty-five patients (27%) demonstrated low-risk findings on EST, of which 19 were asymptomatic and 26 were symptomatic. Six patients with low-risk EST findings had SPERRI/APERP ≤ 250 ms at EPS, and two of them were asymptomatic. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of low-risk EST for excluding patients with SPERRI/APERP ≤ 250 ms were 40, 91, 87, 51, and 60%, respectively. The number of patients with inducible arrhythmia at EPS was similar in the asymptomatic (36, 69%) and symptomatic (73, 61%) groups. CONCLUSION Sudden loss of pre-excitation during EST has a low NPV in excluding high-risk APs. The EPS with the use of isoproterenol should be considered to accurately assess the risk of patients with pre-excitation regardless of symptoms (ClinicalTrials.gov Identifier: NCT03301935).
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Affiliation(s)
- Anette Jemtrén
- Heart and Lung Disease Unit, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Serkan Saygi
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Finn Åkerström
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Fahd Asaad
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Tara Bourke
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Frieder Braunschweig
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Carina Carnlöf
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Nikola Drca
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Per Insulander
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Göran Kennebäck
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Astrid Paul Nordin
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Bita Sadigh
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Anette Rickenlund
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ott Saluveer
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Jonas Schwieler
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Emma Svennberg
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Jari Tapanainen
- Department of Clinical Sciences, Danderyd Hospital Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Yusuf Turkmen
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Hamid Bastani
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
| | - Mats Jensen-Urstad
- Department of Cardiology, Heart and Vascular Centre, Karolinska University Hospital Huddinge, Department of Medicine Huddinge, Karolinska Institutet, Hälsovägen, 141 86 Stockholm, Sweden
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Nunes A, Lebreiro A, Campelo M, Adão L, Maciel MJ. Iatrogenic ventricular fibrillation in Wolff-Parkinson-White syndrome. Rev Port Cardiol 2022; 41:S0870-2551(22)00366-3. [PMID: 36114111 DOI: 10.1016/j.repc.2019.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/19/2019] [Accepted: 06/09/2019] [Indexed: 10/14/2022] Open
Abstract
Wolff-Parkinson-White (WPW) syndrome is the most common manifestation of ventricular pre-excitation syndrome and is mostly found in individuals with no structural heart disease. Although the risk of malignant arrhythmias is low, sudden cardiac death (SCD) as the first clinical manifestation of WPW syndrome is well documented, and atrial fibrillation (AF) with a rapid ventricular response is the main mechanism involved. Unfortunately, the signs of pre-excitation and arrhythmias are sometimes under-diagnosed and under-treated. We describe the case of a 31-year-old man who was admitted with an irregular wide complex tachycardia consistent with pre-excited AF, which was not promptly diagnosed, and who developed ventricular fibrillation (VF) after administration of atrioventricular (AV) nodal blockers, as a primary manifestation of WPW syndrome. Blocking the AV node in patients with pre-excited AF may increase the ventricular rate and potentially result in hemodynamic instability. Among patients with WPW syndrome who survive an episode of SCD, catheter ablation of the accessory pathway is the treatment of choice.
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Affiliation(s)
- Alzira Nunes
- Serviço de Cardiologia, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - Ana Lebreiro
- Serviço de Cardiologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Manuel Campelo
- Serviço de Cardiologia, Centro Hospitalar Universitário de São João, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Luís Adão
- Serviço de Cardiologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Maria Júlia Maciel
- Serviço de Cardiologia, Centro Hospitalar Universitário de São João, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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3
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Maines M, Zorzi A, Peruzza F, Catanzariti D, Moggio P, Angheben C, Del Greco M. Endocavitary electrophysiological study by percutaneous antecubital vein and without X-ray for risk stratification of asymptomatic ventricular pre-excitation in young athletes. IJC HEART & VASCULATURE 2021; 36:100879. [PMID: 34604501 PMCID: PMC8463852 DOI: 10.1016/j.ijcha.2021.100879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022]
Abstract
Evaluation of AP is usually performed by transesophageal and intracardiac studies. In young athletes with AVP, our standard of care is to perform ESnoXR. ESnoXR may considered a less invasive alternative for risk stratification of AP.
Athletes with asymptomatic ventricular pre-excitation (VP) should undergo electrophysiological study for risk stratification. We aimed to evaluate the feasibility, efficacy, safety and tolerability of an electrophysiological study using a percutaneous antecubital vein access and without the use of X-ray (ESnoXr). Methods: We collected data from all young athletes < 18 year-old with AVP, who underwent ESnoXr from January 2000 to September 2020 for evaluation of accessory pathway refractoriness and arrhythmia inducibility using an antecubital percutaneous venous access. Endocavitary signals were used to advance the catheter in the right atrium and ventricle. Results: We included 63 consecutive young athletes (mean age 14.6 ± 1.9 years, 46% male). Feasibility of the ESnoXr technique was 87% while in 13% fluoroscopy and/or a femoral approach were needed. Specifically, fluoroscopy was used in 7 cases to position the catheter inside the heart cavities with an average exposure of 43 ± 38 s while in 2 femoral venous access was needed. The mean procedural time was 35 ± 11 min. The exam was diagnostic in all patients, there were no procedural complications and tolerability was excellent. 53% of the patients had an accessory pathway with high refractoriness and no inducible atrio-ventricular reentry tachycardia: this subgroup was considered eligible to competitive sports and no event was observed during long-term follow-up (13.6 ± 5.2 years) without drug use. The others underwent catheter ablation. Conclusion. ESnoXr has been shown to be a feasible, effective, safe and well-tolerated procedure for the assessment of arrhythmic risk in a population of young athletes with asymptomatic VP.
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Affiliation(s)
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | | | | | - Paolo Moggio
- Santa Maria del Carmine Hospital (Rovereto-TN), Italy
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Okishige K, Yamauchi Y, Nagase S, Kusano K, Miyamoto K, Ozawa T, Sawayama Y, Takeda H, Manita M, Asahi T, Miwa Y, Soejima K, Sasano T. Transcatheter cryo-ablation of septal accessory pathways, multicenter observational study in Japan. J Cardiol 2020; 77:380-387. [PMID: 33342639 DOI: 10.1016/j.jjcc.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/16/2020] [Accepted: 09/26/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Ablation using radiofrequency energy has to be carefully performed when the arrhythmia substrate is located in close proximity to the atrioventricular (AV) node due to the risk of inadvertent permanent AV block. The aim of this study was to evaluate the efficacy and safety of catheter-based cryo-therapy for septal accessory pathways (APs). METHODS A total of eleven patients (median = 56.3 years, range 13-74 years) with septal APs underwent cryoablation. Ice-mapping was performed during sinus rhythm and an AV reciprocating tachycardia utilizing the APs as a requisite limb with cooling of the catheter tip temperature to a maximum of -30℃ for less than 45 s. Cryo-ablation was performed for 4 min at a temperature of -80℃ only if ice-mapping abolished the pre-excitation or retrograde conduction over the AP without injury to the AV nodal conduction. RESULTS Cryo-ablation was acutely successful in all eleven patients. No permanent cryo-related complications or adverse outcomes were reported. During the follow-up (range 14-26 months), no patients experienced any arrhythmia recurrences. CONCLUSION Ice-mapping was a feasible and reliable method to determine the exact location of the APs owing to the possibility of validating the ablation site. Cryo-ablation of APs located near the AV junction is a safe and efficacious technique with a high success rate over the long term. IRB INFORMATION Ethical Committee of Japan Red Cross Yokohama City Bay Hospital #2018-19.
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Affiliation(s)
- Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan.
| | - Yasuteru Yamauchi
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoya Ozawa
- Cardiovascular Department, Shiga University, School of Medicine, Ohtsu, Japan
| | - Yuichi Sawayama
- Cardiovascular Department, Shiga University, School of Medicine, Ohtsu, Japan
| | - Hiroto Takeda
- Cardiovascular Center, Ohta-Nishinouchi Hospital, Kouriyama, Japan
| | - Mamoru Manita
- Cardiology Department, Naha Municipal Hospital, Naha, Japan
| | - Tomohiro Asahi
- Cardiology Department, Naha Municipal Hospital, Naha, Japan
| | - Yosuke Miwa
- Cardiovascular Department, Kyorin University, School of Medicine, Mitaka, Japan
| | - Kyoko Soejima
- Cardiovascular Department, Kyorin University, School of Medicine, Mitaka, Japan
| | - Tetsuo Sasano
- Cardiovascular Department, Tokyo Medical and Dental University, Tokyo, Japan
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Matta M, Marazzato J, De Ponti R, Gaita F, Anselmino M. Ablation of Accessory Pathways with Uncommon Electrophysiologic Properties. Card Electrophysiol Clin 2020; 12:567-581. [PMID: 33162004 DOI: 10.1016/j.ccep.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In rare cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic features that may be related to their specific anatomy. Most of these bundles show decremental nodelike conduction properties and sustain peculiar forms of arrhythmias that require careful differential diagnosis. On the other hand, some pathways do not actively sustain any reentrant circuit and should nevertheless be promptly recognized to avoid unnecessary ablation attempts. Although rare, these variants of accessory pathway should be known to warrant a safe and effective catheter ablation procedure.
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Affiliation(s)
- Mario Matta
- Cardiology Division, Sant'Andrea Hospital, corso Mario Abbiate, 21, Vercelli 13100, Italy
| | - Jacopo Marazzato
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy
| | - Fiorenzo Gaita
- Cardiology Unit, J Medical Via Druento, 153/56, Turin 10151, Italy
| | - Matteo Anselmino
- Cardiology Division, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Turin, Corso Bramante, 88, Turin 10126, Italy.
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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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7
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Abstract
In some cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic properties related to their specific anatomy. Most of these fibers, which may be responsible for variants of ventricular preexcitation, show decremental conduction properties due to a nodelike aspect or a peculiar tortuous anatomic route across the atrioventricular groove. Moreover, some fibers do not actively sustain any reentrant circuit and can be only involved as bystander in other arrhythmias. Although rare, these accessory pathway variants should be properly diagnosed using noninvasive and invasive methods to guide catheter ablation procedures when needed.
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8
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Delise P, Sciarra L. Sudden Cardiac Death in Patients with Ventricular Preexcitation. Card Electrophysiol Clin 2020; 12:519-525. [PMID: 33162000 DOI: 10.1016/j.ccep.2020.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with the Wolff-Parkinson-White syndrome may experience benign and malignant arrhythmias, the most common being atrioventricular reentrant tachycardias. This arrhythmia may degenerate into atrial fibrillation, which can be conducted over an accessory pathway capable of exceptionally fast conduction to the ventricles and degenerate into ventricular fibrillation, leading to sudden cardiac death. These life-threatening events generally affect symptomatic patients in their third or fourth decade. Although rare, ventricular fibrillation may be the first clinical manifestation in subjects who are asymptomatic or unaware of their conditions. Electrophysiologic study may be useful to identify subjects at high risk of sudden cardiac death.
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Affiliation(s)
- Pietro Delise
- Division of Cardiology, Ospedale P. Pederzoli, Via Monte Baldo, 24, Peschiera del Garda, Verona 37019, Italy.
| | - Luigi Sciarra
- Cardiology Unit, Policlinico Casilino, Via Casilina 1049, Rome 00169, Italy
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9
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LaRocca TJ, Beyersdorf GB, Li W, Foltz R, Patel AR, Tanel RE. Comparison of Electrophysiologic Profiles in Pediatric Patients with Incidentally Identified Pre-Excitation Compared with Wolff-Parkinson-White Syndrome. Am J Cardiol 2019; 124:389-395. [PMID: 31204032 DOI: 10.1016/j.amjcard.2019.04.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/19/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
The rising utilization of screening electrocardiograms has resulted in increased incidental identification of ventricular pre-excitation in pediatric patients. We compared accessory pathways of incidentally identified pre-excitation to Wolff-Parkinson-White Syndrome (WPW) with the aim to identify factors important in preprocedural counseling and planning. This single-center, retrospective study of patients ≤18 years without congenital heart disease identified 227 patients diagnosed with pre-excitation and referred for invasive electrophysiology study between 2008 and 2017. WPW Syndrome was diagnosed in 178 patients, while 49 patients had incidental identification of pre-excitation. Anterograde conduction of incidentally identified accessory pathways was not clinically different between the two cohorts at baseline or upon isoproterenol infusion. However, the proportion of accessory pathways meeting high-risk criteria was significantly lower than in patients diagnosed with WPW, 12% versus 28% (p < 0.05). Retrograde conduction at baseline of incidentally diagnosed accessory pathways was slower with a median block cycle length 365 milliseconds (IQR 260 to 450) versus 290 milliseconds (IQR 260 to 330, p < 0.01). In the incidentally identified cohort, right-sided, paraHisian, and fascicular pathways were more common with fewer attempted ablations (71% vs 94%, p < 0.001) and lower success rate (91% vs 97%, p < 0.001). A binomial logistic regression analysis further indicated patients incidentally identified with pre-excitation were associated with having lower rates of inducible supraventricular tachycardia, atrial fibrillation, and ablations performed, in addition, to having right-sided pathways. In conclusion, as patients with incidentally identified pre-excitation present more frequently for consideration of invasive electrophysiology study, these results impact procedural approaches, technical considerations, patient counseling, and outcome expectations.
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10
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Efficacy and safety of cryoablation of para-Hisian and mid-septal accessory pathways using a specific protocol: single-center experience in consecutive patients. J Interv Card Electrophysiol 2019; 55:47-54. [DOI: 10.1007/s10840-018-0498-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
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11
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Brugada J, Keegan R. Asymptomatic Ventricular Pre-excitation: Between Sudden Cardiac Death and Catheter Ablation. Arrhythm Electrophysiol Rev 2018; 7:32-38. [PMID: 29636970 DOI: 10.15420/aer.2017.51.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Debate about the best clinical approach to the management of asymptomatic patients with ventricular pre-excitation and advice on whether or not to invasively stratify and ablate is on-going. Weak evidence about the real risk of sudden cardiac death and the potential benefit of catheter ablation has probably prevented the clarification of action in this not infrequent and sometimes conflicting clinical situation. After analysing all available data, real evidence-based medicine could be the alternative strategy for managing this group of patients. According to recent surveys, most electrophysiologists invasively stratify. Based on all accepted risk factors - younger age, male, associated structural heart disease, posteroseptal localisation, ability of the accessory pathway to conduct anterogradely at short intervals of ≤250 milliseconds and inducibility of sustained atrioventricular re-entrant tachycardia and/or atrial fibrillation - a shared decisionmaking process on catheter ablation is proposed.
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Affiliation(s)
- Josep Brugada
- Cardiovascular Institute, Hospital Clinic and Paediatric Arrhythmia Unit, Hospital Sant Joan de Déu, University of BarcelonaBarcelona, Spain
| | - Roberto Keegan
- Electrophysiology Service, Private Hospital of the SouthBahia Blanca, Argentina
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Di Mambro C, Drago F, Milioni M, Russo MS, Righi D, Placidi S, Remoli R, Palmieri R, Gimigliano F, Santucci LM, Silvetti MS, Prosperi M. Sports Eligibility After Risk Assessment and Treatment in Children with Asymptomatic Ventricular Pre-excitation. Sports Med 2016; 46:1183-90. [DOI: 10.1007/s40279-016-0475-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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