1
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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:S1547-5271(24)02560-8. [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] [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
- Yale University School of Medicine, New Haven, Connecticut
| | | | - 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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2
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Etheridge SP, Gakenheimer-Smith L, Asaki SY, Niu M. Asymptomatic Wolff-Parkinson-White Syndrome: An Ounce of Prevention Is Worth the Risk of Cure. Curr Cardiol Rep 2023; 25:543-551. [PMID: 37115433 DOI: 10.1007/s11886-023-01879-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE OF REVIEW With increased electrocardiogram screening, asymptomatic preexcitation has become more prevalent. Historically, the asymptomatic-symptomatic dichotomy has directed management. This approach warrants scrutiny, as asymptomatic Wolff-Parkinson-White (WPW) syndrome is not without risk. Children may be unreliable symptom reporters, have atypical arrhythmia symptoms, yet have years to become symptomatic. RECENT FINDINGS In a large WPW study, symptomatic patients were more likely to undergo ablation than asymptomatic patients, yet, except for symptoms, there were no differences in clinical or electrophysiology study (EPS) characteristics. Present data confirm real risk in asymptomatic WPW-sudden death can be the first symptom. Although malignant arrhythmias correlate better with EPS risk stratification than with symptoms, EPS data are imperfect predictors. Unlike adults with WPW, children have yet to prove survivorship. Asymptomatic children must be treated differently than adults. Sudden death risk is low but front-loaded in the young. An aggressive approach to asymptomatic WPW is warranted in this era of highly successful, low-risk catheter ablations.
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Affiliation(s)
- Susan P Etheridge
- Primary Children's Hospital, The University of Utah, 84112, Salt Lake City, UT, USA.
| | | | - S Yukiko Asaki
- Primary Children's Hospital, The University of Utah, 84112, Salt Lake City, UT, USA
| | - Mary Niu
- Primary Children's Hospital, The University of Utah, 84112, Salt Lake City, UT, USA
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3
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Hessling G, Telishevska M, Lengauer S, Deisenhofer I. ["Asymptomatic WPW" : Is treatment necessary?]. Herzschrittmacherther Elektrophysiol 2023; 34:114-121. [PMID: 36939928 DOI: 10.1007/s00399-023-00930-x] [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: 12/30/2022] [Accepted: 01/30/2023] [Indexed: 03/21/2023]
Abstract
The term "asymptomatic WPW" (Wolff-Parkinson-White) is often used as a synonym for ventricular pre-excitation of the WPW type due to an accessory pathway characterized by a short PR interval and a delta wave on the electrocardiogram (ECG) without the clinical occurrence of paroxysmal tachycardia. Asymptomatic WPW is often diagnosed in young and otherwise healthy people. There is a small associated risk of sudden cardiac death due to rapid antegrade conduction over the accessory pathway during atrial fibrillation. This paper highlights aspects of noninvasive and invasive risk stratification, therapy by catheter ablation, and the ongoing risk-benefit discussion in asymptomatic WPW.
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Affiliation(s)
- Gabriele Hessling
- Abteilung für Elektrophysiologie, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstr. 36, 80636, München, Deutschland.
| | - Marta Telishevska
- Abteilung für Elektrophysiologie, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstr. 36, 80636, München, Deutschland
| | - Sarah Lengauer
- Abteilung für Elektrophysiologie, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstr. 36, 80636, München, Deutschland
| | - Isabel Deisenhofer
- Abteilung für Elektrophysiologie, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstr. 36, 80636, München, Deutschland
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4
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Marx M, Gass M, Michel-Behnke I. Generationenübergreifende Betreuung von Patienten mit tachykarden Rhythmusstörungen. Monatsschr Kinderheilkd 2022; 170:870-882. [PMID: 36105264 PMCID: PMC9461413 DOI: 10.1007/s00112-022-01591-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2022] [Indexed: 11/26/2022]
Abstract
Die Versorgung von Patienten mit Rhythmusstörungen hat sich in den letzten Jahrzehnten von einer rein konservativ medikamentösen Therapie zu einer echten kurativen Therapie mit Beseitigung des arryhthmogenen Substrats durch technisch immer ausgereiftere Möglichkeiten im Sinn der elektrophysiologische Untersuchung (EPU) und Ablation entwickelt. Parallel dazu haben sich in pädiatrisch-kardiologischen Zentren rhythmologische Spezialambulanzen zur Betreuung von Patienten mit Ionenkanalerkrankungen etabliert. Deren Aufgabe besteht in der generationenübergreifenden Betreuung von ganzen Familien, mit dem Ziel, präventiv, durch entsprechende Beratung und Führung, maligne Rhythmusstörungen primär zu verhindern.
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Affiliation(s)
- Manfred Marx
- Klinische Abteilung für Pädiatrische Kardiologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18–20, 1090 Wien, Österreich
| | - Matthias Gass
- Klinische Abteilung für Pädiatrische Kardiologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18–20, 1090 Wien, Österreich
- Pädiatrische Kardiologie, Universitäts-Kinderklinik Zürich, Zürich, Schweiz
| | - Ina Michel-Behnke
- Klinische Abteilung für Pädiatrische Kardiologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18–20, 1090 Wien, Österreich
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5
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Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2021; 41:655-720. [PMID: 31504425 DOI: 10.1093/eurheartj/ehz467] [Citation(s) in RCA: 518] [Impact Index Per Article: 172.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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6
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Fröemming Junior C, Leiria TLL, Lima GGD, Pires LM, Kruse ML, Moreira TC, Pinos JFV, Finkler BS, Zanotta DB. A Brief review of the risks and the stratification of sudden death in the ventricular Pre-excitation syndrome. JOURNAL OF CARDIAC ARRHYTHMIAS 2020. [DOI: 10.24207/jca.v33i4.3400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective: The diagnosis of ventricular preexcitation syndromes is often occasional and with underestimated risk, showing controversies in its stratification and indication of prophylactic ablation. This work aims to explore and summarize the data in the literature, exposing the authors’ conclusions regarding this review. Methods: The authors prepared this work based on the latest guideline of the European Society of Cardiology plus a search for articles published in MEDLINE whose titles related to sudden death from ventricular fibrillation in patients with ventricular preexcitation. Discussion: Sudden death secondary to preexcited atrial fibrillation with degeneration to ventricular fibrillation is the most feared event in Wolff-Parkinson-White syndrome, has an average annual incidence of 0.15 to 0.39%, affecting individuals with structurally normal heart. The noninvasive stratification methods do not demonstrate adequate efficacy, and an electrophysiological study is recommended for all cases at the time of diagnosis. The most severe criteria for sudden death are shortest preexcited RR interval ≤ 250 ms (SPERRI or SPRRI); accessory pathway effective refractory period (APERP) ≤ 250 ms; presence of multiple accessory bundles; shortest paced cycle length with preexcitation during atrial pacing ≤ 250ms (SPPCL); Ebstein anomaly; induction of sustained supraventricular tachycardia. Conclusion: The low rate of complications during the diagnostic exam as well as in the therapeutic procedure, added to the high percentage of success of radiofrequency ablation, leads to indicate early the execution of electrophysiological study as a more diligent and accurate measure in the reduction of sudden death events in patients with ventricular preexcitation syndromes.
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Affiliation(s)
| | - Tiago Luiz Luz Leiria
- Instituto de Cardiologia – Fundação Universitária de Cardiologia – Porto Alegre/RS – Brazil
| | - Gustavo Glotz de Lima
- Instituto de Cardiologia – Fundação Universitária de Cardiologia – Porto Alegre/RS – Brazil
| | - Leonardo Martins Pires
- Instituto de Cardiologia – Fundação Universitária de Cardiologia – Porto Alegre/RS – Brazil
| | - Marcelo Lapa Kruse
- Instituto de Cardiologia – Fundação Universitária de Cardiologia – Porto Alegre/RS – Brazil
| | - Thiago Camargo Moreira
- Instituto de Cardiologia – Fundação Universitária de Cardiologia – Porto Alegre/RS – Brazil
| | | | - Bruno Schaaf Finkler
- Instituto de Cardiologia – Fundação Universitária de Cardiologia – Porto Alegre/RS – Brazil
| | - Danilo Barros Zanotta
- Instituto de Cardiologia – Fundação Universitária de Cardiologia – Porto Alegre/RS – Brazil
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7
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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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8
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Abela M, Sharma S. Electrocardiographic interpretation in athletes. Minerva Cardiol Angiol 2020; 69:533-556. [PMID: 33059398 DOI: 10.23736/s2724-5683.20.05331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Participation in regular exercise of moderate intensity is associated with a plethora of systemic benefits, including a reduction in risk factors for coronary atherosclerosis; however, intensive exercise may paradoxically culminate in sudden cardiac arrest among individuals harboring arrhythmogenic substrates. The precise mechanism for arrhythmogenesis is likely multifactorial, however, surges in catecholamines, electrolyte shifts, acid-base disturbances, increased core temperature and demand myocardial ischemia are potential contributors. Although most deaths occur in middle aged and older males with atherosclerotic coronary artery disease, a significant proportion also affect young athletes with inherited or congenital cardiac abnormalities. The impact of such catastrophes on society, particularly when a young high-profile athlete is affected could be considered a justified reason for identifying individuals who may be at risk. Given the rarity of deaths in young athletes, only the simplest screening test, such as the 12-lead electrocardiography (ECG) may be considered to be cost effective. The ECG is effective for detecting serious electrical diseases in young athletes such as congenital electrical accessory pathways and ion channel diseases but can also identify athletes with potential life-threatening structural diseases such as hypertrophic and arrhythmogenic cardiomyopathy. One of the concerns about ECG screening is that regular intensive exercise results in several physiological alterations in cardiac structure and function that are reflected on the athlete's ECG. Sinus bradycardia, first-degree atrioventricular block, incomplete right bundle branch block, minor J-point elevation and large QRS voltages are common. Conversely, some repolarization anomalies affecting the ST segment, T waves and QT interval may overlap with patterns observed in patients with serious cardiac diseases. The situation is complicated further because age, sex and ethnicity of the athletes also influence the ECG and there is a risk that erroneous interpretation could have serious consequences. This review will describe the normal electrical patterns of the "athlete's heart" and provide insights into differentiation physiological electrical patterns from those observed in serious cardiac disease.
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Affiliation(s)
- Mark Abela
- Department of Cardiology, Mater Dei Hospital, Msida, Malta - .,Malta Medical School, University of Malta, Msida, Malta - .,St. George's University Hospitals, NHS Foundation Trust, St George's University, London, UK -
| | - Sanjay Sharma
- St. George's University Hospitals, NHS Foundation Trust, St George's University, London, UK
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9
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Babayiğit E, Ulus T, Görenek B. What Have We Learned from the European Society of Cardiology 2019 Guidelines on Supraventricular Tachycardia. Cardiology 2020; 145:492-503. [DOI: 10.1159/000508264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022]
Abstract
Supraventricular tachycardias (SVTs) are common arrhythmic conditions in clinical practice. Increased knowledge and experience on SVTs and some unclear situations in clinical practice led the European Society of Cardiology (ESC) team to write a new guideline. In this review, we touch upon the important points in the new ESC 2019 SVT guidelines and present changing approaches and suggestions. By providing a general review on SVTs, we also mention the basic mechanism, epidemiology, and clinical presentation of SVTs, approaching narrow and wide QRS tachycardias, SVTs in special patient groups, and treatment of SVTs.
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10
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Abela M, Sharma S. Abnormal ECG Findings in Athletes: Clinical Evaluation and Considerations. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:95. [PMID: 31865466 DOI: 10.1007/s11936-019-0794-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Pre-participation cardiovascular evaluation with electrocardiography is normal practice for most sporting bodies. Awareness about sudden cardiac death in athletes and recognizing how screening can help identify vulnerable athletes have empowered different sporting disciplines to invest in the wellbeing of their athletes. RECENT FINDINGS Discerning physiological electrical alterations due to athletic training from those representing cardiac pathology may be challenging. The mode of investigation of affected athletes is dependent on the electrical anomaly and the disease(s) in question. This review will highlight specific pathological ECG patterns that warrant assessment and surveillance, together with an in-depth review of the recommended algorithm for evaluation.
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Affiliation(s)
- Mark Abela
- Cardiology Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK.
- University of Malta, Msida, Malta.
| | - Sanjay Sharma
- Cardiology Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
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11
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Sharma S, Drezner JA, Baggish A, Papadakis M, Wilson MG, Prutkin JM, La Gerche A, Ackerman MJ, Borjesson M, Salerno JC, Asif IM, Owens DS, Chung EH, Emery MS, Froelicher VF, Heidbuchel H, Adamuz C, Asplund CA, Cohen G, Harmon KG, Marek JC, Molossi S, Niebauer J, Pelto HF, Perez MV, Riding NR, Saarel T, Schmied CM, Shipon DM, Stein R, Vetter VL, Pelliccia A, Corrado D. International recommendations for electrocardiographic interpretation in athletes. Eur Heart J 2019; 39:1466-1480. [PMID: 28329355 DOI: 10.1093/eurheartj/ehw631] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 12/08/2016] [Indexed: 12/14/2022] Open
Abstract
Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.
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Affiliation(s)
- Sanjay Sharma
- Cardiology Clinical Academic Group, St George's, University of London, UK
| | - Jonathan A Drezner
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Aaron Baggish
- Division of Cardiology, Massachusettes General Hospital, MA, USA
| | - Michael Papadakis
- Cardiology Clinical Academic Group, St George's, University of London, UK
| | - Mathew G Wilson
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Qatar
| | - Jordan M Prutkin
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Andre La Gerche
- Department of Cardiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Michael J Ackerman
- Department of Cardiovascular Diseases, Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, MN, USA
| | - Mats Borjesson
- Department of Neuroscience and Physiology, Sahlgrenska University Hospital/Ostra Sahlgrenska Academy, Goteborg, Sweden
| | - Jack C Salerno
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Irfan M Asif
- Department of Family Medicine, University of South Carolina, Greenville, SC, USA
| | - David S Owens
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Eugene H Chung
- Division of Cardiology, University of North Carolina School of Medicine, NC, USA
| | - Michael S Emery
- Center of Cardiovascular Care in Athletics, Indiana University School of Medicine, IN, USA
| | | | - Hein Heidbuchel
- Department of Cardiology, Arrhythmology Hasselt University, Hasselt, Belgium.,Department of Cardiology, Antwerp, Belgium
| | - Carmen Adamuz
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Qatar
| | | | - Gordon Cohen
- Division of Pediatric Cardiothoracic Surgery, University of California San Francisco School of Medicine, CA, USA
| | - Kimberly G Harmon
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | | | - Silvana Molossi
- Division of Pediatric Cardiology, Baylor College of Medicine, TX, USA
| | - Josef Niebauer
- University Institute of Sports Medicine, Paracelsus Medical University, Austria
| | - Hank F Pelto
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Marco V Perez
- Center for Inherited Cardiovascular Disease, Stanford University, CA, USA
| | - Nathan R Riding
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Qatar
| | - Tess Saarel
- Pediatric Cardiology, Cleveland Clinic, OH, USA
| | | | - David M Shipon
- Heart Center of Philadelphia, Jefferson University Hospitals, PA, USA
| | - Ricardo Stein
- Department of Cardiology, Hospital de Clinicas de Porte Allegre, Brazil
| | | | | | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Italy
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12
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Management of asymptomatic ventricular preexcitation. Indian Pacing Electrophysiol J 2019; 19:232-239. [PMID: 31669128 PMCID: PMC6904806 DOI: 10.1016/j.ipej.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/19/2019] [Indexed: 11/24/2022] Open
Abstract
An incidental discovery of Wolff Parkinson White (WPW) pattern on the electrocardiogram (ECG) is not an infrequent finding facing the physician. Most patients discovered incidentally are asymptomatic and it is hard to justify further management of such patients given the time-honored adage to “first do no harm.” However, this finding does have implications. This article is an attempt to guide clinicians about this important issue that is often faced in the office.
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13
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Schnell F. [ECG in sportsmen: Distinguishing the normal from the pathological]. Presse Med 2019; 48:1393-1400. [PMID: 31471091 DOI: 10.1016/j.lpm.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 07/01/2019] [Indexed: 11/18/2022] Open
Abstract
An ECG is recommended by the French Society of Cardiology in the screening of a competitive athlete. An intense and prolonged physical activity (>4 hours of intense sport/week) can lead to a physiological electric remodeling. In addition to physical activity (type, intensity, duration), the ECG should be interpreted according to the athlete's ethnicity and age. It is necessary to know the physiological modifications related to sport practice to avoid either false reassurances or the realization of unjustified additional examinations because of a wrong interpretation. The latest athlete ECG classification published in 2017 can be used to identify in which athlete additional tests are recommended (figure 1).
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Affiliation(s)
- Frédéric Schnell
- CHU de Rennes, Université de Rennes 1, hôpital Pontchaillou, service de médecine du sport, LTSI-UMR, Inserm, 1099 Rennes, France.
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14
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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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15
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Sharma S, Drezner JA, Baggish A, Papadakis M, Wilson MG, Prutkin JM, La Gerche A, Ackerman MJ, Borjesson M, Salerno JC, Asif IM, Owens DS, Chung EH, Emery MS, Froelicher VF, Heidbuchel H, Adamuz C, Asplund CA, Cohen G, Harmon KG, Marek JC, Molossi S, Niebauer J, Pelto HF, Perez MV, Riding NR, Saarel T, Schmied CM, Shipon DM, Stein R, Vetter VL, Pelliccia A, Corrado D. International Recommendations for Electrocardiographic Interpretation in Athletes. J Am Coll Cardiol 2017; 69:1057-1075. [PMID: 28231933 DOI: 10.1016/j.jacc.2017.01.015] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On February 26-27, 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.
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Affiliation(s)
- Sanjay Sharma
- Cardiology Clinical and Academic Group, St George's University of London, United Kingdom.
| | - Jonathan A Drezner
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Aaron Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Papadakis
- Cardiology Clinical and Academic Group, St George's University of London, United Kingdom
| | - Mathew G Wilson
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Qatar
| | - Jordan M Prutkin
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Andre La Gerche
- Department of Cardiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Michael J Ackerman
- Department of Cardiovascular Diseases, Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Mats Borjesson
- Department of Neuroscience and Physiology, Sahlgrenska University Hospital/Ostra Sahlgrenska Academy, Goteborg, Sweden
| | - Jack C Salerno
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Irfan M Asif
- Department of Family Medicine, University of South Carolina, Greenville, South Carolina
| | - David S Owens
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Eugene H Chung
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael S Emery
- Center of Cardiovascular Care in Athletics, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Hein Heidbuchel
- Department of Cardiology, Arrhythmology Hasselt University, Belgium; Department of Cardiology, Antwerp, Belgium
| | - Carmen Adamuz
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Qatar
| | | | - Gordon Cohen
- Division of Pediatric Cardiothoracic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Kimberly G Harmon
- Department of Family Medicine, University of Washington, Seattle, Washington
| | | | - Silvana Molossi
- Division of Pediatric Cardiology, Baylor College of Medicine, Houston, Texas
| | - Josef Niebauer
- University Institute of Sports Medicine, Paracelsus Medical University, Austria
| | - Hank F Pelto
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Marco V Perez
- Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California
| | - Nathan R Riding
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Qatar
| | - Tess Saarel
- Pediatric Cardiology, Cleveland Clinic, Cleveland, Ohio
| | | | - David M Shipon
- Heart Center of Philadelphia, Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Ricardo Stein
- Department of Cardiology, Hospital de Clinicas de Porte Allegre, Brazil
| | | | | | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Italy
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Jastrzębski M, Kukla P, Pitak M, Rudziński A, Baranchuk A, Czarnecka D. Intermittent preexcitation indicates "a low-risk" accessory pathway: Time for a paradigm shift? Ann Noninvasive Electrocardiol 2017; 22. [PMID: 28497860 DOI: 10.1111/anec.12464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We report three patients with intermittent loss of the preexcitation pattern in the ECG that had undergone an electrophysiological study. Despite apparently poorly conducting accessory pathway (AP), in each case a fast anterograde conduction, either during spontaneous atrial fibrillation or during incremental atrial pacing (on isoproterenol) was documented; shortest preexcited RR intervals of 200-240 ms were observed. We review the literature and conclude that intermittent preexcitation observed on resting 12-lead ECG lacks sufficient specificity for the diagnosis of an AP with long refractory period and cannot be considered a substitute for electrophysiological study in patients with this electrocardiographical phenomenon.
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Affiliation(s)
- Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Kukla
- Department of Cardiology, H. Klimontowicz Specialistic Hospital, Gorlice, Poland
| | - Maciej Pitak
- Department of Cardiology, Institute of Pediatrics, Jagiellonian University Medical College, Cracow, Poland
| | - Andrzej Rudziński
- Department of Cardiology, Institute of Pediatrics, Jagiellonian University Medical College, Cracow, Poland
| | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Danuta Czarnecka
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Cracow, Poland
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Abstract
Risk stratification of patients with Wolff-Parkinson-White syndrome for sudden death is a complex process, particularly in understanding the utility of the repeat exercise stress test. We report a case of an 18-year-old patient who was found to have a high-risk pathway by both invasive and exercise stress testing after an initial exercise stress test showing beat-to-beat loss of pre-excitation.
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Drezner JA, Sharma S, Baggish A, Papadakis M, Wilson MG, Prutkin JM, Gerche AL, Ackerman MJ, Borjesson M, Salerno JC, Asif IM, Owens DS, Chung EH, Emery MS, Froelicher VF, Heidbuchel H, Adamuz C, Asplund CA, Cohen G, Harmon KG, Marek JC, Molossi S, Niebauer J, Pelto HF, Perez MV, Riding NR, Saarel T, Schmied CM, Shipon DM, Stein R, Vetter VL, Pelliccia A, Corrado D. International criteria for electrocardiographic interpretation in athletes: Consensus statement. Br J Sports Med 2017; 51:704-731. [PMID: 28258178 DOI: 10.1136/bjsports-2016-097331] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 01/16/2023]
Abstract
Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.
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Affiliation(s)
- Jonathan A Drezner
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Sanjay Sharma
- Cardiology Clinical Academic Group, St. George's, University of London, London, UK
| | - Aaron Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, US
| | - Michael Papadakis
- Cardiology Clinical Academic Group, St. George's, University of London, London, UK
| | - Mathew G Wilson
- Department of Sports Medicine, ASPETAR, Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Jordan M Prutkin
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Andre La Gerche
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Michael J Ackerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Department of Paediatric, Mayo Clinic, Rochester, Minnesota, USA.,Department of Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Molecular Pharmacology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Mats Borjesson
- Department of Neuroscience, Sahlgrenska University Hospital/Ostra Sahlgrenska Academy, Goteborg, Sweden.,Department of Physiology, Sahlgrenska University Hospital/Ostra Sahlgrenska Academy, Goteborg, Sweden
| | - Jack C Salerno
- Department of Pediatrics, University of Washington, Seattle, Washington, US
| | - Irfan M Asif
- Department of Family Medicine, University of South Carolina, Greenville, USA
| | - David S Owens
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Eugene H Chung
- Division of Cardiology, University of North Carolina, School of Medicine, Chapel Hill, North Carolina, USA
| | - Michael S Emery
- Center of Cardiovascular Care in Athletics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Carmen Adamuz
- Department of Sports Medicine, ASPETAR, Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | | | - Gordon Cohen
- Division of Paediatric Surgery, University of California, San Francisco School of Medicine, San Francisco, California, USA.,Division of Cardiothoracic Surgery, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Kimberly G Harmon
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | | | - Silvana Molossi
- Division of Pediatric, Baylor College of Medicine, Houston, Texas, USA.,Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Josef Niebauer
- University Institute of Sports Medicine, Research Institute of Molecular Sports Medicine and Rehabilitation, Paracelsus Medical University, Salzburg, Austria
| | - Hank F Pelto
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Marco V Perez
- Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California, USA
| | - Nathan R Riding
- Department of Sports Medicine, ASPETAR, Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Tess Saarel
- Department of Pediatrics, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - David M Shipon
- Heart Centre of Philadelphia, Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ricardo Stein
- Department of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Victoria L Vetter
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Domenico Corrado
- Department of Cardiac Science, University of Padua Medical School, Padua, Italy.,Department of Thoracic Sciences, University of Padua Medical School, Padua, Italy.,Department of Vascular Sciences, University of Padua Medical School, Padua, Italy
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Abstract
The Wolff-Parkinson-White pattern refers to the electrocardiographic appearance in sinus rhythm, wherein an accessory atrioventricular pathway abbreviates the P-R interval and causes a slurring of the QRS upslope - the "delta wave". It may be asymptomatic or it may be associated with orthodromic reciprocating tachycardia; however, rarely, even in children, it is associated with sudden death due to ventricular fibrillation resulting from a rapid response by the accessory pathway to atrial fibrillation, which itself seems to result from orthodromic reciprocating tachycardia. Historically, patients at risk for sudden death were characterised by the presence of symptoms and a shortest pre- excited R-R interval during induced atrial fibrillation <250 ms. Owing to the relatively high prevalence of asymptomatic Wolff-Parkinson-White pattern and availability of catheter ablation, there has been a need to identify risk among asymptomatic patients. Recent guidelines recommend invasive evaluation for such patients where pre-excitation clearly does not disappear during exercise testing. This strategy has a high negative predictive value only. The accuracy of this approach is under continued investigation, especially in light of other considerations: Patients having intermittent pre-excitation, once thought to be at minimal risk may not be, and the role of isoproterenol in risk assessment.
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20
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Evaluation and Management of the Asymptomatic Child with Wolff–Parkinson–White. CURRENT PEDIATRICS REPORTS 2016. [DOI: 10.1007/s40124-016-0096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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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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Electrophysiology testing and catheter ablation are helpful when evaluating asymptomatic patients with Wolff-Parkinson-White pattern: the con perspective. Card Electrophysiol Clin 2015; 7:377-83. [PMID: 26304516 DOI: 10.1016/j.ccep.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The association between asymptomatic Wolff-Parkinson-White (WPW) syndrome and sudden cardiac death (SCD) has been well documented. The inherent properties of the accessory pathway determine the risk of SCD in WPW, and catheter ablation essentially eliminates this risk. An approach to WPW syndrome is needed that incorporates the patient's individualized considerations into the decision making. Patients must understand that there is a trade-off of a small immediate risk of an invasive approach for elimination of a small lifetime risk of the natural history of asymptomatic WPW. Clinicians can minimize the invasive risk by only performing ablation for patients with at-risk pathways.
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Dalili M, Vahidshahi K, Aarabi-Moghaddam MY, Rao JY, Brugada P. Exercise testing in children with Wolff-Parkinson-White syndrome: what is its value? Pediatr Cardiol 2014; 35:1142-6. [PMID: 24728424 DOI: 10.1007/s00246-014-0907-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/25/2014] [Indexed: 11/26/2022]
Abstract
This study was conducted to evaluate the accuracy of exercise testing for predicting accessory pathway characteristics in children with Wolff-Parkinson-White (WPW) syndrome. The study enrolled 37 children with WPW syndrome and candidates for invasive electrophysiologic study (EPS). Exercise testing was performed for all the study participants before the invasive study. Data from the invasive EPS were compared with findings from the exercise testing. The sudden disappearance of the delta (Δ) wave was seen in 10 cases (27 %). No significant correlation was found between the Δ wave disappearance and the antegrade effective refractory period of the accessory pathway (AERP-AP) or the shortest pre-excited RR interval (SPERRI). The sensitivity, specificity, and positive and negative predictive values of Δ wave disappearance, based on AERP-AP as gold standard, were respectively 29.4, 80, 71.4, and 40 %. The corresponding values with SPERRI as the gold standard were respectively 23.8, 71.4, 71.4 and 23.8 %. Exercise testing has a medium to low rate of accuracy in detecting low-risk WPW syndrome patients in the pediatric age group.
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Affiliation(s)
- M Dalili
- Rajaie Cardiovascular Medical and Research Center, Tehran, Islamic Republic of Iran,
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24
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25
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Kubuš P, Vít P, Gebauer RA, Materna O, Janoušek J. Electrophysiologic Profile and Results of Invasive Risk Stratification in Asymptomatic Children and Adolescents With the Wolff–Parkinson–White Electrocardiographic Pattern. Circ Arrhythm Electrophysiol 2014; 7:218-23. [DOI: 10.1161/circep.113.000930] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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.
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Affiliation(s)
- Peter Kubuš
- From the Children’s Heart Center, University Hospital, Motol, Prague (P.K., O.M., J.J.); Pediatric Cardiology, Children’s University Hospital Brno, Brno, Czech Republic (P.V.); Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany (R.A.G.)
| | - Pavel Vít
- From the Children’s Heart Center, University Hospital, Motol, Prague (P.K., O.M., J.J.); Pediatric Cardiology, Children’s University Hospital Brno, Brno, Czech Republic (P.V.); Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany (R.A.G.)
| | - Roman A. Gebauer
- From the Children’s Heart Center, University Hospital, Motol, Prague (P.K., O.M., J.J.); Pediatric Cardiology, Children’s University Hospital Brno, Brno, Czech Republic (P.V.); Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany (R.A.G.)
| | - Ondřej Materna
- From the Children’s Heart Center, University Hospital, Motol, Prague (P.K., O.M., J.J.); Pediatric Cardiology, Children’s University Hospital Brno, Brno, Czech Republic (P.V.); Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany (R.A.G.)
| | - Jan Janoušek
- From the Children’s Heart Center, University Hospital, Motol, Prague (P.K., O.M., J.J.); Pediatric Cardiology, Children’s University Hospital Brno, Brno, Czech Republic (P.V.); Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany (R.A.G.)
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26
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Obeyesekere MN, Sy RW, Modi S. When can ablation be considered a reasonable option in young asymptomatic patients with a Wolff–Parkinson–White ECG? Expert Rev Cardiovasc Ther 2014; 10:1451-3. [DOI: 10.1586/erc.12.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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WACKEL PHILIP, IRVING CLAIRE, WEBBER STEVEN, BEERMAN LEE, ARORA GAURAV. Risk Stratification in Wolff-Parkinson-White Syndrome: The Correlation Between Noninvasive and Invasive Testing in Pediatric Patients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1451-7. [DOI: 10.1111/j.1540-8159.2012.03518.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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30
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Hoyt WJ, Thomas PE, DeSena HC, Steinberg JS, Harmon DE, Snyder CS. Atrial fibrillation induction by transesophageal electrophysiology studies in patients with asymptomatic ventricular preexcitation. CONGENIT HEART DIS 2012; 8:57-61. [PMID: 22716259 DOI: 10.1111/j.1747-0803.2012.00689.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Ventricular preexcitation is a conduction abnormality caused by an accessory pathway bridging the atria and ventricles. If the accessory pathway conducts rapidly during atrial fibrillation (AFib), sudden death may result. The purpose of this study was to determine the ability of transesophageal electrophysiology studies (TEEPS) to induce AFib in pediatric patients with asymptomatic ventricular preexcitation (aVPE). DESIGN A retrospective review of patients with aVPE who had a TEEPS was conducted. Inclusion criteria were evidence of ventricular preexcitation on electrocardiogram; age <18 years; and no history of tachycardia, palpitations, or syncope. Data gathered included age, weight, height, form of sedation, and TEEPS results. If AFib was induced, patients were classified as at risk of sudden death if the shortest preexcited RR interval during AFib was <250 ms or no risk if ≥ 250 ms. RESULTS A total of 26 patients met the inclusion criteria, with average age of 11.9 years, weight of 48.9 kg, and height of 149.2 cm. During the procedure, nine patients underwent conscious sedation (34.6%), and 17 underwent general anesthesia (65.4%). AFib was induced in 23 patients (88.5%), of whom 17 (73.9%) had no risk and six (26.1%) had risk. No statistical differences were noted in age, weight, height, or form of sedation when comparisons were made between AFib induction and no AFib induction. CONCLUSIONS TEEPS induced AFib in 88.5% of patients. Age, weight, height, and form of sedation had no effect upon AFib inducibility. TEEPS is an effective modality to induce AFib in pediatric patients with aVPE.
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Affiliation(s)
- Walter J Hoyt
- Department of Pediatrics, Tulane University, New Orleans, LA, USA
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Hoyt WJ, Thomas PE, Snyder CS. Induction of atrial fibrillation with adenosine during a transesophageal electrophysiology study to risk stratify a patient with asymptomatic ventricular preexcitation. CONGENIT HEART DIS 2012; 8:E99-E101. [PMID: 22676712 DOI: 10.1111/j.1747-0803.2012.00682.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
An asymptomatic adolescent male athlete was incidentally found to have ventricular preexcitation on electrocardiogram during a sports preparticipation physical. A transesophageal electrophysiology study (TEEPS) was performed after an exercise stress test failed to delineate the patient's risk of sudden cardiac death. The TEEPS was favored in this case over a transvenous electrophysiology study due to reduced invasiveness. The goal of the TEEPS was to place the patient into atrial fibrillation (AFib) and evaluate the shortest preexcited RR interval during AFib, thereby assessing the risk of his accessory pathway. Conventional pacing modalities were unable to induce AFib. During atrial burst pacing, adenosine was then administered, which successfully induced AFib. This case highlights adenosine's potential to induce atrial fibrillation during transesophageal electrophysiology studies when atrial pacing alone was unable to do so.
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Affiliation(s)
- Walter J Hoyt
- Department of Pediatrics, Tulane University, New Orleans, LA, USA
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32
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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; 9:1006-24. [PMID: 22579340 DOI: 10.1016/j.hrthm.2012.03.050] [Citation(s) in RCA: 218] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Indexed: 10/28/2022]
Affiliation(s)
-
- Arizona Pediatric Cardiology Consultants & Phoenix Children's Hospital, Phoenix, AZ, USA
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Spar DS, Silver ES, Hordof AJ, Liberman L. Relation of the utility of exercise testing for risk assessment in pediatric patients with ventricular preexcitation to pathway location. Am J Cardiol 2012; 109:1011-4. [PMID: 22221954 DOI: 10.1016/j.amjcard.2011.11.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 11/11/2011] [Accepted: 11/11/2011] [Indexed: 10/14/2022]
Abstract
The gradual loss of ventricular preexcitation during exercise stress testing (EST) has an unclear risk of an association with life-threatening arrhythmia and could be related to the accessory pathway (AP) location. We compared the loss of preexcitation during EST with the risk assessment during invasive electrophysiology testing and determined whether the loss of preexcitation correlates with the AP location. We retrospectively reviewed patients aged ≤21 years with ventricular preexcitation who had undergone both EST and an electrophysiology study. The patients were divided into 3 groups: sudden loss (SL), gradual loss (GL), or no loss (NL) of preexcitation during EST. A total of 76 patients were included, with 11 (14%) in the SL group, 18 (24%) in the GL group, and 47 (62%) in the NL group. The SL group demonstrated a longer cycle length with 1-to-1 conduction by way of the AP during incremental atrial pacing compared with the NL group (375 ± 135 ms vs 296 ± 52 ms, p = 0.002), with no difference between the GL and NL groups (325 ± 96 vs 296 ± 52 ms, p = NS). Of the patients with 1-to-1 AP conduction of <270 ms, none (0 of 11) were in the SL group compared to 18 of 47 in the NL group (p = 0.0017), with no significant difference in the GL group (5 of 18) compared to the NL group (p = NS). The patients in the GL group were more likely to have a left-sided AP (14 of 18) than the NL group (17 of 47, p = 0.002) and the SL group (3 of 11, p = 0.002). In conclusion, a sudden loss of preexcitation during an EST predicted a long cycle length with 1-to-1 conduction by way of the AP. Also, the AP conduction characteristics in patients with GL compared to those with NL did not differ, and the GL of preexcitation was more frequently seen in patients with a left-sided AP.
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36
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Zardini M, Yee R, Thakur RK, Klein GJ. Risk of sudden arrhythmic death in the Wolff-Parkinson-White syndrome: current perspectives. Pacing Clin Electrophysiol 1994; 17:966-75. [PMID: 7517532 DOI: 10.1111/j.1540-8159.1994.tb01440.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- M Zardini
- Department of Medicine, University of Western Ontario, London, Canada
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Middlekauff HR, Stevenson WG, Klitzner TS. Linking: a mechanism of intermittent preexcitation in the Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol 1990; 13:1629-36. [PMID: 1704516 DOI: 10.1111/j.1540-8159.1990.tb06865.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Intermittent preexcitation in the Wolff-Parkinson-White syndrome has been equated with a long accessory pathway refractory period and long R-R interval between preexcited beats in atrial fibrillation and therefore a low risk for sudden death. A case of Wolff-Parkinson-White syndrome in which preexcitation became intermittent following procainamide infusion, with only moderate prolongation of the accessory pathway refractory period but marked prolongation of the shortest preexcited R-R interval in atrial fibrillation, is described. Programmed ventricular and atrial stimulation demonstrated that intermittent preexcitation was caused by concealed conduction producing a linking phenomenon, facilitated by the antiarrhythmic drug. Linking due to concealed retrograde penetration of a propagated impulse into the accessory pathway may contribute to the disparity between accessory pathway refractory period and shortest preexcited R-R interval in atrial fibrillation in some patients and may be a confounding factor in the interpretation of noninvasive tests of accessory pathway conduction.
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Yamamoto T, Yeh SJ, Lin FC, Wu DL. Effects of isoproterenol on accessory pathway conduction in intermittent or concealed Wolff-Parkinson-White syndrome. Am J Cardiol 1990; 65:1438-42. [PMID: 2353648 DOI: 10.1016/0002-9149(90)91351-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The effects of isoproterenol on accessory pathway conduction were evaluated in 24 patients with intermittent and 60 patients with concealed pre-excitation, using atrial and ventricular incremental and extrastimulus testing techniques. The atrial paced cycle length that induced block in the accessory pathway could be compared in 11 of the 24 patients with intermittent preexcitation before and after isoproterenol; it decreased from 622 +/- 212 ms to 408 +/- 128 ms (mean +/- standard deviation) after isoproterenol (p less than 0.01). The anterograde effective refractory period of the accessory pathway could be compared in 5 patients before and after isoproterenol; it decreased from 460 +/- 131 to 310 +/- 48 ms after isoproterenol (p less than 0.01). None of the 60 patients with concealed preexcitation showed ventricular preexcitation with isoproterenol infusion. Eighty-one of the 84 patients had clinically documented supraventricular tachycardia, suggesting the accessory pathway was capable of retrograde conduction. Retrograde study was performed in all 84 patients; 83 had retrograde conduction and the other had no retrograde conduction before and after isoproterenol. The ventricular paced cycle length that induced block in the accessory pathway could be compared in 38 patients before and after isoproterenol; it decreased from 342 +/- 71 to 296 +/- 39 ms after isoproterenol (p less than 0.001). The retrograde effective refractory period of the accessory pathway could be compared in 56 patients; it decreased from 293 +/- 76 to 238 +/- 36 ms after isoproterenol (p less than 0.001). In conclusion, isoproterenol facilitates anterograde and retrograde accessory pathway conduction, but the facilitation of anterograde conduction occurs only in those capable of spontaneous conduction.
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Affiliation(s)
- T Yamamoto
- Department of Medicine, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, Republic of China
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