Prophylactic Radiofrequency Ablation in Asymptomatic Patients With Wolff–Parkinson–White Is Not Yet a Good Strategy

Comparison of Outcomes of Catheter Ablation in Asymptomatic Versus Symptomatic Preexcitation to Guidelines and Beyond

Management of asymptomatic subjects with preexcitation remains controversial. Our objective was to analyze the reasons an electrophysiological study (EPS) was performed in an asymptomatic population referred for the procedure, and compare the results of catheter ablation between asymptomatic and symptomatic patients. Patients ≥18 years of age with preexcitation referred for an EPS and ablation were grouped as either symptomatic or asymptomatic. We analyzed in both subsets for (1) reasons for the procedure, (2) EPS results (anterograde effective refractory period of the accessory pathway, tachycardia/atrial fibrillation inducibility, anatomical localization), (3) success of the procedure, and (4) incidence of complications. We included 175 patients, 121 of which were symptomatic (39 ± 16 years) and 54 were asymptomatic (35 ± 14 years, p = NS not significant). The most frequent symptoms were palpitations (87%) and syncope (7%). EPS was performed in 44 of 54 asymptomatic patients mainly because of involvement in sports (60%) or high-risk employment (14%). Anterograde effective refractory period was significantly longer in asymptomatic patients (314 ± 55 milliseconds) than in symptomatic patients (278 ± 46 milliseconds; p <0.001). Orthodromic tachycardia inducibility was significantly higher in symptomatic than in asymptomatic patients (69% and 27%, respectively; p <0.001). A total of 170 accessory pathways (49% left free wall, 12% right free wall, 39% septal) were observed without significant differences in the anatomical location between groups. Catheter ablation was attempted in all patients, succeeding in 98% of symptomatic and 95% of asymptomatic patients, without major complications in either group. In conclusion, the reasons for invasive evaluation of asymptomatic patients with preexcitation may be outside the scope of current guidelines. Catheter ablation produces excellent results without major complications.

Clinical Approach to Symptomatic and Asymptomatic Patients with Ventricular Pre-excitation

Despite extensive knowledge of the physiopathology of ventricular pre-excitation, management of asymptomatic patients with this condition remains controversial.

Catheter ablation in ASymptomatic PEDiatric patients with ventricular preexcitation: results from the multicenter "CASPED" study

BACKGROUND

As there are limited data about the clinical practice of catheter ablation in asymptomatic children and adolescents with ventricular preexcitation on ECG, we performed the multicenter "CASPED" (Catheter ablation in ASymptomatic PEDiatric patients with Ventricular Preexcitation) study.

METHODS AND RESULTS

In 182 consecutive children and adolescents aged between 8 and 18 years (mean age 12.9 ± 2.6 years; 65% male) with asymptomatic ventricular preexcitation, a total of 196 accessory pathways (APs) were targeted. APs were right sided (62%) or left sided (38%). The most common right-sided AP location was the posteroseptal region (38%). Ablation was performed using radiofrequency (RF) energy (93%), cryoablation (4%) or both (3%). Mean procedure time was 137.6 ± 62.0 min with a mean fluoroscopy time of 15.6 ± 13.8 min. A 3D mapping or catheter localization system was used in 32% of patients. Catheter ablation was acutely successful in 166/182 patients (91.2%). Mortality was 0% and there were no major periprocedural complications. AP recurrence was observed in 14/166 patients (8.4%) during a mean follow-up time of 19.7 ± 8.5 months. A second ablation attempt was performed in 20 patients and was successful in 16/20 patients (80%). Overall, long-term success rate was 92.3%.

CONCLUSION

In this retrospective multicenter study, the outcome of catheter ablation for asymptomatic preexcitation in children and adolescents irrespective of antegrade AP conduction properties is summarized. The complication rate was low and success rate was high, the latter mainly depending on pathway location. The promising results of the study may have future impact on the ongoing risk-benefit discussion regarding catheter ablation in the setting of asymptomatic preexcitation in children and adolescents.

Asymptomatic Ventricular Pre-excitation: Between Sudden Cardiac Death and Catheter Ablation

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.

Risk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre-Excitation: A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia

Objective—

To review the literature systematically to determine whether noninvasive or invasive risk stratification, such as with an electrophysiological study of patients with asymptomatic pre-excitation, reduces the risk of arrhythmic events and improves patient outcomes.

Methods—

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (all January 1, 1970, through August 31, 2014) were searched for randomized controlled trials and cohort studies examining noninvasive or invasive risk stratification in patients with asymptomatic pre-excitation. Studies were rejected for low-quality design or the lack of an outcome, population, intervention, or comparator of interest or if they were written in a language other than English.

Results—

Of 778 citations found, 9 studies met all the eligibility criteria and were included in this paper. Of the 9 studies, 1 had a dual design—a randomized controlled trial of ablation versus no ablation in 76 patients and an uncontrolled prospective cohort of 148 additional patients—and 8 were uncontrolled prospective cohort studies (n=1594). In studies reporting a mean age, the range was 32 to 50 years, and in studies reporting a median age, the range was 19 to 36 years. The majority of patients were male (range, 50% to 74%), and <10% had structural heart disease. In the randomized controlled trial component of the dual-design study, the 5-year Kaplan-Meier estimates of the incidence of arrhythmic events were 7% among patients who underwent ablation and 77% among patients who did not undergo ablation (relative risk reduction: 0.08; 95% confidence interval: 0.02 to 0.33; P <0.001). In the observational cohorts of asymptomatic patients who did not undergo catheter ablation (n=883, with follow-up ranging from 8 to 96 months), regular supraventricular tachycardia or benign atrial fibrillation (shortest RR interval >250 ms) developed in 0% to 16%, malignant atrial fibrillation (shortest RR interval ≤250 ms) in 0% to 9%, and ventricular fibrillation in 0% to 2%, most of whom were children in the last case.

Conclusions—

The existing evidence suggests risk stratification with an electrophysiological study of patients with asymptomatic pre-excitation may be beneficial, along with consideration of accessory-pathway ablation in those deemed to be at high risk of future arrhythmias. Given the limitations of the existing data, well-designed and well-conducted studies are needed.

SUDDEN CARDIAC DEATH AND WOLFF-PARKINSON-WHITE ELECTROCARDIOGRAPHIC PATTERN: A REVIEW

The causes of sudden cardiac death in patients with Wolff-Parkinson-White syndrome are considered; necessity of endocardial electrophysiological study and radiofrequency catheter ablation is discussed, including asymptomatic patients with accessory pathways.

Decision tree analysis of traditional risk factors of carotid atherosclerosis and a cutpoint-based prevention strategy

BACKGROUND

Reducing the exposure to risk factors for the prevention of cardio-cerebral vascular disease is a crucial issue. Few reports have described practical interventions for preventing cardiovascular disease in different genders and age groups, particularly detailed and specific cutpoint-based prevention strategies.

METHODS

We collected the health examination data of 5822 subjects between 20 and 80 years of age. The administration of medical questionnaires and physical examinations and the measurement of blood pressure, fasting plasma glucose (FPG) and blood lipids [total cholesterol (TC), triglycerides (TG), high density lipoprotein-cholesterol (HDL-C), and low density lipoprotein-cholesterol (LDL-C)] were performed by physicians. Carotid ultrasound was performed to examine the carotid intima-media thickness (CIMT), which was defined as carotid atherosclerosis when CIMT ≥0.9 mm. Decision tree analysis was used to screen for the most important risk factors for carotid atherosclerosis and to identify the relevant cutpoints.

RESULTS

In the study population, the incidence of carotid atherosclerosis was 12.20% (men: 14.10%, women: 9.20%). The statistical analysis showed significant differences in carotid atherosclerosis incidence between different genders (P<0.0001) and age groups (P<0.001). The decision tree analysis showed that in men, the most important traditional risk factors for carotid atherosclerosis were TC (cutpoint [CP]: 6.31 mmol/L) between the ages of 20-40 and FPG (CP: 5.79 mmol/L) between the ages of 41-59. By comparison, LDL-C (CP: 4.27 mmol/L) became the major risk factor when FPG ≤5.79 mmol/L. FPG (CP: 5.52 mmol/L) and TG (CP: 1.51 mmol/L) were the most important traditional risk factors for women between 20-40 and 41-59 years of age, respectively.

CONCLUSION

Traditional risk factors and relevant cutpoints were not identical in different genders and age groups. A specific gender and age group-based cutpoint strategy might contribute to preventing cardiovascular disease.