Asymptomatic WPW in Children and Adolescents

8/10/2019 Asymptomatic WPW in Children and Adolescents

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DOI: 10.1161/CIRCEP.113.000930

Electrophysiologic Profile and Results of Invasive Risk Stratification in

Asymptomatic Children and Adolescents with the Wolff-Parkinson-White

Electrocardiographic Pattern

Running title: Kubuš et al.; Risk stratification in children with WPW pattern

Peter Kubuš, MD1; Pavel Vít, MD2; Roman A. Gebauer, MD3; 1;

Jan Janoušek, MD, PhD1

1 Children’s Heart Center, University Hospital Motol, Prague;2Pediatric Cardiology, Children’sUniversity Hospital Brno, Brno, Czech Republic;3Department of Pediatric Cardiology,

University of Leipzig, Heart Center, Leipzig, Germany

s eart C tr , U iver i s ital ot l, r g e diatr ic C rd o , Ch l

rsity osp tal Br o, Br o, Czech

R u ; De artment of Pediatri Cardiolog

r p rt t

p ,



DOI: 10.1161/CIRCEP.113.000930

Abstract:

Background - Data on the results and clinical impact of an invasive risk stratification strategy inasymptomatic young patients with the Wolff-Parkinson-White (WPW) electrocardiographic pattern are scarce. Methods and Results - 85 consecutive patients aged <18 years with a WPW pattern and persistent preexcitation at maximum exercise undergoing invasive risk stratification wereretrospectively studied. Adverse accessory pathway (AP) properties were defined according tocurrently consented criteria as any of the following: shortest preexcited RR interval (SPERRI)during atri

-entrant tachycardia.Age at evaluation was median 14.9 years. 82 patients had a structurally normal heart and 3 had

hypertrophic cardiomyopathy. A single manifest AP was present in 80, one manifest and 1concealed AP in 4 and two manifest APs in 1 patient. Adverse AP properties were present in32/85 patients (37.6 %) at baseline and in additional 16/44 (36.4 %) after isoproterenol. Ablationwas 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 - 37.6 % of the evaluated patients with an asymptomatic WPW preexcitation

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ic a o thy. A single manifest A as present n 8 ,

0 one manifest and 1

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n s 37.6 ) t ba in nd tona 64 .4 ) a

ter sopr

ter ol.e n 41 t s 48 ents. A a o s de rre n t e rem n g 7 or at

o t e atr ove r cu ar no e. In a t on, o t e ow-

s t ents were ted

arenta ec s on.



DOI: 10.1161/CIRCEP.113.000930

Introduction

Although infrequently, asymptomatic patients with a Wolff-Parkinson-White (WPW)electrocardiographic pattern suffer from sudden cardiac death due to life-threatening arrhythmias

(typically atrial fibrillation with rapid antegrade conduction through an atrioventricular (AV)

accessory pathway (AP), resulting in ventricular fibrillation)0,0,0. The risk of such an event has

been reported to be approximately 0.1 % per patient-year 0. Attempts have been made to identify

patients at high risk, but specific guidelines for risk stratification in the asymptomatic young

patients with WPW, including recommendation for the invasive electrophysiologic (EP)

evaluation and prophylactic catheter ablation of the AP, have not been published until recently0.

The aim of the present study was to evaluate retrospectively the electrophysiologic profile of

asymptomatic children and adolescents with a WPW electrocardiographic pattern and to assess

the results of an invasive risk stratification strategy applying currently consented risk criteria0.

Methods

Patients

op ys o og c

pu s e u

n r e

t e n s dy was to evaluate retroe tively the elect physiologic profile

children a a esc nts a P e e tr c r gra p att r

n t as

of an asive r s s rati

a on s ategy

app y

ng urr

nt y conse e r s cr er



DOI: 10.1161/CIRCEP.113.000930

on patient management and completely anonymous data presentation, informed consent of the

subjects (or their parents) and ethical approval have not been obtained. EP Procedures

Retrospective analysis of EP records was performed. The EP procedures were routinely

performed under conscious sedation or general anesthesia in selected patients. All patients have

been evaluated for risk parameters of the AP at baseline. Adverse AP properties were defined

according to a recent Consensus Statement document ( Figure 1 )0 as the presence of shortest

inducible AV re-entrant tachycardia (AVRT). If SPERRI measurement was not available (21/85

patients)

used as a substitute. Furthermore, in the absence of risk parameters at baseline, isoproterenol

(repetitive doses of 0.1μ g/kg i.v. or continuous infusion) was given to achieve an increase in the

baseline heart rate of50 % in order to overcome the effect of anesthesia/conscious sedation on

autonomic tone and to reproduce the effects of adrenergic stimulation0,0. Isoproterenol challenge

t was

no av

a a

titute. Furt er re, the as nce of k ar ete s at ase ne, o oter n

doses .1μ g

g .v. or ontinu us n us on wa g v

en o ac e

e an ncrease

a t rate o 5 % n or er to overcome t e e ect o an st e a consc ous at



DOI: 10.1161/CIRCEP.113.000930

between two groups and Kruskall-Wallis one way analysis of variance on ranks for comparison

of 3 groups. The Wilcoxon signed rank test was used to assess the effect of isoproterenolchallenge on accessory pathway properties in individual patients. Differences in proportions

between 3 groups were tested by the chi-square test followed by the Fisher´s exact test for pair-

wise comparisons. All statistical analysis was performed using the SigmaPlot for Windows

Version 11.0 (Systat Software Inc., San Jose, California, USA) and SAS Version 9.2 (SAS

Institute Inc. 100 SAS Campus Drive Cary, NC 27513-2414, USA).

Results

Patients

Structurally normal heart was present in 82/85 and hypertrophic cardiomyopathy in 3/85

patients. A single manifest AP was found in 80 patients, two manifest APs in 1 patient and the

combination of 1 manifest AP and 1 concealed AP in 4 patients. Additional diagnoses were AV

nodal re-entrant tachycardia in two patients (slow pathway RF ablation was performed in one)

and focal atrial tachycardia in one patient (not ablated) The proportion of asymptomatic patients

normal hea

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ro ccar omy p

o a 5

si

if s was o d i ti

ts, t a s P a

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t n e t . er

trant tac car a n two a ents s ow a wa a a on was er orme n o



DOI: 10.1161/CIRCEP.113.000930

AP ERP. In one patient, measurement of AP properties could not be performed because of the

lack of both antegrade and retrograde conduction through the AP during the EP study.A group of 44/53 patients without adverse AP properties at baseline was subsequently subjected

to isoproterenol challenge shifting 16 of these 44 patients tested (36.4 %) into the higher risk

category if using the cut- ) patients at the cut-

(Table 1 ). Isoproterenol significantly increased the antegrade conduction capacity of the pathway

(Table 2 ).

From the total of 86 manifest APs, 10/86 (11.6 %) were located at the right free wall,

51/86 (59.3 %) were septal and the remaining 25/86 (29.1 %) were left-sided (P <0.001). There

were no significant differences in antegrade conduction parameters and in the proportion of APs

with adverse conduction parameters between the three localizations (Table 3 ).

Intermittent preexcitation was present in 7/85 patients during the pre-procedural Holter

monitoring. Antegrade AP conduction properties were not different from the remaining patients

(Table 4 ). AVRT was inducible in 2 of these 7 patients.

a e r g ree

t-si e .

0 .

ni n fe nces in antegrade condu n parameters a in the proportion o

e onduction para ete

r be ee t e thr e

ca zat o s

T e 3).

rm preexc ta on wa

presen

n pat nt ur

ng e pre-

roce ura

. Antegrade con

duct on propert es were no

t i fere t r

the rem

ai pa



DOI: 10.1161/CIRCEP.113.000930

There were no complications related to the EP study or RF ablation.

There were no significant differences between both large centers participating in thestudy in any of the parameters evaluated.

Discussion

As shown in several studies, sudden cardiac death may be the first manifestation of the disease in patients with asymptomatic WPW preexcitation0,0,0. Infants and small children are probably at

lower risk 0. In a group of 184 asymptomatic children with a median age of 10 (range 8-12) years,

short AP ERP and multiple APs were independent predictors of life-threatening arrhythmic

event0

. Although non-invasive diagnostic methods such as 24-hour Holter monitoring andexercise stress testing are useful for basic assessment of the preexcitation, invasive testing should

be considered to define electrophysiologic properties of the AP in case of antegrade AP

conduction persistence through maximum exercise0,0-0. Persistent preexcitation during exercise

has high sensitivity and high negative predictive value for detection of patients at risk 0. On the

other hand patients with clear and abrupt loss of preexcitation during exercise testing are at low

reat i r

- -s testing a s o a ssess e t o t e p e xc t t on, v s e t ng

e t e l ct o hy o ic e i s o t in e of te ade P

pe te c t u is - . t t xer

ns t v t an ne a ve re c ve va ue ore ec on o a en s at r s . On



DOI: 10.1161/CIRCEP.113.000930

positives and negatives. Pappone et al. could show a significant risk reduction of arrhythmic

events in a randomized study of prophylactic ablation in asymptomatic patients35 years of agewith the WPW electrocardiographic pattern0. On the other hand catheter ablation is associated

with a low but definite risk of complications0. This all has to be kept in mind when counseling

the families.

Patients with intermittent preexcitation on ECG/24-hour Holter monitoring are thought to

be at lower risk for life-threatening arrhythmias0,0. Intermittent preexcitation is presumed to be a

predictor of decreased antegrade AP conduction capacity0, however, antegrade AP conduction

may be present up to maximum exercise. Rare cases of patients with intermittent preexcitation

and cardiac arrest have been reported0. Moreover, patients with intermittent preexcitation are still

at risk for AVRT with retrograde activation of the atria via AP0. In our group, AVRT was

inducible in 2/7 patients with intermittent preexcitation. None of these seven patients exhibited

rapid antegrade AP conduction. The difference in manifest AP antegrade conduction properties

between patients with persistent and intermittent preexcitation was, however, not statistically

n egra e con

termt en preex a

a ve een reported. Moreover, a it ents with inter ttent preexcitation a

VRT with ret og a e tiva o of ea r a a .I o r gr o p, a

2 ents w n erm ent pr exc ta on. on o ese seven pat en s ex

rade con ction. e ifference n man est an egra e con uct o ope



DOI: 10.1161/CIRCEP.113.000930

isoproterenol challenge has not yet been clearly defined0. In several previous reports SPERRI

-risk patients24

. Due to the absence ofconsented criteria to define a potentially dangerous AP on isoproterenol, we used SPERRI and/or

AP ERP cut-

the yield of invasive testing. In general, isoproterenol lead to an increase of the number of

individuals exhibiting adverse AP parameters regardless of the cut-off used, presumably at the

expense of a lower specificity. As conscious sedation/general anesthesia is used in children, the

use of isoproterenol may evoke a real-life situation of adrenergic stimulation and should be, in

our opinion, a routine to better characterize the range of antegrade conduction capacity of the

AP. In our study isoproterenol challenge converted 36.4 % of patients without adverse AP

properties at baseline into the higher risk group, a finding in accordance with the data by Szabo0.

In this study, the difference in manifest AP antegrade conduction properties between the

right free wall, septal and left free wall APs was not significant. Compared to pediatric reports on

the prevalence of specific pathway locations in children undergoing an invasive

0 0

a on an s ou e

ducton capac ty t

st r ot r enol challenge converte .4 % of patient ithout adverse AP

t aseline into th g r r s gr up, f n acco a ce th t e ta by S

is s , the erence man st P an egr econ uc on proert es e wee

all, septal a le t ree wal A s was not signi cant. omp red to pe a rep



DOI: 10.1161/CIRCEP.113.000930

centre preference) were the main limitations of the study. In contrast to the recently published

consensus statement0

case of the absence of SPERRI measurement. Given the fact that SPERRI was significantly more

sensitive in detecting high AP conduction capacity than AP ERP, some patients fulfilling the risk

criteria might thus have been missed. The technique of isoproterenol administration varied

between the two centers providing invasive EP studies (intravenous bolus vs. continuous

infusion). Isoproterenol challenge was not performed in 9 patients without adverse AP properties

at baseline (all these patients were ablated based on patient/parental decision).

Conclusion

Applying retrospectively a currently consented risk stratification strategy0, 37.6 % of the

evaluated asymptomatic patients with the WPW electrocardiographic pattern persisting at peak

exercise exhibited adverse AP properties at baseline fulfilling either the class IIA or IIB ablation

indication. Isoproterenol challenge shifted additional 36.4 % of those tested into one these 2indication classes Safe ablation (remote from the AV node) could be performed in 85 4 % of

c s on .

t spective r t c nsen e r sk strat c t o r e y , . % o e

s ic ti ts t e le t o a o r tt si tin a

h r r es li s ab

Iso rotereno c a en e s te a ona6. 4 o ose es e n o one t ese



DOI: 10.1161/CIRCEP.113.000930

References:

1. Montoya PT, Brugada P, Smeets J, Talajic M, Della Bella P, Lezaun R, vd Dool A, WellensHJ, Bayés de Luna A, Oter R. Ventricular fibrillation in the Wolff-Parkinson-White syndrome. Eur Heart J. 1991;12:144–150.

2. Klein GJ, Bashore TM, Sellers TD, Pritchett EL, Smith WM, Gallagher JJ. Ventricularfibrillation in the Wolff-Parkinson-White syndrome. N Engl J Med . 1979;301:1080–1085.

3. Paul T, Guccione P, Garson A Jr. Relation of syncope in young patients with Wolff-Parkinson-White syndrome to rapid ventricular response during atrial fibrillation. Am J Cardiol.1990;65:318–321.

4. Klein GJ, Prystowsky EN, Yee R, Sharma AD, Laupacis A. Asymptomatic Wolff-Parkinson-White. Should we intervene?Circulation. 1989;80:1902–1905.

5. Cohen MI, Triedman JK, Cannon BC, Davis AM, Drago F, Janoušek J, Klein GJ, Law IH,Morady FJ, Paul T, Perry JC, Sanatani S, Tanel RE. PACES/HRS Expert consensus statement onthe management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW,ventricular preexcitation) electrocardiographic pattern. Heart Rhythm. 2012;9:1006–1124.

6. Moore JP, Kannankeril PJ, Fish FA. Isoproterenol administration during general anesthesia forthe evaluation of children with ventricular preexcitation.Circ Arrhythm Electrophysiol.2011;4:73–78.

7. Wellens HJ, Brugada P, Roy D, Weiss J, Bär FW. Effect of isoproterenol on the anterograderefractory period of the accessory pathway in patients with the Wolff-Parkinson-Whitesyndrome. Am J Cardiol . 1982;50:180-184.

k J, e n , a

m o mptomatic young patie ith a Wolff Pa nson-hite (WPWr excitat on e e r ar r tter . H R y m. 01 00 – .

, annan er l PJ ish A. o oter nol ad inis ra i n uri g gene al ne t eion o ren w ventr u ar p eexcta on. ir Arr y m E ec rop y sio .78.

HJ, Bru , , s J .. o r o t anterog



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2002;12:248–252.

13. Gaita F, Giustetto C, Riccardi R, Mangiardi L, Brusca A. Stress and pharmacologic tests asmethods to identify patients with Wolff-Parkinson-White syndrome at risk of sudden death. Am JCardiol. 1989;64:487–490.

14. Pappone C, Santinelli V, Manguso F, Augello G, Santinelli O, Vicedomini G, Gulletta S,Mazzone P, Tortoriello V, Pappone A, Dicandia C, Rosanio S. A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-Parkinson-Whitesyndrome. N Engl J Med. 2003;349:1803-1811.

15. Kugler JD, Danford DA, Houston KA, Felix G; Pediatric Radiofrequency Ablation Registryof the Pediatric Electrophysiology Society. Pediatric radiofrequency catheter ablation registrysuccess, fluoroscopy time, and complication rate for supraventricular tachycardia: comparison ofearly and recent eras. J Cardiovasc Electrophysiol. 2002;13:336-341.

16. Milstein S, Sharma AD, Klein GJ. Electrophysiologic profile of asymptomatic Wolff-Parkinson-White pattern. Am J Cardiol. 1986;57:1097–1100.

17. Klein GJ, Gulamhusein SS. Intermittent preexcitation in the Wolff-Parkinson-Whitesyndrome. Am J Cardiol . 1983;52:292–296.

18. Kinoshita S, Konishi G, Kinoshita Y. Mechanism of intermittent preexcitation in the Wolff-Parkinson-White syndrome. The concept of electronically mediated conduction across aninexcitable gap.Chest . 1990;98:1279–1281.

19. Pietersen AH, Andersen ED, Sandoe E. Atrial fibrillation in the Wolff-Parkinson-Whitesyndrome. Am J Cardiol. 1992;70:38–43.

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, Gulam s n S . te te pr c at o t Par n- J Cardio 9 3;52 92– 9 .

ita , onis , nos . c an sm o te m t n preexc on n t es e. ep r n

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follow up study. Heart . 2003;89:215-217.

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Journal. 2007;14:384-90.

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Table 1: Accessory pathway properties at baseline and during isoproterenol challenge

Risk parameter Baseline (N=85) Isoproterenol (N=44*)

Rapid antegrade conduction 18 (21.2 %)† 15 (34.1 %)† 6 (13.6 %)‡

Inducible AVRT 22 (25.9 %) 4 (9.1 %) 4 (9.1 %)

Total 32 (37.6 %) 16 (36.4 %) 9 (20.5 %)*without adverse AP properties at baseline

reno c a enge

e e Baseline N 5) Isoproterenol (N=44*)

g a e conducti n (21. (3 .1 † 13.6

V .9 ) . ) . )

. ) . (20.5 %



DOI: 10.1161/CIRCEP.113.000930

1

Table 3 : Baseline accessory pathway properties according to localization

AP properties Right free wall (N=10) Septal (N=51) Left free wall (N=25) P overall

AP ERP median (Q1-Q3) [ms] 300 (270-323) 300 (280-320) 290 (260-300) 0.098

SPERRI median (Q1-Q3) [ms] 290 (270-300) 300 (252-325) 300 (255-366) 0.619

Rapid antegrade conduction* 0/10† 10/51† 8/25† 0.103

† P NS for all pair-wise comparisons by the Fisher exact test.For abbreviations see Table 2

Table 4 : Baseline accessory pathway properties in patients with persistent and intermittent preexcitation during pre-procedural Holtermonitoring

AP properties Persistent preexcitation (N=78) Intermittent preexcitation (N=7) P value

AP ERP median (Q1-Q3) [ms] 300 (280-320) 300 (280-330) 0.794

SPERRI median (Q1-Q3) [ms] 300 (260-330) 310 (300-358) 0.266

For abbreviations see Table 2

sher xact test...

http://circep.ahajournals.org/




DOI: 10.1161/CIRCEP.113.000930

Figure Legends:

Figure 1 Management algorithm for the asymptomatic young patient with a WPW

electrocardiographic pattern. Reproduced with permission from HeartRhythm [Cohen MI,

Triedman JK, Cannon BC, Davis AM, Drago F, Janoušek 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. Heart Rhythm 2012; 9:1006–1124].

Figure 2 Number of WPW patients undergoing invasive electrophysiologic testing during the

study period.

– .

u patients undergoing insive electrophysio ogic testing during

.


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Asymptomatic WPW in Children and Adolescents