Hostname: page-component-586b7cd67f-l7hp2 Total loading time: 0 Render date: 2024-11-27T22:00:16.389Z Has data issue: false hasContentIssue false
  • English
  • Français

Wolff–Parkinson–White syndrome: lessons learnt and lessons remaining

Published online by Cambridge University Press:  13 January 2017

D. Woodrow Benson  and
Mitchell I. Cohen
D. Woodrow Benson
Affiliation:
Congenital & Pediatric Cardiac Research, Department of Pediatrics, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, United States of America
Mitchell I. Cohen*
Affiliation:
Heart Center, Department of Pediatric Cardiology, Phoenix Children’s Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, United States of America
*
Correspondence to: M. I. Cohen, MD, FACC, FHRS, Heart Center, Pediatric Cardiology, Phoenix Children’s Hospital, University of Arizona College of Medicine-Phoenix, 1919 E. Thomas Road, 2nd Floor, Heart Center, Phoenix, AZ 85016, United States of America. Tel: 602 933 3366; Fax: 602 933 4166; E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

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.

Keywords

Wolff–Parkinson–Whitesudden deathatrial fibrillation
Type
Original Articles
Information
Cardiology in the Young , Volume 27 , Supplement S1: Sudden Cardiac Arrest in the Young: A Contemporary Perspective , January 2017 , pp. S62 - S67
Copyright
© Cambridge University Press 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Dreifus, LS, Haiat, R, Watanabe, Y, Arriaga, J, Reitman, N. Ventricular fibrillation. A possible mechanism of sudden death in patients and Wolff-Parkinson-White syndrome. Circulation 1971; 43: 520–527.CrossRefGoogle ScholarPubMed
2. Olen, MM, Baysa, SJ, Rossi, A, Kanter, RJ, Fishberger, SB. Wolff-Parkinson-White syndrome: a stepwise deterioration to sudden death. Circulation 2016; 133: 105–106.CrossRefGoogle ScholarPubMed
3. Wolff, L, White, P. Bundle-branch block with short PR interval in healthy young people to paroxysmal tachycardia. Am Heart J 1930; 6: 685–704.CrossRefGoogle Scholar
4. Scheinman, MM. History of Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol 2005; 28: 152–156.CrossRefGoogle ScholarPubMed
5. Pick, A, Katz, LN. Disturbances of impulse formation and conduction in the preexcitation (WPW) syndrome; their bearing on its mechanism. Am J Med 1955; 19: 759–772.CrossRefGoogle ScholarPubMed
6. Durrer, D, Schoo, L, Schuilenburg, RM, Wellens, HJ. The role of premature beats in the initiation and the termination of supraventricular tachycardia in the Wolff-Parkinson-White syndrome. Circulation 1967; 36: 644–662.CrossRefGoogle ScholarPubMed
7. Burchell, HB, Frye, RL, Anderson, MW, McGoon, DC. Atrioventricular and ventriculoatrial excitation in Wolff-Parkinson-White syndrome (type B). Temporary ablation at surgery. Circulation 1967; 36: 663–672.CrossRefGoogle ScholarPubMed
8. Cobb, FR, Blumenschein, SD, Sealy, WC, Boineau, JP, Wagner, GS, Wallace, AG. Successful surgical interruption of the bundle of Kent in a patient with Wolff-Parkinson-White syndrome. Circulation 1968; 38: 1018–1029.CrossRefGoogle Scholar
9. Klein, GJ, Bashore, TM, Sellers, TD, Pritchett, EL, Smith, WM, Gallagher, JJ. Ventricular fibrillation in the Wolff-Parkinson-White syndrome. N Engl J Med 1979; 301: 1080–1085.CrossRefGoogle ScholarPubMed
10. Bromberg, BI, Lindsay, BD, Cain, ME, Cox, JL. Impact of clinical history and electrophysiologic characterization of accessory pathways on management strategies to reduce sudden death among children with Wolff-Parkinson-White syndrome. J Am Coll Cardiol 1996; 27: 690–695.CrossRefGoogle ScholarPubMed
11. Timmermans, C, Smeets, JL, Rodriguez, LM, Vrouchos, G, von den Dool, A, Wellens, HJ. Aborted sudden death in the Wolff-Parkinson-White syndrome. Am J Cardiol 1995; 76: 492–494.CrossRefGoogle ScholarPubMed
12. Obeyesekere, MN, Leong-Sit, P, Massel, D, et al. Risk of arrhythmia and sudden death in patients with asymptomatic preexcitation: a meta-analysis. Circulation 2012; 125: 2308–2315.CrossRefGoogle ScholarPubMed
13. Obeyesekere, M, Gula, LJ, Skanes, AC, Leong-Sit, P, Klein, GJ. Risk of sudden death in Wolff-Parkinson-White syndrome: how high is the risk? Circulation 2012; 125: 659–660.CrossRefGoogle ScholarPubMed
14. Fitzsimmons, PJ, McWhirter, PD, Peterson, DW, Kruyer, WB. The natural history of Wolff-Parkinson-White syndrome in 228 military aviators: a long-term follow-up of 22 years. Am Heart J 2001; 142: 530–536.CrossRefGoogle Scholar
15. Inoue, K, Igarashi, H, Fukushige, J, Ohno, T, Joh, K, Hara, T. Long-term prospective study on the natural history of Wolff-Parkinson-White syndrome detected during a heart screening program at school. Acta Paediatr 2000; 89: 542–545.CrossRefGoogle ScholarPubMed
16. Sarubbi, B, Scognamiglio, G, Limongelli, G, et al. Asymptomatic ventricular pre-excitation in children and adolescents: a 15 year follow up study. Heart 2003; 89: 215–217.CrossRefGoogle ScholarPubMed
17. Munger, TM, Packer, DL, Hammill, SC, et al. A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953–1989. Circulation 1993; 87: 866–873.CrossRefGoogle ScholarPubMed
18. Cohen, MI, Triedman, JK, Cannon, BC, et al. 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: 1006–1024.CrossRefGoogle Scholar
19. Bershader, RS CF. Exercise testing for risk assessment in pediatric Wolff-Parkinson-White syndrome. Heart Rhythm 2007; 4: 138–139.Google Scholar
20. Gaita, F, Giustetto, C, Riccardi, R, Mangiardi, L, Brusca, A. Stress and pharmacologic tests as methods to identify patients with Wolff-Parkinson-White syndrome at risk of sudden death. Am J Cardiol 1989; 64: 487–490.CrossRefGoogle ScholarPubMed
21. Perry, JC, Giuffre, RM, Garson, A Jr. Clues to the electrocardiographic diagnosis of subtle Wolff-Parkinson-White syndrome in children. J Pediatr 1990; 117: 871–875.CrossRefGoogle Scholar
22. Daubert, C, Ollitrault, J, Descaves, C, Mabo, P, Ritter, P, Gouffault, J. Failure of the exercise test to predict the anterograde refractory period of the accessory pathway in Wolff Parkinson White syndrome. Pacing Clin Electrophysiol 1988; 11: 1130–1138.CrossRefGoogle ScholarPubMed
23. Wackel, P, Irving, C, Webber, S, Beerman, L, Arora, G. Risk stratification in Wolff-Parkinson-White syndrome: the correlation between noninvasive and invasive testing in pediatric patients. Pacing Clin Electrophysiol 2012; 35: 1451–1457.CrossRefGoogle ScholarPubMed
24. 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: 1011–1014.CrossRefGoogle ScholarPubMed
25. Klein, GJ, Gulamhusein, SS. Intermittent preexcitation in the Wolff-Parkinson-White syndrome. Am J Cardiol 1983; 52: 292–296.CrossRefGoogle ScholarPubMed
26. Kiger, ME, McCanta, AC, Tong, S, et al. Intermittent versus persistent Wolff-Parkinson-White syndrome in children: electrophysiologic properties and clinical outcome. Pacing Clin Electrophysiol 2016; 39: 14–20.CrossRefGoogle Scholar
27. Mah, DY, Sherwin, ED, Alexander, ME, et al. The electrophysiological characteristics of accessory pathways in pediatric patients with intermittent preexcitation. Pacing Clin Electrophysiol 2013; 36: 1117–1122.CrossRefGoogle ScholarPubMed
28. Oliver, C, Brembilla-Perrot, B. Is the measurement of accessory pathway refractory period reproducible? Indian Pacing Electrophysiol J 2012; 12: 93–101.CrossRefGoogle ScholarPubMed
29. Lee, PC, Hwang, B, Tai, CT, Chiang, CE, Yu, WC, Chen, SA. The different electrophysiological characteristics in children with Wolff-Parkinson-White syndrome between those with and without atrial fibrillation. Pacing Clin Electrophysiol 2004; 27: 235–239.CrossRefGoogle ScholarPubMed
30. 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.CrossRefGoogle ScholarPubMed
31. Cohen, M, Triedman, J. Guidelines for management of asymptomatic ventricular pre-excitation: brave new world or Pandora’s box? Circ Arrhythm Electrophysiol 2014; 7: 187–189.CrossRefGoogle ScholarPubMed
32. Kubus, P, Vit, P, Gebauer, RA, Materna, O, Janousek, 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: 218–223.CrossRefGoogle ScholarPubMed