Circulation. 2005;112:2201-2216
doi: 10.1161/CIRCULATIONAHA.104.483321
(Circulation. 2005;112:2201-2216.)
© 2005 American Heart Association, Inc.
Controversies in Cardiovascular Medicine |
Should catheter ablation be performed in asymptomatic patients with Wolff-Parkinson-White syndrome?
When to Perform Catheter Ablation in Asymptomatic Patients With a Wolff-Parkinson-White Electrocardiogram
Hein J. Wellens, MD
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Introduction
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What to do when a person without any cardiac complaint shows
a Wolff-Parkinson-White (WPW) pattern on the ECG has been an
important question for more than 2 decades. Recent articles
by Pappone et al
1–3 make it necessary to revisit that
question.
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Background
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Epidemiological data indicate that 0.1% to 0.3% of the general
population have ECG findings suggesting that during sinus rhythm,
in addition to AV conduction over the AV node His pathway, there
is also AV conduction over an accessory AV pathway (AP).
4 This
means that each year
4 new cases are found in a population of
100 000. It is also known that there is a 4-fold increase of
this finding in family members of WPW patients.
5
The WPW patient is often symptomatic because of cardiac arrhythmias. When arrhythmias are present, the disorder is called the WPW syndrome. The 2 most common types of arrhythmia in the WPW syndrome are (1) a circus movement tachycardia (CMT), also called an AV reentrant tachycardia, in which AV conduction goes by way of the normal AV conduction system and VA conduction over the AP and (2) atrial fibrillation (AF).6
AF can be a life-threatening arrhythmia in the WPW syndrome if the AV AP has a short anterograde refractory period (RP), allowing many atrial impulses to be conducted to the ventricle. That will result in very high ventricular rates with possible deterioration into ventricular fibrillation (VF) and sudden death.7,8
A CMT that in general is well tolerated by the patient when additional heart disease is absent may deteriorate into AF, and the ventricular rate and risk for VF will depend on the anterograde RP of the AP. Therefore, the most important question in the asymptomatic WPW patient in whom the typical ECG accidentally is recorded is whether he or she is at risk for VF when AF supervenes. This risk is dependent on the anterograde RP of the AP during AF.
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Recognizing the Risk for Dying Suddenly
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As indicated, the presence of a short anterograde RP of the
AP carries the potential risk of sudden death. A long anterograde
RP of the AP does not exclude the possibility of a CMT, but
the patient is not at risk when the CMT deteriorates into AF.
As shown in
Table 1, information about the anterograde RP of
the AP can be obtained by noninvasive and invasive testing.
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Noninvasive Testing
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Sudden Block in the AP During Exercise
The best indicator of low risk, first decribed by Levy et al,
9 is the sudden disappearance of pre-excitation during exercise.
This indicates a long anterograde RP of the AP. Sympathetic
stimulation occurring during exercise will shorten the duration
of the RP of the AP.
10 When the RP of the AP is reached during
exercise, as manifested by sudden block in the AP, one knows
that the patient is not at risk for AF even during sympathetic
stimulation. One must be careful, however, to distinguish true
block in the AP from diminution of the degree of pre-excitation
over the AP produced by sympathetic stimulation during exercise,
which will shorten the trans-AV nodal conduction time. This
is more likely to occur when the AP is left sided. Therefore,
several leads should be taken simultaneously, and special attention
should be given to the sudden occurrence of block in the AP
during exercise and to the ECG after exercise because, in exercise-induced
block in the AP, a sudden marked change in the ECG takes place
on resumption of AV conduction over the AP. An example of block
in the AP during exercise is shown in
Figure 1.
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Figure 1. Sudden block in the AV AP during exercise testing. As shown, pre-excitation is present on the left. On reaching a heart rate of 150 bpm, there is sudden block in anterograde conduction over the AP. After occasional conduction over the AP, complete block is present on the right.
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Intermittent Pre-Excitation
Intermittent pre-excitation is present when, during sinus rhythm, some QRS complexes show pre-excitation and are followed by QRS complexes showing AV conduction over the normal AV conduction pathway. That finding, shown in Figure 2, indicates a long anterograde RP of the AP.11 This has to be differentiated from a bigeminal ventricular rhythm with a long coupling interval (Figures 3 and 4 
).
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Figure 2. Example of intermittent pre-excitation. Three QRS complexes showing pre-excitation are followed by 6 QRS complexes showing AV conduction over the AV node–His pathway only.
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Figure 3. Pseudointermittent pre-excitation produced by a bigeminal ventricular rhythm (originating in the outflow tract of the right ventricle) with a long coupling interval.
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Figure 4. True 2:1 block in the AP. Note alternating AV conduction only over the normal AV conduction system and a posteroseptal AP.
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In the patient with intermittent pre-excitation, 1-to-1 conduction over the AP may occur during exercise because of shortening of the RP of the AP by sympathetic stimulation. However, there is never such shortening that a dangerously short RP of the AP develops.
Block in the AP After Drug Administration
When during sinus rhythm the intravenous injection of ajmaline (1 mg/kg body weight given in 3 minutes)12 or procainamide (10 mg/kg body weight over a 5-minute period)13 results in complete block of the AP, a long anterograde RP (>270 ms) of that structure is likely. Figure 5 shows block in the AP after administration of 600 mg procainamide. Using a modified ajmaline test, Chimienti et al14 showed that the amount of ajmaline required to block conduction over the AP correlates with the duration of the anterograde RP of the AP. Because ajmaline and procainamide also prolong the RP of the His-Purkinje system, these tests should be done in an area in which the possible complication of complete AV block can be appropriately managed.
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Figure 5. Example of complete block in the AP during sinus rhythm after administration of 600 mg IV procainamide.
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The weak aspect of pharmacological testing is that the drugs are given at rest. The test does not indicate what the drug will do on RP duration during sympathetic stimulation such as exercise, emotion, anxiety, and "recreational" drug use. However, by combining the different noninvasive tests, we usually can identify patients at low risk for sudden death because of a relatively long anterograde RP of the AP.15 Some authors have questioned the sensitivity and specificity of these noninvasive markers because of the low incidence of future adverse events.16,17
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Invasive Evaluation of the Anterograde RP of the AP
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As shown 30 years ago,
18 in patients with the WPW syndrome,
there is good correlation between the value of the anterograde
RP of the AP obtained during atrial single-test stimulation
and atrial pacing at increasing rates and the ventricular rate
during AF. Such an investigation may therefore be considered
in situations in which noninvasive testing does not lead to
the conclusion that a relatively long anterograde RP is present.
Programmed electrical stimulation of the atrium can be performed by the transesophageal route, and the value of the anterograde RP of the AP can be determined.19
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The Risk of Dying Suddenly
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Following the reports by Dreifus et al
7 and Klein et al,
8 several
authors described sudden death in the WPW syndrome based on
AF with a high ventricular rate deteriorating into VF. But,
as discussed by Todd et al,
20 longitudinal natural history studies,
either electrophysiology or population based, suggest very low
risk of sudden death during follow-up in the asymptomatic WPW
patient.
21–33 Thus, it is important to recognize certain
features that have been reported in WPW patients with cardiac
arrest who were successfully resuscitated and subsequently studied
electrophysiologically.
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Characteristics of the WPW Patient With Cardiac Arrest
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Previously published articles
8,34–36 reported the following
4 risk factors associated with the development of VF: (1) male
gender; (2) a very rapid ventricular rate during AF because
of a short anterograde RP of the AP; (3) a history of previous
supraventricular tachycardias (SVTs), especially AF; and (4)
the presence of multiple APs.
Although Timmermans et al36 could not confirm multiple APs as a risk factor for VF, they found a high incidence of septal APs in their VF patients. Another interesting finding in the Timmermans et al study was that sudden death usually occurred during increased adrenergic tone such as during emotion and/or physical stress. Table 2 summarizes the characteristics of the WPW patient dying suddenly. Both Torner34 and Timmermans36 showed that, in about half of the patients resuscitated from VF, this arrhythmia was the first symptomatic arrhythmia they ever experienced.
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Management of the Asymptomatic Patient
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When confronted with the asymptomatic patient showing a WPW
ECG, the first step is to perform the noninvasive tests outlined
above to recognize the low-risk patient. For the low-risk patient,
no measures are advised other than an explanation to the patient
of the ECG findings. It is advisable to give the patient a copy
of his or her ECG and a short note about the fact that the WPW
syndrome is present to prevent the misdiagnosis of myocardial
infarction and to explain the basis of cardiac arrhythmias in
case they develop later.
Until now, if noninvasive testing suggested a short anterograde RP of the AP, the decision to advise an invasive study and catheter ablation of the accessory AP was made individually, depending on the age of the patient, the location of the AP, and social and professional factors. If RF catheter ablation were a totally risk-free procedure, one would logically advise such a procedure to the asymptomatic WPW patient with a short anterograde RP. However, certain risks are associated with RF ablation. They include the general risks of any cardiac catheterization such as thromboembolic complications, infection, bleeding, cardiac perforation with or without cardiac tamponade, valvular damage, and radiation damage. In addition, there are specific risks in patients with APs, eg, in small children in whom the catheter ablation lesion is relatively large because of the size of the heart.
Risk may also be related to the location of the AP. For example, ablation of a para-Hissian AP carries the risk of complete AV block. In epicardially located posteroseptal or left posterior APs in which ablation has to be performed from the coronary venous system, there is the risk of damage to the coronary artery or perforation of the venous system, leading to cardiac tamponade. In addition, in right free wall APs, the right coronary artery may be damaged. Three registry studies37–39 reported the complications of RF ablation in symptomatic patients with APs. Although rare, deaths were reported in all 3 studies, along with other complications such as complete AV block, cardiac perforation with and without tamponade, and cerebrovascular accidents.
These studies were done in the early 1990s. Unfortunately, we do not have more recent information about the current complication rate of catheter ablation in patients with APs with the exception of the pediatric group.40 Kugler et al40 compared 1991 to 1995 with 1996 to 1999 and found an increased success rate of catheter ablation of APs but no significant change in complications.
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The Role of Invasive Testing
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Recent publications by Pappone and coworkers
1–3 make it
necessary to revisit our ideas about the management of asymptomatic
WPW.
In the first study,1 asymptomatic WPW patients were studied invasively. Ages ranged from 7 to 63 years, with 50% of patients in the third and fourth decades. During the electrophysiological study, the anterograde RP of the AP was determined and initiation of tachycardia was attempted by atrial and ventricular pacing, including atrial burst pacing to induce AF. Arrhythmias were considered sustained if they lasted >1 minute. One hundred sixty-two patients were studied twice. During follow-up (mean, 37.7 months), only 4 of 115 noninducible patients developed symptomatic SVT. In contrast, 29 of 47 inducible patients developed either SVT (n=21) or AF (n=8). Inducible patients were younger, had shorter anterograde RPs of their AP, and more often had multiple APs compared with patients who remained asymptomatic. Of the 8 patients with symptomatic episodes of AF and inducible sustained AF, 2 had resuscitated cardiac arrest, and 1 died suddenly. All 3 were inducible for AV reentrant tachycardia and AF and had multiple APs.
Shortly thereafter, Pappone et al2 published a randomized study of prophylactic catheter ablation in asymptomatic patients with the WPW syndrome. Of 224 asymptomatic patients who underwent an AP study similar to that used in the previous publication,1 72 patients with inducible arrhythmias were randomized to radiofrequency catheter ablation of their APs (37 patients) or no treatment (35 patients). During follow-up, 2 of the 37 patients who underwent ablation had an arrhythmic event (median follow-up, 27 months). In contrast, 21 of the 35 patients in the control group had an arrhythmic event (median follow-up, 21 months), with 1 patient successfully resuscitated from VF.
Most recently, Pappone et al3 described invasive testing and catheter ablation in children with asymptomatic WPW. Of 165 eligible children 5 to 12 years of age, 60 were determined, after an AP study, to be at high risk for arrhythmias and were invited to participate in a randomized study of catheter ablation of the AP or no treatment. The parents of 13 children withdrew them from the study; of the remaining children, 20 underwent prophylactic ablation, and 27 had no treatment. During follow-up (median, 34 months for the ablation group and 19 months for the control group), no patient from the ablation group had recurrence of ventricular pre-excitation, and only 1 patient had an SVT using an additional concealed posteroseptal AP. In contrast, all controlled patients continued to have ventricular pre-excitation, and 7 had symptomatic arrhythmias. In addition, in 5 apparently asymptomatic patients in the control group, follow-up Holter monitoring documented silent episodes of sustained AF, remaining asymptomatic despite extremely rapid ventricular responses over their APs. Three children in the control group had VF, which led to the death of 1 child.
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Problems
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The 3 articles by Pappone et al
1–3 suggest that the ability
to induce a sustained arrhythmia (SVT or AF) in the asymptomatic
patient with a WPW ECG is a marker of risk and should be followed
by catheter ablation of the AP. They put less emphasis on the
length of the anterograde RP of the AP as a risk factor, although
in asymptomatic WPW patients, a short duration identifies risk
for a high ventricular rate in case of AF. In addition, the
risk of dying suddenly with SVT is not the same as the risk
when AF occurs in a patient with a short anterograde RP of the
AP.
The electrophysiological properties of both the AP and normal AV conduction system may change over time, often unpredictably.21,26,41 In patients with a short anterograde RP of their AP (<260 ms), however, it is rare to see marked lengthening of that value during an AP study years later, whereas such lengthening, even complete block, in the AP is not unusual in patients not having a short anterograde RP of their AP.
Another important point is that the inability to induce an arrhythmia now is no guarantee that arrhythmia will be noninducible years from now. For example, in the patient with a short anterograde RP of the AP, arrhythmia may not be inducible at a young age, but AF may develop when the patient is in his or her 60s. Thus, I am reluctant to accept the suggestion by Pappone et al that the asymptomatic WPW patient is at low risk when >35 years of age.
A major problem is that the studies by Pappone et al1–3 report a much higher incidence of (serious) arrhythmias than previous natural history publications.21–33 As discussed elsewhere,42 it may not be easy to identify the asymptomatic WPW patient. This seems to be especially difficult in children. In view of the prevalence of the WPW ECG, to find 165 children between 5 and 12 years of age with asymptomatic WPW (the number reported by Pappone et al), you have to obtain 200 000 ECGs in asymptomatic children. Apparently, ECGs are performed in asymptomatic children frequently in Italy, but this practice is unusual in other countries. In balancing risk and benefits of catheter ablation in asymptomatic patients, one should know the success and complication rates of the center to which the patient is referred. As indicated earlier, that information is often not available.
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Current Guidelines
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The most recent guidelines of the American College of Cardiology
and the European Society of Cardiology on the management of
asymptomatic WPW patients suggest restricting catheter ablation
of APs to those in high-risk occupations and professional athletes—ie,
to advise on the basis of individual considerations.
43 Catheter
ablation in asymptomatic pre-excitation was classified as a
IIA indication with a B level of evidence.
According to the NASPE Expert Consensus Conference, asymptomatic WPW pattern on the ECG without recognized tachycardia is a class IIB indication for catheter ablation in children >5 years of age and a class III indication in younger children.44
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Conclusions
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Recent publications and recommendations by Pappone et al force
us to look again at the management of the asymptomatic patient
with a WPW ECG. A problem with these studies is the much higher
incidence of (serious) arrhythmic complications than in previous
natural history studies on asymptomatic patients. Other difficulties
are the identification of asymptomatic patients and the risks
of invasive studies and catheter ablation. In view of those
risks, one should start with noninvasive studies (exercise,
Holter, effect of a pharmacological intervention) to identify
the low-risk patient because of a long anterograde RP of the
AP. In patients not showing block in their AP during these noninvasive
studies, esophageal pacing can be performed to determine the
anterograde RP of the AP and the ability to induce sustained
arrhythmias. If arrhythmias can be induced, benefits and risk
of an invasive investigation and catheter ablation should be
based on individual considerations such as age, gender, occupation,
and athletic wishes. This should be discussed with the patient
or, in the case of a child, with the parents. Because knowledge
about the success and complication rate at the electrophysiological
center plays a major role in decision making, that information
should be made available so that the appropriate place for invasive
diagnosis and treatment can be selected.
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Should catheter ablation be performed in asymptomatic patients with Wolff-Parkinson-White syndrome?
When to Perform Catheter Ablation in Asymptomatic Patients With a Wolff-Parkinson-White Electrocardiogram
Catheter Ablation Should Be Performed in Asymptomatic Patients With Wolff-Parkinson-White Syndrome
Carlo Pappone, MD, PhD;
Vincenzo Santinelli, MD
Although the clinical presentation and natural history of people with accessory pathways (APs) are largely unknown, previous studies have found asymptomatic Wolff-Parkinson-White (WPW) to be associated with a good prognosis.1–11 Subjects with ventricular pre-excitation on the ECG but who are asymptomatic and have no clinical arrhythmias are usually described as having "ventricular pre-excitation" or "WPW ECG pattern." In our experience, asymptomatic WPW patients are also those who have totally silent tachyarrhythmias that occasionally may be life-threatening, as documented during Holter monitoring.12 Silent tachy-arrhythmias frequently occur in young WPW patients who may experience ventricular fibrillation (VF), cardiac arrest, or sudden cardiac death (SD) as their first clinical presentation.12 Recognizing silent or minimally symptomatic life-threatening arrhythmias despite extremely
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Introduction
Background