The Asymptomatic Wolff-Parkinson-White Patient

• Editorials
• ablation techniques
• accessory atrioventricular pathway
• atrial fibrillation
• death, sudden, cardiac
• tachycardia, atrioventricular nodal reentry
• tachycardia, supraventricular
• ventricular fibrillation
• Wolff-Parkinson-White syndrome

It is well known by now that sudden cardiac death (SCD) may occur even in the asymptomatic individual with Wolff-Parkinson-White (WPW) pattern.¹ This is related to the occurrence of atrial fibrillation with a rapid ventricular response leading to ventricular fibrillation (VF). The essential and critical risk factor is the presence of an accessory pathway(s) (AP) with critically short antegrade refractoriness. The most common numeric in the literature reflecting this is the shortest RR interval between preexcited cycles <250 ms (SPRRI) in atrial fibrillation. The risk of SCD in the individual with asymptomatic WPW has been estimated to be low, in the range of 0.05% to 0.2% per year,¹ a risk that can obviously be eliminated with successful, uncomplicated catheter ablation. These facts are not in dispute. The controversy that remains is related simply to the fact that population-wide electrophysiological assessment and ablation cannot be performed without risk of complications and even mortality that can mitigate the benefit, and broad screening and electrophysiologically based management would be very costly.² Current guidelines reflect this³ by suggesting that electrophysiological assessment with a view to ablation is reasonable when a well-informed patient chooses the small risk of ablation over a small risk due to the natural history (2A recommendation) depending on their individual circumstances. Furthermore, there is little advocacy in the guidelines for large-scale population screening. Do we now have evidence to support improved clinical outcomes for electrophysiological assessment with a view to ablation in all individuals with the WPW pattern in the general population?

Article see p 811

The data presented in the article, “The natural history of WPW syndrome in the era of catheter ablation, insights from a registry study of 2169 patients,” by Pappone et al,⁴ in the current issue of Circulation, demonstrate the outcomes …