Electrophysiological guided accessory-pathway ablation strategy in children with asymptomatic WPW: it may not be enough to prevent sudden cardiac death

J Interv Card Electrophysiol. 2023 Aug;66(5):1125-1133. doi: 10.1007/s10840-022-01409-4. Epub 2022 Nov 17.

Abstract

Background: Sudden cardiac death (SCD) may rarely occur among asymptomatic patients with Wolff-Parkinson-White (WPW) pattern. Risk stratification is based on electrophysiological study (EPS). We aimed to evaluate long-term efficacy of such a strategy in preventing SCD.

Methods: Retrospective analysis of asymptomatic children with WPW who underwent EPS using isoproterenol. Patients considered at risk had inducible sustained atrial fibrillation or atrioventricular reentry tachycardia (AVRT) associated with the following: (1) accessory pathway (AP) effective refractory period or (2) 1:1 shortest cycle length along the AP or (3) shortest pre-excited R-R interval during AF ≤ 250 ms.

Results: Fifty-one consecutive cases (7-18 years, 12 ± 3) were identified, 40 (78%) with right and 11 (22%) with left AP. Twenty-eight (55%) were classified as high risk (HI) and 23 (45%) as low risk (LO), with no significant differences in demographic characteristics and AP locations. Ablation was performed in 20/28 HI and 11/23 LO patients (p 0.08), with no significant differences in acute success (20/20 versus 10/11, p 0.17) or recurrence (1/20 versus 2/10, p 0.15). Follow-up (46 ± 27 months): ablated patients remained asymptomatic; among the 23 non-ablated, 18 (78%) remained asymptomatic, 5 (22%) were successfully ablated, and 5 (22%) presented events (4 AVRT, 1 SCD). Arrhythmic events did not differ significantly between non-ablated HR and LR (2/8 versus 3/15, p 0.29) and the SCD was in the LO group.

Conclusions: More than 50% asymptomatic WPW children present high-risk AP properties. EPS-based risk stratification using isoproterenol was not able to identify increased risk of future events or SCD.

Keywords: Electrophysiological study; Sudden death; WPW.

MeSH terms

  • Accessory Atrioventricular Bundle* / surgery
  • Atrial Fibrillation* / etiology
  • Catheter Ablation* / adverse effects
  • Child
  • Death, Sudden, Cardiac / prevention & control
  • Electrocardiography
  • Humans
  • Isoproterenol
  • Retrospective Studies
  • Tachycardia, Supraventricular*
  • Wolff-Parkinson-White Syndrome* / surgery

Substances

  • Isoproterenol