Treatment of symptomatic arrhythmias associated with the Wolff-Parkinson-White syndrome
- Luigi Di Biase, MD, PhD, FHRS, FACC
Luigi Di Biase, MD, PhD, FHRS, FACC
- Cardiologist, Electrophysiologist, Section Head Electrophysiology, Director of Arrhythmia Services, Associate Professor, Albert Einstein College of Medicine at Montefiore Hospital, New York
- Senior Researcher, Texas Cardiac Arrhythmia Institute at St. David's Medical Center
- Edward P Walsh, MD
Edward P Walsh, MD
- Chief, Cardiac Electrophysiology, Boston Children’s Hospital
- Professor of Pediatrics, Harvard Medical School
- Section Editors
- Samuel Lévy, MD
Samuel Lévy, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Cardiology
- University of Marseille, France
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
Conduction from the atria to the ventricles normally occurs via the atrioventricular node (AV)-His-Purkinje system. Patients with a preexcitation syndrome have an additional pathway, known as an accessory pathway, which directly connects the atria and ventricles, bypassing the AV node. Normal conduction through the AV node is slower than conduction over the accessory pathway. Thus, when there is conduction over an accessory pathway, the ventricles are activated earlier than if the impulse had traveled through the AV node. This early activation, referred to as preexcitation, is responsible for the classic electrocardiographic (ECG) findings of a shortened PR interval and, in most patients, a delta wave (waveform 1).
Symptoms, ranging from mild palpitations to syncope and, rarely, even sudden cardiac death, are the result of tachycardia, usually due to a macroreentrant circuit involving the AV node, the ventricles, the accessory pathway, and the atria. This classic supraventricular tachycardia associated with WPW syndrome is called AV reentrant or reciprocating tachycardia (AVRT). However, preexcited atrial fibrillation or atrial flutter with a rapid ventricular response may also result in symptoms. Fortunately, the incidence of sudden death in patients with the WPW syndrome is quite low, ranging from 0 to 0.39 percent annually in several large case series, with the lowest risk seen in asymptomatic patients.
Patients with the WPW syndrome are usually treated because of symptomatic arrhythmias. Treatment may sometimes be extended to asymptomatic patients with a WPW pattern if certain "high-risk" features are present. However, most asymptomatic patients with the WPW electrocardiographic pattern are not treated. Treatment options for persons with arrhythmias and the WPW syndrome include nonpharmacologic therapies (ie, catheter ablation of the accessory pathway) as well as pharmacologic therapy (to slow ventricular heart rates or to prevent arrhythmias). The choice of the optimal therapy depends on the acuity of the arrhythmia(s) and the risk of sudden cardiac death, with pharmacologic agents being the treatment of choice for most acute arrhythmias, while catheter ablation is nearly always preferred for the long-term prevention of recurrent arrhythmias involving the accessory pathway.
This topic will review the available therapeutic options for the treatment of arrhythmias in the WPW syndrome. The clinical manifestations, approach to diagnosis, and the types of arrhythmias which can occur in persons with an accessory pathway and the WPW pattern are discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of the Wolff-Parkinson-White syndrome" and "Atrioventricular reentrant tachycardia (AVRT) associated with an accessory pathway".)
ACUTE TREATMENT OF SYMPTOMATIC ARRHYTHMIAS
While the preferred long-term treatment approach for patients with an accessory pathway, preexcitation, and symptomatic arrhythmias is catheter-based radiofrequency ablation, patients who present with an acute arrhythmia often require initial pharmacologic therapy for ventricular rate control or restoration of sinus rhythm. However, because of the electrophysiologic differences between AV nodal tissue and tissue comprising an accessory pathway, standard therapy for heart rate control may actually worsen symptoms and lead to clinical deterioration in patients with a tachycardia involving an accessory pathway. Knowledge of the presence of an accessory pathway is critical in choosing the correct initial pharmacologic therapy. (See 'Treatment to prevent recurrent arrhythmias' below and "Overview of the acute management of tachyarrhythmias".)
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- ACUTE TREATMENT OF SYMPTOMATIC ARRHYTHMIAS
- Initial assessment of hemodynamic stability
- Acute termination of orthodromic AVRT
- - Permanent junctional reciprocating tachycardia
- Acute termination of antidromic AVRT
- Acute treatment of atrial fibrillation with preexcitation
- - Avoidance of AV nodal blockers
- TREATMENT TO PREVENT RECURRENT ARRHYTHMIAS
- Catheter ablation
- - Indications for ablation
- Symptomatic patients
- Asymptomatic patients
- - Localizing the accessory pathway
- - Efficacy
- - Arrhythmia recurrence
- - Complications
- Surgical ablation
- Medical therapy for arrhythmia prevention
- - Prevention of recurrent orthodromic AVRT
- - Prevention of recurrent antidromic AVRT
- - Prevention of recurrent preexcited atrial fibrillation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS