SHA24/086003

WPW high risk group and early ablation Dr Khalid Dagriri PSCC SHA 24

WPW syndrome • Definition : – Pre-excitation pattern with symptoms • • • •

Palpitation Pre-syncope or syncope Evidence of atrial tachycardia Rare VF arrest

Natural History • Prevelance – Large scale studies ped+adult 1-3 /1000 – Familial studies 5.5/1000

• 65% adolescent and 40% adult>30 y are asymptomatic • Presentation of symptoms with normal heart depends on AP numbers, location and properties • Symptoms in relation to age

Natural history • Definite high risk group depend on history is a dilemma • With absent noninvasive and invasive testing warning flags – Age <30 years – Male gender – History of AF – Prior syncope – Associated congenital heart disease – Familial WPW

Heart rhythm June 2012

Natural history: With age class IIa turns into class I.

Likelihood

New onset arrhythmia in previously asymptomatic patient

5 Pappone, Circulation, Oct 4 2005

10

20

30

40

AGE

50

60

70

Risk stratification of WPW • Noninvasive evaluation of WPW patients – 12 lead ECG – Ambulatory monitoring – Medication Challenge – Exercise testing

Low Risk

Wellens, Circulation, Oct 4 2005

High risk

Wellens, Circulation, Oct 4 2005

Pappone, Circulation, Oct 4 2005

Risk stratification of WPW • Invasive EP study – Tranesophageal catheter study – Intracardiac catheter study • Use of Isoproterenol

Heart rhythm June 2012

Management Plan • Catheter Ablation – Efficacy of catheter ablation – Ablation outcomes in the very young child – Cryoablation – Risk and complications

• WPW and CHD • WPW and sport participation

Procedural risk

Hans Henrik Odland 2009

Pappone, Circulation, Oct 4 2005

Ablation in high risk asymptomatic WPW

Pappone et al.

Multiple pathways

Pappone et al.

Pappone, Circulation, Oct 4 2005

Pappone, Circulation, Oct 4 2005

Management Plan • Catheter Ablation – Efficacy of catheter ablation – Ablation outcomes in the very young child – Cryoablation – Risk and complications

• WPW and CHD • WPW and sport participation

Management Plan • Catheter Ablation – Efficacy of catheter ablation – Ablation outcomes in the very young child – Cryoablation – Risk and complications

• WPW and CHD • WPW and sport participation

Management Plan • Catheter Ablation – Efficacy of catheter ablation – Ablation outcomes in the very young child – Cryoablation – Risk and complications

• WPW and CHD • WPW and sport participation

Management Plan • Catheter Ablation – Efficacy of catheter ablation – Ablation outcomes in the very young child – Cryoablation – Risk and complications

• WPW and CHD • WPW and sport participation

Management Plan • Catheter Ablation – Efficacy of catheter ablation – Ablation outcomes in the very young child – Cryoablation – Risk and complications

• WPW and CHD • WPW and sport participation

Hans Henrik Odland 2009

Conclusion • Sudden cardiac death with WPW is very rare, devastated but can be avoided • Use of non invasive methods has high positive predictive value to identify high risk group • Catheter ablation is save procedure and recommended in young patient with high risk