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