The use of echocardiography in Wolff–Parkinson–White syndrome

Echocardiographic Patterns of Abnormal Septal Motion: Beyond Myocardial Ischemia

Abnormal septal motion (ASM), which often is associated with myocardial ischemia, is also observed in other diseases. Owing to the position of the interventricular septum (IVS) in the heart, its movement not only relies on contractile properties but is also affected by the pressure gradient between the 2 ventricles and by the mode of electrical activation. Echocardiography allows the operator to focus on the motion of the IVS, analyzing its characteristics and thereby gaining information about the possible underlying pathophysiological mechanism. In this review, we focused on the main echocardiographic patterns of ASM that are not related to a failure of contractile properties of the septum (i.e., acute coronary syndrome and cardiomyopathies), showing their pathophysiological mechanisms and underlining their diagnostic usefulness in clinical practice.

Left ventricular systolic motion pattern differs among patients with left bundle branch block patterns

The study aimed to investigate left ventricular (LV) motion pattern in patients with LBBB patterns including patients with pacemaker rhythm (PM), type B Wolff-Parkinson-White syndrome (B-WPW), premature ventricular complexes originating from the right ventricular outflow tract (RVOT-PVC), and complete left bundle branch block (CLBBB). Two-dimensional speckle tracking was used to evaluate peak value and time to peak value of the LV twist, LV apex rotation, and LV base rotation in patients with PM, B-WPW, RVOT-PVC, and CLBBB with normal LV ejection fraction, and in age-matched control subjects. The LV motion patterns were altered in all patients compared to the control groups. Patients with PM and CLBBB had a similar LV motion pattern with a reduced peak value of LV apex rotation and LV twist. Patients with B-WPW demonstrated the opposite trend in the reduction of LV rotation peak value, which was more dominant in the basal layer. The most impairment in the LV twist/rotation peak value was identified in patients with RVOT-PVC. Compared to the control group, the apical-basal rotation delay was prolonged in patients with CLBBB, followed by those with B-WPW, PM, and RVOT-PVC. The LV motion patterns were different among patients with different patterns of LBBB. CLBBB and PM demonstrated a reduction in LV twist/rotation that was pronounced in the apical layer, B-WPW showed a reduction in the basal layer, and RVOT-PVC in both layers. CLBBB had the most pronounced LV apical-basal rotation dyssynchrony.

A case of Wolff–Parkinson–White syndrome in which two-dimensional speckle-tracking echocardiography was useful for identifying the location of the accessory atrioventricular pathway

Background

In Wolff–Parkinson–White (WPW) syndrome, accessory atrioventricular pathways (AP) result in abnormal pre-excitation around the atrioventricular annuli and produce a dyssynchronous contraction of cardiac chambers. Identification of the AP affects the outcome of catheter ablation.

Case summary

We report a case of WPW syndrome and paroxysmal atrial fibrillation in a 65-year-old man. Wolff–Parkinson–White syndrome Type B was suspected from lead V1, but when two-dimensional speckle-tracking echocardiography (2D-STE) was performed, a decrease in regional strain was observed in the anterior basal wall of the left ventricle. We identified the earliest site of atrioventricular conduction, and improvement in the regional strain at the site of ablation was observed after successful AP ablation.

Discussion

Various echocardiographic techniques have been investigated as non-invasive alternatives for AP localization. Longitudinal 2D-STE accurately identified contractile abnormalities associated with the AP, allowing us to non-invasively estimate the localization of the AP in WPW syndrome.

Pre-excitation cardiac problems in children: recognition and treatment

The prevalence of ventricular pre-excitation is 0.07-0.2% in the pediatric population. Kent bundle is the most common atrioventricular accessory pathway and Mahaim fiber is relatively rare. Approximately, 30-60% of children with ventricular pre-excitation have onset of atrioventricular reentrant tachycardia. Persistent atrioventricular reentrant tachycardia can lead to tachycardiomyopathy. The anterograde conduction of right accessory pathway might lead to ventricular systolic dyssynchrony which might result in cardiac dysfunction even in patients with no tachycardia onset. This type of dilated cardiomyopathy was named as accessory pathway-induced dilated cardiomyopathy. Antiarrhythmic drugs can be used to acutely terminate tachycardia or taken orally to decrease tachycardia recurrence in the long term. However, antiarrhythmic drugs that can be chosen for children are quite limited. Sotalol has become a new choice. With the maturation of radiofrequency catheter ablation technique, progress in three-dimensional electro-anatomic mapping, use of cryoablation, and accumulation of experience in children with small age and weight, catheter ablation has become the first choice for children with pre-excitation syndrome.Conclusion: For ventricular pre-excitation co-exists with dilated cardiomyopathy, differential diagnosis of tachycardiomyopathy or accessory pathway-induced dilated cardiomyopathy should be considered. Catheter ablation (radiofrequency and cryoablation) is a relatively safe and effective treatment option and has become the first choice to treat children with ventricular pre-excitation. What is Known: • Persistent atrioventricular reentrant tachycardia in children can lead to tachycardiomyopathy; • Antiarrhythmic drugs that can be chosen for children are quite limited. What is New: • The anterograde conduction of right accessory pathway (not related to supraventricular tachycardia) might lead to accessory pathway-induced dilated cardiomyopathy. • Catheter ablation (including radiofrequency and cryoablation) has become the first choice for children with pre-excitation syndrome.

Accessory pathway-related left ventricular wall motion abnormality and the effects of radiofrequency catheter ablation in patients with Wolff-Parkinson-White syndrome

INTRODUCTION

The objective of the current study was to elucidate the effects of the accessory pathways (APs) on the left ventricular (LV) wall motion and radiofrequency catheter ablation (RFCA) on AP-related regional wall motion abnormality (RWMA) in patients with Wolff-Parkinson-White (WPW) syndrome.

METHODS AND RESULTS

We included 348 consecutive patients (age, 37.6 ± 17.3 years; men, 58.3%) with WPW syndrome who underwent RFCA for AP. We analyzed electrocardiographic data, the AP location, LV ejection fraction (LVEF), and RWMA patterns and their changes after RFCA. The locations of APs were right, septal, and left in 78, 94, and 176 patients, respectively. RWMA at the AP location (44.9%, 51.1%, and 17.6%, respectively; P < 0.001), decreased LVEF (10.3%, 6.4%, and 1.1%, respectively; P = 0.004), and dyskinesia (16.7%, 16.0%, and 1.1%, respectively; P < 0.001) were significantly more frequent in patients with a right or septal AP than in those with a left AP. In 31 of 50 patients with RWMA who underwent post-RFCA echocardiography (62.0%), RWMA was completely improved after RFCA. Right AP (odds ratio [OR], 22.084; 95% confidence interval [CI], 3.628-134.420; P = 0.001) and dyskinesia (OR, 6.275; 95% CI, 1.186-33.213; P = 0.031) were significantly associated with the absence of RWMA improvement after RFCA.

CONCLUSIONS

AP-related RWMA is frequent in patients with right or septal APs. A substantial number of patients with right AP or dyskinesia may show no improvement in RWMA after RFCA.

Investigation of ventricular pre-excitation electrocardiographic pattern in two horses: clinical presentation and potential causes

Two horses referred to the Unitat Equina, Fundació Hospital Clínic Veterinari, Universitat Autònoma de Barcelona, for unrelated clinical problems, and with no previous history of cardiac disease exhibited an intermittent ventricular pre-excitation electrocardiographic pattern during hospitalization. Both animals showed decreased plasma total and ionized magnesium concentrations, but no other relevant electrolyte disturbances were detected. Altered interventricular septal motion associated with ventricular pre-excitation beats (VPBs) was detected on M-mode echocardiography in both horses. The likely localization of an accessory pathway (AP) was identified in case 2 using pulsed-wave tissue Doppler imaging in the left anterior paraseptal location. Decreased frequency of the VPB was observed with long-term magnesium supplementation and restoration of plasma magnesium concentrations. The presence of ventricular pre-excitation electrocardiographic pattern was attributed to higher sensitivity of the AP to hypomagnesemia in both cases.

Noninvasive Localization of Accessory Pathways in Wolff-Parkinson-White Syndrome by Three-Dimensional Speckle Tracking Echocardiography

BACKGROUND

We have developed a noninvasive isochrone activation imaging (AI) system with 3-dimensional (3D) speckle tracking echocardiography (STE), which allows visualization of the wavefront image of mechanical propagation of the accessory pathway (ACP) in Wolff-Parkinson-White syndrome.

METHODS AND RESULTS

Patients with manifest Wolff-Parkinson-White syndrome were imaged in 3D-STE AI mode, which quantified the time from QRS onset to regional endocardial deformation. In 2 patients with left- and right-side ACP, we confirmed that intraoperative contact endocardial electric mapping and the 3D-STE AI system showed comparable images pre- and postablation. In normal heart assessment by 3D-echo AI, the earliest activation sites were found at the attachment of the papillary muscles in the left ventricle and midseptum in the right ventricle, and none showed earliest activation at the peri-atrioventricular valve annuli. An analyzer who was unaware of the clinical information assessed 39 ACP locations in 38 Wolff-Parkinson-White syndrome patients using 3D-STE. All showed abnormal perimitral or tricuspid annular activations, and the location of 34 ACP (87%) showed agreement with the successful ablation sites within a 2-o'clock range. Especially for left free wall ACP, 17/18 (94%) showed consistency with the ablation site within a 2 o'clock range. Among 15 ACP at the ventricular septum, 9 (60%) showed early local activation in both right and left sides of the septum.

CONCLUSIONS

Isochrone AI with 3D-STE may be a promising noninvasive imaging tool to assess cardiac synchronized activation in normal hearts and detect abnormal breakthrough of mechanical activation from both atrioventricular annuli in Wolff-Parkinson-White syndrome.

Assessment of atrial fibrillation and vulnerability in patients with Wolff-Parkinson-White syndrome using two-dimensional speckle tracking echocardiography

Purpose

The aim was to assess atrial fibrillation (AF) and vulnerability in Wolff-Parkinson-White (WPW) syndrome patients using two-dimensional speckle tracking echocardiography (2D-STE).

Methods

All patients were examined via transthoracic echocardiography and 2D-STE in order to assess atrial function 7 days before and 10 days after RF catheter ablation. A postoperative 3-month follow-up was performed via outpatient visit or telephone calls.

Results

Results showed significant differences in both body mass index (BMI) and supraventricular tachycardia (SVT) duration between WPW patients and DAVNP patients (both P<0.05). Echocardiography revealed that the maximum left atrial volume (LAV_max) and the left ventricular mass index (LVMI) in diastole increased noticeably in patients with WPW compared to patients with DAVNP both before and after ablation (all P<0.05). Before ablation, there were obvious differences in the levels of SRs, SRe, and SRa from the 4-chamber view (LA) in the WPW patients group compared with patients in the DAVNP group (all P<0.05). In the AF group, there were significant differences in the levels of systolic strain rate (SRs), early diastolic strain rate (SRe), and late diastolic strain rate (SRa) from the 4-chamber view (LA) both before and after ablation (all P<0.05). In the non-AF group, there were decreased SRe levels from the 4-chamber view (LA/RA) pre-ablation compared to post-ablation (all P<0.05).

Conclusion

Our findings provide convincing evidence that WPW syndrome may result in increased atrial vulnerability and contribute to the development of AF. Further, RF catheter ablation of AAV pathway can potentially improve atrial function in WPW syndrome patients. Two-dimensional speckle tracking echocardiography imaging in WPW patients would be necessary in the evaluation and improvement of the overall function of RF catheter ablation in a long-term follow-up period.

Does accessory pathway significantly alter left ventricular twist/torsion? A study in Wolff-Parkinson-White syndrome by velocity vector imaging

BACKGROUND

The aim of this study was to determine the impact of manifest accessory pathway on left ventricle (LV) twist physiology in Wolff-Parkinson-White (WPW) patients. Although this issue was addressed in 1 study based on speckle tracking method, there was no comparative study with a different technique. We planned to use velocity vector imaging (VVI) to find out how much an accessory pathway can affect LV twist mechanics.

METHODS

Thirty patients were enrolled regarding inclusion and exclusion criteria. Two serial comprehensive transthoracic echocardiography evaluations were performed before and after radiofrequency catheter ablation (RFCA) within 24 hours. Stored cine loops were analyzed using VVI technique and LV twist and related parameters were extracted.

RESULTS

Comparing pre- and post-RFCA data, no significant changes were observed in LV systolic and diastolic dimensions, LV ejection fraction (LVEF), and Doppler and tissue Doppler-related parameters. VVI study revealed remarkable rise in peak LV apical rotation (10.3º ± 3.0º to 13.8º ± 3.6º, P < 0.001) and basal rotation (-6.0 ± 1.8º to -7.7 ± 1.8º, P < 0.001) after RFCA. Subsequently LV twist showed a surge from 14.7º ± 3.9º to 20.2º ± 4.4º (P < 0.001). LV untwisting rate changed significantly from -96 ± 67 to -149.0 ± 47.5°/sec (P < 0.001) and apical-basal rotation delay showed a remarkable decline after RFCA (106 ± 81 vs. 42.8 ± 26.0 msec, P < 0.001).

CONCLUSION

Accessory pathways have a major impact on LV twist mechanics.