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Maines M, Zorzi A, Peruzza F, Catanzariti D, Moggio P, Angheben C, Del Greco M. Endocavitary electrophysiological study by percutaneous antecubital vein and without X-ray for risk stratification of asymptomatic ventricular pre-excitation in young athletes. IJC HEART & VASCULATURE 2021; 36:100879. [PMID: 34604501 PMCID: PMC8463852 DOI: 10.1016/j.ijcha.2021.100879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022]
Abstract
Evaluation of AP is usually performed by transesophageal and intracardiac studies. In young athletes with AVP, our standard of care is to perform ESnoXR. ESnoXR may considered a less invasive alternative for risk stratification of AP.
Athletes with asymptomatic ventricular pre-excitation (VP) should undergo electrophysiological study for risk stratification. We aimed to evaluate the feasibility, efficacy, safety and tolerability of an electrophysiological study using a percutaneous antecubital vein access and without the use of X-ray (ESnoXr). Methods: We collected data from all young athletes < 18 year-old with AVP, who underwent ESnoXr from January 2000 to September 2020 for evaluation of accessory pathway refractoriness and arrhythmia inducibility using an antecubital percutaneous venous access. Endocavitary signals were used to advance the catheter in the right atrium and ventricle. Results: We included 63 consecutive young athletes (mean age 14.6 ± 1.9 years, 46% male). Feasibility of the ESnoXr technique was 87% while in 13% fluoroscopy and/or a femoral approach were needed. Specifically, fluoroscopy was used in 7 cases to position the catheter inside the heart cavities with an average exposure of 43 ± 38 s while in 2 femoral venous access was needed. The mean procedural time was 35 ± 11 min. The exam was diagnostic in all patients, there were no procedural complications and tolerability was excellent. 53% of the patients had an accessory pathway with high refractoriness and no inducible atrio-ventricular reentry tachycardia: this subgroup was considered eligible to competitive sports and no event was observed during long-term follow-up (13.6 ± 5.2 years) without drug use. The others underwent catheter ablation. Conclusion. ESnoXr has been shown to be a feasible, effective, safe and well-tolerated procedure for the assessment of arrhythmic risk in a population of young athletes with asymptomatic VP.
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Affiliation(s)
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | | | | | - Paolo Moggio
- Santa Maria del Carmine Hospital (Rovereto-TN), Italy
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Książczyk TM, Pietrzak R, Werner B. Management of Young Athletes with Asymptomatic Preexcitation-A Review of the Literature. Diagnostics (Basel) 2020; 10:diagnostics10100824. [PMID: 33076240 PMCID: PMC7602380 DOI: 10.3390/diagnostics10100824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION The management of young athletes with asymptomatic preexcitation remains a challenge, regardless of the progress we have made in understanding the basis of condition and developing catheter ablation procedures. The risk of sudden death, however small, yet definite, being the first symptom is determining our approach. The aim of the study was to establish the current state of knowledge regarding the management of young athletes diagnosed with asymptomatic preexcitation, by conducting a literature review. MATERIAL AND METHODS A comprehensive literature review was completed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was limited to English language publications using the following search terms: "asymptomatic" or "incidental" and "pre-excitation" or "Wolff-Parkinson-White" or "delta wave" and "athlete" or "sport". The search was supplemented by hand review of the bibliographies of previous relevant systematic reviews. RESULTS The search resulted in 85 of abstracts, and the manual search of the bibliographies resulted in 24 additional papers. After careful analysis 10 publications were included in the review. In all but one of the presented papers, the authors used non-invasive methods and then either trans-esophageal or invasive EPS as a way to risk stratify asymptomatic patients. Evidence of rapid conduction through the accessory pathway was considered high risk and prompted sport disqualification. In the analysed reports there were combined: 142 episodes of the life-threatening events (LTE)/sudden death (SCD), of which 56 were reported to occur at rest, 61 during activity and no data were available for 25. CONCLUSIONS athletic activity may impose an increased risk of life-threatening arrhythmias in patients with asymptomatic preexcitation; hence, a separate approach could be considered, especially in patients willing to engage in high-intensity, endurance and competitive sports.
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Rodriguez-Gonzalez M, Castellano-Martinez A, Perez-Reviriego AA. Risk-Stratification Strategy for Sudden Cardiac Death in the Very Young Children with Asymptomatic Ventricular Preexcitation. Curr Cardiol Rev 2019; 16:83-89. [PMID: 30827253 PMCID: PMC7460710 DOI: 10.2174/1573403x15666190301150754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/18/2018] [Accepted: 02/20/2019] [Indexed: 11/22/2022] Open
Abstract
Asymptomatic VPE refers to the presence of this abnormal ECG pattern in the absence of any symptoms. The natural history in these patients is usually benign, and most children (60%) with VPE are usually asymptomatic. However, Sudden Cardiac Death (SCD) has been reported to be the initial symptom in many patients too. The increased risk of SCD is thought to be due to the rapid conduction of atrial arrhythmias to the ventricle, via the AP, which degenerates into Ventricular Fibrillation (VF). The best method to identify high-risk patients with asymptomatic VPE for SCD is the characterization of the electrophysiological properties of the AP through an Electrophysiological Study (EPS). Also, catheter ablation of the AP with radiofrequency as definitive treatment to avoid SCD can be performed by the same procedure with high rates of success. However, the uncertainty over the absolute risk of SCD, the poor positive predictive value of an invasive EPS, and complications associated with catheter ablation have made the management of asymptomatic VPE challenging, even more in those children younger than 8-year-old, where there are no clear recommendations. This review provides an overview of the different methods to make the risk stratification for SCD in asymptomatic children with, as well as our viewpoint on the adequate approach to those young children not included in current guidelines.
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Affiliation(s)
- Moises Rodriguez-Gonzalez
- Department of Pediatric Cardiology, Puerta del Mar University Hospital, Cadiz, Spain.,Biomedical Research and Innovation Institute of Cadiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cadiz, Cadiz, Spain
| | - Ana Castellano-Martinez
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cadiz, Cadiz, Spain.,Department of Pediatric Nephrology, Puerta del Mar University Hospital, Cadiz, Spain
| | - Alvaro A Perez-Reviriego
- Department of Pediatric Cardiology, Puerta del Mar University Hospital, Cadiz, Spain.,Biomedical Research and Innovation Institute of Cadiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cadiz, Cadiz, Spain
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Brembilla-Perrot B, Girerd N, Sellal JM. Unresolved questions associated with the management of ventricular preexcitation syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:839-844. [PMID: 29754436 DOI: 10.1111/pace.13367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/12/2018] [Accepted: 04/24/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Many recent recommendations concern the management of preexcitation syndrome. In clinical practice, they are sometimes difficult to use. The purpose of the authors was to discuss the main problems associated with this management. Three problems are encountered: (1) the reality of the absence of symptoms or the interpretation of atypical symptoms, (2) the electrocardiographic diagnosis of preexcitation syndrome that can be missed, and (3) the exact electrophysiological protocol and its interpretation used for the evaluation of the prognosis. Because of significant progress largely related to the development of curative treatment, it seems easy to propose ablation in many patients despite the related risks of invasive studies and to minimize the invasive risk by only performing ablation for patients with at-risk pathways. However, there is a low risk of spontaneous events in truly asymptomatic patients and the indication of accessory pathway ablation should be discussed case by case.
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Affiliation(s)
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques 1433, Université de Lorraine, Institut Lorrain du cœur et des vaisseaux, Nancy University Hospital, Nancy, France
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Koca S, Pac FA, Kavurt AV, Cay S, Mihcioglu A, Aras D, Topaloglu S. Transesophageal and invasive electrophysiologic evaluation in children with Wolff-Parkinson-White pattern. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:808-814. [PMID: 28436586 DOI: 10.1111/pace.13100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/16/2017] [Accepted: 04/12/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Risk stratification for Wolff-Parkinson-White (WPW) pattern either by noninvasive or invasive tests is important to determine whether an ablation is necessary or not. The aim was to compare noninvasive tests and invasive studies in a pediatric WPW population. METHODS A total of 71 WPW patients (median age 14 years [interquartile range, 11-16 years]; 43 male) underwent Holter monitoring, exercise stress test (EST), and transesophageal electrophysiological study (TEEPS). In the case of a ≤270-ms effective refractory period of accessory pathway or induction of supraventricular tachycardia using TEEPS, patients were classified as high risk and underwent invasive electrophysiological study (EPS). RESULTS Nine of 23 patients with low risk by Holter and eight of 26 patients with low risk by EST had high risk in TEEPS. Risky TEEPS results were detected in 42 of 71 patients and those patients underwent EPS. High-risk characteristic in EPS was detected in seven of nine patients with low risk by Holter and in seven of eight with low risk by EST. Both tests yielded moderate specificity (52-69%) and negative predictive value (61-69%) according to TEEPS. CONCLUSION Holter and EST have low predictive value in WPW risk stratification. However, TEEPS and EPS are extremely valuable in WPW risk stratification. TEEPS may reveal important and useful results for WPW risk determination, especially in small children not having undergone EPS in order to avoid its complications.
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Affiliation(s)
- Serhat Koca
- Department of Pediatric Cardiology, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara, Turkey
| | - Feyza Aysenur Pac
- Department of Pediatric Cardiology, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara, Turkey
| | - Ahmet Vedat Kavurt
- Department of Pediatric Cardiology, Diyarbakir Children Hospital, Diyarbakir, Turkey
| | - Serkan Cay
- Division of Arrhythmia and Electrophysiology, Department of Cardiology, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara, Turkey
| | - Ajda Mihcioglu
- Department of Pediatric Cardiology, Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Dursun Aras
- Division of Arrhythmia and Electrophysiology, Department of Cardiology, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara, Turkey
| | - Serkan Topaloglu
- Division of Arrhythmia and Electrophysiology, Department of Cardiology, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara, Turkey
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Long term risk of Wolff-Parkinson-White pattern and syndrome. Trends Cardiovasc Med 2017; 27:260-268. [DOI: 10.1016/j.tcm.2016.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 12/01/2016] [Accepted: 12/01/2016] [Indexed: 11/18/2022]
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Brembilla-Perrot B, Sellal JM, Olivier A, Villemin T, Moulin-Zinsch A, Beurrier D, Lethor JP, Marçon F, DE Chillou C, Felblinger J, Vincent J. Evolution of Clinical and Electrophysiological Data in Children with a Preexcitation Syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:951-8. [PMID: 27448170 DOI: 10.1111/pace.12922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/30/2016] [Accepted: 07/17/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND With ablation, the follow-up of preexcitation syndrome now is difficult to assess. The purpose was to collect data of children with a preexcitation syndrome studied on two separate occasions within a minimal interval of 1 year. METHODS This is a retrospective chart review of 47 children initially aged 12 ± 4 years, who underwent two or more invasive electrophysiological studies (EPS) within 1-25 years of one another (6.3 ± 4.8) for occurrence of symptoms or new evaluation. RESULTS Among initially symptomatic children (n = 25), four (19%) became asymptomatic and one presented life-threatening arrhythmia. Among asymptomatic children (n = 22), five became symptomatic (22.7%). Anterograde conduction disappeared in seven of 23 children with initially long accessory pathway-effective refractory period, but four of six had still induced atrioventricular reentrant tachycardia (AVRT). AVRT was induced at second EPS in three of 13 asymptomatic preexcitation syndrome with negative initial EPS. There were no spontaneous adverse events in the five children with criteria of malignancy at initial EPS; signs of malignancy disappeared in two. At multivariate analysis, AVRT at initial EPS was the only independent factor of symptomatic AVRT during follow-up. Absence of induced AVRT at initial EPS was the only factor of absence of symptoms and a negative study at the second EPS. CONCLUSIONS There were no significant changes of data in children after 6.3 ± 4.8 years of follow-up. Most children with spontaneous/inducible AVRTs at initial EPS had still inducible AVRT at second EPS. Induced AF conducted with high rate has a relatively low prognostic value for the prediction of adverse events.
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Affiliation(s)
| | - Jean-Marc Sellal
- Adult and Paediatric Cardiology, CHU de Brabois, Vandoeuvre Les Nancy, France
| | - Arnaud Olivier
- Adult and Paediatric Cardiology, CHU de Brabois, Vandoeuvre Les Nancy, France
| | - Thibaut Villemin
- Adult and Paediatric Cardiology, CHU de Brabois, Vandoeuvre Les Nancy, France
| | - Anne Moulin-Zinsch
- Adult and Paediatric Cardiology, CHU de Brabois, Vandoeuvre Les Nancy, France
| | - Daniel Beurrier
- Adult and Paediatric Cardiology, CHU de Brabois, Vandoeuvre Les Nancy, France
| | - Jean-Paul Lethor
- Adult and Paediatric Cardiology, CHU de Brabois, Vandoeuvre Les Nancy, France
| | - François Marçon
- Adult and Paediatric Cardiology, CHU de Brabois, Vandoeuvre Les Nancy, France
| | | | | | - Julie Vincent
- Adult and Paediatric Cardiology, CHU de Brabois, Vandoeuvre Les Nancy, France
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Di Mambro C, Drago F, Milioni M, Russo MS, Righi D, Placidi S, Remoli R, Palmieri R, Gimigliano F, Santucci LM, Silvetti MS, Prosperi M. Sports Eligibility After Risk Assessment and Treatment in Children with Asymptomatic Ventricular Pre-excitation. Sports Med 2016; 46:1183-90. [DOI: 10.1007/s40279-016-0475-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gülgün M, Özer S, Karagöz T, Akın A, Aykan HH, Özkutlu S, Alehan D, Çeliker A. Is transesophageal electrophysiologic study valuable in children with successful radiofrequency ablation of supraventricular tachycardia on follow-up for recurrence? Anatol J Cardiol 2015; 16:126-30. [PMID: 26467372 PMCID: PMC5336727 DOI: 10.5152/akd.2015.5895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective: The aim of this study was to evaluate the efficacy of transesophageal electrophysiologic study (TEEPS) for the determination of supraventricular tachycardia (SVT) recurrences in symptomatic and asymptomatic children after successful radiofrequency ablation (RFA) for SVT. Methods: A total of 66 patients who underwent TEEPS after successful RFA were included. The demographic features, symptoms of the patients, and the characteristics of the recurrences induced by TEEPS were evaluated. The arrhythmia types induced during RFA were compared with those induced by TEEPS in terms of the compatibility of the diagnosis. Results: Forty-two (63.6%) girls and 24 (36.4%) boys with a mean age of 11.8±3.4 years were followed-up for 44.1±15.7 months. The average time between RFA and TEEPS was 5.2±5.9 months. The diagnoses during RFA were atrioventricular nodal reentrant tachycardia (AVNRT) in 47 of 66 patients, atrioventricular reentrant tachycardia (AVRT) in 18 of 66 patients, and ectopic atrial tachycardia in 1 of 66 patients. SVT was induced by TEEPS in 2 of 25 symptomatic and 5 of 41 asymptomatic patients. The SVT inducibility rate was 5.5% (1/18) and 12.7% (6/47) in patients with AVRT and AVNRT, respectively. In addition, 85.7% (6/7) of all recurrences occurred within 3.5 months. The recurrences as AVNRT in 2 of 25 symptomatic patients occurred in the first month after RFA. AVNRT in 4 of 41 and AVRT in 1 of 41 asymptomatic patients were induced within 3.5 months and 15 months, respectively. Conclusion: TEEPS seems to be a valuable screening and diagnostic method for the determination of recurrence in symptomatic and asymptomatic children who underwent successful RFA.
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Affiliation(s)
- Mustafa Gülgün
- Department of Pediatric Cardiology, Faculty of Medicine, Hacettepe University; Ankara-Turkey.
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Electrophysiology testing and catheter ablation are helpful when evaluating asymptomatic patients with Wolff-Parkinson-White pattern: the con perspective. Card Electrophysiol Clin 2015; 7:377-83. [PMID: 26304516 DOI: 10.1016/j.ccep.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The association between asymptomatic Wolff-Parkinson-White (WPW) syndrome and sudden cardiac death (SCD) has been well documented. The inherent properties of the accessory pathway determine the risk of SCD in WPW, and catheter ablation essentially eliminates this risk. An approach to WPW syndrome is needed that incorporates the patient's individualized considerations into the decision making. Patients must understand that there is a trade-off of a small immediate risk of an invasive approach for elimination of a small lifetime risk of the natural history of asymptomatic WPW. Clinicians can minimize the invasive risk by only performing ablation for patients with at-risk pathways.
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Brembilla-Perrot B, Sellal JM, Olivier A, Manenti V, Beurrier D, Al Jouma B, Andronache M, de Chillou C, Girerd N, Villemin T. A case series of patients with poorly-tolerated arrhythmias related to a preexcitation syndrome and presenting with atypical ECG. Int J Cardiol 2014; 174:348-54. [PMID: 24794061 DOI: 10.1016/j.ijcard.2014.04.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 03/25/2014] [Accepted: 04/09/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED The aim of study was to report different and unusual patterns of preexcitation syndrome (PS) noted in patients referred for studied for poorly-tolerated arrhythmias and their frequency. Electrophysiologic study (EPS) is an easy means to identify a patient with PS at risk of serious events. However the main basis for this diagnosis is the ECG which associates short PR interval and widening of QRS complex with a delta wave. METHODS ECGs of 861 patients in whom PS related to an atrioventricular accessory pathway (AP) was identified at electrophysiological study (EPS), were studied. RESULTS The most frequent unusual presentation (9.6%) was the PS presenting with a normal or near normal ECG, noted preferentially for left lateral AP and rarely for posteroseptal or right lateral location. More exceptional (0.1%) was the presence of a long PR interval, which did not exclude a rapid conduction over AP. The association of a complete AV block with symptomatic tachycardias was exceptional (0.3%) and was shown related to a rapid conduction over AP after isoproterenol. Most of the presented patients were at high-risk at EPS. CONCLUSION The diagnosis of PS is not always evident and symptoms should draw attention to minor abnormalities and lead to enlarge indications of EPS, only means to confirm or not PS.
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Affiliation(s)
| | - Jean Marc Sellal
- Department of Cardiology, University Hospital of Brabois, Vandoeuvre Les Nancy, France
| | - Arnaud Olivier
- Department of Cardiology, University Hospital of Brabois, Vandoeuvre Les Nancy, France
| | - Vladimir Manenti
- Department of Cardiology, University Hospital of Brabois, Vandoeuvre Les Nancy, France
| | - Daniel Beurrier
- Department of Cardiology, University Hospital of Brabois, Vandoeuvre Les Nancy, France
| | - Bassam Al Jouma
- Department of Cardiology, University Hospital of Brabois, Vandoeuvre Les Nancy, France
| | - Marius Andronache
- Department of Cardiology, University Hospital of Brabois, Vandoeuvre Les Nancy, France
| | - Christian de Chillou
- Department of Cardiology, University Hospital of Brabois, Vandoeuvre Les Nancy, France
| | - Nicolas Girerd
- Department of Cardiology, University Hospital of Brabois, Vandoeuvre Les Nancy, France
| | - Thibaut Villemin
- Department of Cardiology, University Hospital of Brabois, Vandoeuvre Les Nancy, France
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Brembilla-Perrot B, Moejezi RV, Zinzius PY, Jarmouni S, Schwartz J, Beurrier D, Sellal JM, Nossier I, Muresan L, Andronache M, Moisei R, Selton O, Louis P, de la Chaise AT. Missing diagnosis of preexcitation syndrome on ECG: clinical and electrophysiological significance. Int J Cardiol 2013; 163:288-293. [PMID: 21704397 DOI: 10.1016/j.ijcard.2011.06.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 04/20/2011] [Accepted: 06/06/2011] [Indexed: 11/25/2022]
Abstract
UNLABELLED Electrocardiographic criteria of preexcitation syndrome are sometimes not visible on ECG in sinus rhythm (SR). The purpose of the study was to evaluate the significance of unapparent preexcitation syndrome in SR, when overt conduction through accessory pathway (AP) was noted at atrial pacing. METHODS Anterograde conduction through atrioventricular AP was identified at electrophysiological study (EPS) in 712 patients, studied for tachycardia (n=316), syncope (n=89) or life-threatening arrhythmia (n=55) or asymptomatic preexcitation syndrome (n=252). ECG in SR at the time of EPS was analysed. RESULTS 78 patients (11%) (group I) had a normal ECG in SR and anterograde conduction over AP at atrial pacing; 634 (group II) had overt preexcitation in SR. Group I was as frequently asymptomatic (35%) as group II (35%), had as frequently tachycardias, syncope or life-threatening arrhythmia as group II (43, 5, 2% vs 43, 13, 8%). AP was more frequently left lateral in group I (57%) than in group II (36%)(p<0.001). AV re-entrant tachycardia, atrial fibrillation (AF), antidromic tachycardia were induced as frequently in group I (54, 18, 10%) as in group II (54, 27, 7%). Malignant forms (induced AF with RR intervals between preexcited beats <250ms in control state or <200ms after isoproterenol) were as frequent in group I (11.5%) as II (14%). CONCLUSIONS The frequency of unapparent preexcitation syndrome represents 11% of our population with anterograde conduction through an AP and could be underestimated. The risk to have a malignant form is as high as in patients with overt preexcitation syndrome in SR.
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Affiliation(s)
| | | | - Pierre Yves Zinzius
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Soumaya Jarmouni
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Jérôme Schwartz
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Daniel Beurrier
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Jean Marc Sellal
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Ibrahim Nossier
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Lucian Muresan
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Marius Andronache
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Radou Moisei
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Olivier Selton
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
| | - Pierre Louis
- Department of cardiology, University Hospital of Brabois, Vandoeuvre, France
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WACKEL PHILIP, IRVING CLAIRE, WEBBER STEVEN, BEERMAN LEE, ARORA GAURAV. Risk Stratification in Wolff-Parkinson-White Syndrome: The Correlation Between Noninvasive and Invasive Testing in Pediatric Patients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1451-7. [DOI: 10.1111/j.1540-8159.2012.03518.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Obeyesekere MN, Leong-Sit P, Krahn AD, Gula LJ, Yee R, Skanes AC, Klein GJ. Asymptomatic Wolff-Parkinson-White Syndrome: Who Should Be Treated? Card Electrophysiol Clin 2012; 4:273-280. [PMID: 26939946 DOI: 10.1016/j.ccep.2012.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This article discusses the merits of electrophysiology study (EPS) and/or ablation for asymptomatic preexcitation Wolff-Parkinson-White (WPW) ECG pattern. Sudden deaths in asymptomatic patients are too few to merit broad screening and aggressive intervention. It also discusses the risks of ablation and the low predictive accuracy of EPS. When WPW is an incidental finding, the decision to proceed with investigation and ablation can be made considering patients' situations and preferences. An invasive strategy is targeted at patients concerned about the low risk of life-threatening arrhythmia as a first presentation after a discussion of the risks and benefits.
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Affiliation(s)
- Manoj N Obeyesekere
- Division of Cardiology, Western University, 339 Windermere Road, C6-110, London, Ontario N6A 5A5, Canada
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Pappone C, Santinelli V. Asymptomatic Wolff-Parkinson-White Syndrome Should be Ablated. Card Electrophysiol Clin 2012; 4:281-285. [PMID: 26939947 DOI: 10.1016/j.ccep.2012.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Wolff-Parkinson-White syndrome (WPW) is associated with a small but lifetime risk of cardiac arrest and/or sudden cardiac death (SCD). However, the exact risk is not well defined, particularly in asymptomatic persons. Over recent years the authors have collected and reported new follow-up data among a large number of asymptomatic WPW patients, particularly children, intensively followed. These data have significantly contributed to the knowledge and definition of the natural history of WPW from childhood to adulthood. The risk of SCD is higher in asymptomatic children than in adults, and early ablation can be offered only to selected subjects after electrophysiologic testing.
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Affiliation(s)
- Carlo Pappone
- Arrhythmology Department, Maria Cecilia Hospital, Via Corriera 1, 48010 Cotignola, Italy
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Evolution of clinical and electrophysiologic data in patients with a preexcitation syndrome. J Electrocardiol 2012; 45:398-403. [DOI: 10.1016/j.jelectrocard.2012.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Indexed: 11/23/2022]
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18
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Hoyt WJ, Thomas PE, DeSena HC, Steinberg JS, Harmon DE, Snyder CS. Atrial fibrillation induction by transesophageal electrophysiology studies in patients with asymptomatic ventricular preexcitation. CONGENIT HEART DIS 2012; 8:57-61. [PMID: 22716259 DOI: 10.1111/j.1747-0803.2012.00689.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Ventricular preexcitation is a conduction abnormality caused by an accessory pathway bridging the atria and ventricles. If the accessory pathway conducts rapidly during atrial fibrillation (AFib), sudden death may result. The purpose of this study was to determine the ability of transesophageal electrophysiology studies (TEEPS) to induce AFib in pediatric patients with asymptomatic ventricular preexcitation (aVPE). DESIGN A retrospective review of patients with aVPE who had a TEEPS was conducted. Inclusion criteria were evidence of ventricular preexcitation on electrocardiogram; age <18 years; and no history of tachycardia, palpitations, or syncope. Data gathered included age, weight, height, form of sedation, and TEEPS results. If AFib was induced, patients were classified as at risk of sudden death if the shortest preexcited RR interval during AFib was <250 ms or no risk if ≥ 250 ms. RESULTS A total of 26 patients met the inclusion criteria, with average age of 11.9 years, weight of 48.9 kg, and height of 149.2 cm. During the procedure, nine patients underwent conscious sedation (34.6%), and 17 underwent general anesthesia (65.4%). AFib was induced in 23 patients (88.5%), of whom 17 (73.9%) had no risk and six (26.1%) had risk. No statistical differences were noted in age, weight, height, or form of sedation when comparisons were made between AFib induction and no AFib induction. CONCLUSIONS TEEPS induced AFib in 88.5% of patients. Age, weight, height, and form of sedation had no effect upon AFib inducibility. TEEPS is an effective modality to induce AFib in pediatric patients with aVPE.
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Affiliation(s)
- Walter J Hoyt
- Department of Pediatrics, Tulane University, New Orleans, LA, USA
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19
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Risk of atrial fibrillation according to the initial presentation of a preexcitation syndrome. Int J Cardiol 2012; 157:359-63. [DOI: 10.1016/j.ijcard.2010.12.078] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 12/21/2010] [Indexed: 11/23/2022]
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20
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Obeyesekere MN, Leong-Sit P, Massel D, Manlucu J, Modi S, Krahn AD, Skanes AC, Yee R, Gula LJ, Klein GJ. Risk of Arrhythmia and Sudden Death in Patients With Asymptomatic Preexcitation. Circulation 2012; 125:2308-15. [DOI: 10.1161/circulationaha.111.055350] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The incidence of sudden cardiac death (SCD) and the management of this risk in patients with asymptomatic preexcitation remain controversial. The purpose of this meta-analysis was to define the incidence of SCD and supraventricular tachycardia in patients with asymptomatic Wolff-Parkinson-White ECG pattern.
Methods and Results—
We performed a systematic search of prospective, retrospective, randomized, or cohort English-language studies in EMBASE and Medline through February 2011. Studies reporting asymptomatic patients with preexcitation who did not undergo ablation were included. Twenty studies involving 1869 patients met our inclusion criteria. Participants were primarily male with a mean age ranging from 7 to 43 years. Ten SCDs were reported involving 11 722 person-years of follow-up. Seven studies originated from Italy and reported 9 SCDs. The risk of SCD is estimated at 1.25 per 1000 person-years (95% confidence interval [CI], 0.57–2.19). A total of 156 supraventricular tachycardias were reported involving 9884 person-years from 18 studies. The risk of supraventricular tachycardia was 16 (95% CI, 10–24) events per 1000 person-years of follow-up. Children had numerically higher SCD (1.93 [95% CI, 0.57–4.1] versus 0.86 [95% CI, 0.28–1.75];
P
=0.07) and supraventricular tachycardia (20 [95% CI, 12–31] versus 14 [95% CI, 6–25];
P
=0.38) event rates compared with adults.
Conclusion—
The low incidence of SCD and low risk of supraventricular tachycardia argue against routine invasive management in most asymptomatic patients with the Wolff-Parkinson-White ECG pattern.
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Affiliation(s)
- Manoj N. Obeyesekere
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
| | - Peter Leong-Sit
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
| | - David Massel
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
| | - Jaimie Manlucu
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
| | - Simon Modi
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
| | - Andrew D. Krahn
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
| | - Allan C. Skanes
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
| | - Raymond Yee
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
| | - Lorne J. Gula
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
| | - George J. Klein
- From the University of Western Ontario, Division of Cardiology, London, Ontario, Canada
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21
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Cohen MI, Triedman JK, Cannon BC, Davis AM, Drago F, Janousek J, Klein GJ, Law IH, Morady FJ, Paul T, Perry JC, Sanatani S, Tanel RE. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm 2012; 9:1006-24. [PMID: 22579340 DOI: 10.1016/j.hrthm.2012.03.050] [Citation(s) in RCA: 215] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Indexed: 10/28/2022]
Affiliation(s)
-
- Arizona Pediatric Cardiology Consultants & Phoenix Children's Hospital, Phoenix, AZ, USA
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22
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Benzakin F, Brembilla-Perrot B. [Accessory pathway ablation in children: indications and results]. Ann Cardiol Angeiol (Paris) 2011; 60:218-24. [PMID: 21664599 DOI: 10.1016/j.ancard.2011.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 04/28/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Radiofrequency ablation of accessory pathways (AP) has become a first-line treatment, except in young children where the indications are discussed because of radiation risks and complications of catheterization. The purpose of the study was to evaluate the indications and results of radiofrequency AP ablation in children and teenagers. METHODS Electrophysiological study (EPS) was performed in 145 patients aged from 5 to 18 years (13.5±3) with a preexcitation syndrome (PS). RESULTS AP ablation was indicated in 66 children (group 1); others represent the group I. Group I was older and less frequently asymptomatic. All children with a spontaneous malignant form had an ablation. Group 1 has a faster conduction through the AP than group 2. The induction of reentrant tachycardia (RT), atrial fibrillation and the presence of a malignant form is more common in group 1. Failures or reappearances of WPW after ablation were frequent (20, 26%) related to a younger age (15±3 vs 17±4) (<0.05). In group 2, one 18-year-old teenager with untreated RT died before ablation. Asymptomatic children are well with disappearance of PS in two. Medically treated symptomatic children are well. CONCLUSION If spontaneous malignant forms, symptoms with drugs or practice of competitive sport are indications of AP ablation, it is recommended to wait for adolescence in other children.
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Affiliation(s)
- F Benzakin
- Service de cardiologie, hôpital cardiologique, CHU de Brabois, Vandœuvre-les-Nancy, France
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23
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CZOSEK RICHARDJ, ANDERSON JEFFREYB, MARINO BRADLEYS, MELLION KATELYN, KNILANS TIMOTHYK. Noninvasive Risk Stratification Techniques in Pediatric Patients with Ventricular Preexcitation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:555-62. [DOI: 10.1111/j.1540-8159.2010.03011.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Brembilla-Perrot B, Tatar C, Suty-Selton C. Risk Factors of Adverse Presentation as the First Arrhythmia in Wolff-Parkinson-White Syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:1074-81. [PMID: 20487358 DOI: 10.1111/j.1540-8159.2010.02782.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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25
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Cantu F, Goette A. Sudden cardiac death stratification in asymptomatic ventricular preexcitation. Europace 2009; 11:1536-7. [DOI: 10.1093/europace/eup340] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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26
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Santinelli V, Radinovic A, Manguso F, Vicedomini G, Ciconte G, Gulletta S, Paglino G, Sacchi S, Sala S, Ciaccio C, Pappone C. Asymptomatic Ventricular Preexcitation. Circ Arrhythm Electrophysiol 2009; 2:102-7. [PMID: 19808453 DOI: 10.1161/circep.108.827550] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Sudden cardiac death can be the first clinical presentation of asymptomatic ventricular preexcitation.
Methods and Results—
From 1995 to 2005, we prospectively collected clinical and electrophysiological data among 293 adults with asymptomatic ventricular preexcitation (61.4% males; median age, 36 years; interquartile range [IQR], 28 to 47.5). After electrophysiological testing, patients were prospectively followed, taking no drugs. The primary end point of the study was the occurrence of a first arrhythmic event. Predictors of arrhythmic events were analyzed by univariate and multivariate Cox models. Over a median follow-up of 67 months (minimum to maximum, 8 to 90), after electrophysiological testing, 262 patients (median age, 37 years; IQR, 30 to 48) did not experience arrhythmic events, remaining totally asymptomatic, whereas 31 patients (median age, 25 years; IQR, 22 to 29; median follow-up, 27 months; minimum to maximum, 8 to 55) had a first arrhythmic event, which was potentially life-threatening in 17 of them (median age, 24 years; IQR, 20 to 28.5; median follow-up, 25 months; minimum to maximum, 9 to 55). Potentially life-threatening tachyarrhythmias resulted in resuscitated cardiac arrest (1 patient), presyncope (7 patients) syncope (4 patients), or dizziness (5 patients). In multivariate analysis age (
P
=0.004), inducibility (
P
=0.001) and anterograde effective refractory period of the accessory pathway ≤250 ms (
P
=0.001) predicted potentially life-threatening arrhythmias.
Conclusions—
These results indicate that prognosis of adults who present with asymptomatic ventricular preexcitation is good, and the risk of a significant event is small. Short anterograde effective refractory period of the accessory pathway and inducibility at baseline are independent predictors of potentially life-threatening arrhythmic events, and the risk decreases with increasing age.
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Affiliation(s)
- Vincenzo Santinelli
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Radinovic
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Manguso
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Vicedomini
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Ciconte
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Simone Gulletta
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Paglino
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Sacchi
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Simone Sala
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Cristiano Ciaccio
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Pappone
- From the Department of Arrhythmology, Electrophysiology, and Cardiac Pacing Unit, San Raffaele Scientific Institute, Milan, Italy
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Santinelli V, Radinovic A, Manguso F, Vicedomini G, Gulletta S, Paglino G, Mazzone P, Ciconte G, Sacchi S, Sala S, Pappone C. The Natural History of Asymptomatic Ventricular Pre-Excitation. J Am Coll Cardiol 2009; 53:275-80. [PMID: 19147045 DOI: 10.1016/j.jacc.2008.09.037] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 08/18/2008] [Accepted: 09/10/2008] [Indexed: 10/21/2022]
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28
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Balaji S. Asymptomatic Wolff-Parkinson-White Syndrome in Children. J Am Coll Cardiol 2009; 53:281-3. [DOI: 10.1016/j.jacc.2008.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 10/14/2008] [Indexed: 11/24/2022]
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29
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[Transesophageal electrophysiological study in non sedated children younger than 11 years with a Wolff-Parkinson-White syndrome]. Ann Cardiol Angeiol (Paris) 2008; 58:1-6. [PMID: 18937924 DOI: 10.1016/j.ancard.2008.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Accepted: 07/25/2008] [Indexed: 11/20/2022]
Abstract
UNLABELLED The electrophysiological evaluation of Wolff-Parkinson-White syndrome (WPW) is recommended in children aged more than five years to detect a risk of life-threatening arrhythmia. The purposes of the study were to determine the feasibility of transesophageal EPS in a child between six and 10 years in out-patient clinic. METHODS Electrophysiological study (EPS) was indicated in 22 children, aged six to 10 years, with a manifest WPW either for no documented tachycardia (n=7), unexplained dizziness (n=2) or for a sportive authorization in 10 asymptomatic children. Two of the last children had a history of permanent tachycardia after the birth but were asymptomatic since the age of one year without drugs. RESULTS EPS was performed in all children. The main difficulty lied in passing the catheter through the mouth. Programmed stimulation at cycle length of 380 ms was performed in all children to avoid high rates of pacing when the conduction through the accessory pathway (AP) and normal AV system was evaluated. Isoproterenol was not required in five children, because they developed a catecholaminergic sinus tachycardia. The AP refractory period was determined in all children between 200 and 270 ms. Orthodromic reentrant tachycardia (RT) was induced in 11 children, three asymptomatic children (27%), seven complaining of tachycardia and one with syncope. Rapid antidromic tachycardia was induced in this last child with dizziness. Atrial fibrillation was never induced. CONCLUSIONS Esophageal EPS can be performed without sedation in a young child six to 10-year-old with a shortened protocol of stimulation, which was capable to clearly evaluate the WPW-related risks.
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30
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Brembilla-Perrot B. When and how to assess an asymptomatic ventricular pre-excitation syndrome? Arch Cardiovasc Dis 2008; 101:407-11. [DOI: 10.1016/j.acvd.2008.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 05/13/2008] [Accepted: 05/19/2008] [Indexed: 01/02/2023]
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