1
|
Leoni L, Bronzetti G, Colonna D, Porcedda G, Rimini A, Silvetti MS. Diagnosis and treatment of fetal and pediatric age patients (0-12 years) with Wolff-Parkinson-White syndrome and atrioventricular accessory pathways. J Cardiovasc Med (Hagerstown) 2023; 24:589-601. [PMID: 37409656 PMCID: PMC10836786 DOI: 10.2459/jcm.0000000000001484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/16/2023] [Indexed: 07/07/2023]
Abstract
Overt or concealed accessory pathways are the anatomic substrates of ventricular preexcitation (VP), Wolff-Parkinson-White syndrome (WPW) and paroxysmal supraventricular tachycardia (PSVT). These arrhythmias are commonly observed in pediatric age. PSVT may occur at any age, from fetus to adulthood, and its symptoms range from none to syncope or heart failure. VP too can range from no symptoms to sudden cardiac death. Therefore, these arrhythmias frequently need risk stratification, electrophysiologic study, drug or ablation treatment. In this review of the literature, recommendations are given for diagnosis and treatment of fetal and pediatric age (≤12 years) WPW, VP, PSVT, and criteria for sport participation.
Collapse
Affiliation(s)
- Loira Leoni
- Cardiology, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padua, European Reference Network for Rare and Low Prevalence Complex Disease of the Heart (ERN GUARD-Heart), Padua
| | - Gabriele Bronzetti
- Cardio-Thoraco-Vascular Department, Sant’Orsola Hospital, University Hospital of Bologna IRCCS, Bologna
| | - Diego Colonna
- Adult Congenital Heart Disease Unit, Monaldi Hospital, Naples
| | - Giulio Porcedda
- Unit of Pediatric Cardiology, Anna Meyer Children's Hospital, Florence
| | | | - Massimo Stefano Silvetti
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, and Bambino Gesù Children's Hospital, IRCCS, European Reference Network for Rare and Low Prevalence Complex Disease of the Heart (ERN GUARD-Heart). Rome, Italy
| |
Collapse
|
2
|
Paul T, Krause U, Sanatani S, Etheridge SP. Advancing the science of management of arrhythmic disease in children and adult congenital heart disease patients within the last 25 years. Europace 2023; 25:euad155. [PMID: 37622573 PMCID: PMC10450816 DOI: 10.1093/europace/euad155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 08/26/2023] Open
Abstract
This review article reflects how publications in EP Europace have contributed to advancing the science of management of arrhythmic disease in children and adult patients with congenital heart disease within the last 25 years. A special focus is directed to congenital atrioventricular (AV) block, the use of pacemakers, cardiac resynchronization therapy devices, and implantable cardioverter defibrillators in the young with and without congenital heart disease, Wolff-Parkinson-White syndrome, mapping and ablation technology, and understanding of cardiac genomics to untangle arrhythmic sudden death in the young.
Collapse
Affiliation(s)
- Thomas Paul
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Pediatric Heart Center, Georg-August-University Medical Center, Robert-Koch-Str, 40, Göttingen D-37075, Germany
| | - Ulrich Krause
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Pediatric Heart Center, Georg-August-University Medical Center, Robert-Koch-Str, 40, Göttingen D-37075, Germany
| | - Shubhayan Sanatani
- Children’s Heart Centre, British Columbia Children’s Hospital, Vancouver, BC, Canada
| | - Susan P Etheridge
- Pediatric Cardiology, University of Utah School of Medicine and Primary Children’s Medical Center, Salt Lake City, UT
| |
Collapse
|
3
|
Christmyer Z, Pisupati M, Shah MJ, Srinivasan C, Vetter VL, Iyer VR, Triguba M, Janson CM. Risk Stratification in Pediatric Wolff-Parkinson-White: Practice Variation Among Pediatric Cardiologists and Electrophysiologists. Pediatr Cardiol 2023:10.1007/s00246-023-03247-1. [PMID: 37544951 DOI: 10.1007/s00246-023-03247-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Published guidelines provide recommendations for risk stratification in pediatric Wolff-Parkinson-White (WPW). There are no data on provider concordance with these guidelines. We hypothesized that significant practice variation exists between pediatric cardiologists (PC) and electrophysiologists (EP). METHOD The records of all patients, age 8 to 21 years, with a new ECG diagnosis of WPW between 1/1/2013 and 12/31/2018, from a single center, were retrospectively reviewed. Subjects were categorized on the basis of symptoms and resting ECG findings as one of the following: asymptomatic intermittent WPW, asymptomatic persistent WPW, or symptomatic WPW. The performance and results of diagnostic testing, including Holter monitor, event monitor, exercise stress test (EST), and electrophysiology study (EPS), were recorded. The primary outcome was concordance with published guidelines. A secondary outcome was documentation of a discussion of sudden cardiac death (SCD) risk. RESULTS 615 patient encounters were analyzed in 231 patients with newly diagnosed WPW pattern on ECG (56% male; mean age at diagnosis 13.9 ± 2.5 years). EP were observed to have a significantly higher rate of guideline concordance than PC (95% vs. 71%, p < 0.001). There was significant practice variation between PC and EP in the documentation of a discussion of SCD risk: 96% in EP vs. 39% in PC (p < 0.001). CONCLUSION Significant practice variation exists in the non-invasive and invasive risk stratification of pediatric WPW, with lower concordance to published guidelines amongst PC, when compared to EP. This report highlights the need to promote awareness of current WPW guidelines in the pediatric cardiology community at large.
Collapse
Affiliation(s)
- Zane Christmyer
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Meghana Pisupati
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Maully J Shah
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Chandra Srinivasan
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Victoria L Vetter
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - V Ramesh Iyer
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Mary Triguba
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Christopher M Janson
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| |
Collapse
|
4
|
Upadia J, Li Y, Walano N, Deputy S, Gajewski K, Andersson HC. Genotype–phenotype correlation in IARS2‐related diseases: A case report and review of literature. Clin Case Rep 2022; 10:e05401. [PMID: 35228874 PMCID: PMC8867157 DOI: 10.1002/ccr3.5401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 11/24/2022] Open
Abstract
Isoleucyl‐tRNA synthetase 2 (IARS2) encodes mitochondrial isoleucine‐tRNA synthetase. Pathogenic variants in the IARS2 gene are associated with mitochondrial disease. We report a female with IARS2 compound heterozygous variants, p.Val499Glyfs*14 and p.Arg784Trp who presented with infantile spasms, Leigh disease and Wolff‐Parkinson White (WPW) pattern. This report expands the phenotypic spectrum of IARS2‐related disease.
Collapse
Affiliation(s)
- Jariya Upadia
- Hayward Genetics Center Tulane University School of Medicine New Orleans Louisiana USA
- Department of Pediatrics Tulane University School of Medicine New Orleans Louisiana USA
| | - Yuwen Li
- Hayward Genetics Center Tulane University School of Medicine New Orleans Louisiana USA
- Department of Pediatrics Tulane University School of Medicine New Orleans Louisiana USA
| | - Nicolette Walano
- Hayward Genetics Center Tulane University School of Medicine New Orleans Louisiana USA
- Department of Pediatrics Tulane University School of Medicine New Orleans Louisiana USA
| | - Stephen Deputy
- Division of Pediatric Neurology Department of Pediatrics Louisiana State University Health Sciences Center/Children's Hospital New Orleans Louisiana USA
| | - Kelly Gajewski
- Division of Pediatric Cardiology Department of Pediatrics Louisiana State University Health Sciences Center/Children's Hospital New Orleans Louisiana USA
| | - Hans C. Andersson
- Hayward Genetics Center Tulane University School of Medicine New Orleans Louisiana USA
- Department of Pediatrics Tulane University School of Medicine New Orleans Louisiana USA
| |
Collapse
|
5
|
Campal JMR, Blanco ÁM, Calero LB, Rivera CL, García-Talavera CS, Olmedilla AC, Fernández JT. Comparison of Outcomes of Catheter Ablation in Asymptomatic Versus Symptomatic Preexcitation to Guidelines and Beyond. Am J Cardiol 2021; 161:51-55. [PMID: 34794618 DOI: 10.1016/j.amjcard.2021.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/28/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
Management of asymptomatic subjects with preexcitation remains controversial. Our objective was to analyze the reasons an electrophysiological study (EPS) was performed in an asymptomatic population referred for the procedure, and compare the results of catheter ablation between asymptomatic and symptomatic patients. Patients ≥18 years of age with preexcitation referred for an EPS and ablation were grouped as either symptomatic or asymptomatic. We analyzed in both subsets for (1) reasons for the procedure, (2) EPS results (anterograde effective refractory period of the accessory pathway, tachycardia/atrial fibrillation inducibility, anatomical localization), (3) success of the procedure, and (4) incidence of complications. We included 175 patients, 121 of which were symptomatic (39 ± 16 years) and 54 were asymptomatic (35 ± 14 years, p = NS not significant). The most frequent symptoms were palpitations (87%) and syncope (7%). EPS was performed in 44 of 54 asymptomatic patients mainly because of involvement in sports (60%) or high-risk employment (14%). Anterograde effective refractory period was significantly longer in asymptomatic patients (314 ± 55 milliseconds) than in symptomatic patients (278 ± 46 milliseconds; p <0.001). Orthodromic tachycardia inducibility was significantly higher in symptomatic than in asymptomatic patients (69% and 27%, respectively; p <0.001). A total of 170 accessory pathways (49% left free wall, 12% right free wall, 39% septal) were observed without significant differences in the anatomical location between groups. Catheter ablation was attempted in all patients, succeeding in 98% of symptomatic and 95% of asymptomatic patients, without major complications in either group. In conclusion, the reasons for invasive evaluation of asymptomatic patients with preexcitation may be outside the scope of current guidelines. Catheter ablation produces excellent results without major complications.
Collapse
|
6
|
Di Mambro C, Martinelli D, Tamborrino PP, Drago F. Involvement of the cardiac conduction system in Kearns-Sayre syndrome is progressive: Authors' reply. Europace 2021; 23:980. [PMID: 33982081 DOI: 10.1093/europace/euab056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Corrado Di Mambro
- Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza Rome Sant'Onofrio 4, Rome, Italy.,European Reference Network for Rare and Low Prevalence Complex Disease of the Heart (ERN GUARD-Heart), Rome, Italy
| | - Diego Martinelli
- Genetics and Rare Diseases Research Division, Unit of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Paolo Tamborrino
- Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza Rome Sant'Onofrio 4, Rome, Italy.,European Reference Network for Rare and Low Prevalence Complex Disease of the Heart (ERN GUARD-Heart), Rome, Italy
| | - Fabrizio Drago
- Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza Rome Sant'Onofrio 4, Rome, Italy.,European Reference Network for Rare and Low Prevalence Complex Disease of the Heart (ERN GUARD-Heart), Rome, Italy
| |
Collapse
|
7
|
Characteristics of antegrade-only accessory pathways in children and adolescents. Cardiol Young 2021; 31:1258-1262. [PMID: 33487196 DOI: 10.1017/s1047951121000056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There is minimal data regarding antegrade-only accessory pathways in young patients. Given evolving recommendations and treatments, retrospective analysis of the clinical and electrophysiologic properties of antegrade-only pathways in patients <21 years old was performed, with subsequent comparison of electrophysiology properties to age-matched controls with bidirectional pathways. Of 522 consecutive young patients with ventricular pre-excitation referred for electrophysiology study, 33 (6.3%) had antegrade-only accessory pathways. Indications included palpitations (47%), chest pain (25%), and syncope (22%). The shortest value for either the accessory pathway effective refractory period or the pre-excited R-R interval was taken for each patient, with the median of the antegrade-only group significantly greater than shortest values for the bidirectional group (310 [280-360] ms versus 270 [240-302] ms, p < 0.001). However, the prevalence of pathways with high-risk properties (effective refractory period or shortest pre-excited R-R interval <250 ms) was similar in both study patients and controls (13% versus 21%) (p = 0.55). Sixteen patients had a single antegrade-only accessory pathway and no inducible arrhythmia. Six patients had Mahaim fibres, all right anterolateral with inducible antidromic reciprocating tachycardia. However, 11 patients with antegrade-only accessory pathways and 3 with Mahaim fibres had inducible tachycardia due to a second substrate recognised at electrophysiology study. These included concealed accessory pathways (7), bidirectional accessory pathways (5), and atrioventricular node re-entry (2). Antegrade-only accessory pathways require comprehensive electrophysiology evaluation as confounding factors such as high-risk conduction properties or inducible Supraventricular Tachycardia (SVT) due to a second substrate of tachycardia are often present.
Collapse
|
8
|
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.
Collapse
|
9
|
Escudero CA, Ceresnak SR, Collins KK, Pass RH, Aziz PF, Blaufox AD, Ortega MC, Cannon BC, Cohen MI, Dechert BE, Dubin AM, Motonaga KS, Epstein MR, Erickson CC, Fishberger SB, Gates GJ, Capone CA, Nappo L, Kertesz NJ, Kim JJ, Valdes SO, Kubuš P, Law IH, Maldonado J, Moore JP, Perry JC, Sanatani S, Seslar SP, Shetty I, Zimmerman FJ, Skinner JR, Marcondes L, Stephenson EA, Asakai H, Tanel RE, Uzun O, Etheridge SP, Janson CM. Loss of ventricular preexcitation during noninvasive testing does not exclude high-risk accessory pathways: A multicenter study of WPW in children. Heart Rhythm 2020; 17:1729-1737. [DOI: 10.1016/j.hrthm.2020.05.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 11/25/2022]
|
10
|
Kato Y, Suzuki T, Yoshida Y, Ozaki N, Kishimoto S, Aoki H, Yoshida S, Watanabe S, Nakamura Y. Catheter ablation in children and patients with congenital heart disease: Review of 1021 procedures at a high-volume single center in Japan. Heart Rhythm 2020; 17:49-55. [DOI: 10.1016/j.hrthm.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Indexed: 11/26/2022]
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Catheter ablation in ASymptomatic PEDiatric patients with ventricular preexcitation: results from the multicenter "CASPED" study. Clin Res Cardiol 2018; 108:683-690. [PMID: 30519781 DOI: 10.1007/s00392-018-1397-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND As there are limited data about the clinical practice of catheter ablation in asymptomatic children and adolescents with ventricular preexcitation on ECG, we performed the multicenter "CASPED" (Catheter ablation in ASymptomatic PEDiatric patients with Ventricular Preexcitation) study. METHODS AND RESULTS In 182 consecutive children and adolescents aged between 8 and 18 years (mean age 12.9 ± 2.6 years; 65% male) with asymptomatic ventricular preexcitation, a total of 196 accessory pathways (APs) were targeted. APs were right sided (62%) or left sided (38%). The most common right-sided AP location was the posteroseptal region (38%). Ablation was performed using radiofrequency (RF) energy (93%), cryoablation (4%) or both (3%). Mean procedure time was 137.6 ± 62.0 min with a mean fluoroscopy time of 15.6 ± 13.8 min. A 3D mapping or catheter localization system was used in 32% of patients. Catheter ablation was acutely successful in 166/182 patients (91.2%). Mortality was 0% and there were no major periprocedural complications. AP recurrence was observed in 14/166 patients (8.4%) during a mean follow-up time of 19.7 ± 8.5 months. A second ablation attempt was performed in 20 patients and was successful in 16/20 patients (80%). Overall, long-term success rate was 92.3%. CONCLUSION In this retrospective multicenter study, the outcome of catheter ablation for asymptomatic preexcitation in children and adolescents irrespective of antegrade AP conduction properties is summarized. The complication rate was low and success rate was high, the latter mainly depending on pathway location. The promising results of the study may have future impact on the ongoing risk-benefit discussion regarding catheter ablation in the setting of asymptomatic preexcitation in children and adolescents.
Collapse
|
13
|
Kyi NHNN, Tse G, Chousou PA. Ventricular pre-excitation using a 12-lead ECG: a challenging diagnosis. Oxf Med Case Reports 2018; 2018:omy085. [PMID: 30214817 PMCID: PMC6130329 DOI: 10.1093/omcr/omy085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 08/19/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nang Hnin Nu Nu Kyi
- Cardiology Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Panagiota Anna Chousou
- Norwich Medical School, University of East Anglia, Norwich, UK
- Cardiology Department, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
14
|
Stasiak A, Niewiadomska-Jarosik K, Kędziora P. Clinical course and treatment of children and adolescents with the preexcitation syndrome - own studies. DEVELOPMENTAL PERIOD MEDICINE 2018. [PMID: 30056397 PMCID: PMC8522904 DOI: 10.34763/devperiodmed.20182202.113122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Essentially, preexcitation syndrome is the presence of an accessory pathway in the heart, which can lead to serious consequences, ranging from atrioventricular reentrant tachycardia to sudden cardiac death. Wolff-Parkinson-White syndrome is the most common preexcitation syndrome. AIM OF THE STUDY The aim of the study was to evaluate the clinical course of the disease, as well as the treatment of children and adolescents hospitalized in the Department of Pediatric Cardiology in the years 2008-2015. MATERIALS AND METHODS The study was carried out in 45 children (62 % male, 38% female; the mean age 11 years). During the study we analyzed 12-lead ECG, 24-hour Holter ECG, echocardiography and the cycloergometric exercise test. The results of treatment were also discussed. RESULTS Apart from the typical features of preexcitation, the most prevalent abnormality found in ECG was atrioventricular reentrant tachycardia. In 24-hour Holter ECG the most frequently detected disorders were premature ventricular beats and premature atrial contractions. Structural heart defects were detected in 8.9% of the children. The cycloergometric exercise test was positive in 8.9% of patients. The mean duration of symptoms before the diagnosis was 2.5 years. 25% of the patients were asymptomatic. 42.2% of the children needed antiarrhythmic therapy, while 44.4% had accessory pathways ablated. CONCLUSIONS The most common symptom of preexcitation in the study group were heart palpitations. The most frequent type of arrhythmia in children with preexcitation syndrome was orthodromic atrioventricular reentrant tachycardia. For the majority of older children ablation of the accessory pathway was a recommended form of treatment. In younger children the standard preventive pharmacological treatment was applied for 6 to 12 months.
Collapse
Affiliation(s)
- Aleksandra Stasiak
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, LodzPoland,Aleksandra Stasiak Department of Pediatric Cardiology and Rheumatology ul. Sporna 36/50, 91-738 Łódź tel. (+48 42) 617-77-00
| | | | - Piotr Kędziora
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, LodzPoland
| |
Collapse
|
15
|
Brugada J, Keegan R. Asymptomatic Ventricular Pre-excitation: Between Sudden Cardiac Death and Catheter Ablation. Arrhythm Electrophysiol Rev 2018; 7:32-38. [PMID: 29636970 DOI: 10.15420/aer.2017.51.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Debate about the best clinical approach to the management of asymptomatic patients with ventricular pre-excitation and advice on whether or not to invasively stratify and ablate is on-going. Weak evidence about the real risk of sudden cardiac death and the potential benefit of catheter ablation has probably prevented the clarification of action in this not infrequent and sometimes conflicting clinical situation. After analysing all available data, real evidence-based medicine could be the alternative strategy for managing this group of patients. According to recent surveys, most electrophysiologists invasively stratify. Based on all accepted risk factors - younger age, male, associated structural heart disease, posteroseptal localisation, ability of the accessory pathway to conduct anterogradely at short intervals of ≤250 milliseconds and inducibility of sustained atrioventricular re-entrant tachycardia and/or atrial fibrillation - a shared decisionmaking process on catheter ablation is proposed.
Collapse
Affiliation(s)
- Josep Brugada
- Cardiovascular Institute, Hospital Clinic and Paediatric Arrhythmia Unit, Hospital Sant Joan de Déu, University of BarcelonaBarcelona, Spain
| | - Roberto Keegan
- Electrophysiology Service, Private Hospital of the SouthBahia Blanca, Argentina
| |
Collapse
|
16
|
Cho Y. Supraventricular Tachycardia in Special Population. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2017. [DOI: 10.18501/arrhythmia.2017.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
17
|
Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, Estes NM, Field ME, Goldberger ZD, Hammill SC, Indik JH, Lindsay BD, Olshansky B, Russo AM, Shen WK, Tracy CM, Al-Khatib SM. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. Circulation 2016; 133:e506-74. [DOI: 10.1161/cir.0000000000000311] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | - Hugh Calkins
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Jamie B. Conti
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Barbara J. Deal
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - N.A. Mark Estes
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Michael E. Field
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Stephen C. Hammill
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Julia H. Indik
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Bruce D. Lindsay
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Andrea M. Russo
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | - Cynthia M. Tracy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. HRS Representative. ACC/AHA Representative. ACC/AHA Task Force on Performance Measures Liaison. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Former Task Force member; current member during this writing effort
| | | |
Collapse
|
18
|
Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, Estes III NM, Field ME, Goldberger ZD, Hammill SC, Indik JH, Lindsay BD, Olshansky B, Russo AM, Shen WK, Tracy CM, Al-Khatib SM. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. Heart Rhythm 2016; 13:e136-221. [DOI: 10.1016/j.hrthm.2015.09.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Indexed: 01/27/2023]
|
19
|
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]
|
20
|
Bunch TJ, May HT, Bair TL, Anderson JL, Crandall BG, Cutler MJ, Jacobs V, Mallender C, Muhlestein JB, Osborn JS, Weiss JP, Day JD. Long-Term Natural History of Adult Wolff–Parkinson–White Syndrome Patients Treated With and Without Catheter Ablation. Circ Arrhythm Electrophysiol 2015; 8:1465-71. [DOI: 10.1161/circep.115.003013] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 10/14/2015] [Indexed: 11/16/2022]
Abstract
Background—
There are a paucity of data about the long-term natural history of adult Wolff–Parkinson–White syndrome (WPW) patients in regard to risk of mortality and atrial fibrillation. We sought to describe the long-term outcomes of WPW patients and ascertain the impact of ablation on the natural history.
Methods and Results—
Three groups of patients were studied: 2 WPW populations (ablation: 872, no ablation: 1461) and a 1:5 control population (n=11 175). Long-term mortality and atrial fibrillation rates were determined. The average follow-up for the WPW group was 7.9±5.9 (median: 6.9) years and was similar between the ablation and nonablation groups. Death rates were similar between the WPW group versus the control group (hazard ratio, 0.96; 95% confidence interval, 0.83–1.11;
P
=0.56). Nonablated WPW patients had a higher long-term death risk compared with ablated WPW patients (hazard ratio, 2.10; 95% confidence interval: 1.50–20.93;
P
<0.0001). Incident atrial fibrillation risk was higher in the WPW group compared with the control population (hazard ratio, 1.55; 95% confidence interval, 1.29–1.87;
P
<0.0001). Nonablated WPW patients had lower risk than ablated patients (hazard ratio, 0.39; 95% confidence interval, 0.28–0.53;
P
<0.0001).
Conclusions—
Long-term mortality rates in WPW patients are low and similar to an age-matched and gender-matched control population. WPW patients that underwent the multifactorial process of ablation had a lower mortality compared to nonablated WPW patients. Atrial fibrillation rates are high long-term, and ablation does not reduce this risk.
Collapse
Affiliation(s)
- T. Jared Bunch
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - Heidi T. May
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - Tami L. Bair
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - Jeffrey L. Anderson
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - Brian G. Crandall
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - Michael J. Cutler
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - Victoria Jacobs
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - Charles Mallender
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - Joseph B. Muhlestein
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - Jeffrey S. Osborn
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - J. Peter Weiss
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| | - John D. Day
- From the Department of Cardiology, Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT (T.J.B., H.T.M., T.L.B., J.L.A., B.G.C., M.J.C., V.J., C.M., J.B.M., J.S.O., J.P.W., J.D.D.); and Department of Internal Medicine, Stanford University, Palo Alto, CA (T.J.B.)
| |
Collapse
|
21
|
Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, Estes NAM, Field ME, Goldberger ZD, Hammill SC, Indik JH, Lindsay BD, Olshansky B, Russo AM, Shen WK, Tracy CM, Al-Khatib SM. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2015; 67:e27-e115. [PMID: 26409259 DOI: 10.1016/j.jacc.2015.08.856] [Citation(s) in RCA: 239] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
22
|
COHEN MITCHELL. Intermittent Preexcitation: Should We Rethink the Current Guidelines? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 39:9-11. [DOI: 10.1111/pace.12745] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/18/2015] [Indexed: 11/29/2022]
Affiliation(s)
- MITCHELL COHEN
- Arizona Pediatric Cardiology Heart Center at Phoenix Children's Hospital; University of Arizona College of Medicine-Phoenix; Phoenix Arizona
| |
Collapse
|
23
|
Pappone C, Santinelli V. Electrophysiology testing and catheter ablation are helpful when evaluating asymptomatic patients with Wolff-Parkinson-White pattern: the pro perspective. Card Electrophysiol Clin 2015; 7:371-6. [PMID: 26304515 DOI: 10.1016/j.ccep.2015.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Important advances in the natural history and diagnosis of, and therapy for, asymptomatic Wolff-Parkinson-White (WPW) syndrome have been made in the last decade by our group. These data have necessitated revisiting current practice guidelines to decide on the optimal management of the asymptomatic WPW population. There has also been an emphasis on identifying initially asymptomatic individuals who are at risk by nationwide screening programs using the electrocardiogram for prophylactic catheter ablation to prevent the lifetime risk of sudden cardiac death, particularly in young asymptomatic people, because only a subgroup of them is at high risk, requiring early catheter ablation.
Collapse
Affiliation(s)
- Carlo Pappone
- Department of Arrhythmology, Policlinico San Donato, University of Milan, Piazza Edmondo Malan, Milan 20097, Italy.
| | - Vincenzo Santinelli
- Department of Arrhythmology, Policlinico San Donato, University of Milan, Piazza Edmondo Malan, Milan 20097, Italy
| |
Collapse
|
24
|
De Ponti R, Marazzi R, Doni LA, Cremona V, Marazzato J, Salerno-Uriarte JA. Invasive electrophysiological evaluation and ablation in patients with asymptomatic ventricular pre-excitation persistent at exercise stress test. Europace 2015; 17:946-952. [DOI: 10.1093/europace/euu324] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
|