A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989

A boy with fatigue and heart block: what's the mechanism?

When the atrioventricular node is damaged, accessory pathways can perform primary atrioventricular conduction but may spontaneously degrade during childhood. After surgical atrial septal defect repair during infancy, an adolescent male presented with fatigue due to iatrogenic complete atrioventricular node block with a degrading antegrade accessory pathway resulting in symptomatic bradyarrhythmia.

Risk assessment in patients with symptomatic and asymptomatic pre-excitation

AIMS

Controversy remains as to whether the exercise stress test (EST) is sufficient for risk evaluation in patients with pre-excitation. This study aims to clarify the usefulness of EST in risk stratification in both asymptomatic and symptomatic patients presenting with pre-excitation.

METHODS AND RESULTS

This prospective study includes consecutive asymptomatic and symptomatic patients with pre-excitation referred for risk assessment. All participants performed an incremental EST (bicycle) prior to an electrophysiology study (EPS). Primary data from the EST included loss of pre-excitation during exercise, and primary data from the EPS included the measurement of accessory pathway effective refractory period (APERP), shortest pre-excited RR interval (SPERRI), and inducible arrhythmia with the use of a beta-adrenergic receptor agonist if deemed necessary. One hundred and sixty-four patients (59 asymptomatic, 105 symptomatic) completed an EST and EPS. Forty-five patients (27%) demonstrated low-risk findings on EST, of which 19 were asymptomatic and 26 were symptomatic. Six patients with low-risk EST findings had SPERRI/APERP ≤ 250 ms at EPS, and two of them were asymptomatic. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of low-risk EST for excluding patients with SPERRI/APERP ≤ 250 ms were 40, 91, 87, 51, and 60%, respectively. The number of patients with inducible arrhythmia at EPS was similar in the asymptomatic (36, 69%) and symptomatic (73, 61%) groups.

CONCLUSION

Sudden loss of pre-excitation during EST has a low NPV in excluding high-risk APs. The EPS with the use of isoproterenol should be considered to accurately assess the risk of patients with pre-excitation regardless of symptoms (ClinicalTrials.gov Identifier: NCT03301935).

Wolf-Parkinson-White Syndrome: Diagnosis, Risk Assessment, and Therapy-An Update

Wolf-Parkinson-White (WPW) syndrome is a disorder characterized by the presence of at least one accessory pathway (AP) that can predispose people to atrial/ventricular tachyarrhythmias and even sudden cardiac death. It is the second most common cause of paroxysmal supraventricular tachycardia in most parts of the world, affecting about 0.1-0.3% of the general population. Most patients with WPW syndrome have normal anatomy, but it may be associated with concomitant congenital heart disease or systemic diseases. Although many individuals are asymptomatic, during supraventricular arrhythmia episodes, they may experience severe symptoms, including syncope or even sudden cardiac death (mainly due to pre-excited atrial fibrillation over rapidly conducting AP). In addition to arrhythmia-related symptoms, for some specific locations of the APs with overt anterograde conduction, there might be a reduction in exercise capacity mediated by a reduction in LV systolic performance due to anomalous LV depolarization. Although it is typically diagnosed through electrocardiography (ECG), additional tests are necessary for risk assessment. Management of WPW syndrome may be quite challenging and can vary from only acknowledging the presence of the accessory pathway to pharmacological treatment or radiofrequency ablation. Early diagnosis, risk assessment, and appropriate treatment are critical steps in the management of WPW syndrome, aiming to improve the quality of life and reduce the risk of life-threatening arrhythmias.

Sudden Cardiac Death in Young Athletes: JACC State-of-the-Art Review

Athletes epitomize the healthiest segment of society. Despite this premise, sudden cardiac death may occur in apparently healthy athletes, attracting significant attention not only in the medical community but also in laypersons and media. The incidence of sudden cardiac death is variably reported, and epidemiological burden differs among cohorts. Athletes appear to be at risk of developing fatal arrhythmias when harboring a quiescent cardiac disorder. Primary cardiomyopathies, ion channelopathies, and coronary artery anomalies are prevalent causes in young individuals. Cardiac assessment of athletes can be challenging because these individuals exhibit a plethora of electrical, structural, and functional physiological changes that overlap with cardiac pathology. A diagnosis of cardiac disease in a young athlete is not necessarily an indication to terminate competition and sports participation. International guidelines, traditionally focused on disqualification of individuals with cardiac disease, have recently adopted a more liberal attitude, based on a careful assessment of the risk and on a shared-decision making approach.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Patient Characteristics Associated with Hospital Admission or Antiarrhythmic Medication Changes After Emergency Department Evaluation of Supraventricular Tachycardia

BACKGROUND

Supraventricular tachycardia (SVT) is a relatively frequent diagnosis in the pediatric emergency department (ED). However, there are no consensus guidelines for ED disposition, and there are limited data on ED outcomes. Better understanding of those who are admitted or have antiarrhythmic medication changes may avoid potentially unnecessary transfers or admissions. Our objective was to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED.

DESIGN/METHODS

A retrospective review of children aged 0-18 years seen in the emergency department for SVT was conducted using electronic medical record data over a ten-year period at a single academic tertiary children's hospital. Patients with congenital cardiac disease or prior cardiac surgeries were excluded. Multivariable logistic regression analysis was used to determine association between patient factors of interest and the primary outcome of admission and secondary outcome of change to antiarrhythmic medications.

RESULTS

We analyzed 197 patients encounters. The mean age was 7 years. Of these 104 (52.8%) were admitted to the hospital or discharged with antiarrhythmic medication changes. This primary outcome was associated with younger age (aOR 0.77, 95% CI 0.67-0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01-18.8), intercurrent illness (aOR 3.75, 95% CI 1.27-12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55-22.3), and in-person cardiology consultation (aOR 6.42, 95% CI 2.43-19.4).

CONCLUSIONS

Nearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. We identified patient factors associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions.

Diagnosis and treatment of fetal and pediatric age patients (0-12 years) with Wolff-Parkinson-White syndrome and atrioventricular accessory pathways

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.

Risk Stratification in Pediatric Wolff-Parkinson-White: Practice Variation Among Pediatric Cardiologists and Electrophysiologists

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.

The Wolff-Parkinson-White pattern in neonates: results from a large population-based cohort study

AIMS

Wolff-Parkinson-White (WPW) syndrome is a conduction disorder characterized by an accessory electrical pathway between the atria and ventricles, which may predispose to supraventricular tachycardia (SVT) and sudden cardiac death. It can be seen as an isolated finding or associated with structural heart disease. Our aims were to determine the prevalence of a WPW pattern in a large and unselected cohort of neonates and to describe the electro- and echocardiographic characteristics as well as the natural history during early childhood.

METHODS AND RESULTS

Electrocardiograms and echocardiograms of neonates (aged 0-30 days) from a large, prospective, population-based cohort study were included. Neonates with a WPW pattern were identified and matched 1:4 to controls. Localization of the accessory pathway was assessed by different algorithms. Among 17 489 neonates, we identified 17 (76% boys) with a WPW pattern consistent with a prevalence of 0.1%. One neonate had moderate mitral regurgitation while other echocardiographic parameters were similar between cases and controls (all P > 0.05). The accessory pathways were primarily predicted to be left-sided. At follow-up (available in 14/17 children; mean age 3.2 years) the pre-excitation pattern persisted in only four of the children and none of the children had experienced any episodes of SVT.

CONCLUSION

The prevalence of a WPW pattern in our cohort of unselected neonates was 0.1%. The WPW pattern was more frequent in boys and generally not associated with structural heart disease, and the accessory pathways were primarily left-sided. At follow-up, the WPW pattern had disappeared in most of the children suggesting either an intermittent nature or that normalization occurs.

CLINICAL TRIAL REGISTRATION

Copenhagen Baby Heart, NCT02753348.

Asymptomatic Wolff-Parkinson-White Syndrome: An Ounce of Prevention Is Worth the Risk of Cure

PURPOSE OF REVIEW

With increased electrocardiogram screening, asymptomatic preexcitation has become more prevalent. Historically, the asymptomatic-symptomatic dichotomy has directed management. This approach warrants scrutiny, as asymptomatic Wolff-Parkinson-White (WPW) syndrome is not without risk. Children may be unreliable symptom reporters, have atypical arrhythmia symptoms, yet have years to become symptomatic.

RECENT FINDINGS

In a large WPW study, symptomatic patients were more likely to undergo ablation than asymptomatic patients, yet, except for symptoms, there were no differences in clinical or electrophysiology study (EPS) characteristics. Present data confirm real risk in asymptomatic WPW-sudden death can be the first symptom. Although malignant arrhythmias correlate better with EPS risk stratification than with symptoms, EPS data are imperfect predictors. Unlike adults with WPW, children have yet to prove survivorship. Asymptomatic children must be treated differently than adults. Sudden death risk is low but front-loaded in the young. An aggressive approach to asymptomatic WPW is warranted in this era of highly successful, low-risk catheter ablations.

["Asymptomatic WPW" : Is treatment necessary?]

The term "asymptomatic WPW" (Wolff-Parkinson-White) is often used as a synonym for ventricular pre-excitation of the WPW type due to an accessory pathway characterized by a short PR interval and a delta wave on the electrocardiogram (ECG) without the clinical occurrence of paroxysmal tachycardia. Asymptomatic WPW is often diagnosed in young and otherwise healthy people. There is a small associated risk of sudden cardiac death due to rapid antegrade conduction over the accessory pathway during atrial fibrillation. This paper highlights aspects of noninvasive and invasive risk stratification, therapy by catheter ablation, and the ongoing risk-benefit discussion in asymptomatic WPW.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Transseptal versus retrograde approach for ablation of left-sided accessory pathways: impact on radiation exposure

Management of left-sided accessory pathways (APs) is based on catheter ablation through an antegrade or retrograde approach. Both are safe and effective but are associated with exposure to x-rays; however, recipients of ablation are generally young. We sought to evaluate the impact of the approach chosen on dose-area product (DAP). A total of 95 patients who underwent radiofrequency ablation of a left-sided AP between January 2011 and January 2020 were included. The primary endpoint was the radiation dose received by the patient. Secondary endpoints were procedural success and complication and recurrence rates. The mean age of the study population was 34.3 ± 16.6 years. The antegrade transseptal approach was used in 63.5% of cases. By multivariate analysis, the antegrade transseptal approach was associated with a 53% reduction in DAP (p< 0.001). The radiation dose received was also significantly associated with body mass index and total fluoroscopy time (p< 0.001). There was no significant difference in other secondary endpoints between approaches. The use of an antegrade transseptal approach is associated with a significant reduction in DAP compared with the retrograde approach, and procedural success and complication and recurrence rates are similar.

Association of T-box gene polymorphisms with the risk of Wolff-Parkinson-White syndrome in a Han Chinese population

Abnormal development of the atrioventricular ring can lead to the formation of a bypass pathway and the occurrence of Wolff-Parkinson-White (WPW) syndrome. The genetic mechanism underlying the sporadic form of WPW syndrome remains unclear. Existing evidence suggests that both T-box transcription factor 3 (TBX3) and T-box transcription factor 2 (TBX2) genes participate in regulating annulus fibrosus formation and atrioventricular canal development. Thus, we aimed to examine whether single-nucleotide polymorphisms (SNPs) in the TBX3 and TBX2 genes confer susceptibility to WPW syndrome in a Han Chinese Population. We applied a SNaPshot SNP assay to analyze 5 selected tagSNPs of TBX3 and TBX2 in 230 patients with sporadic WPW syndrome and 231 sex- and age-matched controls. Haplotype analysis was performed using Haploview software. Allele C of TBX3 rs1061657 was associated with a higher risk of WPW syndrome (odds ratio [OR] = 1.41, 95% confidence interval [CI]: 1.08-1.83, P = .011) and left-sided accessory pathways (OR = 1.40, 95% CI: 1.07-1.84, P = .016). However, allele C of TBX3 rs8853 was likely to reduce these risks (OR = 0.71, 95% CI: 0.54-0.92, P = .011; OR = 0.70, 95% CI: 0.53-0.92, P = .011, respectively). The data revealed no association between TBX3 rs77412687, TBX3 rs2242442, or TBX2 rs75743672 and WPW syndrome. TBX3 rs1061657 and rs8853 are significantly associated with sporadic WPW syndrome among a Han Chinese population. To verify our results, larger sample sizes are required in future studies.

Routine Interictal EEG Recording Should be Performed Together with Simultaneous Two-Lead ECG Recording

We aimed to evaluate the contribution of simultaneous electrocardiography (ECG) recording during routine interictal electroencephalography (EEG) recording in patients with seizures or epilepsy and therefore to provide evidence-based data on this subject. Patients with interictal cardiac arrhythmia on routine EEG-ECG recordings were determined and evaluated based on cardiologic and neurologic findings. Out of 1,078 patients aged between 5 and 16 years (mean: 10.2 ± 3.2), 9 (0.08%) patients were found to have an arrhythmia. Six patients had both epilepsy and cardiac arrhythmia (premature ventricular contractions [PVCs] in 5; Wolff-Parkinson-White [WPW] in 1 patient) and the remaining three patients had nonepileptic paroxysmal events (NPEs) and arrhythmia (PVC in 2; WPW in 1). Three patients had other diseases (neurofibromatosis type 1, tuberous sclerosis, and congenital heart disease status postsurgery). Cardiac arrhythmia required radiofrequency ablation or antiarrhythmic drug treatment in two patients with epilepsy and also two patients with NPE; however, it improved with no specific treatment in the remaining five patients. NPE was not related to arrhythmia in one of three patients with NPE. Our study suggests that routine interictal EEG-ECG recording provides a valuable and feasible opportunity to reveal unnoticed or new-onset cardiac arrhythmias. Therefore, ECG should be recorded simultaneously during routine interictal EEG recordings. Cardiac arrhythmias detected by routine interictal EEG-ECG recordings would require arrhythmia treatment in nearly half of the patients.

A novel mechanism of sudden infant death syndrome during atrioventricular reentrant tachycardia: a case report

Background

Although orthodromic atrioventricular reentrant tachycardia (AVRT) using retrograde conduction through an accessory pathway (AP) is a common manifestation of Wolff-Parkinson-White (WPW) syndrome, a rare yet critical consequence is sudden cardiac arrest in a few patients. This fatal event used to be reported as a result of rapid atrioventricular conduction of atrial fibrillation via an AP.

Case summary

A 3-month-old infant with WPW syndrome had AVRT accompanied by global cardiac ischaemia, apparently caused by a rapid ventricular rate itself that degenerated into ventricular fibrillation during the AVRT.

Discussion

Our case suggested that orthodromic AVRT may be sufficient to cause WPW-related sudden cardiac death (SCD) or sudden infant death syndrome via fatal ischaemia and ventricular arrhythmias even when the effective refractory period of an antegrade AP conduction is long or even when an antegrade AP is not present. It is possible that an AP ablation in those who have a history of a fast orthodromic AVRT would be useful to prevent SCD in addition to symptom control.

Accessory pathway properties are similar in symptomatic and asymptomatic preexcitation

PURPOSE

Patients with WPW syndrome have an increased mortality rate compared to the general population. Although asymptomatic preexcitation has previously been considered benign, recent studies have found that also asymptomatic patients have clinical and electrophysiological factors associated with increased risk of sudden cardiac death. This study compares the baseline electrophysiological characteristics of accessory pathways in symptomatic and asymptomatic patients with preexcitation. We hypothesized that a significant proportion of asymptomatic patients has inducible orthodromic tachycardia during programmed electrical stimulation.

METHODS

This retrospective study includes 1853 patients with preexcitation who underwent invasive electrophysiological testing in two Swedish University Hospitals between 1991 and 2018. The mean age was 36 ± 17 years with a range of 3-89 years. Thirty-nine percent was women. A total of 269 patients (15%) were children younger than 18 years. Electrophysiological data included effective refractory period of the accessory pathway (APERP, in 1069 patients), tachycardia cycle length, inducibility and type of tachycardia, and AP localization.

RESULTS

A total of 1703 (93%) patients reported symptoms suggesting tachyarrhythmias before the study and 128 (7%) were asymptomatic. The proportion of potentially dangerous pathways with short APERP (≤ 250 ms) were similar in symptomatic and asymptomatic patients (187/949, 20% vs. 25/108, 23%) (P = 0.40) as was the mean APERP (303 ± 68 ms vs. 307 ± 75) (P = 0.61). The proportion of patients who had inducible arrhythmia was larger in the symptomatic group (64% vs. 31%) (P < 0.001).

CONCLUSION

The results of this study strengthen the present guideline recommendation (IIA) to consider invasive risk assessment in patients with asymptomatic preexcitation.

Anatomy for ablation of atrioventricular nodal reentry tachycardia and accessory pathways

The atrioventricular (AV) valve plane and the central septum are of particular importance for electrophysiological diagnosis and interventional therapy of supraventricular tachycardias because accessory electrical connections of various types may be present in addition to the specific conduction system. Although modern 3D electroanatomic reconstruction systems including high-density mapping can be of great assistance, detailed knowledge of the anatomic structures involved, their complex three-dimensional arrangement, and their electrical properties in conjunction with electrophysiological features of supraventricular arrhythmias is essential for safe and efficient electrophysiological treatment. The aim of this article is to present current anatomical, topographical, and electrophysiological findings against the background of historical, seminal, and still indispensable literature.

Local Variation and Age-Related Change in Atrial and Ventricular Myocardial Contiguity at the Atrioventricular Junction in Human Hearts

Background: We explored the histologic patterns of and age-related changes in atrial and ventricular myocardial contiguity at the left and right atrioventricular (AV) junction that could be a target site for catheter ablation.

Methods and Results: Twenty-three structurally normal adult hearts obtained at autopsy were studied. The 2 AV annuli were divided into 13 clinically recognized portions in which we measured distance between the atrial and ventricular myocardium at the AV junction. Overall, measured distance was less on the right than left side (mean [±SD] 0.74±0.59 vs. 1.15±0.78 mm, respectively), and distance increased gradually with age. The gap was smallest at the anterolateral portion on the right side and posterolateral portion on the left side. Three specific features were noted, namely extension of the ventricular myocardium (coarse trabeculae) towards the atrium on the right side of the AV junction, extension of the atrial myocardium onto the AV valve leaflets, and a collection of small myocardial cells, perhaps including specialized cells, in the right anterolateral portion. No concealed AV muscular connections were found.

Conclusions: Contiguity and separation of the myocardium at the AV junction have specific patterns, and myocardial proximity is influenced by age. These histologic features of the AV junction may prove to be informative for catheter ablation of tachyarrhythmias related to the AV junction.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions: Part 1: Supraventricular arrhythmias. A position statement of the Section of Sports Cardiology and Exercise from the European Association of Preventive Cardiology (EAPC) and the European Heart Rhythm Association (EHRA), both associations of the European Society of Cardiology

Symptoms attributable to arrhythmias are frequently encountered in clinical practice. Cardiologists and sport physicians are required to identify high-risk individuals harbouring such conditions and provide appropriate advice regarding participation in regular exercise programmes and competitive sport. The three aspects that need to be considered are: (a) the risk of life-threatening arrhythmias by participating in sports; (b) control of symptoms due to arrhythmias that are not life-threatening but may hamper performance and/or reduce the quality of life; and (c) the impact of sports on the natural progression of the underlying arrhythmogenic condition. In many cases, there is no unequivocal answer to each aspect and therefore an open discussion with the athlete is necessary, in order to reach a balanced decision. In 2006 the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology published recommendations for participation in leisure-time physical activity and competitive sport in individuals with arrhythmias and potentially arrhythmogenic conditions. More than a decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of these conditions. The present document presents a combined effort by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and the European Heart Rhythm Association to offer a comprehensive overview of the most updated recommendations for practising cardiologists and sport physicians managing athletes with supraventricular arrhythmias, and provides pragmatic advice for safe participation in recreational physical activities, as well as competitive sport at amateur and professional level. A companion text on recommendations in athletes with ventricular arrhythmias, inherited arrhythmogenic conditions, pacemakers and implantable defibrillators is published as Part 2 in Europace.

Sudden Cardiac Death: The Most Feared but Potentially Preventable Presentation of Wolff-Parkinson-White Syndrome

Background. Wolff-Parkinson-White syndrome is an uncommon cardiac disorder characterized by the presence of one or more accessory pathways that predispose patients to frequent episodes of arrhythmias. The prognosis is usually good, but there is a lifetime risk of malignant arrhythmias and sudden cardiac death. Case Summary. A 25-year-old male presented a witnessed out-of-hospital cardiac arrest with ventricular fibrillation rhythm. Due to rapid initiation of prehospital advanced life support, return of spontaneous circulation was observed. During the transport to the hospital, an irregular wide complex tachycardia suggestive of preexcited atrial fibrillation with haemodynamic instability was also observed and a synchronized shock was applied. Baseline 12-lead electrocardiogram was compatible with sinus rhythm and ventricular preexcitation pattern. After clinical stabilization, an electrophysiological study was performed confirming the presence of a left anterolateral accessory pathway with a short antegrade effective refractory period. Successful radiofrequency catheter ablation was achieved. Discussion. The reported clinical case recalls fundamental features of the Wolff-Parkinson-White syndrome and outlines the increasing evidence and importance of the invasive risk stratification and even catheter ablation in asymptomatic patients who suffer from this uncommon disease that may have a dramatic and fatal initial clinical manifestation.

A case report of a patient with wide complex tachycardia due to Wolff–Parkinson–White syndrome mimicking ventricular tachycardia

Background

Wide complex tachycardia (WCT) associated with syncope as manifestation of an underlying, life-threatening arrhythmia might potentially be the harbinger of sudden cardiac death. Identifying the aetiology of a WCT is imperative to provide appropriate treatment and prevent recurrence.

Case summary

We report the case of a 22-year-old male who had been experiencing haemodynamically significant WCT leading to syncope at the age of 13 years. As the patient and the family rejected an electrophysiological (EP) study, he had received an implantable cardioverter-defibrillator (ICD) for secondary prevention. After 7 years of experiencing multiple shocks, the patient finally gave consent to an EP study, which identified a left-sided accessory atrioventricular pathway that was successfully ablated during the same procedure.

Discussion

The differential diagnosis of WCT might be challenging and includes both ventricular and supraventricular tachycardias. In young patients without structural heart disease experiencing WCT, an EP study should be offered before ICD implantation to make a final diagnosis with the potential to provide definitive treatment.

Successful risk stratification of a patient with ventricular preexcitation by improved transesophageal electrophysiological study

The patient is a 19 years‐old man who often wakes up in dreams with palpitations and fatigue. The ECG shows: 1. Sinus rhythm; 2. Preexcitation syndrome. Transesophageal electrophysiological study (TEEPS) diagnosis:High‐risk accessory pathway. During radiofrequency catheter ablation, the patient suddenly developed atrial fibrillation and quickly converted to ventricular fibrillation. After defibrillation, ventricular fibrillation is transformed into sinus rhythm. Subsequently, the patient's high‐risk accessory pathway was successfully ablated. Studies have shown that about 25% of patients with WPW syndrome have a refractory period of less than 250 ms, which is one of the risk factors for the conversion of atrial fibrillation to ventricular fibrillation. Therefore, risk stratification is recommended for these symptomatic patients. From 1980 to 1990, there were literature reports on risk stratification of patients with preexcitation syndrome by TEEPS. But it has not become a routine examination of risk stratification in patients with preexcitation syndrome.The reason may be related to the hardware conditions and risk stratification methods used at that time. The TEEPS equipment currently used in our hospital can control the pacing voltage at about 12 mv on average. The voltage in this case report is 9 mv only. In addition, we successfully stratified the risk of patient with preexcitation syndrome without inducing atrial fibrillation. All the electrophysiological records of the patient during the examination were recorded simultaneously with the 12‐lead ECG and the esophageal lead ECG. These improvements makes TEEPS a simple, safe and reliable non‐invasive cardiac electrophysiological detection technology, which is worth popularizing in hospitals.

Application of CRISPR-Cas9 gene editing for congenital heart disease

Clustered regularly interspaced short palindromic repeats and CRISPR-associated protein 9 (CRISPR-Cas9) is an ancient prokaryotic defense system that precisely cuts foreign genomic DNA under the control of a small number of guide RNAs. The CRISPR-Cas9 system facilitates efficient double-stranded DNA cleavage that has been recently adopted for genome editing to create or correct inherited genetic mutations causing disease. Congenital heart disease (CHD) is generally caused by genetic mutations such as base substitutions, deletions, and insertions, which result in diverse developmental defects and remains a leading cause of birth defects. Pediatric CHD patients exhibit a spectrum of cardiac abnormalities such as septal defects, valvular defects, and abnormal chamber development. CHD onset occurs during the prenatal period and often results in early lethality during childhood. Because CRISPR-Cas9-based genome editing technology has gained considerable attention for its potential to prevent and treat diseases, we will review the CRISPR-Cas9 system as a genome editing tool and focus on its therapeutic application for CHD.

Ventricular pre-excitation in primary care patients: Evaluation of the risk of mortality

BACKGROUND

Ventricular pre-excitation is characterized by the presence of atrioventricular accessory pathways, predisposing to arrhythmias. Although it is well established that risk stratification in symptomatic patients should be invasive, there is a lack of evidence of the benefit in asymptomatic.

OBJECTIVE

Evaluate ventricular pre-excitation in the electrocardiogram (ECG) as a risk factor for overall mortality in patients of Telehealth Network of Minas Gerais (TNMG), Brazil.

METHODS

This observational study was developed with the database of digital ECGs (2010-2017) from TNMG. The electronic cohort was obtained by linking data from ECG exams and those from the national mortality information system. Only the first ECG was considered. Clinical data were self-reported, and ECGs were interpreted manually by cardiologists and automatically by the Glasgow University Interpreter software. Hazard ratio (HR) for mortality was estimated using weighted Cox regression.

RESULTS

Nearly 1 665 667 patients were included (median age: 50 [Q1: 34; Q3: 63] years; 41.4% were male). In a mean follow-up of 3.7 years, the overall mortality rate was 3.1%. The prevalence of ventricular pre-excitation was 0.07%. In multivariate analysis, adjusting for sex and age, ventricular pre-excitation was not associated with an increased risk of mortality (HR: 1.41; 95% confidence interval [CI]: 0.56-3.57; p = .47) when compared to the whole sample or to patients with normal ECG (HR: 1.41; 95% CI: 0.53-4.36; p = .43). In a subanalysis on accessory pathway location, there was no evidence of a higher risk of death related to any location.

CONCLUSION

Ventricular pre-excitation was not associated with an increased risk of mortality in a primary care cohort.

A Brief review of the risks and the stratification of sudden death in the ventricular Pre-excitation syndrome

Objective: The diagnosis of ventricular preexcitation syndromes is often occasional and with underestimated risk, showing controversies in its stratification and indication of prophylactic ablation. This work aims to explore and summarize the data in the literature, exposing the authors’ conclusions regarding this review. Methods: The authors prepared this work based on the latest guideline of the European Society of Cardiology plus a search for articles published in MEDLINE whose titles related to sudden death from ventricular fibrillation in patients with ventricular preexcitation. Discussion: Sudden death secondary to preexcited atrial fibrillation with degeneration to ventricular fibrillation is the most feared event in Wolff-Parkinson-White syndrome, has an average annual incidence of 0.15 to 0.39%, affecting individuals with structurally normal heart. The noninvasive stratification methods do not demonstrate adequate efficacy, and an electrophysiological study is recommended for all cases at the time of diagnosis. The most severe criteria for sudden death are shortest preexcited RR interval ≤ 250 ms (SPERRI or SPRRI); accessory pathway effective refractory period (APERP) ≤ 250 ms; presence of multiple accessory bundles; shortest paced cycle length with preexcitation during atrial pacing ≤ 250ms (SPPCL); Ebstein anomaly; induction of sustained supraventricular tachycardia. Conclusion: The low rate of complications during the diagnostic exam as well as in the therapeutic procedure, added to the high percentage of success of radiofrequency ablation, leads to indicate early the execution of electrophysiological study as a more diligent and accurate measure in the reduction of sudden death events in patients with ventricular preexcitation syndromes.

Sudden Cardiac Death in Patients with Ventricular Preexcitation

Patients with the Wolff-Parkinson-White syndrome may experience benign and malignant arrhythmias, the most common being atrioventricular reentrant tachycardias. This arrhythmia may degenerate into atrial fibrillation, which can be conducted over an accessory pathway capable of exceptionally fast conduction to the ventricles and degenerate into ventricular fibrillation, leading to sudden cardiac death. These life-threatening events generally affect symptomatic patients in their third or fourth decade. Although rare, ventricular fibrillation may be the first clinical manifestation in subjects who are asymptomatic or unaware of their conditions. Electrophysiologic study may be useful to identify subjects at high risk of sudden cardiac death.

Cardiac arrhythmias in the emergency settings of acute coronary syndrome and revascularization: an European Heart Rhythm Association (EHRA) consensus document, endorsed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Acute Cardiovascular Care Association (ACCA)

Despite major therapeutic advances over the last decades, complex supraventricular and ventricular arrhythmias (VAs), particularly in the emergency setting or during revascularization for acute myocardial infarction (AMI), remain an important clinical problem. Although the incidence of VAs has declined in the hospital phase of acute coronary syndromes (ACS), mainly due to prompt revascularization and optimal medical therapy, still up to 6% patients with ACS develop ventricular tachycardia and/or ventricular fibrillation within the first hours of ACS symptoms. Despite sustained VAs being perceived predictors of worse in-hospital outcomes, specific associations between the type of VAs, arrhythmia timing, applied treatment strategies and long-term prognosis in AMI are vague. Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia that may be asymptomatic and/or may be associated with rapid haemodynamic deterioration requiring immediate treatment. It is estimated that over 20% AMI patients may have a history of AF, whereas the new-onset arrhythmia may occur in 5% patients with ST elevation myocardial infarction. Importantly, patients who were treated with primary percutaneous coronary intervention for AMI and developed AF have higher rates of adverse events and mortality compared with subjects free of arrhythmia. The scope of this position document is to cover the clinical implications and pharmacological/non-pharmacological management of arrhythmias in emergency presentations and during revascularization. Current evidence for clinical relevance of specific types of VAs complicating AMI in relation to arrhythmia timing has been discussed.

The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.

Management of Young Athletes with Asymptomatic Preexcitation-A Review of the Literature

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.

Management of asymptomatic ventricular preexcitation

An incidental discovery of Wolff Parkinson White (WPW) pattern on the electrocardiogram (ECG) is not an infrequent finding facing the physician. Most patients discovered incidentally are asymptomatic and it is hard to justify further management of such patients given the time-honored adage to “first do no harm.” However, this finding does have implications. This article is an attempt to guide clinicians about this important issue that is often faced in the office.

Management of Asymptomatic Wolff-Parkinson-White Pattern by Pediatric Electrophysiologists

OBJECTIVE

To determine the present-day approach of pediatric cardiac electrophysiologists to asymptomatic Wolff-Parkinson-White (WPW) pattern and to contrast to both published consensus statements and a similar survey.

STUDY DESIGN

A questionnaire was sent to 266 Pediatric and Congenital Electrophysiology Society physician members in 25 countries; 21 questions from the 2003 survey were repeated, with new questions added regarding risk stratification and decision making.

RESULTS

We received 113 responses from 13 countries, with responders having extensive electrophysiology experience (median 15 years [IQR 8.5-25 years]). Only 12 (11%) believed that intermittent pre-excitation and 37 (33%) that sudden loss of pre-excitation on exercise test were sufficient evidence of accessory pathway safety to avoid an invasive electrophysiology study. Optimal weight for electrophysiology study was 20 kg (IQR 18-22.5 kg), and 61% and 58% would then ablate all right-sided or left-sided accessory pathways, respectively, regardless of electrophysiological properties, whereas only 23% would ablate all septal accessory pathways (P < .001). Compared with 2003, respondents were more likely to consider inducible arrhythmia (77% vs 26%, P < .001) as sufficient indication alone for ablation.

CONCLUSIONS

In the context of recent literature regarding the reliability of risk-stratification tools, most operators are now performing electrophysiology study for asymptomatic Wolff-Parkinson-White regardless of noninvasive findings. Many will then proceed to default ablation of all accessory pathways distant from critical conduction structures.

Notch and interacting signalling pathways in cardiac development, disease, and regeneration

Cardiogenesis is a complex developmental process involving multiple overlapping stages of cell fate specification, proliferation, differentiation, and morphogenesis. Precise spatiotemporal coordination between the different cardiogenic processes is ensured by intercellular signalling crosstalk and tissue-tissue interactions. Notch is an intercellular signalling pathway crucial for cell fate decisions during multicellular organismal development and is aptly positioned to coordinate the complex signalling crosstalk required for progressive cell lineage restriction during cardiogenesis. In this Review, we describe the role of Notch signalling and the crosstalk with other signalling pathways during the differentiation and patterning of the different cardiac tissues and in cardiac valve and ventricular chamber development. We examine how perturbation of Notch signalling activity is linked to congenital heart diseases affecting the neonate and adult, and discuss studies that shed light on the role of Notch signalling in heart regeneration and repair after injury.

Validation of a novel automated signal analysis tool for ablation of Wolff-Parkinson-White Syndrome

Background

In previous pilot work we demonstrated that a novel automated signal analysis tool could accurately identify successful ablation sites during Wolff-Parkinson-White (WPW) ablation at a single center.

Objective

We sought to validate and refine this signal analysis tool in a larger multi-center cohort of children with WPW.

Methods

A retrospective review was performed of signal data from children with WPW who underwent ablation at two pediatric arrhythmia centers from 2008–2015. All patients with WPW ≤ 21 years who underwent invasive electrophysiology study and ablation with ablation signals available for review were included. Signals were excluded if temperature or power delivery was inadequate or lesion time was < 5 seconds. Ablation lesions were reviewed for each patient. Signals were classified as successful if there was loss of antegrade and retrograde accessory pathway (AP) conduction or unsuccessful if ablation did not eliminate AP conduction. Custom signal analysis software analyzed intracardiac electrograms for amplitudes, high and low frequency components, integrated area, and signal timing components to create a signal score. We validated the previously published signal score threshold 3.1 in this larger, more diverse cohort and explored additional scoring options. Logistic regression with lasso regularization using Youden’s index criterion and a cost-benefit criterion to identify thresholds was considered as a refinement to this score.

Results

347 signals (141 successful, 206 unsuccessful) in 144 pts were analyzed [mean age 13.2 ± 3.9 years, 96 (67%) male, 66 (45%) left sided APs]. The software correctly identified the signals as successful or unsuccessful in 276/347 (80%) at a threshold of 3.1. The performance of other thresholds did not significantly improve the predictive ability. A signal score threshold of 3.1 provided the following diagnostic accuracy for distinguishing a successful from unsuccessful signal: sensitivity 83%, specificity 77%, PPV 71%, NPV 87%.

Conclusions

An automated signal analysis software tool reliably distinguished successful versus unsuccessful ablation electrograms in children with WPW when validated in a large, diverse cohort. Refining the tools using an alternative threshold and statistical method did not improve the original signal score at a threshold of 3.1. This software was effective across two centers and multiple operators and may be an effective tool for ablation of WPW.

Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS)

Asymptomatic arrhythmias are frequently encountered in clinical practice. Although studies specifically dedicated to these asymptomatic arrhythmias are lacking, many arrhythmias still require proper diagnostic and prognostic evaluation and treatment to avoid severe consequences, such as stroke or systemic emboli, heart failure, or sudden cardiac death. The present document reviews the evidence, where available, and attempts to reach a consensus, where evidence is insufficient or conflicting.

Risk-Stratification Strategy for Sudden Cardiac Death in the Very Young Children with Asymptomatic Ventricular Preexcitation

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.

Reentry Tachycardia in Children: Adenosine Can Make It Worse

OBJECTIVES

We report on a rare but severe complication of adenosine use in a child with reentry tachycardia.

METHODS AND RESULTS

Treatment with adenosine, which is the standard medical therapy of atrioventricular reentry tachycardia, led to the development of an irregular wide complex tachycardia, caused by rapid ventricular response to atrial fibrillation. The girl was finally stabilized with electrical cardioversion. We analyze the pathomechanism and discuss possible treatment options.

CONCLUSIONS

Atrial fibrillation, as well as its conduction to the ventricles, can be caused by adenosine. Rapid ventricular response in children with Wolff-Parkinson-White syndrome is more frequent than previously believed. A patient history of atrial fibrillation is a contraindication for cardioversion with adenosine and needs to be assessed in children with reentry tachycardia. High-risk patients may potentially profit from prophylactic comedication with antiarrhythmic agents, such as flecainide, ibutilide, or vernakalant, before adenosine administration.

Supraventricular Arrhythmias: Clinical Framework and Common Scenarios for the Internist

Supraventricular arrhythmias can cause uncomfortable symptoms for patients. Often, the first point of contact is in the primary care setting, and thus, it is imperative for the general internist to have a clinical framework in place to recognize this cluster of cardiac arrhythmias, be familiar with immediate and long-term management of supraventricular tachycardias, and understand when cardiac electrophysiologic consultation is necessary. The electrocardiographic characteristics can have subtle but important clues to the diagnosis and initial management. An understanding of the mechanisms of these arrhythmias is essential to provide proper therapy to the patient. In addition, there are common practice strategies that should be emphasized to avoid common misperceptions that could pose risk to the patient. In this review, we provide a framework to more easily recognize and classify these arrhythmias. We also illustrate the mechanism for these arrhythmias to provide an understanding of the interventions generally used.

Transseptal or retrograde approach for transcatheter ablation of left sided accessory pathways: a systematic review and meta-analysis

BACKGROUND

Transcatheter ablation is the most effective treatment for patients with symptomatic or high-risk accessory pathways (AP). At present, no clear recommendations have been issued on the optimal approach for left sided AP ablation. We performed this meta-analysis to compare the safety and efficacy of transaortic retrograde versus transseptal approach for left sided AP ablation.

METHODS AND RESULTS

MEDLINE/PubMed and Cochrane database were searched for pertinent articles from 1990 until 2016. Following inclusion/exclusion criteria application, 29 studies were selected including 2030 patients (1013 retrograde, 1017 transseptal) from 28 observational single Centre studies and one randomized trial. Patients approached by transseptal puncture presented a significantly higher acute success (98% vs. 94%, p = 0.040). The incidence of late recurrences (p = 0.381) and complications (p = 0.301) did not differ among the two groups, but the pattern of complications differed: vascular complications were more frequent with transaortic retrograde approach, while cardiac tamponade was the main transseptal complication. No difference was noted in terms of procedural duration and fluoroscopy time (p = 0.230 and p = 0.980, respectively). Meta-regression analysis showed no relation between year of publication and acute success (p = 0.325) or incidence of complications (p = 0.795); additionally, no direct relation was found between age and acute success (p = 0.256) or complications (p = 0.863).

CONCLUSIONS

Left sided AP transcatheter ablation is effective in around 95% of the cases, with a very limited incidence of complications. Transseptal access provides higher acute success in achieving AP ablation; late recurrences are rare but observed similarly following both approaches. Retrograde approach is affected by a relatively high incidence of vascular complications.

Does the age of evaluation change the long-term follow-up of untreated pre-excitation syndrome?

BACKGROUND

Due to high rates of ablation at the time of diagnostic EP study, follow-up of the natural history of untreated pre-excitation syndrome has become difficult. We present patients in which such data is available and study the effect of initial age on the evolution.

METHODS

In this retrospective review, 126 patients, 47 aged ≤19 years, 79 aged more than>19 underwent 2 similar electrophysiological studies (EPS) within 1 to 25 years of one another (8.8 ± 6.8) for occurrence of symptoms or new evaluation. First EPS was indicated for syncope (10), atrioventricular re-entrant tachycardias (AVRT) (58), atrial fibrillation (AF) (5), spontaneous PS-related adverse event (7) or asymptomatic PS (46).

RESULTS

Clinical data remained unchanged in 76 patients (60.3%). AVRT symptom was more frequently unchanged than other symptoms. Electrophysiological data remained unchanged in 105 patients (82%), but signs of initial malignant signs were variable with a disappearance in 53.5% of patients. At EPS1, AF induction was rarer in patients ≤19 years. Syncope had a low predictive value of malignant form. AVRT induction at EPS1 was not predictive of AVRT occurrence. Maximal rate over accessory pathway increased, but unexpected changes could occur. After multivariate analysis, data of first EPS were limited for the prediction of AVRT or adverse event; effect of age was not significant.

CONCLUSIONS

Clinical data remained unchanged in 60.3% of patients and electrophysiological data in 82%. Initial age of evaluation did not change the modifications. Electrophysiological signs associated with sudden death varied over time. Clinical AVRT was inconstantly related to inducible AVRT (78.5%).