wolff - parkinson - white syndrome

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Y.B. Liu Wolff-Parkinson-White Syndrome Yen-Bin Liu, 2013 March

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Page 1: Wolff - Parkinson - White Syndrome

Y.B. Liu

Wolff-Parkinson-White Syndrome

Yen-Bin Liu, 2013 March

Page 2: Wolff - Parkinson - White Syndrome

Y.B. Liu

Outline

• General consideration of SVT

• WPW and accessory pathway

• Catheter ablation of accessory pathway

• Multiple accessory pathway

• Special considerations in WPW and AVRT

• Issue not covered in today’s talk

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General consideration of SVT

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(AVNRT)

(slow-intermediate)

(fast-slow) (decremental AP)

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Esophageal Lead

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SVT v.s. AV conduction

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(macro-reentry)

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Wide QRS tachycardia ( >120 ms)

• SVT with BBB • Antidromic AVRT • SVT (AT, AVNRT, orthodromic AVRT, AFL, AF) with

bystander manifest AP • BBB reentry tachycardia • VT

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WPW and accessory pathway

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Pre-excitation

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Re-entry

• Dural pathway • Slow conduction zone • Unidirectional block

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Tachycardia associated with AP

5-10% 95%

1/3

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Incidence

• Overall incidence of accessory pathway (AP) – 0.1-0.3% of general population

• First-degreee relatives of patients with AP – 0.55%

• Incidence of multiple APs – 3-20% in surgical series – 5-18% in RFCA series

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Classification of Accessory Pathway

• Anatomy: – Left (mitral annulus) vs. right (tricuspid

annulus) • Electrophysiology:

– Decremental vs. nondecremental – 8% of AP with decremental characteristics

• Direction: Anterograde vs. retrograde – Concealed: retrograde conduction only – Manifest: bi-directional conduction

(* anterograde only: uncommon)

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Anatomy of Accessory Pathway

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Anterograde vs. Retrograde

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Decremental vs. nondecremental

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Intermittent Pre-excitation

• Weakness of accessory pathway conduction • Strengthen of AV nodal conduction

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WPW syndrome

The diagnosis of WPW syndrome is reserved for patients who have both pre-excitation and tachyarrhythmias.

ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias; 2003

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WPW, type A &B

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Localization of Accessory Pathway in WPW syndrome

• Transition zone • R in lead I • Positive or

Negative vector of delta wave in II, III, aVF

[PACE 1995; 18: 1469-1473]

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Localization of Accessory Pathway in WPW syndrome

Cardiovasc Electrophysiol. 1998;9:2-12

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Left lateral accessory pathway

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Right free wall accessory pathway

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Right anteroseptal accessory pathway

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Left posteroseptal accessory pathway

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Localization of AP by retrograde P wave during AVRT

III. aVF (+)

anterior anterior

late

ral

late

ral

poterior poterior

Poterior Poterior

Lateral Lateral

Anterior Anterior

J Interv Card Electrophysiol (2008) 22:55–63

J Am Coll Cardiol 1997;29:394–402

III. aVF (-)

Page 29: Wolff - Parkinson - White Syndrome

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Catheter ablation of accessory pathway

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Intracardiac ECG for Localization of AP

• Localization of AV rings • AV fusion: anterograde and retrograde • VA interval, HH interval, HA time • Zone of transition

–Pattern of initiation and termination –VEST or VPC during SVT –BBB during SVT –AV block during SVT

Page 31: Wolff - Parkinson - White Syndrome

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Localization of AV rings

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Example: Ablation site

RAO view LAO view

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AV fusion: anterograde

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AV fusion: Retrograde

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Decremental Accessory Pathway

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Pattern of initiation

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Pattern of termination

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Ventricular extra-stimulus Reset Tachycardia during His-refractoriness

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BBB during SVT

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Antidromic AVRT

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WPW with Atrial Fibrillation

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WPW with Atrial Fibrillation

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Endpoints of accessory pathway ablation

• Atrial pacing: – No pre-excitation – AV nodal decremental conduction (AH

prolongation in AEST)

• Ventricular pacing: – Total VA block OR – VA nodal decremental conduction (be sure

site of Cs orifice and no SVT inducible)

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Endpoint of RFCA

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Endpoint of RFCA

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Causes of failed ablation of accessroy pathway

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RFCA in WPW

•約有93-95% (87-99%)的成功率,而復發率則約為7% (0-11%) 。

•手術的併發症發生率約為1-4%,主要和手術傷口、電極導管的操作或高頻波的燒灼有關,約有1%的機會發生心房室傳導阻斷,但會因RFCA而發生致命性併發症的機率則很低 (<0.2%)。

•對AVRT而言,RFCA的成功率和復發率取決於是否能精準的定位accessory pathway並加以燒灼移除,因此,手術的結果和手術者的經驗十分相關,而和病人的年齡則無明顯的關聯。

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Multiple accessory pathway

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Definition of multiple accessory pathway

• APs separated by 1-3 cm

• Multistranded or broad-banded bypass tracts as wide as 3 cm had been reported

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Oblique accessory pathway

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ECG Clues to Multiple APs

• Variations in pre-excited QRS morphology (esp. during A fib.)

• Atypical patterns of pre-excitation • Antidromic AVRT using a posterior septal

AP • Orthodromic AVRT with changing

retrograde P wave morphology • Antidromic AVRT with varying degrees of

antegrade fusion

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Variations in pre-excitation

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Variations in pre-excitation

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Variations in pre-excitation

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Atypical patterns of pre-excitation

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EP Evidence of Multiple APs

• Chang in pre-excited morphology at different pacing cycle length and sites

• Differing pattern of antegrade and retrogade conduction

• Varying patterns of retrograde atrial activation sequence during AVRT or V pacing or from orthodromic to antidromic AVRT

• Appearance of an AP after AAD or ablation

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Differing pattern of antegrade and retrogade conduction

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Appearance of an AP after Ablation

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Varying patterns of retrograde atrial activation sequence

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Distribution • R. free wall AP +R. posteroseptal AP

(manifest > concealed about 2: 1) • 2 L. free wall

(concealed > manifest)

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Arrhythmias associated with multiple APs

• Orthodromic AVRT • Antidromic AVRT

– 33% vs. 6% • Atrial fibrillation

– More clinical AF – More induced AF – More AF after RV pacing and AVRT

• AP as a bystander

Sudden death?

Page 64: Wolff - Parkinson - White Syndrome

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RFCA in multiple APs

• Longer procedure time • Greater radiation time • Higher recurrent rate

– per patient – per AP

Dual AV nodal pathway, 10-20%

– Only 1 patient develop AVNRT

Page 65: Wolff - Parkinson - White Syndrome

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Special considerations in WPW and AVRT

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WPW v.s. Sudden Death

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WPW and Sudden Cardiac Death • 0.15% to 0.39% over 3 to 10 yr follow-up • In case with SCD, half of them is the first

manifestation of WPW • Risk factors:

–Shortest pre-excited RR<250 ms –Symptomatic tachycardia –Multiple APs –Ebstein’s anomaly –Familial WPW

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Pharmacological Treatment of WPW

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Pharmacological Treatment of WPW

• Pre-excited tachycardia – Adenosine used with caution – Verapamil, diltiazem, digoxin: Class III

• Long-term therapy – Propafenon: 69% effective; side effects:25% – Sotalol – Amiodarone: not superior to other AAD – Single use of verapamil, diltiazem, digoxin: not

recommended • Pill-in-the-Pocket

– Diltiazem 120 mg + propranolol 80 mg – 32 ± 22 min

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PSVT during Pregnancy

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RFCA in Asymptomatic WPW

但WPW發生心臟猝死猝死的比例並不高 (約0.15%),而RFCA也的確會有約2%的手術的併發症發生率,因此對於預防性的RFCA治療宜用於特定高危險群之病人,似乎尚未有足夠的證據支持將其列為常規性的治療。在北美心律學會,把RFCA在無症狀的WPW病人治療適應症列為Class III。

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Issue NOT covered in today’s talk

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Unusual connection

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Unusual connection: Mahaim fiber

The true Mahaim fiber is the nodofascicular or nodoventricular connection faithful to the original pathologic description. Over time, the term became a generic description for any pathway with slow decremental conduction properties.

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Unusual location: Epicardial AP

With or without diverticulum in coronary veins

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Thank you for your attention !