Guidelines Summary
2012 PACES/HRS guidelines (Wolff-Parkinson-White)
The 2012 Pediatric and Congenital Electrophysiology Society (PACES)/Heart Rhythm Society (HRS) guidelines indicate that more invasive EPS should be considered when the absolute loss of manifest preexcitation cannot be clearly demonstrated. The recommendations include the following [17] :
-
Measurement of the shortest preexcited RR interval during induced atrial fibrillation (AF)
-
Determination of the number and location of accessory pathways (APs)
-
Evaluation of the anterograde and retrograde features of the APs and atrioventricular (AV) node
-
Assessment at multiple cycle lengths of the effective efractory period of the APs and the ventricle
For the evaluation of asymptomatic patients aged 8-21 years with WPW, the guidelines recommend an exercise stress test when ambulatory ECGs show persistent excitation. [17] If noninvasive testing does not clearly show abrupt loss of preexcitation, clinicians should consider using invasive risk stratification (transesophageal/intracardiac) to assess the shortest preexcite RR interval in AF. [17]
The guidelines include the following management recommendations in asymptomatic patients aged 8-21 years with WPW [17] :
-
For those with a shortest preexcited RR interval (SPERRI) of 250 ms or less in AF, consider catheter ablation and factor in the associated procedural risk factors on the basis of the AP anatomic site.
-
Consider catheter ablation also for those with concomitant (1) structural heart disease, regardless of the anterograde AP features, or (2) ventricular dysfunction due to dyssynchronous contractions, regardless of the anterograde bypass tract characteristics.
-
Previously asymptomatic patients who develop cardiovascular (CV) symptoms should be considered symptomatic and thus potential candidates for catheter ablation.
-
For those with a SPERRI longer than 250 ms in AF, consider deferring catheter ablation.
-
Consider administration of attention-deficit/hyperactivity disorder (ADHD) medications; if ADHD medications are used, closely monitor patients for CV symptoms.
2014 AHA/ACC/HRS guidelines (Atrial Fibrillation)
The 2014 American Heart Association (AHA)/American College of Cardiology (ACC)/HRS guidelines management of atrial fibrillation (AF) include the following specific recommendations for WPW and preexcitation syndromes [36] :
Class I (Level of evidence: C)
-
Patients with AF, WPW syndrome, and rapid ventricular response who are hemodynamically compromised should receive prompt direct-current cardioversion. (Level of evidence: C)
-
For patients with preexcited AF and rapid ventricular response who are not hemodynamically compromised, administer IV procainamide or ibutilide to restore sinus rhythm or slow the ventricular rate. (Level of evidence: C)
-
Catheter ablation of the accessory pathway in symptomatic patients with preexcited AF, especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction.
Class III:(Level of evidence: B)
-
Administration of intravenous amiodarone, adenosine, digoxin (oral or intravenous), or nondihydropyridine calcium channel antagonists (oral or intravenous) in patients with WPW syndrome who have preexcited AF is potentially harmful because these drugs accelerate the ventricular rate.
2015 ACC/AHA/HRS guidelines (supraventricular tachycardia)
In 2015, joint ACC/AHA/HRS guidelines for the management of supraventricular tachycardia (SVT) were released that included specific recommendations for both acure and ongoing managment of AV reentry tachycardia (AVRT). [37]
Vagal maneuvers and/or IV adenosine are the recommended initial treatments for acute AVRT. (Class I; Level of evidence B-R)
Additional recommendations for acute treatment when adenosine and vagal maneuvers are ineffective or contraindicated are summarized below.
Hemodynamically unstable patients
-
Synchronized cardioversion (class I; level of evidence, B-NR)
Hemodynamically stable patients
-
IV beta blockers, diltiazem, or verapamil (class IIa; level of evidence, B-R for patients without preexcitation on their resting ECG during sinus rhythm; and class IIb; level of evidence, B-R for patients with preexcitation on their resting ECG during sinus rhythm)
-
Synchronized cardioversion when beta blockers, diltiazem, or verapamil are ineffective or contraindicated (class I; level of evidence, B-NR)
The guidelines note that for rhythms that break or recur spontaneously, synchronized cardioversion is not appropriate.
IV digoxin or amiodarone and intravenous or oral beta blockers, diltiazem, and verapamil are potentially harmful for treatment in patients with pre-excited atrial fibrillation (class III; level of evidence, C-LD).
For management of ongoing orthodromic AVRT, the guidelines recommend catheter ablation of the accessory pathway.(class I; level of evidence, B-R) Patients with preexcitation resting ECG who are not candidates or prefer not to undergo catheter ablation have the following alternative treatment options:
-
Flecainide or propafenone in patients without structural heart disease or ischemic heart disease (class IIa; Level of evidence B-R)
-
Sotalol or dofetilide (class IIb; level of evidence, B-R)
-
Oral beta blockers, diltiazem, verapamil (class IIb; level of evidence, C-LD)
-
Oral amiodaronewhen other therapies are ineffective or contraindicated (class IIb; level of evidence, C-LD)
-
Oral digoxin is potentially harmful for ongoing management in patients with AVRT or AF and preexcitation on their resting ECG (class III; level of evidence, C-LD)
2015 ESC guidelines (Ventricular Arrhythmias and Prevention of Sudden Cardiac Death
In its 2015 guidelines for management of venticular arrhythmias and prevention of sudden cardiac death, the European Society of Cardiology (ESC) recommends ablation is in WPW patients resuscitated from sudden cardiac arrest due to AF and rapid conduction over the accessory pathway causing VF. (class I; level of evidence, B). Additionally, ablation should be considered in patients who are symptomatic and/or who have accessory pathways with refractory periods ≤240 ms in duration. (class IIb; level of evidence, B) [38]
2014 PACES/HRS guidelines (Arrhythmias in Adult Congenital Heart Disease)
The 2014 PACES/HRS guidelines for managment of arrhythmias in adult congenital heart disease (CHD) recommend preoperative EPS for the identification and mapping of arrhythmias that may be managed with surgical ablation or incisional lesion sets in patients with [12] :
-
History of unexplained syncope or sustained ventricular tachycardia that is not due to a correctable predisposing etiology;
-
Documented SVT, not including AF;
-
Ventricular preexcitation.
A preoperative electrophysiology study may be considered in adults with CHD and any of the following criteria:
-
Nonsustained rapid atrial or ventricular tachyarrhythmias
-
Moderate or complex CHD known to be at high risk for atrial arrhythmia development but without documented sustained arrhythmia
-
History of palpitations or symptoms thought to be related to arrhythmia
-
Atrial fibrillation triggering supraventricular arrhythmia
Preoperative EPS is not recommended in adults with CHD and the following criteria:
-
Simple forms of CHD, no history of palpitations or arrhythmia symptoms, and no significant documented arrhythmia
-
AF without a triggering supraventricular arrhythmia.
-
Classic Wolff-Parkinson-White electrocardiogram with short PR, QRS >120 ms, and delta wave.
-
Preexcited atrial fibrillation.
-
Variants of Wolff-Parkinson-White syndrome (unusual accessory pathways).
-
Accessory pathway potential and local AV fusion at successful RF ablation site with loss of preexcitation and return of normal HV interval.
-
Electrocardiogram of asymptomatic 17-year-old male who was incidentally discovered to have Wolff-Parkinson-White pattern. It shows sinus rhythm with evident preexcitation. To locate accessory pathway (AP), initial 40 ms of QRS (delta wave) is evaluated. Note that delta wave is positive in I and aVL, negative in III and aVF, isoelectric in V1, and positive in rest of precordial leads. Therefore, this is likely posteroseptal AP.
-
12-lead electrocardiogram from asymptomatic 7-year-old boy with Wolff-Parkinson-White pattern. Delta waves are positive in I and aVL; negative in II, III, and aVF; isoelectric in V1; and positive in rest of precordial leads. This predicts posteroseptal location for accessory pathway.
-
12-lead electrocardiogram showing short PR interval and delta waves consistent with presence of accessory pathway.
