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Pre-excitation Syndrome: When not to ablate
Yoga Yuniadi
Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Indonesia, and National
Cardiovascular Center Harapan Kita, Jakarta
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Epidemiology
• The incidence of manifest pre-excitation on ECG tracings in the general population is 0.1% to 0.3%.
• SVT is the most common tacyarrhythmia in pre-excitation:– 90-95% orthodromic AVRT
– 5% pre-excited AVRT
• However, not all patients with manifest ventricular pre-excitation develop PSVT
2015 ACC/AHA/HRS Guideline for the Management of Adult Patients WithSupraventricular Tachycardia. JACC. 2016; 67: e27-115
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N Eng J Med. 1979; 301: 1080-5
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Recommendation for On going Management of Orthodromic AVRT
2015 ACC/AHA/HRS Guideline for the Management of Adult Patients WithSupraventricular Tachycardia. JACC. 2016; 67: e27-115
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On going Management of Orthodromic AVRT
2015 ACC/AHA/HRS Guideline for the Management of Adult Patients WithSupraventricular Tachycardia. JACC. 2016; 67: e27-115
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When not to ablate Pre-excitation?
• Aymptomatic or Isolated pre-excitation?
• The abnormal pre-excitation ECG pattern in the absence of documented SVT or symptoms consistent with SVT.
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2003 ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias
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Abrupt loss of pre-excitation
2015 ACC/AHA/HRS Guideline for the Management of Adult Patients WithSupraventricular Tachycardia. JACC. 2016; 67: e27-115
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Loss of Pre-excitation During Long-term Follow Up of Asymptomatic Pre-excitation
Obeyesekere et al. Int J Cardiol. 2012;160:75–7
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Incidence of AF During Long-term Follow Up of Asymptomatic Pre-Excitation
Obeyesekere et al. Int J Cardiol. 2012;160:75–7
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Risk of SVT among AsymptomaticPre-excitation Patients
Obeyesekere et al. Circulation. 2012;125:2308-2315
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Risk of SCD of Asymptomatic Pre-excitation Patient
Obeyesekere et al. Circulation. 2012;125:2308-2315
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Pappone et al. Circulation. 2014;130:811-819
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Question
What is the usefulness of :
invasive EP study
versus
noninvasive testing or no testing
for predicting arrhythmic events (including SCD) in patients with asymptomatic pre-excitation?
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Pappone et al. J Am Coll Cardiol. 2003;41:239–44
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Santinelli et al. Circ Arrhythmia Electrophysiol. 2009;2:102-107
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QuestionWhat are the efficacy and effectiveness of:
invasive EP study + catheter ablation of the accessory pathway
versus noninvasive tests with treatment (including
observation) or no testing/ablation
for preventing arrhythmic events (including SCD) and improving outcomes in patients with
asymptomatic pre-excitation?
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RCT of Prophylactic Ablation in High Risk Asymptomatic Pre-excitation
Pappone et al. N Engl J Med 2003;349:1803-11.
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Freedom from Malignant Arrhythmias and VF in Pre-excitation: RFA vs. No RFA
Pappone et al. Circulation. 2014;130:811-819
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Al Khatib et al. JACC. 2016: 67: 1624-38
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Sistematic Review on Asymptomatic Pre-excitation Managemnet
• Data from observational studies on 883 patients who did not undergo ablation:– up to 9% developed malignant arrhythmias
– up to 2% developed VF
• Very low risk of complications of EP study
• Risk stratification using an EP study may be beneficial, with consideration of accessorypathway ablation in those deemed to be at high risk of future arrhythmia
Al Khatib et al. JACC. 2016: 67: 1624-38
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Recommendation Management of Asymptomatic Pre-excitation
2015 ACC/AHA/HRS Guideline for the Management of Adult Patients WithSupraventricular Tachycardia. JACC. 2016; 67: e27-115
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19 yo Male, rejected to enter Flight School due to Asymptomatic Preexcitation
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My Approach
1. Observe/Non-invasive Testing
2. EP Study
a) High Risk: Ablation
b) Low Risk:
i. No Ablation: Delta wave
ii. Ablation: Normal SR become a good Pilot.
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Conclusion
• All pre-excitation syndrome (icl. asymptomatic patient) warant EP Study with consideration of accessory-pathway ablation in those deemed to be at high risk of future arrhythmias.
• Asymptomatic patient with low risk arrhythmic events: (may be) no ablation
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