wolff - parkinson - white syndrome
TRANSCRIPT
Y.B. Liu
Wolff-Parkinson-White Syndrome
Yen-Bin Liu, 2013 March
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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 (-)
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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
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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?
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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
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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 !