WPW: Background 10/23/10. Asymptomatic Subjects with WPW Should Undergo Catheter Ablation:! Proponent

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1 Asymptomatic Subjects with WPW Should Undergo Catheter Ablation:! Proponent Ronn E. Tanel, MD Director, Pediatric Arrhythmia Center Associate Professor of Pediatrics UCSF School of Medicine WPW: Background Prevalence % >50% of WPW patients are asymptomatic Annual SCD risk %/year 40-50% of WPW patients with SCD have no prior sxs or knowledge of dx 1

2 Initially described by Dreifus, et al. in 1971 WPW in the Young Up to 20% of pediatric sudden cardiac arrest survivors have WPW Silka, et al. Circ % of children with WPW and SCD had no prior clinical events Deal, et al. PACE 1995 Adult natural history studies may underestimate the lifetime risk of WPW since patients have already survived childhood WPW in the Young In general, the AP has more rapid conduction characteristics at a younger age Changes in AP conduction properties over time are not fully understood, especially in young patients WPW occurs with increased frequency in CHD (Ebstein s, HCM, CCTGA). The mortality risk may increase over time for the patient with persistent WPW who develops an increased risk of AF with age 2

3 RISK WPW Risk Factors Clinical Risk Factors Nature and severity of symptoms Male gender Multiple pathways Right anteroseptal AV groove AP Inducibility of SVT (AVRT or AF) WPW Risk Factors Gold Standard for high risk: Short (< 220 ms) pre-excited RR interval during AF APERP Rapid 1:1 AP conduction during AOD 3

4 WPW: Risk in Childhood Short APERP observed regardless of inducibility of SVT Sarubbi, et al. Heart 2003 Similar APERP in all patients, including those with rapidly conducted AF Sarubbi, et al. Int J Cardiol 2005 No differences in APERP, multiple pathways, AP location, or inducibility in those with vs without sxs Dubin, et al. Cardiol Young 2002 WPW: Risk Assessment Pappone, et al. NEJM asymptomatic children Ablation randomized amongst the high-risk 26% of controls developed sxs 18.5% of controls had silent rapidly conducted AF documented VF in 3, resulting in 1 death Much lower risk of life-threatening arrhythmias in most other natural hx studies Exercise Testing Assessment of persistent delta during EST 74 pediatric (14.3 y) pts had EST and EPS Only 16% had loss of delta during EST EST findings did not correlate with usual clinical risk factors Some with loss of delta during EST had highrisk EPS Exercise testing adds little to decision making Bershader, et al. Heart Rhythm

5 Ablation Risk Early (91-95) vs Late (96-99) Pediatric RF Ablation Registry Increased success rate Decreased fluoro times High-grade AVB: 0.6% Perforation: 0.5% Thromboembolic events: 0.2% 1 death in 3187 pediatric RF ablations Kugler, et al. JCE

6 US Childhood Obesity Epidemic 6

7 ADHD ADHD ~ 3-5% of youth < 19 yo 2.25 million medicated children Stimulant therapy introduced 1950 s Youth with ADHD are at risk for: High school drop-out Auto accidents Criminal activity Drug and alcohol use Suicide 7

8 SCD and ADHD Cardiac abnormalities: aberrant CA origin, HCM, BiAoV, hypertrophy, family hx ventricular arrhythmia, Nissen 2006 NEJM 25 total deaths 19 pediatric deaths No data exist to identify the actual risks of stimulant medication in children with congenital heart disease What other hurdles and restrictions may children with Wolff-Parkinson-White syndrome encounter during their lifetime? 8

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11 Indications for Ablation of WPW in Asymptomatic Subjects Asymptomatic patients are not free of risk and WPW contributes significantly to SCD in the young Noninvasive risk assessment is frequently inconclusive in the young AP conduction characteristics and associated risk are not static Comorbidities Lifestyle Livelihood 11

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13 WPW Risk Factors Milstein: EPS in asymptomatic vs symptomatic controls: less risk for short SPERRI Bromberg: SPERRI in 35% with SVT, 74% with syncope, and 100% with SCA. Severity of presentation was not a/w other clinical risk factors. SPERRI < 220 a/w 3x risk of SCA 13

14 Can Non-invasive Techniques Obviate the Need for EPS? Holter monitor and EST: Does pre-excitation disappear at high physiologic HRs Gaita, AJC 1989: These tests may be sensitive for those at risk, but are non-specific and have low positive predictive value Bershader, Heart Rhythm 2007: loss of pre-excitation on EST was a/w longer average APERPs, but only 15% had that finding with many having intermediate risk APs 14