«Aσθενής με ασυμπτωματικό WPW και παροξυσμική κολπική μαρμαρυγή» Χάρης Κοσσυβάκης Επιμελητής A Καρδιολογικό Τμήμα Γ.Ν.Α. «Γ.

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1 «Aσθενής με ασυμπτωματικό WPW και παροξυσμική κολπική μαρμαρυγή» Χάρης Κοσσυβάκης Επιμελητής A Καρδιολογικό Τμήμα Γ.Ν.Α. «Γ. ΓΕΝΝΗΜΑΤΑΣ»

2 the primary mechanism of SCD in patients with WPW is the rapid conduction of AF down an accessory pathway (AP) up to 64% of episodes

3 Half of patients with life-threatening event J Am Coll Cardiol EP 2018;4:433 44

4 Incidence of atrial fibrillation in asymptomatic Wolff Parkinson White patients The risk of AF is estimated at 9.25 (95% CI: 3.37 to 18.00) per 1000 personyears of follow-up 15% and 30% of patients will develop atrial fibrillation International Journal of Cardiology Volume 160, Issue 1, 20 September 2012, Pages 75-7

5 In the observational cohorts of asymptomatic patients who did not undergo catheter ablation (n=883, with follow-up ranging from 8 to 96 months) regular supraventricular tachycardia or benign atrial fibrillation (shortest RR interval >250 ms) developed in 0% to 16%, malignant atrial fibrillation (shortest RR interval 250 ms) in 0% to 9% ventricular fibrillation in 0% to 2% Circulation. 2016;133:e575-e586

6 ΙΣΤΟΡΙΚΟ Ανδρας 23 ετών επαγγελματική ενασχόληση με καταδύσεις ασυμπτωματική προδιέγερση στο ΗΚΓ 12 απαγωγών προ 5ετιας

7 ΗΚΓ με προδιέγερση

8 Risk Stratification for Sudden Death in asymptomatic patients With Wolff-Parkinson-White Syndrome Non invasive Invasive ECG Ampulatory ECG Stress exercise Pharmacologic Testing EP testing Loss of pre-excitation?

9 specificity and positive predictive value of 100 % sensitivity was low (17.7 %). Abrupt loss of preexcitation during graded exercise

10 Noninvasive tests have an approximately 90% positive predictive value and 30% negative predictive value for identifying pathways with life-threatening properties

11 EP testing risk factors for development of lifethreatening ventricular arrhythmias R-R interval <250 ms between 2 pre-excited complexes during induced AF the presence of multiple accessory pathways the finding of AVRT precipitating pre-excited AF an accessory pathway refractory period < 240 ms

12 J Am Coll Cardiol EP 2018;4: Shortest pre-excited RR interval (SPERRI) of 250 ms

13 J Am Coll Cardiol EP 2018;4: treating asymptomatic patients?? RISC OF SCD: 0.1 % 22 of 60 (37 %) did not have EPSdetermined high risk characteristics, and number needed to ablate of 15 of 60 (25 %) had neither 1,000 per year to prevent concerning pathway characteristics 1 death/neurological injury nor inducible AVRT

14 Sudden cardiac death secondary to pre-excited AF is the most feared manifestation of WPW syndrome J.Brugada, Arrhythmia & Electrophysiology Review 2018;7(1):32 8.

15 Management of Patients with Asymptomatic Pre-excitation Arrhythmia & Electrophysiology Review 2018;7(1):32 8.

16 Holter ρυθμού 24ωρου The hallmark ECG features of AF in WPW include rhythm irregularity, very rapid ventricular response, and wide QRS complexes with a morphology that changes from beat to beat

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22 Treatment for pre-excited atrial fibrillation Acute termination Chronic prevention Unstable patients: Synchronized cardioversion Stable patients: First line: IV ibutilide or IV procainamide Other therapies: IC antiarrhythmic agent or dofetilide; synchronized cardioversion if other therapies are ineffective or not available First line: Catheter ablation of the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Third line: Oral IA antiarrhythmic agent OR oral amiodarone Contraindicated agents Amiodarone,Digoxin Beta blockers,adenosine Verapamil, diltiazem Contraindicated agents Oral Digoxin

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25 recurrence rate of paroxysmal atrial fibrillation after successful ablation of the AP is high (20%). higher incidence of post-ablation atrial fibrillation in patients older than 50 years of age Europace (2015) 17,

26 The atrial vulnerability in the WPW syndrome seems to be either reversible and AP-dependent or intrinsic and AP-independent Europace (2008) 10,

27 Conclusions Occurrence of paroxysmal atrial fibrillation in previously asymptomatic WPW patients, significantly worsen prognosis Catheter ablation of accessory pathway should be considered as first line therapy for pre-excited atrial fibrillation Postablation accessory pathway reccurence of atrial fibrillation indicates a different mechanism of genesis Treating asymptomatic patients with ecg preexcitation to prevent atrial fibrillation continues to be controversial ablation procedure should be considered when accepted high-risk factors are present and after discussion of the risks, benefits, and alternatives of the ablation procedure with the patient

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33 spontaneous degeneration of atrioventricular reciprocating tachycardia into AF The incidence of spontaneous degeneration of induced AVRT into AF has been reported to be in the range of 16% to 26%, AVRT can increase atrial vulnerability as a result of : a shortened atrial cycle length increased sympathetic tone atrial stretch due to hemodynamic changes Shorter cycle lenght of AVRT easier to develop AF

34 Retrograde conduction: electrophysiological properties of the AP retrograde multiple AP as a mechanism of premature atrial contraction that initiates atrial repetitive firing or intra-atrial reentry in the vulnerable period of the atrium during AVRT. Anterograde conduction shorter anterograde AP ERP allows faster ventricular rates during AF, associated atrial stretch and hypoxia may contribute to sustaining the arrhythmia

35 effects of accessory pathway on atrial architecture structural differences in the AP apparently affected refractoriness and conduction properties of the pathway Dispersion of the refractory periods and conduction disturbances apparently occur around the interconnection between different tissues such as the atrium and the AP.

36 underlying atrial muscle disease atrial inflamatory infiltrates in patients with the WPW syndrome supports the hypothesis that atrial inflammatory foci may act as a trigger of AF abnormally prolonged and fractionated atrial electrograms and significantly found in the high right atrial sites distant from the atrioventricular groove and AP location. Atrial conduction delay wider interatrial conduction delay zone

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38 Prevalence and prognostic significance of pre-excitated atrial fibrillation WPW pattern on surface ECG has been estimated between 0.13% and 0.25% of the general population The prevalence of the actual WPW syndrome is substantially lower, involving only approximately 1.0% to 1.8% of those patients with a WPW pattern on ECG Sudden cardiac death (SCD) as the first clinical manifestation of Wolff- Parkinson-White (WPW) syndrome is a well-documented, although rare occurrence. (ranges from 0% to 0.39% annually) Rapid anterograde accessory pathway conduction during AF can result in SCD in patients with a manifest accessory pathway, with a 10-year risk ranging from 0.15% to 0.24% Rev Cardiovasc Med. 2014;15(4):

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40 Accesory pathway Catheter ablation of Asymptomatic Pre-excitation asymptomatic patient identified to have high risk properties or to be associated with an AP mediated tachycardia with EP testing high risk occupations / hobbies and competitive athletics antero-septal or mid-septal APs may preclude ablation of an asymptomatic antero-septal or mid-septal AP in an asymptomatic patient should only be performed after discussion of the risks, benefits, and alternatives of the ablation procedure with the patient Catheter ablation of low-risk asymptomatic pre-excitation in appropriately experienced centres according to patient values and preferences Arrhythmia & Electrophysiology Review 2018;7(1):32 8.

41 Incidence of Afib according to different anatomical sites of the accessory pathway Anatomical site rate anteroseptal AP 62% right free wall AP 21% left free wall 44% posteroseptal AP 36%

42 Loss of pre-excitation? ECG observed in up to 67 % of patients predictor of poor anterograde conduction and low risk of SCD

43 Sodium channel-blocking agents have been used to determine the anterograde AP conduction. procainamide, propafenone and ajmaline εμφανίζει από τριημέρου αίσθημα παλμών με συνοδό δύσπνοια

44 about sensitivity and specifity JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 4, NO. 4, 2018

45 Symptomatic patient R-R interval <250 ms between 2 pre-excited complexes during induced AF the presence of multiple accessory pathways the finding of AVRT precipitating pre-excited AF an accessory pathway refractory period < 240 ms

46 Patients with WPW syndrome and AF have shorter ERPs of PVs and greater maximal venoatrial conduction delay J Cardiovasc Electrophysiol, Vol. 23, pp , March 2012

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48 mechanisms that may be involved in the development of AF in the WPW syndrome spontaneous degeneration of atrioventricular reciprocating tachycardia into AF the electrophysiological properties of the AP the effects of AP on atrial architecture intrinsic atrial muscle vulnerability