WPW in Athletes Should we treat all? age? RAMI FOGELMAN SCHNEIDER CHILDREN MEDICAL CENTER OF ISRAEL

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1 WPW in Athletes Should we treat all? age? RAMI FOGELMAN SCHNEIDER CHILDREN MEDICAL CENTER OF ISRAEL

2 W.P.W

3 Clues in sinus rhythm No Q in Lt chest leads (WPW 88%, control 5%) PR < 100msec (WPW 80%, control 16%) QRS > 80msec (WPW 89%, control 2%) Lt axis deviation (WPW 33%, control 4%) Perry, Garson J. Ped 12/1990

4 WPW - Statistics Prevalence ~ 1-3:1000. Among 1 st degree relatives 5.5:1000. Majority have normal heart 20% have structural congenital heart disease, mostly Ebstien s anomaly, hypertrophic CM, congenital corrected TGA

5 What are the options Asymptomatic 55-65%. SVT AVRT 35-45%. A.Flutter/Fib with risk of antegrade conduction via the A.P %. (1:1000 Pt years). Desynchrony unknown percentage (usually septal pathways).

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7 W.P.W - SVT

8 18Y old previously healthy Mazur A et al (Hillel Yaffe)

9 The real risk Very rapid conduction of atrial flutter or AF, which provokes VF and sudden death. This may be the 1 st manifestation. Estimated as 1/1000 Pt years Risk of S.C.D -4% over a lifetime. (Am. Heart J 1999;138:403-13)

10 Natural history of WPW diagnosed in childhood. Cain et al. Am. J. Cardiol 2013;112: Pts (Pittsburgh Penn)- Mean age 7Y (between ) Median F/U (time of presentation to last clinic F/U or ablation or death) - 3Y. Mode of presentation SVT-38%, Palpitation 22%, Incidental finding 26%, Chest pain-5%, Syncope -4%, A.F -0.4%, Sudden death 0.2%,, Data unavailable-4%. During F/U 54% developed SVT, 1.6% developed AF. 6 sudden death (1.3%)= 2.8 per 1000 Pts years. Normal heart 1.1/1000. Structural heart disease 27/1000.

11 WPW in the era of catheter ablation Insights from a registry study of 2169 Pts Pappone C et al Circ 2014; 130: Y F/U of 2169 WPW Pts (symp+asymp) 1001 (550 asymp) didn t undergo RFA (Pt or referring physician choice), 1168-RFA No clinical or EP differences among the 2 groups. 15/1001 (1.5%) of non RFA Pts experienced VF. 13/15 were children (median age 11Y). 13/15 were asymptomatic. All 15 had APERP<240, 11/15 had inducible AVRT, 5/15 had multiple accessory pathways.

12 WPW in Athletes Should we treat all? SVT AVRT 35-45% Yes for ablation. A.Fib with fast (est. 1/1000) conduction via the A.P. ablation. Yes for Desynchrony Rare (unknown percentage) (usually septal pathways) Yes for ablation. Asymptomatic 55-65% - Yes for risk stratification.

13 Asymptomatic WPW Yes - for risk stratification But How? AHA, HRS guidelines for athletes Holter and/or Exercise test to look for sudden loss of, or intermittent preexcitation. If so Follow with counselling regarding symptom awareness. If persistent preexcitation continue with EPS. ESC guidelines All should have risk assessment by EPS. Risk assessment : APERP, SPERR during A.F

14 Isuprel <22o PACES/HRS 2012 Cohen M et al. Heart Rhythm, Vol 9, No 6, June 2012

15 Intermittent W.P.W

16 Intermittent preexcitation Mah JD, Triedman J et al. PACE 2013; 36: Kiger M.E, Collins K et al. PACE 2016; 39: Pts with IPX had larger APERP than those with PPX, but the incidence of pathways with APERP<250msec was not significantly different. The finding of IPX on a baseline ECG does not rule out potentially high risk pathway. Low negative predictive value.

17 Survey of current practice of Pediatric Electrophysiologists for asymptomatic WPW. Cambell et al Pediatrics 2013 Survey of the Pediatric and Congenital E.P Society (P.A.C.E.S) 43 responding Ped Eps EPS used for risk stratification by 84%.

18 Risk stratification and ablation in pediatric Pts. Campbell Pediatrics 2013

19 Practice survey: Asymptomatic WPW Adults, Europe Svendsen H.S et al Europace centers (EHRA EP research network) surveyed Question: How do you anticipate a Pt with accidentally diagnosed WPW (asymptomatic and without occutational risk) would be treated at your institution. Results are given as percent of responders

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21 Own experience: EP profile of asymptomatic WPW in the pediatric population S.C.M.C.I 183 Pts underwent risk assessment over 12Y. 72/183 (38%) children underwent AP ablation. 10 (14%) were in the high risk group. 47 (65%) were in the inducible SVT group. 15 (21%) were both high risk & had inducible SVT. Among these 72 children, 69 (96%) had successful ablation of the AP.

22 Electrophysiologic profile of asymptomatic WPW syndrome in the Follow up pediatric population During a mean follow up period of 46 months, only one child who did not undergo ablation, developed SVT. None of the children had an episode of syncope, malignant arrhythmia or SCD.

23 Electrophysiologic profile of asymptomatic WPW syndrome in the Conclusion: pediatric population About 40% of asymptomatic WPW children met the high risk criteria for SCD or SVT was inducible during EPS. Ablation of this population is highly successful and safe.

24 2 Final thoughts

25 Long term follow up in adult WPW Higher risk for AF (H.R 3.12) and for heart failure (H.R 2.11) (with Rt anteroseptal pathways). Long term mortality compares to the general population. Skov M. et al- Circ Arrhythm 2017; 10 Higher long term AF (with and without ablation)- Implying mechanism other than those related only to the presence of A.P Long term mortality in adult WPW- low and similar to control. Bunct T.J et al Circ Arrhythm 2015; 8:

26 Which of the following heredetery/congenital causes for sudden cardiac death in athlete can be cured? LQTS SQTS CPVT ARVD HCM DCM WPW Idiopathic VF Anom. coronary origin/course syndrome Marfan

27 WPW in Athlete - Conclusions WPW with SVT or AF with fast conduction or Ventricular dysynchrony > Ablation. Asymptomatic WPW Invasive risk assessment. If high risk or induced AVRT > ablation. If not > Allow all sport and follow. Physician should discuss the upfront risk of an invasive approach Vs a low long-term risk of watchful waiting.

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30 Yes Treatment = Ablation

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36 The Electrophysiological Characteristics of Accessory Pathways in Pediatric Patients with Intermittent Preexcitation Mah D, Triedman et al PACE 2013; 36:

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