Long term risk of Wolff-Parkinson-White pattern and syndrome

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Abstract

For years, conventional wisdom has held that patients with asymptomatic ventricular pre-excitation (asymptomatic WPW or WPW pattern) were at low risk for adverse outcomes. This assumption has been challenged more recently in a number of observational/natural history studies as well as in prospective trials in which patients were more aggressively studied via invasive electrophysiology study (EPS) and more aggressively treated, in some cases, with pre-emptive catheter ablation, despite the lack of symptoms. In sum, the data do not definitively support one approach (early, up-stream EPS and/or ablation) vs. the other (watchful waiting with close monitoring). The most recent pediatric and adult guidelines reflect this ambiguity with a broad spectrum of approaches endorsed.

Introduction

In 1921, a phenomenon of “intraventricular block and a PR interval of 0.08 ms” in a 19 year-old patient with paroxysms of tachycardia was described by Wedd [1]. In 1930, Louis Wolff, MD; John Parkinson, MD; and Paul D. White, MD described a set of eleven patients with “Bundle-Branch Block with Short P-R Interval in Healthy young People Prone to Paroxysmal Tachycardia” [2]. Thus began our understanding of ventricular pre-excitation. Though a century has passed, our understanding of what is ventricular pre-excitation and the WPW syndrome is still incomplete. While ventricular pre-excitation or the WPW pattern on ECG is not uncommon with an prevalence of up to 0.1–0.3%, [3] a complete understanding of the long-term risk in patients with the WPW pattern vs. the WPW syndrome has not been reached. This review will attempt to summarize our understanding of prognosis to date and outline areas that would benefit from further clarification.

Section snippets

Terminology and pathophysiology

Two terms, the “WPW pattern” and the “WPW syndrome” are often used when describing patients with ventricular pre-excitation (Fig. 1, Panels A and B). The “WPW pattern” refers to ventricular pre-excitation seen on surface ECG while the “WPW syndrome” refers to the presence of ventricular pre-excitation on surface ECG plus the presence of symptoms suggestive of arrhythmia related to the pre-excitation, such as palpitations, episodic lightheadedness, pre-syncope, syncope, or cardiac arrest

Conclusion

The risk of cardiac arrest in patients with WPW pattern (ventricular pre-excitation without symptoms) is very low and the risk of death is even lower, with the rate of cardiac arrest ranging from 0.85 to 1.5 per 1000 patient years. This low risk must be weighed against the risk of EPS and AP ablation when contemplating management of these patients (complication rates were 3.00% in one study, including one patient with complete heart block; 4.09% when including patients with new RBBB and LBBB

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