Scenario Rounds - Wolff Parkinson White Syndrome

What to do with symptomatic patients? (ACC Guidelines on ablation, ACC Guidelines on the management of supraventricular tachycardia)

AVRT is the most common arrythmia seen in WPW.

• If you've had sudden death -- you need an ablation.
• If your refractory period is short (less than 240ms) you should consider an ablation to prevent sudden death.
• Risk of cardiac death is about 0.25% per year or 3-4% over lifetime, with the majority of the risk in patients with refractory periods of the accessory pathway that are less than 220ms.

• Success of ablatation approaches 95% with ~ 5% recurrance rate.
  
  • Risk of major complications is ~ 2% including:
    
    • complete heart block 0.2-1%
    • tamponade 0.3-1%
    • stroke 0.2-0.5%
      
    • death 1-2 per 1000.

What to do with asymptomatic patients with WPW on ECG?

Low risk for sudden death is seen in patients who lose the conduction via the accessory pathway during exercise (or stress), patients with intermittant pre-excitation (comes and goes), and patients who stop conducting down the accessory pathway when given a dose of procainamide. Low risk patients should receive a copy of their ECG with diagnosis and should be managed expectantly.

Patients without low risk features should be considered for EP study, and if high risk features on EP study are found should be considered for ablation, depending on age, gender, occupation, athletic lifestyle.

NB: One of the earlier publications, by Wolff, is available here.