Wolff - Parkinson - White Syndrome

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Wolff - Parkinson - White Syndrome

  1. 1. Wolff-Parkinson-White Syndrome Yen-Bin Liu, 2013 March Y.B. Liu
  2. 2. Outline• General consideration of SVT• WPW and accessory pathway• Catheter ablation of accessory pathway• Multiple accessory pathway• Special considerations in WPW and AVRT• Issue not covered in today’s talk Y.B. Liu
  3. 3. General consideration of SVT Y.B. Liu
  4. 4. Y.B. Liu
  5. 5. (AVNRT) (decremental AP) (fast-slow) (slow-intermediate) Y.B. Liu
  6. 6. Esophageal Lead Y.B. Liu
  7. 7. SVT v.s. AV conduction Y.B. Liu
  8. 8. (macro-reentry) Y.B. Liu
  9. 9. Wide QRS tachycardia ( >120 ms)• SVT with BBB• Antidromic AVRT• SVT (AT, AVNRT, orthodromic AVRT, AFL, AF) with bystander manifest AP• BBB reentry tachycardia• VT Y.B. Liu
  10. 10. WPW and accessory pathway Y.B. Liu
  11. 11. Pre-excitation Y.B. Liu
  12. 12. Re-entry • Dural pathway • Slow conduction zone • Unidirectional block Y.B. Liu
  13. 13. Tachycardia associated with AP95% 5-10%1/3 Y.B. Liu
  14. 14. Incidence• Overall incidence of accessory pathway (AP) – 0.1-0.3% of general population• First-degreee relatives of patients with AP – 0.55%• Incidence of multiple APs – 3-20% in surgical series – 5-18% in RFCA series Y.B. Liu
  15. 15. Classification of Accessory Pathway• Anatomy: – Left (mitral annulus) vs. right (tricuspid annulus)• Electrophysiology: – Decremental vs. nondecremental – 8% of AP with decremental characteristics• Direction: Anterograde vs. retrograde – Concealed: retrograde conduction only – Manifest: bi-directional conduction (* anterograde only: uncommon) Y.B. Liu
  16. 16. Anatomy of Accessory Pathway Y.B. Liu
  17. 17. Anterograde vs. Retrograde Y.B. Liu
  18. 18. Decremental vs. nondecremental Y.B. Liu
  19. 19. Intermittent Pre-excitation• Weakness of accessory pathway conduction• Strengthen of AV nodal conduction Y.B. Liu
  20. 20. WPW syndromeThe diagnosis of WPW syndrome isreserved for patients who have bothpre-excitation and tachyarrhythmias. ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias; 2003 Y.B. Liu
  21. 21. WPW,type A &B Y.B. Liu
  22. 22. Localization of AccessoryPathway in WPW syndrome • Transition zone • R in lead I • Positive or Negative vector of delta wave in II, III, aVF [PACE 1995; 18: 1469-1473] Y.B. Liu
  23. 23. Localization of Accessory Pathway in WPW syndromeCardiovasc Electrophysiol. 1998;9:2-12 Y.B. Liu
  24. 24. Left lateral accessory pathway Y.B. Liu
  25. 25. Right free wall accessory pathway Y.B. Liu
  26. 26. Right anteroseptal accessory pathway Y.B. Liu
  27. 27. Left posteroseptal accessory pathway Y.B. Liu
  28. 28. Localization of AP by retrograde P wave during AVRT Anterior Anterior III. aVF (+) anterior anterior Lateral Lateral lateral lateral poterior poterior J Am Coll Cardiol Poterior III. aVF (-) Poterior 1997;29:394–402J Interv CardElectrophysiol (2008)22:55–63 Y.B. Liu
  29. 29. Catheter ablation of accessory pathway Y.B. Liu
  30. 30. Intracardiac ECG for Localization of AP • Localization of AV rings • AV fusion: anterograde and retrograde • VA interval, HH interval, HA time • Zone of transition –Pattern of initiation and termination –VEST or VPC during SVT –BBB during SVT –AV block during SVT Y.B. Liu
  31. 31. Localization of AV rings Y.B. Liu
  32. 32. Example: Ablation siteRAO view LAO view Y.B. Liu
  33. 33. AV fusion: anterograde Y.B. Liu
  34. 34. AV fusion: Retrograde Y.B. Liu
  35. 35. Decremental Accessory Pathway Y.B. Liu
  36. 36. Pattern of initiation Y.B. Liu
  37. 37. Pattern of termination Y.B. Liu
  38. 38. Ventricular extra-stimulus Reset Tachycardiaduring His-refractoriness Y.B. Liu
  39. 39. BBB during SVT Y.B. Liu
  40. 40. Y.B. Liu
  41. 41. Y.B. Liu
  42. 42. Antidromic AVRT Y.B. Liu
  43. 43. WPW with Atrial Fibrillation Y.B. Liu
  44. 44. WPW with Atrial Fibrillation Y.B. Liu
  45. 45. Endpoints of accessory pathway ablation • Atrial pacing: – No pre-excitation – AV nodal decremental conduction (AH prolongation in AEST) • Ventricular pacing: – Total VA block OR – VA nodal decremental conduction (be sure site of Cs orifice and no SVT inducible) Y.B. Liu
  46. 46. Endpoint of RFCA Y.B. Liu
  47. 47. Endpoint of RFCA Y.B. Liu
  48. 48. Causes of failed ablation of accessroy pathway Y.B. Liu
  49. 49. RFCA in WPW•約有93-95% (87-99%)的成功率,而復發率則 約為7% (0-11%) 。•手術的併發症發生率約為1-4%,主要和手術傷 口、電極導管的操作或高頻波的燒灼有關,約 有1%的機會發生心房室傳導阻斷,但會因RFCA 而發生致命性併發症的機率則很低 (<0.2%)。•對AVRT而言,RFCA的成功率和復發率取決於是 否能精準的定位accessory pathway並加以燒 灼移除,因此,手術的結果和手術者的經驗十 分相關,而和病人的年齡則無明顯的關聯。 Y.B. Liu
  50. 50. Multiple accessory pathway Y.B. Liu
  51. 51. Definition of multiple accessory pathway • APs separated by 1-3 cm • Multistranded or broad-banded bypass tracts as wide as 3 cm had been reported Y.B. Liu
  52. 52. Oblique accessory pathway Y.B. Liu
  53. 53. ECG Clues to Multiple APs• Variations in pre-excited QRS morphology (esp. during A fib.)• Atypical patterns of pre-excitation• Antidromic AVRT using a posterior septal AP• Orthodromic AVRT with changing retrograde P wave morphology• Antidromic AVRT with varying degrees of antegrade fusion Y.B. Liu
  54. 54. Variations in pre-excitation Y.B. Liu
  55. 55. Variations in pre-excitation Y.B. Liu
  56. 56. Variations in pre-excitation Y.B. Liu
  57. 57. Atypical patterns of pre-excitation Y.B. Liu
  58. 58. EP Evidence of Multiple APs• Chang in pre-excited morphology at different pacing cycle length and sites• Differing pattern of antegrade and retrogade conduction• Varying patterns of retrograde atrial activation sequence during AVRT or V pacing or from orthodromic to antidromic AVRT• Appearance of an AP after AAD or ablation Y.B. Liu
  59. 59. Differing pattern of antegrade andretrogade conduction Y.B. Liu
  60. 60. Appearance of an AP after Ablation Y.B. Liu
  61. 61. Varying patterns of retrograde atrialactivation sequence Y.B. Liu
  62. 62. Distribution• R. free wall AP +R. posteroseptal AP (manifest > concealed about 2: 1)• 2 L. free wall (concealed > manifest) Y.B. Liu
  63. 63. Arrhythmias associated with multiple APs • Orthodromic AVRT • Antidromic AVRT – 33% vs. 6% • Atrial fibrillation – More clinical AF – More induced AF – More AF after RV pacing and AVRT • AP as a bystander Sudden death? Y.B. Liu
  64. 64. RFCA in multiple APs• Longer procedure time• Greater radiation time• Higher recurrent rate – per patient – per APDual AV nodal pathway, 10-20% – Only 1 patient develop AVNRT Y.B. Liu
  65. 65. Special considerations in WPW and AVRT Y.B. Liu
  66. 66. WPW v.s. Sudden Death Y.B. Liu
  67. 67. WPW and Sudden Cardiac Death• 0.15% to 0.39% over 3 to 10 yr follow-up• In case with SCD, half of them is the first manifestation of WPW• Risk factors: –Shortest pre-excited RR<250 ms –Symptomatic tachycardia –Multiple APs –Ebstein’s anomaly –Familial WPW Y.B. Liu
  68. 68. Pharmacological Treatment of WPW Y.B. Liu
  69. 69. Pharmacological Treatment of WPW • Pre-excited tachycardia – Adenosine used with caution – Verapamil, diltiazem, digoxin: Class III • Long-term therapy – Propafenon: 69% effective; side effects:25% – Sotalol – Amiodarone: not superior to other AAD – Single use of verapamil, diltiazem, digoxin: not recommended • Pill-in-the-Pocket – Diltiazem 120 mg + propranolol 80 mg – 32 ± 22 min Y.B. Liu
  70. 70. PSVT during Pregnancy Y.B. Liu
  71. 71. RFCA in Asymptomatic WPW但WPW發生心臟猝死猝死的比例並不高 (約0.15%),而RFCA也的確會有約2%的手術的併發症發生率,因此對於預防性的RFCA治療宜用於特定高危險群之病人,似乎尚未有足夠的證據支持將其列為常規性的治療。在北美心律學會,把RFCA在無症狀的WPW病人治療適應症列為Class III。 Y.B. Liu
  72. 72. Issue NOT covered in today’s talk Y.B. Liu
  73. 73. Unusual connection Y.B. Liu
  74. 74. Unusual connection: Mahaim fiberThe true Mahaim fiber is the nodofascicular or nodoventricular connection faithfulto the original pathologic description. Over time, the term became a genericdescription for any pathway with slow decremental conduction properties. Y.B. Liu
  75. 75. Unusual location: Epicardial AP With or without diverticulum in coronary veins Y.B. Liu
  76. 76. Thank you for your attention ! Y.B. Liu

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