Wolff - Parkinson - White Syndrome
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  • 1. Wolff-Parkinson-White Syndrome Yen-Bin Liu, 2013 March Y.B. Liu
  • 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. General consideration of SVT Y.B. Liu
  • 4. Y.B. Liu
  • 5. (AVNRT) (decremental AP) (fast-slow) (slow-intermediate) Y.B. Liu
  • 6. Esophageal Lead Y.B. Liu
  • 7. SVT v.s. AV conduction Y.B. Liu
  • 8. (macro-reentry) Y.B. Liu
  • 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. WPW and accessory pathway Y.B. Liu
  • 11. Pre-excitation Y.B. Liu
  • 12. Re-entry • Dural pathway • Slow conduction zone • Unidirectional block Y.B. Liu
  • 13. Tachycardia associated with AP95% 5-10%1/3 Y.B. Liu
  • 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. 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. Anatomy of Accessory Pathway Y.B. Liu
  • 17. Anterograde vs. Retrograde Y.B. Liu
  • 18. Decremental vs. nondecremental Y.B. Liu
  • 19. Intermittent Pre-excitation• Weakness of accessory pathway conduction• Strengthen of AV nodal conduction Y.B. Liu
  • 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. WPW,type A &B Y.B. Liu
  • 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. Localization of Accessory Pathway in WPW syndromeCardiovasc Electrophysiol. 1998;9:2-12 Y.B. Liu
  • 24. Left lateral accessory pathway Y.B. Liu
  • 25. Right free wall accessory pathway Y.B. Liu
  • 26. Right anteroseptal accessory pathway Y.B. Liu
  • 27. Left posteroseptal accessory pathway Y.B. Liu
  • 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. Catheter ablation of accessory pathway Y.B. Liu
  • 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. Localization of AV rings Y.B. Liu
  • 32. Example: Ablation siteRAO view LAO view Y.B. Liu
  • 33. AV fusion: anterograde Y.B. Liu
  • 34. AV fusion: Retrograde Y.B. Liu
  • 35. Decremental Accessory Pathway Y.B. Liu
  • 36. Pattern of initiation Y.B. Liu
  • 37. Pattern of termination Y.B. Liu
  • 38. Ventricular extra-stimulus Reset Tachycardiaduring His-refractoriness Y.B. Liu
  • 39. BBB during SVT Y.B. Liu
  • 40. Y.B. Liu
  • 41. Y.B. Liu
  • 42. Antidromic AVRT Y.B. Liu
  • 43. WPW with Atrial Fibrillation Y.B. Liu
  • 44. WPW with Atrial Fibrillation Y.B. Liu
  • 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. Endpoint of RFCA Y.B. Liu
  • 47. Endpoint of RFCA Y.B. Liu
  • 48. Causes of failed ablation of accessroy pathway Y.B. Liu
  • 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. Multiple accessory pathway Y.B. Liu
  • 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. Oblique accessory pathway Y.B. Liu
  • 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. Variations in pre-excitation Y.B. Liu
  • 55. Variations in pre-excitation Y.B. Liu
  • 56. Variations in pre-excitation Y.B. Liu
  • 57. Atypical patterns of pre-excitation Y.B. Liu
  • 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. Differing pattern of antegrade andretrogade conduction Y.B. Liu
  • 60. Appearance of an AP after Ablation Y.B. Liu
  • 61. Varying patterns of retrograde atrialactivation sequence Y.B. Liu
  • 62. Distribution• R. free wall AP +R. posteroseptal AP (manifest > concealed about 2: 1)• 2 L. free wall (concealed > manifest) Y.B. Liu
  • 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. 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. Special considerations in WPW and AVRT Y.B. Liu
  • 66. WPW v.s. Sudden Death Y.B. Liu
  • 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. Pharmacological Treatment of WPW Y.B. Liu
  • 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. PSVT during Pregnancy Y.B. Liu
  • 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. Issue NOT covered in today’s talk Y.B. Liu
  • 73. Unusual connection Y.B. Liu
  • 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. Unusual location: Epicardial AP With or without diverticulum in coronary veins Y.B. Liu
  • 76. Thank you for your attention ! Y.B. Liu