Atrial fibrillation Wolff-Parkinson-White preexcitation syndromes
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Anahita Deylamsalehi, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Varun Kumar, M.B.B.S.
Overview
In up to one-third of patients with Wolff-Parkinson-White syndrome, paroxysmal atrial fibrillation develops. Studies have been demonstrated that Wolff-Parkinson-White syndrome with a left lateral bypass tract has even a higher incidence of atrial fibrillation. On the other hand Wolff-Parkinson-White syndrome patients with right free wall accessory pathway have a lower chance of atrial fibrillation development. Development of atrial fibrillation in a patient with Wolff-Parkinson-White syndrome can result in complications such as syncope, ventricular fibrillation and ultimately sudden death. There are some hypothesized mechanisms for development of paroxysmal atrial fibrillation in patients with Wolff-Parkinson-White syndrome, such as effects of accessory pathways on atrium, spontaneous deterioration of AV reentrant tachycardia (AVRT) into atrial fibrillation and atrial muscle's electrical abnormalities. In hemodynamically stable patients, intravenous procainamide may be administered to convert pre-exited atrial fibrillation to sinus rhythm. Atrial fibrillation associated with a rapid tachycardia due to an accessory pathway may be treated with flecainide that has shown to slower the ventricular rate by prolonging the shortest pre-excited cycle length during atrial fibrillation and hence terminate atrial fibrillation.
Atrial fibrillation in Wolff-Parkinson-White preexcitation syndromes
- The incidence of sudden cardiac death is between 0% and 0.6% in patients with Wolff-Parkinson-White syndrome, particularly those with short antegrade bypass tract refractory periods (less than 250 ms) and short R-R intervals during pre-excited atrial fibrillation (180 plus or minus 29 ms).[1][2][3][4][5][6]
- In up to one-third of patients with Wolff-Parkinson-White syndrome, paroxysmal atrial fibrillation develops, nevertheless the mechanism for this elevated incidence is not completely understood.[7]
- Studies have been demonstrated that Wolff-Parkinson-White syndrome with a left lateral bypass tract has even a higher incidence of double atrial potentials and induced atrial fibrillation. On the other hand Wolff-Parkinson-White syndrome patients with right free wall accessory pathway have a lower chance of atrial fibrillation development.[8][9]
- Development of atrial fibrillation in a patient with Wolff-Parkinson-White syndrome can result in complications such as syncope, ventricular fibrillation and ultimately sudden death.[10]
- The following are some of the hypothesized mechanisms for development of paroxysmal atrial fibrillation in patients with Wolff-Parkinson-White syndrome:[7][11][12]
- Spontaneous deterioration of AV reentrant tachycardia (AVRT) into atrial fibrillation
- Effects of accessory pathways on atrium
- Numerous studies have been reported a decreased incidence of atrial fibrillation in patients who undergone a successful ablation of accessory pathways.
- Possible atrial muscle's electrical abnormalities and increased atrial vulnerability (which is independent of the role that accessory pathways play)
- Since a fraction of patients experience atrial fibrillation even after a successful accessory pathway ablation, it can be concluded that there are other mechanisms independent of accessory pathways that cause atrial fibrillation in Wolff-Parkinson-White syndrome.
- More evaluation with atrial endocardial mapping demonstrated the possibility of atrial diseases (such as intrinsic atrial muscle abnormalities) in patients with Wolff-Parkinson-White syndrome.
- Based on a study done on patients with Wolff-Parkinson-White syndrome with documented or induced atrial fibrillation, effective refractory period of the accessory pathway was correlated with the shortest RR interval and ventricular rate average.
- In hemodynamically stable patients, intravenous procainamide may be administered to convert pre-exited atrial fibrillation to sinus rhythm.[13]
- AV nodal blocking agents such as digoxin, diltiazem, or verapamil are contra-indicated as they increase AV-node refractoriness which could encourage preferential conduction over the accessory pathway.[14]
- Atrial fibrillation associated with a rapid tachycardia due to an accessory pathway may be treated with flecainide that has shown to slower the ventricular rate by prolonging the shortest pre-excited cycle length during atrial fibrillation and hence terminate atrial fibrillation.[15][16][17][18]
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[19]
Wolff-Parkinson-White and Pre-Excitation Syndromes
| Class I |
| "1. Prompt direct-current cardioversion is recommended for patients with atrial fibrillation, Wolff-Parkinson-White syndrome (WPW), and rapid ventricular response who are hemodynamically compromised. (Level of Evidence: C)" |
| "2. Intravenous procainamide or ibutilide to restore sinus rhythm or slow the ventricular rate is recommended for patients with pre-excited atrial fibrillation and rapid ventricular response who are not hemodynamically compromised. (Level of Evidence: C)" |
| "3. Catheter ablation of the accessory pathway is recommended in symptomatic patients with pre-excited atrial fibrillation, especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction. (Level of Evidence: C)" |
| Class III: No Benefit |
| "1. Administration of intravenous amiodarone, adenosine, digoxin (oral or intravenous), or nondihydropyridine calcium antagonists (oral or intravenous) in patients with Wolff-Parkinson-White syndrome (WPW) who have pre-excited atrial fibrillation is potentially harmful as these treatments accelerate the ventricular rate. (Level of Evidence: B)" |
2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[20]
Wolff-Parkinson-White (WPW) Preexcitation Syndromes (DO NOT EDIT) [20]
| Class I |
| "1. Catheter ablation of the accessory pathway is recommended in symptomatic patients with atrial fibrillation who have Wolff-Parkinson-White syndrome (WPW), particularly those with syncope due to rapid heart rate or those with a short bypass tract refractory period. (Level of Evidence: B)" |
| "2. Immediate direct-current cardioversion is recommended to prevent ventricular fibrillation in patients with a short anterograde bypass tract refractory period in whom atrial fibrillation occurs with a rapid ventricular response associated with hemodynamic instability. (Level of Evidence: B)" |
| "3. Intravenous procainamide or ibutilide is recommended to restore sinus rhythm in patients with Wolff-Parkinson-White syndrome (WPW) in whom atrial fibrillation occurs without hemodynamic instability in association with a wide QRS complex on the ECG (greater than or equal to 120-ms duration) or with a rapid pre-excited ventricular response. (Level of Evidence: C)" |
| Class III (Harm) |
| "1. Intravenous administration of digitalis glycosides or nondihydropyridine calcium channel antagonists is not recommended in patients with Wolff-Parkinson-White syndrome (WPW) who have preexcited ventricular activation during atrial fibrillation. (Level of Evidence: B)" |
| Class IIa |
| "1. Intravenous flecainide or direct-current cardioversion is reasonable when very rapid ventricular rates occur in patients with atrial fibrillation involving conduction over an accessory pathway. (Level of Evidence: B)" |
| Class IIb |
| "1. It may be reasonable to administer intravenous quinidine, procainamide, disopyramide, ibutilide, or amiodarone to hemodynamically stable patients with atrial fibrillation involving conduction over an accessory pathway. (Level of Evidence: B)" |
Sources
- 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation [22]
- ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter [23]
References
- ↑ Munger TM, Packer DL, Hammill SC, Feldman BJ, Bailey KR, Ballard DJ et al. (1993) A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989. Circulation 87 (3):866-73. PMID: 8443907
- ↑ Leitch JW, Klein GJ, Yee R, Murdock C (1990) Prognostic value of electrophysiology testing in asymptomatic patients with Wolff-Parkinson-White pattern. Circulation 82 (5):1718-23. PMID: 2225373
- ↑ Soria R, Guize L, Chretien JM, Le Heuzey JY, Lavergne T, Desnos M et al. (1989) [The natural history of 270 cases of Wolff-Parkinson-White syndrome in a survey of the general population.] Arch Mal Coeur Vaiss 82 (3):331-6. PMID: 2502088
- ↑ Flensted-Jensen E (1969) Wolff-Parkinson-White syndrome. A long-term follow-up of 47 cases. Acta Med Scand 186 (1-2):65-74. PMID: 5807647
- ↑ Klein GJ, Bashore TM, Sellers TD, Pritchett EL, Smith WM, Gallagher JJ (1979) Ventricular fibrillation in the Wolff-Parkinson-White syndrome. N Engl J Med 301 (20):1080-5. DOI:10.1056/NEJM197911153012003 PMID: 492252
- ↑ Zardini M, Yee R, Thakur RK, Klein GJ (1994) Risk of sudden arrhythmic death in the Wolff-Parkinson-White syndrome: current perspectives. Pacing Clin Electrophysiol 17 (5 Pt 1):966-75. PMID: 7517532
- ↑ 7.0 7.1 Centurión OA, Shimizu A, Isomoto S, Konoe A (2008). "Mechanisms for the genesis of paroxysmal atrial fibrillation in the Wolff Parkinson-White syndrome: intrinsic atrial muscle vulnerability vs. electrophysiological properties of the accessory pathway". Europace. 10 (3): 294–302. doi:10.1093/europace/eun031. PMID 18308751.
- ↑ Hsieh MH, Tai CT, Chiang CE, Tsai CF, Chen YJ, Chan P; et al. (2004). "Double atrial potentials recorded in the coronary sinus in patients with Wolff-Parkinson-White syndrome: a possible mechanism of induced atrial fibrillation". J Interv Card Electrophysiol. 11 (2): 97–103. doi:10.1023/B:JICE.0000042347.27095.b4. PMID 15383772.
- ↑ Della Bella P, Brugada P, Talajic M, Lemery R, Torner P, Lezaun R; et al. (1991). "Atrial fibrillation in patients with an accessory pathway: importance of the conduction properties of the accessory pathway". J Am Coll Cardiol. 17 (6): 1352–6. doi:10.1016/s0735-1097(10)80146-9. PMID 2016453.
- ↑ Pietersen AH, Andersen ED, Sandøe E (1992). "Atrial fibrillation in the Wolff-Parkinson-White syndrome". Am J Cardiol. 70 (5): 38A–43A. doi:10.1016/0002-9149(92)91076-g. PMID 1509997.
- ↑ Konoe A, Fukatani M, Tanigawa M, Isomoto S, Kadena M, Sakamoto T; et al. (1992). "Electrophysiological abnormalities of the atrial muscle in patients with manifest Wolff-Parkinson-White syndrome associated with paroxysmal atrial fibrillation". Pacing Clin Electrophysiol. 15 (7): 1040–52. doi:10.1111/j.1540-8159.1992.tb03098.x. PMID 1378596.
- ↑ Zhang Y, Wang L (2006). "Atrial vulnerability is a major mechanism of paroxysmal atrial fibrillation in patients with Wolff-Parkinson-White syndrome". Med Hypotheses. 67 (6): 1345–7. doi:10.1016/j.mehy.2006.02.053. PMID 16697118.
- ↑ Boahene KA, Klein GJ, Yee R, Sharma AD, Fujimura O (1990). "Termination of acute atrial fibrillation in the Wolff-Parkinson-White syndrome by procainamide and propafenone: importance of atrial fibrillatory cycle length". J Am Coll Cardiol. 16 (6): 1408–14. doi:10.1016/0735-1097(90)90384-2. PMID 2229793.
- ↑ Jacob AS, Nielsen DH, Gianelly RE (1985). "Fatal ventricular fibrillation following verapamil in Wolff-Parkinson-White syndrome with atrial fibrillation". Ann Emerg Med. 14 (2): 159–60. doi:10.1016/s0196-0644(85)81080-5. PMID 3970402.
- ↑ Kappenberger LJ, Fromer MA, Shenasa M, Gloor HO (1985) Evaluation of flecainide acetate in rapid atrial fibrillation complicating Wolff-Parkinson-White syndrome. Clin Cardiol 8 (6):321-6. PMID: 4006340
- ↑ Kim SS, Smith P, Ruffy R (1988) Treatment of atrial tachyarrhythmias and preexcitation syndrome with flecainide acetate. Am J Cardiol 62 (6):29D-34D. PMID: 3136632
- ↑ Crijns HJ, den Heijer P, van Wijk LM, Lie KI (1988) Successful use of flecainide in atrial fibrillation with rapid ventricular rate in the Wolff-Parkinson-White syndrome. Am Heart J 115 (6):1317-21. PMID: 3132032
- ↑ O'Nunain S, Garratt CJ, Linker NJ, Gill J, Ward DE, Camm AJ (1991) A comparison of intravenous propafenone and flecainide in the treatment of tachycardias associated with the Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol 14 (11 Pt 2):2028-34. PMID: 1721219
- ↑ January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.
- ↑ 20.0 20.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA; et al. (2011). "2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". J Am Coll Cardiol. 57 (11): e101–98. doi:10.1016/j.jacc.2010.09.013. PMID 21392637.
- ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
- ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
- ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199