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Overview
Wolff-Parkinson’s white syndrome is considered a congenital abnormality that is associated with abnormal conductivity between the atria and the ventricles, creating a preexcitation syndrome. It is characterized by the presence of an electrical “accessory pathway” that connects the atria and ventricles and bypasses the AV node. Symptoms vary from mild palpitations to syncope, presyncope, or even cardiac arrest and sudden cardiac death.
Treatment of acute symptomatic Arrhythmia
The treatment of choice for symptomatic patients is catheter-based radiofrequency ablation. This is due to its high success rate and low-risk profile, but cryoablation can also be utilized.
Some patients might require initial pharmacological therapy for rate control or for restoring normal sinus rhythm. This approach to rate control should be done cautiously since there are electrophysiological changes between AV nodal tissue and accessory pathway tissue, and when used for patients with tachycardia involving accessory pathways, it might lead to a worsening of symptoms.
An initial assessment should be done for all patients with tachycardia, especially if the involvement of an accessory pathway is suspected. Treatment is initiated based on the patient's hemodynamic stability, and the approach is done as follows; evaluation and treatment based on arrhythmia type in stable patients, whereas hemodynamically unstable patients who present with hypotension, altered mental status, shock signs, ischemic chest discomfort, or acute heart failure should undergo urgent electrical cardioversion or defibrillation.
Orthodromic atrioventricular reciprocating tachycardia (AVRT)
A step-wise approach is usually applied. Vagal maneuvers (Valsalva maneuver, carotid sinus massage) are the initial interventions and are capable of causing AV node block and terminating tachycardia in many patients.
If medications were not effective, pharmacological therapy should be initiated:
For permanent junctional reciprocating tachycardia (PJRT) caused by slowly conducting accessory pathways, ablation of the accessory pathway is the preferred approach. However, if the patient presents with an acute symptomatic PJRT, treatment can be initiated similarly to that of conventional orthodromic AVRT:
Antidromic AVTR
If suspected AVTR is strictly regular and monomorphic: adenosine can be tried. Treatment failure can suggest a second accessory pathway; in such cases, procainamide or amiodarone should be considered.
For most suspected or known AVTR: procainamide is the agent of choice.
For undiagnosed wide complex tachycardia: in patients with uncertain diagnosis and etiology, ventricular tachycardia should be assumed, and patients can be treated accordingly.
AFIB with preexitation
Prevention of recurrent Arrhythmia
1. Catheter ablation is preferred over pharmacological therapy in symptomatic patients with accessory pathways who have orthodromic AVRT, antidromic AVRT, and are excited AF or atrial flutter, whereas surgical ablation is less preferred unless the patient is highly symptomatic, hemodynamically unstable, has a drug-refractory arrhythmia, and radiofrequency ablation has failed.
Indications of ablation:
2. Medical therapy
References
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