What is the management of Wolff-Parkinson-White (WPW) syndrome?

Management of Wolff-Parkinson-White (WPW) Syndrome

Catheter ablation of the accessory pathway is the first-line therapy for symptomatic patients with WPW syndrome, particularly those with syncope due to rapid heart rate or those with a short bypass tract refractory period. 1

Acute Management of WPW with Atrial Fibrillation

Hemodynamically Unstable Patients

• Immediate electrical cardioversion is required to prevent ventricular fibrillation in patients with WPW who develop AF with rapid ventricular response causing hemodynamic instability 1

Hemodynamically Stable Patients

• For patients with pre-excited AF (wide QRS complex ≥120 ms) without hemodynamic instability:
  • Intravenous procainamide or ibutilide to restore sinus rhythm 1
  • Intravenous flecainide may be reasonable when very rapid ventricular rates occur 1
  • Consider intravenous quinidine, disopyramide, or amiodarone in stable patients 1

Contraindicated Medications

• AVOID the following medications in patients with WPW and pre-excited AF as they can accelerate ventricular rate and precipitate ventricular fibrillation 1:
  • AV nodal blocking agents (digoxin)
  • Beta-blockers
  • Calcium channel blockers (diltiazem, verapamil)
  • Adenosine

Definitive Management

Symptomatic Patients

1. Catheter ablation of accessory pathway - success rates >95% with low complication rates 2, 3

   • First-line therapy for symptomatic patients
   • Particularly indicated for:
     • Patients with syncope due to rapid heart rate
     • Patients with short bypass tract refractory period
     • Patients with documented AF

2. Factors associated with challenging ablation procedures 3:

   • Multiple accessory pathways (14.9× higher risk of recurrence)
   • Parahisian location (10.1× higher risk)
   • Broad accessory pathways (6.9× higher risk)

Asymptomatic Patients with WPW Pattern

• Consider electrophysiological risk stratification for:
  • High-risk occupations (pilots, professional athletes)
  • Those who cannot tolerate even a small risk of sudden death
  • Patients with short pre-excitation R-R intervals during AF (<250 ms) 1

Special Considerations

Risk Factors for Sudden Death in WPW

• Short antegrade bypass tract refractory periods (<250 ms) 1
• Short R-R intervals during pre-excited AF 1
• Multiple accessory pathways 1, 3

Surgical Ablation

• Reserved for cases where catheter ablation has failed or is not feasible 4
• Mortality rates 0-1.5% in experienced centers 5

Post-Ablation Care

• Monitor for recurrence, especially within first 36 hours (most common period for recurrence) 3
• Long-term success rates approach 98.5% after repeat procedures if needed 3
• Major complications occur in approximately 0.6% of procedures 3

Management Algorithm

1. Diagnosis confirmation: ECG showing pre-excitation (short PR interval, delta wave, wide QRS)
2. Risk stratification: Assess for history of syncope, palpitations, or documented arrhythmias
3. For symptomatic patients: Proceed directly to catheter ablation
4. For asymptomatic patients: Consider electrophysiologic study for risk assessment
5. For acute AF with pre-excitation:
   • If unstable: Immediate cardioversion
   • If stable: IV procainamide or ibutilide
   • AVOID AV nodal blocking agents

The management of WPW syndrome has evolved significantly, with catheter ablation now firmly established as the definitive treatment with high success and low complication rates, making it the preferred approach for reducing morbidity, mortality, and improving quality of life 2, 6.