What is the treatment for Wolff-Parkinson-White (WPW) syndrome?

Treatment for Wolff-Parkinson-White Syndrome

The definitive treatment for symptomatic Wolff-Parkinson-White syndrome is catheter ablation of the accessory pathway, which is highly effective and should be considered first-line therapy for symptomatic patients, particularly those with syncope due to rapid heart rate or those with a short bypass tract refractory period. 1

Acute Management Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Immediate electrical cardioversion is the treatment of first choice for patients with WPW syndrome who present with AF and rapid ventricular response causing hemodynamic instability 1, 2
• Reanimation equipment should be readily available due to the high risk of ventricular fibrillation in these patients 2

Hemodynamically Stable Patients

• For hemodynamically stable patients with pre-excited AF and rapid ventricular response, intravenous procainamide or ibutilide is recommended to restore sinus rhythm or slow the ventricular rate 1, 2
• Alternative medications for stable patients include intravenous quinidine, disopyramide, or amiodarone (Class IIb recommendation) 1, 2
• Propafenone may be considered as it reduces conduction and increases the effective refractory period of the accessory pathway in both directions 3, 4

Medications to AVOID

• NEVER administer AV nodal blocking agents in patients with WPW syndrome who have pre-excited AF 1, 2
• Specifically contraindicated medications include:
  • Beta-blockers 1, 2
  • Digoxin 1, 2
  • Diltiazem or verapamil 1, 2
  • Adenosine (when QRS complex is wide) 1, 2
• These medications can increase the refractoriness of the AV node, encouraging preferential conduction over the accessory pathway, potentially accelerating the ventricular rate and precipitating ventricular fibrillation 1, 2

Definitive Treatment

• Catheter ablation of the accessory pathway is the treatment of choice for symptomatic patients with WPW syndrome 1, 2, 5
• Success rates for catheter ablation are very high (>95%) with low complication rates 5, 4
• Ablation is particularly indicated in:
  • Patients with documented symptomatic arrhythmias 1, 2
  • Those with syncope due to rapid heart rates 1
  • Patients with accessory pathways having short refractory periods (<250 ms) 2, 6

Special Considerations

• Adenosine may be used only when the QRS complex during tachycardia is narrow (<120 ms), indicating anterograde conduction through the AV node 1, 2
• For regular supraventricular (reciprocating) tachycardia with narrow QRS complexes in WPW patients, propranolol may be effective 7
• In emergency situations with life-threatening arrhythmias not responding to medications, immediate DC cardioversion should be performed 7
• For asymptomatic patients with incidentally discovered WPW pattern, risk stratification with electrophysiological study may be considered, especially for individuals in high-risk occupations 5

Long-term Management

• For patients who are not candidates for catheter ablation, long-term antiarrhythmic therapy with Class IC agents (flecainide, propafenone) or amiodarone may be considered 4, 7
• Surgical ablation is now rarely performed but may be considered in cases where catheter ablation has failed or is not feasible 4, 8

WPW syndrome requires careful management due to the risk of sudden cardiac death from rapidly conducted atrial fibrillation. The treatment approach should be guided by the patient's hemodynamic status, with catheter ablation being the definitive therapy for symptomatic patients.