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

Treatment of Wolff-Parkinson-White (WPW) Syndrome

Catheter ablation of the accessory pathway is the definitive treatment of choice 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, 2

Acute Management Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Immediate electrical cardioversion is the first-line treatment for patients with WPW who are hemodynamically unstable to prevent ventricular fibrillation 1, 2
• Reanimation equipment should be readily available due to the high risk of developing ventricular fibrillation 2

Hemodynamically Stable Patients

• For patients with pre-excited AF and rapid ventricular response who are hemodynamically stable, 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 1, 2
• Adenosine may be used ONLY when the QRS complex is narrow (<120 ms) during tachycardia, indicating antegrade conduction through the AV node 1, 2

Medications to AVOID in WPW

• Administration of intravenous amiodarone, adenosine, digoxin, or nondihydropyridine calcium channel antagonists in patients with WPW who have pre-excited AF is potentially harmful as these drugs can accelerate the ventricular rate 1, 2
• AV nodal blocking agents (beta-blockers, digoxin, diltiazem, verapamil) must be avoided as they can increase refractoriness of the AV node and encourage preferential conduction over the accessory pathway, potentially leading to ventricular fibrillation 1, 2

Definitive Treatment

• Catheter ablation of the accessory pathway is recommended for all symptomatic patients with WPW syndrome 1, 2
• This is especially important for patients with:
  • Pre-excited AF 1
  • Accessory pathways with short refractory periods (<250 ms) that allow rapid antegrade conduction 1, 2
  • History of syncope 1, 2
  • Multiple accessory pathways (higher risk of ventricular fibrillation) 1

Post-Ablation Management

• After successful catheter ablation, patients typically require a recovery period of approximately 3 months 3
• If no complications or recurrences occur, patients can progressively return to normal activities 3
• After 3 months with no recurrences, most patients can return to all work activities without restrictions 3
• Special consideration is needed for high-risk occupations (pilots, professional drivers), which may require medical clearance 3
• ECG monitoring is recommended to confirm absence of pre-excitation before returning to full work duties 3

Long-term Considerations

• Ablation of the accessory pathway does not always prevent AF, especially in older patients 1, 3
• Patients with a history of AF may require additional pharmacological or ablative therapy even after successful ablation of the accessory pathway 1, 3
• Patients with WPW syndrome have approximately a 15% risk of developing AF over 10 years 1

Pharmacological Options When Ablation Is Not Immediately Available

• Medications that prolong accessory pathway refractory periods (flecainide, propafenone, amiodarone) can prevent rapid accessory pathway conduction 4
• Propafenone reduces conduction and increases the effective refractory period of the accessory pathway in both directions 5