From the Guidelines
Catheter ablation of the accessory pathway is the recommended treatment for symptomatic patients with Wolff-Parkinson-White (WPW) syndrome, especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction 1. For patients with WPW syndrome and atrial fibrillation (AF), the management strategy depends on the presence of hemodynamic compromise.
- For hemodynamically compromised patients, prompt direct-current cardioversion is recommended to restore sinus rhythm and prevent further deterioration 1.
- For patients who are not hemodynamically compromised, intravenous procainamide or ibutilide can be used to restore sinus rhythm or slow the ventricular rate 1. It is essential to note that patients with WPW syndrome should avoid medications that exclusively block the AV node, as these can potentially accelerate conduction through the accessory pathway during atrial fibrillation, leading to ventricular fibrillation. In terms of long-term management, catheter ablation is a highly effective treatment option for symptomatic patients with WPW syndrome, with success rates exceeding 95% 1. The choice of treatment should be individualized based on the patient's symptoms, risk factors, and the presence of any underlying heart disease.
- Asymptomatic patients with incidentally discovered WPW pattern may not require treatment but should undergo risk stratification to assess for potential sudden cardiac death risk.
- For acute management of tachycardia episodes, vagal maneuvers like the Valsalva maneuver may terminate the arrhythmia, and if these fail, intravenous adenosine can be used for diagnosis and potential termination.
From the FDA Drug Label
In patients with Wolff-Parkinson-White (WPW) syndrome, propafenone reduces conduction and increases the effective refractory period of the accessory pathway in both directions
- Propafenone can be used to treat WPW syndrome by reducing conduction and increasing the effective refractory period of the accessory pathway.
- The effective refractory period of the accessory pathway is increased in both directions, which can help to prevent arrhythmias.
- Propafenone slows conduction and consequently produces dose-related changes in the PR interval and QRS duration 2
From the Research
WPW Treatment Overview
- WPW syndrome is a condition where an accessory electrical pathway in the heart causes rapid heart rhythms, leading to symptoms such as palpitations and shortness of breath.
- Treatment options for WPW syndrome include medical therapy, surgical ablation, and catheter ablation 3.
Medical Therapy
- Medications that prolong accessory pathway refractory periods, such as flecainide, propafenone, and amiodarone, can prevent rapid anterograde conduction in atrial tachycardias 3.
- Adenosine can be used to terminate atrioventricular reciprocating tachycardias (AVRTs) in emergencies 3.
- Class IA or IC antiarrhythmic agents can be used to slow accessory pathway conduction, either with or without AV nodal blocking agents 3.
Catheter Ablation
- Catheter ablation is a minimally invasive procedure that uses radiofrequency energy to destroy the accessory electrical pathway 3, 4, 5, 6, 7.
- Catheter ablation is considered the first-line treatment for symptomatic WPW syndrome, with a high success rate and low complication rate 4, 5, 6, 7.
- The success rate of catheter ablation for WPW syndrome is around 94.1%, with a recurrence rate of 6.2% and a complication rate of 1% 7.
Surgical Ablation
- Surgical ablation involves open-chest surgery to destroy the accessory electrical pathway 3.
- Surgical ablation is typically reserved for patients who are not candidates for catheter ablation or who have undergone unsuccessful catheter ablation 3.
Patient Selection for Catheter Ablation
- Catheter ablation is recommended for symptomatic patients with WPW syndrome 4, 5, 6, 7.
- Asymptomatic patients with WPW syndrome may be considered for catheter ablation if they are at high risk of developing symptomatic arrhythmias or if they have a high-risk occupation 4.
- Patients with multiple, parahisian, or broad accessory pathways are at higher risk of recurrence after catheter ablation 6.