Treatment of Recurrent Wolff-Parkinson-White Syndrome
Catheter ablation of the accessory pathway is the definitive first-line treatment for recurrent WPW syndrome, with success rates exceeding 95% and should be performed at experienced centers. 1
Why Catheter Ablation is the Treatment of Choice
Catheter ablation eliminates the substrate for recurrent arrhythmias and avoids the need for lifelong antiarrhythmic drug therapy, making it the preferred definitive therapy for symptomatic patients with recurrent episodes 1
The procedure achieves primary success rates of 88-95%, with final success rates reaching 93-98.5% after repeat procedures if needed 1
After successful ablation, no patients developed malignant atrial fibrillation or ventricular fibrillation over 8 years of follow-up 1
The complication rate is remarkably low at <1-2% in experienced centers, with permanent AV block being the most serious concern 1
Indications for Catheter Ablation
Ablation is mandatory for the following patient groups 1:
- All symptomatic patients with documented arrhythmias
- Patients with syncope due to rapid heart rate
- Those with short bypass tract refractory period (<250 ms between pre-excited beats during atrial fibrillation)
- Documented atrial fibrillation with WPW pattern
Managing Acute Recurrent Episodes
Hemodynamically Unstable Patients
- Immediate direct-current cardioversion is the Class I intervention to prevent ventricular fibrillation in any patient presenting with hemodynamic compromise 1, 2
Hemodynamically Stable Patients with Pre-excited Atrial Fibrillation
Intravenous procainamide or ibutilide are first-line pharmacological therapies (Class I recommendation) for stable patients with wide complex irregular rhythm (QRS ≥120 ms) 1, 2
Alternative options include IV flecainide (Class IIa) or IV quinidine, disopyramide, or amiodarone (Class IIb) 2
Critical Medications to Avoid
Never administer AV nodal blocking agents in patients with pre-excited atrial fibrillation, as these can accelerate conduction through the accessory pathway and precipitate ventricular fibrillation 1, 2
Specifically contraindicated medications include 1, 2:
- Beta-blockers (including metoprolol)
- Calcium channel blockers (verapamil, diltiazem)
- Digoxin
- Adenosine (when QRS is wide)
- IV amiodarone in acute pre-excited AF
Risk Factors for Recurrence After Ablation
Certain anatomical and clinical features predict higher recurrence rates 3, 4:
- Multiple accessory pathways (odds ratio 14.88 for recurrence) 4
- Parahisian pathway location (odds ratio 10.14 for recurrence) 4
- Broad accessory pathways (odds ratio 6.88 for recurrence) 4
- Septal pathway location (9.1% complication rate vs 2.0% for left-sided pathways) 3
- Prior antiarrhythmic medication use (12.2% recurrence rate vs 7.6% without prior medication) 3
Timing of Recurrences
- Most recurrences occur during the acute phase within 36 hours post-ablation 4
- Late recurrences (>1 year) are rare but can occur 4
- Patients presenting for repeat ablation have higher complication rates (6.9% vs 2.2% for first-time procedures) 3
Post-Ablation Monitoring
- Even after successful ablation, monitoring is necessary as the procedure does not always prevent atrial fibrillation, especially in older patients 1, 2
- Additional therapy may be required for atrial fibrillation management independent of the accessory pathway 1