Key result
Intermittent preexcitation in children does not connote a lower risk accessory pathway by electrophysiologic criteria compared to persistent WPW (11% vs 16% high-risk pathways; P=0.005).
Why the study?
Does intermittent preexcitation indicate a lower risk accessory pathway or reduced symptoms compared to persistent preexcitation in children with WPW syndrome?
Cohort (n=295)
No
Does intermittent preexcitation indicate a lower risk accessory pathway or reduced symptoms compared to persistent preexcitation in children with WPW syndrome?
Intermittent preexcitation in children with WPW syndrome does not indicate a lower risk accessory pathway by electrophysiologic criteria or reduced symptoms compared to persistent preexcitation.
Intermittent preexcitation should not guide lower-risk stratification in pediatric WPW; leaves open need for EP testing irrespective of pattern.
BACKGROUND: Intermittent Wolff-Parkinson-White (WPW) syndrome is considered to have a lower risk of sudden death. Fewer data exist regarding electrophysiologic (EP) characteristics and the natural history of intermittent WPW in children. METHODS: All patients with WPW age 1-18 years at a single institution (1996-2013) were reviewed. Patients with intermittent preexcitation were compared to those with loss of preexcitation on Holter/exercise testing and those with persistent preexcitation. High-risk accessory pathway (AP) was defined as AP effective refractory period (APERP), block cycle length, or shortest preexcited RR interval during atrial fibrillation ≤250 ms. RESULTS: A total of 295 patients were included: 226 (76.6%) persistent, 39 (13.2%) intermittent, and 30 (10.2%) loss of preexcitation Holter/exercise. There were no differences in symptoms between groups. Median interquartile range APERP was significantly longer in intermittent WPW (380 [320, 488] ms vs 320 [300, 350] ms persistent, 310 [290, 330] ms loss of preexcitation Holter/exercise; P = 0.0008). At baseline, there was no difference between groups in frequency of high-risk pathways. However, when isoproterenol values were included, high-risk pathways were more frequent among patients with loss of preexcitation on Holter/exercise (54% vs 16% persistent, 11% intermittent; P = 0.005). There was one death in a patient with loss of preexcitation on exercise testing, no EP study, and prior drug use. A second patient with persistent WPW and APERP 270 ms required resuscitation following a methadone overdose. CONCLUSION: Intermittent preexcitation in children does not connote a lower risk AP by EP criteria or reduced symptoms. The low number of pediatric WPW patients who develop preexcited atrial fibrillation or sudden death warrants larger studies to investigate these outcomes.
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Kiger et al. (2015) conducted a cohort in Wolff-Parkinson-White (WPW) syndrome (n=295). Intermittent preexcitation vs. Persistent preexcitation and loss of preexcitation on Holter/exercise testing was evaluated on Frequency of high-risk accessory pathways including isoproterenol values (p=0.005). Intermittent preexcitation in children does not connote a lower risk accessory pathway by electrophysiologic criteria compared to persistent WPW (11% vs 16% high-risk pathways; P=0.005).
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