URL: https://clinicaltrials.gov. Unique identifier: NCT02641431.

CorrespondenceWe thank Fenici et al for their interest in our experience on the natural history of the Wolff-Parkinson-White (WPW) syndrome. 1 The authors, on the basis of their experience, suggest the routine use of ambulatory transesophageal atrial pacing (TEAP) as an intermediate approach to minimize "invasiveness" for risk assessment in the asymptomatic WPW population. It is well known that, unlike invasive electrophysiological testing (EPT), TEAP provides less accurate information about "the real electrophysiological profile of the risk" in WPW patients. Potential limitations are an approximate value of the anterograde refractory period of accessory pathways (APs), no identification of multiple APs, no reproducibility or inducibility of atrial fibrillation, no information on AP retrograde conduction, and no AP localization, all of which in a modern electrophysiology laboratory are indeed unacceptable when evaluating the risk of sudden death. Currently, in the era of widespread use of radiofrequency catheter ablation (RFA), more accurate information on the electrophysiological characteristics of potentially dangerous AP is indeed required to definitively eliminate the risk of sudden death.1-5 Recently, we have seen an 11-year-old asymptomatic boy who, after discovering incidentally before a practice the presence of ventricular pre-excitation on the ECG, was reassured after a "negative" ambulatory TEAP (no inducibility of any arrhythmia). Unfortunately, 3 years later, this "good asymptomatic boy" underwent both EPT and RFA of AP immediately after experiencing a resuscitated cardiac arrest caused by ventricular fibrillation as demonstrated by EPT. Because asymptomatic ventricular preexcitation has been supposed for many decades to be at no or minimal risk of sudden death, it is comprehensible that in the pre-RFA era this ambulatory strategy began to be used to stratify a "benign" disease. Besides these important methodological and physiopathological considerations, TEAP is a semi-invasive technique and is not entirely risk free. High-output pacing may frequently be required to activate the atrium from the esophagus, which can be painful, requiring the use of heavy sedation, all of which can modify the electrophysiological properties of AP. Albeit rarely, TEAP may also induce ventricular tachyarrhythmias, including ventricular fibrillation. Our experience with >11 000 WPW patients indicates that in a modern electrophysiology laboratory EPT and RFA performed in the same session are both safe and effective to definitively eliminate the risk of sudden death in patients with ventricular pre-excitation regardless of symptoms. We believe that TEAP remains a pioneering approach in the pre-RFA era that nowadays has become anachronistic, being abandoned by most modern electrophysiology laboratories worldwide, as shown by the fact that in the last 30 years the use of TEAP in patients with WPW syndrome has not been reported in the literature. Our large experience indicates that the risk of sudden death in patients with ve...

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[1][2][3][4][5][6][7][8][9][10][11] Among a large series of WPW patients resuscitated from a sudden cardiac death, more than a half had ventricular fibrillation (VF) as the sentinel event, 4 which suggests that the risk of sudden death in the asymptomatic population is indeed underrecognized.9,10 The earliest alarming reports of sudden cardiac death were published in the late 1930s, 6,7 but the clinical manifestations typically range from an abnormal ECG finding without symptoms to cardiac arrest or sudden cardiac death. Anecdotal case series on the asymptomatic Background-The management of Wolff-Parkinson-White is based on the distinction between asymptomatic and symptomatic presentations, but evidence is limited in the asymptomatic population. Methods and Results-The Wolff-Parkinson-White registry was an 8-year prospective study of either symptomatic or asymptomatic Wolff-Parkinson-White patients referred to our Arrhythmology Department for evaluation or ablation. Inclusion criteria were a baseline electrophysiological testing with or without radiofrequency catheter ablation (RFA). Primary end points were the percentage of patients who experienced ventricular fibrillation (VF) or potentially malignant arrhythmias and risk factors. Among 2169 enrolled patients, 1001 (550 asymptomatic) did not undergo RFA (no-RFA group) and 1168 (206 asymptomatic) underwent ablation (RFA group). There were no differences in clinical and electrophysiological characteristics between the 2 groups except for symptoms. In the no-RFA group, VF occurred in 1.5% of patients, virtually exclusively (13 of 15) in children (median age, 11 years), and was associated with a short accessory pathway antegrade refractory period (P<0.001) and atrioventricular reentrant tachycardia initiating atrial fibrillation (P<0.001) but not symptoms. In the RFA group, ablation was successful in 98.5%, and after RFA, no patients developed malignant arrhythmias or VF over the 8-year follow-up. Untreated patients were more likely to experience malignant arrhythmias and VF (log-rank P<0.001). Time-dependent receiver-operating characteristic curves for predicting VF identified an optimal anterograde effective refractory period of the accessory pathway cutoff of 240 milliseconds. Conclusions-The prognosis of the Wolff-Parkinson-White syndrome essentially depends on intrinsic electrophysiological properties of AP rather than on symptoms. RFA performed during the same procedure after electrophysiological testing is of benefit in improving the long-term outcomes. (Circulation. 2014;130:811-819.)