Prophylactic Radiofrequency Ablation in Asymptomatic Patients With Wolff–Parkinson–White Is Not Yet a Good Strategy

Abstract

Background— Therapeutic management of asymptomatic patients with a Wolff–Parkinson–White (WPW) pattern is controversial. We compared the risk:benefit ratios between prophylactic radiofrequency ablation and no treatment in asymptomatic patients with WPW. Methods and Results— Decision analysis software was used to construct a risk–benefit decision tree. The target population consisted of 20- to 40-year-old asymptomatic patients with WPW without structural fatal heart disease or a family history of sudden cardiac death. Baseline estimates of sudden death and radiofrequency ablation complication rates were obtained from the literature, an empirical data survey, and expert opinion. The outcome measure was death within 10 years. Sensitivity analyses determined the variables that significantly impacted the decision to ablate or not. Threshold analyses evaluated the effects of key variables and the optimum policy. At baseline, the decision to ablate resulted in a reduction of mortality risk of 8.8 patients for 1000 patients compared with abstention. It is necessary to treat 112 asymptomatic patients with WPW to save one life over 10 years. Sensitivity analysis showed that 3 variables significantly impacted the decision to ablate: (1) complication of radiofrequency ablation, (2) success of radiofrequency ablation, and (3) sudden death in asymptomatic patients with WPW. Conclusions— This study provides a decision aid for treating asymptomatic patients with the WPW ECG pattern. Using the model and the population we tested, prophylactic catheter ablation is not yet ready for widespread clinical use.

Understanding the ECG. Part 5: Pre-excitation

“…Secondly, patients may have a strong preference for taking the small but one-off risk of ablation, rather than the small but indefinite risk of SCD. Thirdly, the presence of pre-excitation on the ECG may bar people from certain activities, for example professional flying or competitive sport (Chevalier et al, 2013;Link, 2009). Finally, the location of the pathway must be considered.…”

Wolff–Parkinson–White syndrome (WPW) and athletes: Darwin at play?

“…This may change pathway properties and our ability to interpret the conduction velocity of an accessory pathway in the anesthetized state is not clear. Multiple studies in adults and children have demonstrated that isoproterenol can enhance accessory pathway conduction [4,[20][21][22]. In the pediatric population, Moore et al [20] demonstrated that the addition of isoproterenol increased the percentage of children deemed "high risk" at EPS from 5% to 25%.…”

“…The combination of new data suggesting a significantly increased risk of life-threatening events than previously described coupled with the widespread use of ablation as a safe and effective treatment tool have made WPW one of the most common indications for invasive EP testing and ablation in young people [1]. While there is little argument or disagreement over the management of the symptomatic young patient with WPW, there are still divergent views on the assessment and management of the asymptomatic patient [2][3][4][5]. In light of the new guidelines on the management of the young patient with ventricular preexcitation [6], some have questioned whether we have gone too far on the side of aggressive intervention in the evaluation of the asymptomatic patient with pre-excitation.…”

The Asymptomatic Wolff-Parkinson-White Patient

“…A low WPW prevalence in the population is also a barrier to cost-effectiveness. 2 As highlighted by many publications, risk factors for identifying the truly high-risk patient lack accuracy. However, the identification of factors generally associated with a favorable long-term outcome is somewhat easier.…”