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Electrophysiological evaluation of the different degrees of risk of high frequency atrial fibrillation in wpw syndrome


, : Electrophysiological evaluation of the different degrees of risk of high frequency atrial fibrillation in wpw syndrome. Giornale Italiano di Cardiologia 17(2): 127-133

Sudden death in WPW pattern can occur when atrial fibrillation (a.f.) with rapid ventricular response develops. This event seems to be the final result of three concomitant conditions: 1) the appearance of an ortodromic atrio-ventricular reciprocating tachycardia, the most common form of tachycardia in these patients; 2) a high atrial vulnerability, which makes possible that reciprocating tachycardia degenerates into atrial fibrillation and 3) a short anterograde refractory period of the Kent bundle. With the purpose of evaluating the risk to develop high frequency a.f., 36 WPW subjects were electrophysiologically studied. 22 were symptomatic for palpitations (Group 1)and 14 were totally asymptomatic (Group II). 3/22 patients of Group I had experienced clinical atrial fibrillation (Subgroup I A), which was never documented in the remaining 19/22 (Subgroup I B). In all cases the following parameters were analyzed: 1) the presence or absence of the retrograde conduction of the anomalous pathways, essential for the occurrence of orthodromic reciprocating atrioventricular tachycardia; 2) the presence or absence of a high atrial vulnerability and 3) the presence of RR intervals between prexcited complexes during induced a.f. < 250 msec. As an index of atrial vulnerability were considered a) the spontaneous degeneration into atrial fibrillation of an electrophysiologically induced reciprocating tachycardia and/or b) the induction of a sustained a.f. by programmed right atrial stimulation during sinus rhythm and/or during 600 and 400 ms atrial driving and/or by 160-250/m' atrial bursts. Results: Retrograde conduction of Kent bundle was documented in 100% of Gr.I vs 22% of Gr. II (p < 0.001). A reciprocating atrio-ventricular tachycardia was induced in 77% of Gr. I vs 14% of Gr. II (p < 0.001), which was sustained (.gtoreq. 1 min) in 59% of Gr. I and in no case of Gr. II. A high atrial vulnerability was documented in 41% of Gr. I (100% and 31% in subgroups IA and IB respectively) vs. 22% of Gr. II (NS). RR intervals between preexcited complexes during a.f. < 250 ms were noted in 41% of Gr. I vs 22% of Gr. II (NS). The concomitance of a) retrograde conduction of Kent bundle + b) high atrial vulnerability + c) shortest RR intervals during a.f. < 250 ms was demonstrated in 27% of Gr. I (21% in subgroup I B) and in no case of Gr. II. Conclusions: Our data suggest that, on the basis of a poliparametric electrophysiologic evaluation, about 1/5 of symptomatic WPW patients is predisposed to develop high frequency atrial fibrillation while this possibility seems very unlikely in asymptomatic subjects. It follows that while electrophysiologic study is mandatory in symptomatic patients to recognize the ones at higher risk of rapid atrial fibrillation, this procedure does not seem always necessary in asymptomatic subjects.

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