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Background: Published guidelines provide recommendations for risk stratification in pediatric Wolff-Parkinson-White (WPW). There are no data on provider concordance with these guidelines. We hypothesized that significant practice variation exists between pediatric cardiologists (PC) and electrophysiologists (EP). Method: The records of all patients, age 8 to 21 years, with a new ECG diagnosis of WPW between 1/1/2013 and 12/31/2018, from a single center, were retrospectively reviewed. Subjects were categorized on the basis of symptoms and resting ECG findings as one of the following: asymptomatic intermittent WPW, asymptomatic persistent WPW, or symptomatic WPW. The performance and results of diagnostic testing, including Holter monitor, event monitor, exercise stress test (EST), and electrophysiology study (EPS), were recorded. The primary outcome was concordance with published guidelines. A secondary outcome was documentation of a discussion of sudden cardiac death (SCD) risk. Results: 615 patient encounters were analyzed in 231 patients with newly diagnosed WPW pattern on ECG (56% male; mean age at diagnosis 13.9 ± 2.5 years). EP were observed to have a significantly higher rate of guideline concordance than PC (95% vs. 71%, p < 0.001). There was significant practice variation between PC and EP in the documentation of a discussion of SCD risk: 96% in EP vs. 39% in PC (p < 0.001). Conclusion: Significant practice variation exists in the non-invasive and invasive risk stratification of pediatric WPW, with lower concordance to published guidelines amongst PC, when compared to EP. This report highlights the need to promote awareness of current WPW guidelines in the pediatric cardiology community at large. [ABSTRACT FROM AUTHOR]

Supraventricular tachycardia (SVT) is the most common arrhythmia in infants. Once diagnosed, infants are admitted for antiarrhythmic therapy and discharged after observation. There are limited data on risk factors for readmission and readmission rates, while on medication. The objective of this study was to investigate risk factors for readmission and outcomes in infants diagnosed with SVT. This is a single-center retrospective study over a 10-year period of infants under 6 months of age with documented SVT. Infants with congenital heart disease requiring surgical or catheter intervention, gestational age less than 32 weeks or diagnosis of atrial flutter or fibrillation were excluded. The primary outcome was readmission within 31 days of hospital discharge. Long term need for ablation and eventual discontinuation of medications were assessed. Ninety patients were included. Beta blockers were the initial therapy in 66 and 28 required a medication change. Nineteen were readmitted within 31 days of discharge. The only clinical factor associated with early readmission was presence of ventricular pre-excitation (6/19 vs. 8/71, p = 0.03). Patients who were readmitted within 31 days had a longer length of treatment (12 [11.5, 22.0] vs. 10 [7.5, 12.0] months, p = 0.007) and were more likely to undergo ablation (4/19 vs. 2/71, p = 0.017). In this cohort of infants with SVT, readmission was common and ventricular pre-excitation was identified as a risk factor for readmission. Infants who were readmitted within 31 days of discharge had longer length of antiarrhythmic therapy and were more likely to undergo catheter ablation. [ABSTRACT FROM AUTHOR]

Background: Telecardiology has proven to be a useful and cost-effective tool for ECG screening in several contexts, allowing the evaluation of large cohorts of subjects in a short time, even for non-competitive athletes (NCA). Aim of the study: To evaluate and detail the prevalence of the Wolff-Parkinson-White (WPW) syndrome in a large Italian cohort of young NCA. Methods: In a 4-year period 216,424 consecutive NCA (118,851 males; 55%) underwent preparticipation ECG screening through a Telecardiology System. ECGs were recorded and sent by a network of ‘spoke’ centers located all over Italy; a ‘hub’ center, located in Genoa, received and reported back on ECGs, digitally stored and analyzed. Only asymptomatic NCA were included in the study. Results: Out of 216,424 NCA 88 (mean age: 14 ± 8) presented a WPW pre-excitation at ECG analysis (55 males, 62.5 %); the prevalence of WPW pre-excitation in this population was 4.1 per 10,000 NCA. No significant sex-related differences were found. The highest incidence (29 WPW patterns) was observed in the 10–15 year group with an equal sex ratio (M/F:16/13).Intermittent pre-excitation was found in 8 NCAs. The most frequent accessory pathway locations were right antero-septal (25.0%), mid-septal (21.6%) and postero-septal (13.6%). Conclusions: In a large population of young NCA the prevalence of ECG pre-excitation at telemedicine remote screening was 4.1 per 10,000; intermittent pre-excitation was found in 9% of NCA with ECG pre-excitation.

Ventricular pre-excitation (VP) is a cardiac disorder characterized by the presence of an accessory pathway (AP) that bypasses the atrioventricular node (AVN), which, although often asymptomatic, exposes individuals to an increased risk of re-entrant supraventricular tachycardias and sudden cardiac death (SCD) due to rapid atrial fibrillation (AF) conduction. This condition is particularly significant in sports cardiology, where preparticipation ECG screening is routinely performed on athletes. Professional athletes, given their elevated risk of developing malignant arrhythmias, require careful assessment. Early identification of VP and proper risk stratification are crucial for determining the most appropriate management strategy and ensuring the safety of these individuals during competitive sports. Non-invasive tools, such as resting electrocardiograms (ECGs), ambulatory ECG monitoring, and exercise stress tests, are commonly employed, although their interpretation can sometimes be challenging. This review aims to provide practical tips and electrocardiographic clues for detecting VP beyond the classical triad (short PR interval, delta wave, and prolonged QRS interval) and offers guidance on non-invasive risk stratification. Although the diagnostic gold standard remains invasive electrophysiological study, appropriate interpretation of the ECG can help limit unnecessary referrals for young, often asymptomatic, athletes.

Abstract Background Oblique course of some left accessory pathways is rare An incomplete electrophysiological study may confuse us between an oblique accessory pathway or the presence of two accessory pathways. The proximity of all atrial and ventricular electrograms, at each pole of the catheter, within the coronary sinus may be a novel finding. Case presentation A 68-year-old woman patient presented arrhythmias with hypotension requiring electrical cardioversion. Her electrocardiogram (ECG) was interpreted as atrial fibrillation by accessory pathway. We performed with the protocol of ablation stablished in our laboratory: two punctures on the right femoral vein with placement of introducers (8F and 7F) by Seldigner technique and one puncture on the left femoral vein (7F). The study was performed with BIOTRONIK technology (Multicath study catheter), a non-deflectable 7F quadripolar catheter with 2 mm tip electrode to record the His electrogram, a non-deflectable decapolar catheter with 5 pairs of coronary sinus (CS) electrodes. Accessory pathway mapping was performed in right and left cavities and within the CS. All electrograms into CS showed short AV from proximal to distal CS. Finally, ablation of two accessory pathway recordings was achieved at two distant epicardial points within the CS. Conclusions Ablation at two distant sites, one on the ventricular side and the other on the mitral annulus, suggests the presence of an oblique accessory pathway and at the same time the differential diagnosis of the presence of two accessory pathways. In our point of view according the above, we consider this is a very rare case of oblique AP with epicardial trajectory. The sequence of electrograms (in this case) along the CS has not been seen before in the literature reviewed. It is important, regardless of the urgency, to follow diagnostic and therapeutic protocols in invasive electrophysiology.

This is a challenging case of Wolff-Parkinson-White syndrome which was located in the right posteroseptum region. Patient had a previous unsuccessful attempt at ablation. It is often difficult to precisely locate this type of accessory pathway. A repeat procedure using 3D electroanatomic mapping, the electroanatomic geometry of the heart was created. The accessory pathway potential was identified and the accessory pathway was successfully ablated in minimum amount of time. In this case report showed that the advanced three-dimensional cardiac mapping system plays a very important role in guiding clinicians in order to precisely locate and safely ablate this type of challenging accessory pathway. [ABSTRACT FROM AUTHOR]

Aims Wolff–Parkinson–White (WPW) syndrome is a conduction disorder characterized by an accessory electrical pathway between the atria and ventricles, which may predispose to supraventricular tachycardia (SVT) and sudden cardiac death. It can be seen as an isolated finding or associated with structural heart disease. Our aims were to determine the prevalence of a WPW pattern in a large and unselected cohort of neonates and to describe the electro- and echocardiographic characteristics as well as the natural history during early childhood. Methods and results Electrocardiograms and echocardiograms of neonates (aged 0–30 days) from a large, prospective, population-based cohort study were included. Neonates with a WPW pattern were identified and matched 1:4 to controls. Localization of the accessory pathway was assessed by different algorithms. Among 17 489 neonates, we identified 17 (76% boys) with a WPW pattern consistent with a prevalence of 0.1%. One neonate had moderate mitral regurgitation while other echocardiographic parameters were similar between cases and controls (all P > 0.05). The accessory pathways were primarily predicted to be left-sided. At follow-up (available in 14/17 children; mean age 3.2 years) the pre-excitation pattern persisted in only four of the children and none of the children had experienced any episodes of SVT. Conclusion The prevalence of a WPW pattern in our cohort of unselected neonates was 0.1%. The WPW pattern was more frequent in boys and generally not associated with structural heart disease, and the accessory pathways were primarily left-sided. At follow-up, the WPW pattern had disappeared in most of the children suggesting either an intermittent nature or that normalization occurs. Clinical Trial Registration Copenhagen Baby Heart, NCT02753348. [ABSTRACT FROM AUTHOR]

Background: Oblique course of some left accessory pathways is rare An incomplete electrophysiological study may confuse us between an oblique accessory pathway or the presence of two accessory pathways. The proximity of all atrial and ventricular electrograms, at each pole of the catheter, within the coronary sinus may be a novel finding. Case presentation: A 68-year-old woman patient presented arrhythmias with hypotension requiring electrical cardioversion. Her electrocardiogram (ECG) was interpreted as atrial fibrillation by accessory pathway. We performed with the protocol of ablation stablished in our laboratory: two punctures on the right femoral vein with placement of introducers (8F and 7F) by Seldigner technique and one puncture on the left femoral vein (7F). The study was performed with BIOTRONIK technology (Multicath study catheter), a non-deflectable 7F quadripolar catheter with 2 mm tip electrode to record the His electrogram, a non-deflectable decapolar catheter with 5 pairs of coronary sinus (CS) electrodes. Accessory pathway mapping was performed in right and left cavities and within the CS. All electrograms into CS showed short AV from proximal to distal CS. Finally, ablation of two accessory pathway recordings was achieved at two distant epicardial points within the CS. Conclusions: Ablation at two distant sites, one on the ventricular side and the other on the mitral annulus, suggests the presence of an oblique accessory pathway and at the same time the differential diagnosis of the presence of two accessory pathways. In our point of view according the above, we consider this is a very rare case of oblique AP with epicardial trajectory. The sequence of electrograms (in this case) along the CS has not been seen before in the literature reviewed. It is important, regardless of the urgency, to follow diagnostic and therapeutic protocols in invasive electrophysiology. [ABSTRACT FROM AUTHOR]

Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac preexcitation syndrome that presents with an uninhibited electrical conduction between the atria and ventricles via an accessory pathway that has the potential for life-threatening arrhythmias. This is a case report of an asymptomatic/undiagnosed 43-year-old female with an incidental finding of WPW pattern during hardware removal surgery of the right hip while under general anesthesia. The identification of asymptomatic patients can be difficult because there may be only subtle changes on the electrocardiogram but could still pose as life-threatening in the presence of supraventricular tachycardia. Because of the potential risks, recommendations were given to follow up with the cardiology department to establish an accurate diagnosis. After recognition, the perioperative anesthetic goal was to prepare for any potential arrhythmia, minimize triggers, and provide proper follow-up so that appropriate testing could be conducted to properly diagnose and manage WPW. [ABSTRACT FROM AUTHOR]

Wolff–Parkinson–White (WPW) is a rare congenital arrhythmia that could result in peripartum cardiomyopathy. This condition could be managed by medical treatments or ablation treatments. In this report, we presented a 14-year-old pregnant girl with initial signs of syncope and palpitation, who was later diagnosed with WPW-induced peripartum cardiomyopathy. The baby was successfully delivered at 32 weeks gestational age, and the patient received a beta-blocker as the main treatment strategy. We recommend that a proper cardiology and gynecology care is critical in providing the best prognosis.

Background: Telecardiology has proven to be a useful and cost-effective tool for ECG screening in several contexts, allowing the evaluation of large cohorts of subjects in a short time, even for non-competitive athletes (NCA)., Aim of the Study: To evaluate and detail the prevalence of the Wolff-Parkinson-White (WPW) syndrome in a large Italian cohort of young NCA., Methods: In a 4-year period 216,424 consecutive NCA (118,851 males; 55%) underwent preparticipation ECG screening through a Telecardiology System. ECGs were recorded and sent by a network of 'spoke' centers located all over Italy; a 'hub' center, located in Genoa, received and reported back on ECGs, digitally stored and analyzed. Only asymptomatic NCA were included in the study., Results: Out of 216,424 NCA 88 (mean age: 14 ± 8) presented a WPW pre-excitation at ECG analysis (55 males, 62.5 %); the prevalence of WPW pre-excitation in this population was 4.1 per 10,000 NCA. No significant sex-related differences were found. The highest incidence (29 WPW patterns) was observed in the 10-15 year group with an equal sex ratio (M/F:16/13).Intermittent pre-excitation was found in 8 NCAs. The most frequent accessory pathway locations were right antero-septal (25.0%), mid-septal (21.6%) and postero-septal (13.6%)., Conclusions: In a large population of young NCA the prevalence of ECG pre-excitation at telemedicine remote screening was 4.1 per 10,000; intermittent pre-excitation was found in 9% of NCA with ECG pre-excitation., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier B.V.)

Ventricular pre-excitation (VP) is a cardiac disorder characterized by the presence of an accessory pathway (AP) that bypasses the atrioventricular node (AVN), which, although often asymptomatic, exposes individuals to an increased risk of re-entrant supraventricular tachycardias and sudden cardiac death (SCD) due to rapid atrial fibrillation (AF) conduction. This condition is particularly significant in sports cardiology, where preparticipation ECG screening is routinely performed on athletes. Professional athletes, given their elevated risk of developing malignant arrhythmias, require careful assessment. Early identification of VP and proper risk stratification are crucial for determining the most appropriate management strategy and ensuring the safety of these individuals during competitive sports. Non-invasive tools, such as resting electrocardiograms (ECGs), ambulatory ECG monitoring, and exercise stress tests, are commonly employed, although their interpretation can sometimes be challenging. This review aims to provide practical tips and electrocardiographic clues for detecting VP beyond the classical triad (short PR interval, delta wave, and prolonged QRS interval) and offers guidance on non-invasive risk stratification. Although the diagnostic gold standard remains invasive electrophysiological study, appropriate interpretation of the ECG can help limit unnecessary referrals for young, often asymptomatic, athletes.

Wolff-Parkinson-White (WPW) syndrome is the most common manifestation of ventricular pre-excitation syndrome and is mostly found in individuals with no structural heart disease. Although the risk of malignant arrhythmias is low, sudden cardiac death (SCD) as the first clinical manifestation of WPW syndrome is well documented, and atrial fibrillation (AF) with a rapid ventricular response is the main mechanism involved. Unfortunately, the signs of pre-excitation and arrhythmias are sometimes under-diagnosed and under-treated. We describe the case of a 31-year-old man who was admitted with an irregular wide complex tachycardia consistent with pre-excited AF, which was not promptly diagnosed, and who developed ventricular fibrillation (VF) after administration of atrioventricular (AV) nodal blockers, as a primary manifestation of WPW syndrome. Blocking the AV node in patients with pre-excited AF may increase the ventricular rate and potentially result in hemodynamic instability. Among patients with WPW syndrome who survive an episode of SCD, catheter ablation of the accessory pathway is the treatment of choice. Resumo: A síndrome de Wolff-Parkinson-White (WPW) é a manifestação mais comum da síndrome de pré-excitação ventricular e está presente maioritariamente em indivíduos sem cardiopatia estrutural. Embora o risco de arritmias malignas seja baixo, a morte súbita cardíaca (MSC) como primeira manifestação clínica da síndrome de WPW é uma ocorrência bem documentada e a fibrilhação auricular (FA) com resposta ventricular rápida é o principal mecanismo envolvido. Infelizmente, às vezes, os sinais de pré-excitação e as arritmias são subdiagnosticados e subtratados. Descrevemos o caso de um homem de 31 anos admitido com uma taquicardia irregular de complexos largos consistente com FA pré-excitada, não diagnosticada de imediato, que evoluiu para fibrilhação ventricular (FV) após a administração de bloqueadores do nó auriculoventricular (AV), como manifestação inaugural da síndrome de WPW. O bloqueio do nó AV, em pacientes com FA pré-excitada, pode aumentar a frequência ventricular e potencialmente resultar em instabilidade hemodinâmica. Entre os pacientes com síndrome de WPW que sobrevivem a um episódio de MSC, a ablação por cateter de via acessória (VA) é o tratamento de escolha.

Wolff-Parkinson-White (WPW) is a rare congenital arrhythmia that could result in peripartum cardiomyopathy. This condition could be managed by medical treatments or ablation treatments. In this report, we presented a 14-year-old pregnant girl with initial signs of syncope and palpitation, who was later diagnosed with WPW-induced peripartum cardiomyopathy. The baby was successfully delivered at 32 weeks gestational age, and the patient received a beta-blocker as the main treatment strategy. We recommend that a proper cardiology and gynecology care is critical in providing the best prognosis. [ABSTRACT FROM AUTHOR]

We report treating a term neonate with tuberous sclerosis and giant rhabdomyomas who presented with incessant supraventricular tachycardia with Everolimus. The treatment was efficient in reducing tumor size and assisted as an adjunct therapy in controlling arrhythmia and limiting preexcitation. Treatment was challenged by difficulty to achieve stable drug level and limited by neutropenia as a serious side effect.

The article discusses whether there is a need for a novel algorithm for accessory pathways localization. Topics include the usefulness of electrocardiogram in the localization of accessory pathways, premature ventricular contractions site of origin, and pacing sites; algorithms that are being used by clinicians; and description of most of the accessory pathways' localization algorithms.

Short RP interval atrioventricular re-entrant tachycardias do not typically present as an incessant form. We present 2 cases of incessant atrioventricular re-entrant tachycardias leading to tachycardia-induced cardiomyopathy with severe heart failure presentation in middle-aged adults. Both underwent accessory pathway ablation and recovered normal left ventricle function before hospital discharge. (Level of Difficulty: Intermediate.)

Preexcitation symptom presents morbidity of 0.1% to 0.3% in the general population, which could lead to deadly events while accompanying arrhythmia. The classical type is Wolff-Parkinson-White (WPW) syndrome characterized as a shorter PR period, longer QRS duration, and δ wave. Radiofrequency catheter ablation (RCA) takes a vital role in treating WPW and has a high success rate. While some patients complain of consecutive chest pain after RCA, which influence their daily life severely. A 45-year-old man went to a hospital for examination because of uncomfortable palpitation. The electrocardiogram (ECG) presenting WPW syndrome (left free wall accessory pathway), then he was admitted to the hospital and scheduled for RCA. The RCA was very successful and the ECG became normal. However, after ablation, he reported consecutive chest pain, accompanied by insomnia and hypertension. No abnormal elevations of cardiac-Troponin I, myoglobin, cytokeratin, creatine kinase MB were found, and the left ventricular ejection fraction was 60%. His mental status was measured by Patient-Health Questionnaire-9, 7-item Generalized Anxiety Disorder Scale-7, Athens Insomnia Scale, indicating depressive status and anxiety status. The predominant managements involved flupentixol-melitracen and duloxetine. His chest pain, depressive, and anxiety symptoms were gradually relieved after 3-month treatment, and the drugs were slowly tapered in the 1½ years' follow-up period. Ultimately, he recovered and worked as before. This case highlights the importance of evaluating psychological status in patients with unexplained chest pain resulting from RCA and adopting antidepressants in those patients that coexist with definite depression or anxiety.

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Background: Athletes with asymptomatic ventricular pre-excitation (VP) should undergo electrophysiological study for risk stratification. We aimed to evaluate the feasibility, efficacy, safety and tolerability of an electrophysiological study using a percutaneous antecubital vein access and without the use of X-ray (ESnoXr). Methods: We collected data from all young athletes

Purpose: Accessory pathway (AP) mapping is currently based on point-by-point mapping and identifying if a local electrogram's origin is atrial, pathway, or ventricular, which is time-consuming and prone to insufficient mapping. We sought to determine the feasibility of automated and high-density mapping to define AP location using open-window mapping (OWM), which does not rely on defining the electrogram's origin but simply detects the sharpest local signal at each point. Methods: We enrolled 23 consecutive patients undergoing catheter ablation for atrioventricular reentrant tachycardia. High-density mapping was performed using OWM and ablation was performed. The successful site of ablation was determined by the loss of pathway function. Results: OWM was 100% effective at identifying the successful site of ablation (average mapping time 7.3 ± 4.3 min.) Permanent AP elimination was achieved using a mean radiofrequency energy time of 18.5 ± 24.5 s/patient. Transiently successful ablations were 4.0 ± 1.8 mm from permanently successful sites and had lower contact force (5.1 ± 2.5 g vs. 11.7 ± 9.0 g; P = 0.041). Unsuccessful sites had similar contact force to permanently successful sites (12.2 ± 9.2 g vs. 11.7 ± 9.0 g; P = 0.856) but were 6.4 ± 2.0 mm away from successful sites. Conclusion: A novel technique of high-density, automated, and open-window mapping (OWM) effectively localizes APs without the need to differentiate the signal's site of origin. These findings suggest that OWM can be used to rapidly and successfully map and ablate APs. Both distances from the pathway and contact force were shown to be important for pathway ablation. [ABSTRACT FROM AUTHOR]

Background: Ablation of septal accessory pathways (SAPs) is associated with an increased risk of heart block. Data on outcomes of SAP ablation in adults are limited. Objectives: To describe outcomes of SAP ablation in our center. Methods: Patients with Wolff-Parkinson-White syndrome (WPW) undergoing an EP study at our center between January 2008 and August 2019 were identified from our institutional database. Location of the pathway was noted as anteroseptal (AS), midseptal (MS), or posteroseptal (PS). Outcomes of the ablation including success, complication rates, and recurrences were also recorded. Results: Thirty-three patients with SAP underwent 35 EP studies: AS (n = 13), MS (n = 5), and PS (n = 15). Thirty pathways were targeted for ablation, two of which required a 2nd procedure resulting in 32 attempts at ablation in 30 patients. In the remaining 3 patients, SAP did not have malignant features and were not targeted for ablation. Single-procedure success rate was 28/30 (93.33%): 9/10 AS, 5/5 MS, and 14/15 PS ablations. One AS pathway was successfully ablated during a 2nd procedure. Two complications were observed: 1 pericardial effusion in a patient who underwent epicardial mapping and ablation of both PS and right free wall APs. Additionally, transient 2:1 AV block occurred during an MS pathway ablation that recovered during follow-up and did not require permanent pacing procedure. Conclusion: In this single-center experience, ablation of manifest SAP was associated with high success rates and low complication rates. No instances of permanent heart block requiring pacing occurred. [ABSTRACT FROM AUTHOR]

Background: Wolff-Parkinson-White (WPW) is a congenital defect of the cardiac conduction system (CCS), with proliferation of extra embryologic conduction pathways and rapid conduction of electrical impulses. The estimated neonatal incidence of 0.1% to 0.2% may be misrepresented secondary to missed or misdiagnosis. Undiagnosed WPW can result in sudden cardiac death.Purpose: To discuss the pathogenesis, manifestations, diagnosis, management, and lifespan implications of WPW in the prenatal and postnatal periods.Methods/search Strategy: A literature review was conducted using PubMed, CINAHL, and Google Scholar (2013-2019). Search terms included (newborn OR infant), wolff parkinson white, pathogenesis, management, and ventricular preexcitation. After removal of duplicates, 267 references were identified, abstracts reviewed, and 30 publications fully evaluated.Findings/results: Separation of the heart chambers begins around 7 weeks' gestation with formation of the annulus fibrosis complete after term. The unknown external environmental influence on the development of the preterm infant's CCS places neonates at risk for persistent atrioventricular reentrant tachycardia with WPW development. Ensuring an appropriate diagnosis is crucial, as an incorrect diagnosis could mean death.Implications For Practice: Due to the rarity of WPW, any fetal or neonatal supraventricular tachycardia requires further evaluation with an electrocardiogram and involvement of an experienced cardiologist for diagnosis. One episode of supraventricular tachycardia warrants evaluation for WPW, as recurring episodes may result in irreversible damage.Implications For Research: The recommendations for treatment of WPW in the prenatal and immediate postnatal periods are based heavily on standards of care for the adult population. A paucity of evidenced-based literature exists and future research is crucial to understand the true incidence, physiologic effects, and lifespan implications of WPW on neonates. [ABSTRACT FROM AUTHOR]

We report a pediatric patient with persistent left superior vena cava and a D-transposition of great arteries, which is an uncommon relation. It is crucial to know the anatomy of the persistent left superior vena cava and the dilated coronary sinus to plan the mapping techniques in cases of posterior accessory pathways.

When the atrioventricular node is damaged, accessory pathways can perform primary atrioventricular conduction but may spontaneously degrade during childhood. After surgical atrial septal defect repair during infancy, an adolescent male presented with fatigue due to iatrogenic complete atrioventricular node block with a degrading antegrade accessory pathway resulting in symptomatic bradyarrhythmia.

Competing Interests: None of the authors have conflicts to declare.

The objective of this review is to explore and challenge the superiority of amiodarone for rate control in Wolff-Parkinson-White syndrome and concomitant atrial fibrillation (WPW-AF). The current recommendation for pharmacological treatment of this condition is amiodarone. A review of the past 25 years of literature finds several studies that identify a small risk of ventricular fibrillation secondary to amiodarone administration for rate control in WPW-AF. Additionally, the literature supports the safe and effective use of procainamide for rate control in WPW-AF. This review concludes that amiodarone is not superior to procainamide in rate control for WPW-AF, and may be dangerous.

We report treating a term neonate with tuberous sclerosis and giant rhabdomyomas who presented with incessant supraventricular tachycardia with Everolimus. The treatment was efficient in reducing tumor size and assisted as an adjunct therapy in controlling arrhythmia and limiting preexcitation. Treatment was challenged by difficulty to achieve stable drug level and limited by neutropenia as a serious side effect. [ABSTRACT FROM AUTHOR]

Aims: The precise localization of manifest posteroseptal accessory pathways (APs) often poses diagnostic challenges considering that a small area may encompass AP that may be ablated from the right or left endocardium, or epicardially within the coronary sinus (CS). We sought to explore whether the QRS transition pattern in the precordial lead may help to discriminate the necessary ablation approach.Methods and Results: Consecutive patients who underwent a successful ablation of a single manifest AP over a 5-year period were included. Standard 12-lead electrocardiograms were reviewed. A total of 273 patients were identified. Mean age was 31 ± 15 years and 62% were male. Of the 110 identified posteroseptal AP, 64 were ablated from the right endocardium, 33 from the left endocardium, and 13 inside the CS. While a normal precordial QRS transition was most often observed, a subset of 33 patients presented an atypical 'double transition' pattern which specifically identified right endocardial AP. The combination of a q wave in V1 with a proportion of the positive QRS component in V1 < V2 > V3, predicted a right endocardial AP with a 100% specificity. In case of a positive QRS sum in V2, this 'double transition' pattern predicted a posteroseptal right endocardial AP with 99.5% specificity and 44% sensitivity. The positive predictive value was 97%. The only false positive was a midseptal AP. In the case of a negative or isoelectric QRS sum in V2, APs were located more laterally on the tricuspid annulus.Conclusion: The combination of a q wave in V1 with a double QRS transition pattern in the precordial leads is highly specific of a right endocardial AP and rules out the need for CS or left-sided mapping. [ABSTRACT FROM AUTHOR]

Three‐dimensional transthoracic echocardiography (3DE)‐derived heart models have not previously been utilized to guide catheter ablation. In this case report, we describe the creation of a 3DE model from transthoracic echocardiography, import of the model into CARTO3, and successful use of the model as a guide during mapping and ablation of a right lateral accessory pathway. We believe this technique represents a valuable alternative to the integration of computed tomography or magnetic resonance imaging‐derived anatomic data, and that it has the potential to improve the definition of the atrioventricular valve annuli during catheter ablation of accessory pathways. [ABSTRACT FROM AUTHOR]

Background: Outcomes for catheter ablation of accessory pathways in pediatric patients have steadily improved, with the exception of pathways located in the anteroseptal (AS) and midseptal (MS) regions, where success is limited by the close proximity of normal atrioventricular conduction.Objective: The purpose of this study was to evaluate the efficacy of different catheter approaches and ablation energy modalities used for catheter ablation at these sites.Methods: A retrospective review was performed of all electrophysiology studies conducted between July 2001 and July 2017. Acute success and recurrence rates were assessed by comparing catheter approaches and energy modalities used for ablation.Results: A total of 255 electrophysiology procedures were performed in 223 patients (178 AS, 72 MS, 5 unspecified). Ablation was attempted in 241 procedures, with acute success in 87% (AS 89%, MS 83%). Recurrence was evident in 18% of successful ablation procedures (AS 18%, MS 19%). Success rates were higher with repeat procedures than with primary procedures (P = .006). Multiple approaches were more often used for AS pathways, though no single approach was superior. There was no difference in success when comparing energy modalities, though the overall recurrence rate was higher for cryoablation. Significant complications occurred in 1.2% of procedures, though no patient had complete heart block.Conclusion: Ablation of AS and MS pathways remains challenging. Multiple approaches are often necessary to successfully ablate AS pathways. While both ablation energy modalities were equally successful, cryoablation may be associated with a higher chance of recurrence. Recurrences and repeat procedures may be anticipated to minimize risk to normal atrioventricular conduction during ablation in these regions. [ABSTRACT FROM AUTHOR]

A 31-year old male presented with atrial fibrillation and ventricular preexcitation that was positive in leads V1-V4, negative in lead II, and positive in lead AVR. The patient was cardioverted and invasive electrophysiologic study was performed. Based on the ECG findings, the coronary sinus and its branches were interrogated during orthodromic atrioventricular reentrant tachycardia. The earliest local activation was seen in the true coronary sinus lumen at the bifurcation of the posterolateral branch. Radiofrequency energy application at this area led to loss of preexcitation. When localizing left septal and posterior accessory pathways, ventricular preexcitation that is both negative in II and positive in AVR has been shown in previous studies to be highly sensitive and specific for a subepicardial location. Therefore, investigation of the coronary sinus and its branches may allow for effective ablation without the need for left ventricular access.

Introduction: Wolf-Parkinson-White (WPW) syndrome is characterized by the presence of one or several atrioventricular accessory pathways which can generate symptomatic arrhythmias, commonly atrioventricular reentry tachycardia (AVRT). It often exists alongside atrial fibrillation (AF), which leads to rapid ventricular rates via an accessory pathway, known as pre-excited AF, a potentially malignant type of arrhythmia. Case Report: A 55- year-old male patient was admitted to the emergency department with recent gastrointestinal symptoms. The 12- lead electrocardiogram revealed a regular wide QRS (145ms) tachycardia (225 beats/min), right QRS axis deviation, right bundle branch block morphology (Rr'), without evidence of atrioventricular dissociation, fusion nor capture beats, hemodynamically stable. Intravenous administration of Amiodarone resulted in the conversion to sinus rhythm, revealing a short PR interval, with positive delta wave in DII, DIII, aVF, V4-V5, intermittent R wave > S wave in V1, biphasic T wave in DII, DIII, aVF, V5-V6. Therefore, suspicion of antidromic AVRT secondary to a left free-wall accessory pathway. No pathological findings were revealed after a complete blood count was carried out; transthoracic echocardiogram showed a slightly left atrial enlargement. During the hospitalization, the patient developed an asymptomatic and hemodynamically stable episode of irregular wide-complex tachycardia (F.B.I), with different grades of fusions, revealing the concertina-like phenomenon secondary to AF mediated by accessory pathway, with spontaneous conversion to sinus rhythm. An electrophysiological study was performed, revealing the left free wall accessory pathway, with the induction of antidromic and orthodromic AVRT, with a SPERRI (shortest pre-excited RR interval) of 250ms. Successful radiofrequency catheter ablation was performed. Discussions : The identification of pre-excited AF is an infrequent manifestation of WPW syndrome. Nonetheless, certain individuals may remain asymptomatic despite evident pre-excitation on electrocardiographic recordings. The pronounced irregular RR intervals accompanied by diverse QRS morphology is a sign of pre-excited AF conducted through the accessory pathway. In such circumstances, the administration of intravenous Amiodarone or other agents aimed at AV nodal blockade may attenuate the intrinsic inhibition of orthodromic conduction, potentially fostering the onset of ventricular tachycardia (VT) or ventricular fibrillation (VF). A SPERRI of less than 250ms increases the risk of sudden death. Conclusions: The presence of irregular wide-complex tachycardia necessitates careful consideration for pre-excitation, highlighting the importance of vigilant evaluation and management in such cases. It is imperative to acknowledge the potential risk of sudden death, particularly in instances where SPERRI measures <250ms. [ABSTRACT FROM AUTHOR]

Introduction: Adenosine challenge (AC) can be used to evaluate possible Wolff‐Parkinson‐White (WPW) pattern on an electrocardiogram (ECG). Despite the use of this technique, there is a paucity of studies in the pediatric population evaluating the efficacy, safety, and outcomes of this testing modality. Methods and Results: All ACs performed from January 2009 to June 2017 were retrospectively reviewed. Patient demographics, adenosine dosing, results, adverse effects, and outcomes including results of electrophysiology studies (EPS) were reviewed. Analysis was conducted between AC positive and negative cohorts. ECG criteria of shortest PR interval, longest QRS duration, and the number of suspected pre‐excited leads were evaluated for inter‐rater reliability and correlation to positive AC. Fifty‐six AC (n = 51) were performed (median age, 13.8; range, 0.3‐20 years). Forty‐one AC were pre‐EPS and 15 post‐EPS due to concern for recurrent WPW. Thirty‐one (76%) pre‐EPS AC were negative, 9 (22%) positive, and 1 (2%) equivocal. EPS was performed following seven positive AC revealing 5 (71%) left posterior and 2 (29%) right posteroseptal AP. The 15 post‐EPS AC were all found to be negative. Mean effective adenosine dose was 0.2 ± 0.11 mg/kg. No adverse events were reported. Mean follow up duration after AC was 314 ± 482 days with no documented arrhythmias. Conclusion: Adenosine challenge is an effective and safe testing modality for subtle WPW in the pediatric population. In our population, there were no adverse events or documented arrhythmias in patients following a negative study. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Accessory pathway Wolff‐Parkinson‐white is sometimes not manifested till later in life, as the conduction properties of AV node become slower, other mechanisms are also possible. Brugada pattern on EKG can be associated with various underlying clinical conditions, such as mechanical compression of RVOT by tumors. It is essential to have high index of suspicion for flecainide toxicity when encountering arrhythmias in patients taking the drug. [ABSTRACT FROM AUTHOR]