WPW syndrome (abnormal muscle bundles) Classification of WPW syndrome History of WPW syndrome Electrocardiographic signs of WPW syndrome Diagnosis of WPW syndrome Prevention and treatment of tachyarrhythmia attacks in WPW syndrome
Arrhythmias and blockades in WPW syndrome
- Reciprocal (circular) AV paroxysmal tachycardias account for about 80%
- Atrial fibrillation - from 10 to 32%
- Atrial flutter - about 5%
The ECG phenomenon is detected in large population studies from 0.1 to 3.0 per thousand of the population (on average - 1.5/1000). Most people with ventricular pre-excitation syndrome (WPW syndrome) do not have heart disease. However, there is a combination: WPW syndrome (SVC) with congenital heart pathology and Ebstein's anomaly, Morphan's syndrome, tetralogy of Fallot, etc. Most patients with this pathology have a good prognosis (sudden death is recorded in less than 0.1% of patients).
To prevent paroxysms of AV reciprocal tachycardia in patients with AP, drugs that worsen conduction and/or increase refractoriness in both the AV node and AP are more effective (IC class - propafenone demonstrates an effectiveness of 60-70%).
The high preventive efficacy of propafenone monotherapy (60%) and its combination with beta blockers (more than 90%) was demonstrated in a study by Manolis AS et al. in adult patients with WPW syndrome. It is assumed that cardiac glycosides, verapamil, diltiazem should not be prescribed in this case for the purpose of preventing attacks of AV reciprocal tachycardia in order to avoid the occurrence of serious side effects of these drugs with the possible development of atrial fibrillation or flutter in these patients in the future.
The effectiveness of propafenone (Propanorma) was studied in a group of 11 patients with WPW syndrome against the background of placebo. The effect of propafenone therapy was assessed as complete in the absence of spontaneous relapses of arrhythmia and the impossibility of provoking them during TPE. As a result of the study, the full effect of propafenone was noted in 9 out of 11 patients. Such results were observed when taking propafenone at a dose of 450 mg/day and the dose of the drug was not subsequently increased. A partial effect was observed against the background of placebo in 2 patients, and when they were prescribed propafenone, the effect became complete. No partial effect of propafenone was noted. The effectiveness of therapy in this group of patients was 81.8%, exceeding the effectiveness of placebo by 63.6%.
General information
WPW syndrome or Wolff-Parkinson-White Syndrome is associated with premature excitation of the ventricles, which is caused by the conduction of impulses along additional abnormal cardiac pathways that connect the atria and ventricles.
Premature ventricular excitation syndrome is more common in males and first appears mainly at a young age (10-20 years). The syndrome manifests much less frequently in people of the older age group. The prevalence is 0.15-2%. The clinical significance of Wolff-Parkinson-White syndrome is the high risk of developing severe rhythm disturbances, which, in the absence of properly selected therapy, can lead to death.
It is customary to distinguish between two concepts - WPW Phenomenon and WPW Syndrome . With the WPW phenomenon, the patient does not have any clinical symptoms, and only the ECG shows pre-excitation of the ventricles and the conduction of impulses through additional connections. With the syndrome, changes in the ECG are accompanied by symptomatic tachycardia. The WPW syndrome code according to ICD 10 is I45.6.
Symptoms
WPW syndrome can be asymptomatic or with minor clinical manifestations, without causing severe hemodynamic disorders. The main complaints that patients make are: sudden interruptions in the functioning of the heart and attacks of rapid heartbeat. You may also experience increased fatigue, decreased exercise tolerance, dizziness, and a feeling of general weakness. During an attack of palpitations, shortness of breath, loss of consciousness, and a decrease in blood pressure (arterial hypotension) may occur.
First aid
Paroxysmal tachycardia requires emergency care. In the absence of hemodynamic disturbances, antiarrhythmic medications are used. The list of main drugs is below.
| A drug | Dose | Note |
| Amidaron | 15-450 mg slowly intravenously over 10-30 minutes. | Highly effective in the absence of effect from other medications. |
| Propafenone hydrochloride | 150 mg orally. | May cause slowing of sinoatrial, intraventricular and atrioventricular conduction. Possible bradycardia , decreased myocardial contractility in predisposed individuals. Arrhythmogenic effect is characteristic. Orthostatic hypotension is possible when used in large dosages. |
Additional medicines
| A drug | Dose | Main side effects |
| Bisoprolol | 5-15 mg/day orally | Heart failure, hypotension, bronchospasm, bradycardia. |
| Carbethoxyamino-diethylaminopropionyl-phenothiazine | 200 mg/day | AV block II-III degree, CA blockade II degree, ventricular heart rhythm disturbances together with blockades along the His bundles, cardiogenic shock, severe heart failure, disruption of the renal system and liver, arterial hypotension. |
| Verapamil | 5-10 mg IV at a rate of 1 mg per minute | For idiopathic ventricular tachycardia (ECG shows QRS complexes such as right bundle branch block with deviation of the electrical axis to the left). |
| Diltiazem | 90 mg 2 times a day | With supraventricular tachycardia. |
| Sotalol | 80 mg 2 times a day | With supraventricular tachycardia. |
Treatment
Treatment of a patient with WPW syndrome should be carried out by a qualified cardiologist; self-administration of medications without a prescription from a specialist is extremely unsafe. To stop palpitations, antiarrhythmic drugs are prescribed; in some cases, patients are prescribed continuous medication to prevent the development of new episodes of arrhythmia. The most modern and effective method of treating WPW syndrome is radiofrequency catheter ablation of an additional bundle of the cardiac conduction system.
Causes
The pathology is due to the presence of additional abnormal impulse pathways that conduct excitation from the atria to the ventricles. Wolff-Parkinson-White syndrome is in no way associated with structural changes in the heart. However, patients may exhibit some congenital anomalies of heart development associated with connective tissue dysplasia:
- prolapse ;
- Ehlers-Danlos syndrome;
- Marfan syndrome.
In some cases, the syndrome is associated with congenital heart defects:
- tetralogy of Fallot;
- atrial septal defect;
- ventricular septal defect.
In the literature there is a description of family variants of WPW. The disease can manifest itself at any age, or not manifest itself at all throughout life. Certain factors can trigger the onset of the syndrome:
- addiction to drinking coffee;
- stress;
- smoking;
- abuse of alcoholic beverages;
- frequent emotional overexcitation.
The disease must be detected as early as possible to prevent the development of complications.
Surgical treatment for Wolff-Parkinson-White syndrome
A highly effective treatment method for this disease is surgical excision of the additional pathway. This method is called radiofrequency ablation. Its essence is to cauterize the pathological area using radiofrequency exposure to an electrode contained in a special catheter inserted through the femoral artery. As a result, only one pacemaker remains in this place, since a blockade of the electrical impulse occurs along the additional conductive bundle. Radiofrequency ablation is a minimally invasive and nearly bloodless surgical treatment that addresses the underlying cause of the disease. This surgical intervention is performed under combined anesthesia only in a hospital setting. On average, it lasts about 55 minutes, and after 24 hours the patient can be discharged home. Since this is a low-risk operation, it can be performed even in very old age.
Interesting articles on the topic:
Modern diagnosis of Wolff-Parkinson-White (WPW) syndrome
Indications and contraindications for surgery
As for the indications that are the reason for prescribing the RFA procedure, in addition to WPW syndrome, they are:
- atrial fibrillation;
- ventricular tachycardia;
- AV nodal reciprocal tachycardia.
There are cases when the procedure is undesirable for the patient, or even impossible. Contraindications include:
- chronic renal or liver failure;
- severe forms of anemia, blood clotting disorders; allergic reactions to contrast agents and anesthetics;
- arterial hypertension, which cannot be corrected;
- the presence of infectious diseases and acute fever;
- endocarditis;
- severe forms of heart failure or other non-major heart diseases;
- hypokalemia and glycoside intoxication.
What happens after catheter ablation is completed?
The patient is transferred to a ward, where he is under the supervision of a doctor throughout the day. In the first few hours after surgery, you must maintain strict bed rest and completely limit movement. For now, you are only allowed to lie on your back.
The attending physician explains to the patient the requirements and rules of the recovery process after surgery. During the entire rehabilitation period, which takes up to 2 months, it is necessary to be constantly monitored by a cardiologist, and also to avoid heavy physical activity. The patient may be prescribed antiarrhythmic drugs.
Some operated patients, for example, those diagnosed with diabetes, or those with impaired blood clotting properties, may develop some complications such as bleeding at the site of catheter insertion, or disruption of the integrity of the vessel walls due to the introduction of a foreign body, but they occur in only 1% of patients.
Implementation of radiofrequency ablation: technique
RFA for WPW syndrome, as for other indications, is performed in an operating room equipped with an X-ray television system to monitor the patient’s condition directly during surgery. Also in the room there should be an EPI device, a pacemaker, a defibrillator, and other necessary instruments.
The patient is given special sedatives in advance.
Catheters are introduced into the body by percutaneous puncture - through the right or left femoral vein, one of the subclavian veins, and also through the right jugular vein. In addition, the puncture is also carried out through the veins of the forearm.
An anesthetic is injected at the puncture site, after which a needle of the required length is inserted into the vessel - a conductor is inserted through it. Next, the introducer and catheter-electrode are inserted through the guidewire into the desired chamber of the heart.
After the electrodes are placed in the appropriate chambers of the heart, they are connected to a junction box, which transmits the signal from the electrodes to a special recording device - this is how the EPI procedure is carried out. During the examination, the patient may experience minor chest pain, increased heart rate, discomfort and short-term cardiac arrest. At this moment, the doctor, through electrodes, completely controls the heartbeat processes.
Arrhythmogenic zones are exposed to an electrode located in the corresponding area, after which the EPI procedure is repeated to check the effectiveness of such treatment.
When RFA has reached its target, the catheters are removed and the puncture sites are covered with pressure bandages.
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