Loss of ventricular preexcitation during noninvasive testing does not exclude high-risk accessory pathways: A multicenter study of WPW in children

Carolina A. Escudero, Department of Pediatrics, Division of Pediatric Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada. Electronic address: escudero@ualberta.ca.
Scott R. Ceresnak, Division of Pediatric Cardiology, Department of Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California.
Kathryn K. Collins, Department of Pediatrics, Division of Cardiology, University of Colorado, Aurora, Colorado.
Robert H. Pass, Division of Pediatric Cardiology, The Children's Hospital at Montefiore Medical Center, Bronx, New York.
Peter F. Aziz, Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio.
Andrew D. Blaufox, Department of Pediatrics, Division of Pediatric Cardiology, Cohen Children's Medical Center of New York, New Hyde Park, New York.
Michel Cabrera Ortega, Department of Arrhythmia and Cardiac Pacing, Cardiocentro Pediatrico William Soler, Havana, Cuba.
Bryan C. Cannon, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota.
Mitchell I. Cohen, Division of Pediatric Cardiology, Inova Children's Hospital, Fairfax, Virginia.
Brynn E. Dechert, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
Anne M. Dubin, Division of Pediatric Cardiology, Department of Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California.
Kara S. Motonaga, Division of Pediatric Cardiology, Department of Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California.
Michael R. Epstein, Division of Pediatric Cardiology, Maine Medical Center, Portland, Maine.
Christopher C. Erickson, Division of Pediatric Cardiology, UNMC/CUMC/Children's Hospital and Medical Center, Omaha, Nebraska.
Steven B. Fishberger, Division of Cardiology, Miami Children's Hospital, Miami, Florida.
Gregory J. Gates, Division of Pediatric Cardiology, The Children's Hospital at Montefiore Medical Center, Bronx, New York.
Christine A. Capone, Division of Pediatric Cardiology, The Children's Hospital at Montefiore Medical Center, Bronx, New York.
Lynn Nappo, Division of Pediatric Cardiology, The Children's Hospital at Montefiore Medical Center, Bronx, New York.
Naomi J. Kertesz, Division of Cardiology, Nationwide Children's, Columbus, Ohio.
Jeffrey J. Kim, Department of Pediatrics, Division of Cardiology, Texas Children's Hospital, Houston, Texas.
Santiago O. Valdes, Department of Pediatrics, Division of Cardiology, Texas Children's Hospital, Houston, Texas.
Peter Kubuš, Children's Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic.
Ian H. Law, Department of Pediatrics, Division of Pediatric Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa.
Jennifer Maldonado, Department of Pediatrics, Division of Pediatric Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa.
Jeremy P. Moore, Department of Pediatrics, Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California.
James C. Perry, Division of Pediatric Cardiology, University California San Diego, Rady Children's Hospital, San Diego, California.
Shubhayan Sanatani, Department of Pediatrics, University of British Columbia, Children's Heart Centre, Vancouver, British Columbia, Canada.
Stephen P. Seslar, Department of Pediatrics, Division of Cardiology, Seattle Children's Hospital, Seattle, Washington.
Ira Shetty, Division of Pediatric Cardiology, Advocate Children's Heart Institute at Advocate Children's Hospital, Oak Lawn, Illinois.
Frank J. Zimmerman, Division of Pediatric Cardiology, Advocate Children's Heart Institute at Advocate Children's Hospital, Oak Lawn, Illinois.
Jonathan R. Skinner, Starship Children's Hospital, Auckland, New Zealand.
Luciana Marcondes, Starship Children's Hospital, Auckland, New Zealand.

Abstract

BACKGROUND: Abrupt loss of ventricular preexcitation on noninvasive evaluation, or nonpersistent preexcitation, in Wolff-Parkinson-White syndrome (WPW) is thought to indicate a low risk of life-threatening events. OBJECTIVE: The purpose of this study was to compare accessory pathway (AP) characteristics and occurrences of sudden cardiac arrest (SCA) and rapidly conducted preexcited atrial fibrillation (RC-AF) in patients with nonpersistent and persistent preexcitation. METHODS: Patients 21 years or younger with WPW and invasive electrophysiology study (EPS) data, SCA, or RC-AF were identified from multicenter databases. Nonpersistent preexcitation was defined as absence/sudden loss of preexcitation on electrocardiogram, Holter monitoring, or exercise stress test. RC-AF was defined as clinical preexcited atrial fibrillation with shortest preexcited R-R interval (SPERRI) ≤ 250 ms. AP effective refractory period (APERP), SPERRI at EPS , and shortest preexcited paced cycle length (SPPCL) were collected. High-risk APs were defined as APERP, SPERRI, or SPPCL ≤ 250 ms. RESULTS: Of 1589 patients, 244 (15%) had nonpersistent preexcitation and 1345 (85%) had persistent preexcitation. There were no differences in sex (58% vs 60% male; P=.49) or age (13.3±3.6 years vs 13.1±3.9 years; P=.43) between groups. Although APERP (344±76 ms vs 312±61 ms; P<.001) and SPPCL (394±123 ms vs 317±82 ms; P<.001) were longer in nonpersistent vs persistent preexcitation, there was no difference in SPERRI at EPS (331±71 ms vs 316±73 ms; P=.15). Nonpersistent preexcitation was associated with fewer high-risk APs (13% vs 23%; P<.001) than persistent preexcitation. Of 61 patients with SCA or RC-AF, 6 (10%) had nonpersistent preexcitation (3 SCA, 3 RC-AF). CONCLUSION: Nonpersistent preexcitation was associated with fewer high-risk APs, though it did not exclude the risk of SCA or RC-AF in children with WPW.