successfully ablated. Catheter ablation is also effective in the treatment of PJRT. From a cohort of 194 patients (median age at diagnosis 3.2 months, 57 percent less than one year of age) from 11 institutions treated for PJRT between 2000 and 2010, 140 patients underwent a total of 175 catheter ablation https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 11/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate procedures [17]. PJRT was successfully eliminated in 90 percent of patients, with minor complications reported in only 9 percent of patients, and no major complications. Arrhythmia recurrence Recurrent arrhythmias involving an accessory pathway, manifested by return of delta waves on the electrocardiogram or spontaneous paroxysmal supraventricular tachycardia, have been reported in 5 to 12 percent of patients [36,51,52,58,60]. The recurrence rate is higher with ablation of multiple pathways or right free wall or septal accessory pathways [53,58,60]. Approximately one-half of recurrences occur in the first 12 hours after the procedure [60]. Repeat ablation usually leads to permanent cure in patients who experience a recurrence [60]. To unmask any residual conduction via an accessory pathway prior to ending the ablation procedure, intravenous adenosine can be administered to transiently block the AV node. We primarily use adenosine when there is difficulty determining if the pathway has been successfully ablated. AF can recur following accessory pathway ablation; however, the ability for AF to be preexcited with conduction via an accessory pathway should be reduced or eliminated following ablation. In a series of 91 patients with documented paroxysmal AF prior to successful ablation of an accessory pathways, 18 (20 percent) had recurrent episodes of AF at two-year follow-up, although advancing age was the only independent predictor of recurrent AF on multivariate analysis [61]. Complications Data on complication rates come from both case series and a voluntary national registry. The reported incidence of nonfatal complications is on the order of 2 to 4 percent, which is similar to rates seen with ablation procedures for other arrhythmias [35,36,45]. (See "Overview of catheter ablation of cardiac arrhythmias", section on 'Complications'.) The incidence and nature of complications in general clinical practice was illustrated in a report from a voluntary national registry in the United States of 3357 patients undergoing EP study and ablation for a variety of indications [36]. Among the 654 patients treated for WPW syndrome, major procedural complications occurred in 2 percent, most commonly cardiac tamponade. Specific complications may occur that are related to the anatomic site of ablation, including complete AV block resulting from ablation of a septal accessory pathway near the AV node, acute interatrial shunting related to transseptal catheterization for ablation of left-sided accessory pathways (although there are usually no adverse long-term sequelae), and inappropriate sinus tachycardia may be present following ablation of a posteroseptal accessory pathway, suggesting disruption of the parasympathetic and/or sympathetic innervation of the sinus and AV nodes [62-68]. https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 12/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate Surgical ablation Prior to the advent of catheter-mediated radiofrequency ablation, surgical ablation of accessory pathways was the standard technique in patients with drug-refractory WPW syndrome. The long-term success rate for WPW surgery is now almost 100 percent with an operative mortality rate of less than 1 percent [69-71]. Despite these excellent outcomes, catheter-mediated radiofrequency ablation has emerged as the preferred therapy for treatment of accessory pathways. However, surgical ablation remains an effective treatment strategy in patients suffering from highly symptomatic and hemodynamically unstable, drug-refractory arrhythmias in whom radiofrequency energy catheter ablation has failed, when performed at centers with a proven track record of success in performing the procedure [72]. Medical therapy for arrhythmia prevention For patients with an accessory pathway and symptomatic arrhythmias (including orthodromic AVRT, antidromic AVRT, and preexcited AF or atrial flutter) who are not candidates for or who refuse ablation of the accessory pathway, we suggest pharmacologic therapy aimed at preventing further arrhythmias and/or slowing the ventricular response rate [1]. Chronic therapy with verapamil or digoxin should be avoided in all patients with WPW syndrome. For recurrent orthodromic AVRT The efficacy of an antiarrhythmic drug in preventing orthodromic atrioventricular reciprocating tachycardia (AVRT) is related to its ability to alter the electrophysiologic properties of the circuit, rendering it incapable of sustaining reentry. Antiectopic activity to decrease the number of arrhythmia triggers (eg, premature atrial complex [PACs; also referred to a premature atrial beat, premature supraventricular complex, or premature supraventricular beat] and ventricular premature beats) is another desirable effect. The class IC antiarrhythmic drugs flecainide and propafenone ( table 2) possess the most favorable benefit/risk ratio and are the drugs of choice for prevention of recurrent orthodromic AVRT [73-76]. An important exception is the presence of known coronary disease, a setting in which class IC drugs can increase mortality due to proarrhythmia [77]. Both flecainide and propafenone have been approved for prevention of paroxysmal supraventricular tachyarrhythmias, including orthodromic AVRT. Propafenone has a potential advantage since it also has mild beta blocking activity [75,76]. Beta blockers are still occasionally used as second-line therapy for chronic suppression of orthodromic AVRT in patients with "low-risk" WPW accessory pathways (eg, only intermittently manifest or know to have a long effective refractory period), but they are not advised for patients who have developed or may develop preexcited AF. Chronic therapy with verapamil or digoxin should be avoided in all patients with WPW syndrome. https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 13/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate The class IA antiarrhythmic drugs ( table 2) lengthen antegrade and retrograde refractoriness and slow conduction in the accessory pathway. However, these drugs are less potent than the class IC drugs, they only minimally lengthen AV node refractoriness, and they have a substantial risk of intolerable noncardiac adverse effects. Amiodarone has multiple electrophysiologic effects that make it effective in suppressing orthodromic AVRT, including beta blocking activity, class III effects to prolong action potential repolarization, blockade of the fast sodium and slow calcium inward currents, and suppression of ectopic beats [78-80] (see "Amiodarone: Clinical uses"). These effects result in slowing of impulse conduction and lengthening of refractoriness in both the bypass tract and the AV node/His-Purkinje system. However, it has a number of common adverse effects, including pulmonary, thyroid, and hepatic toxicity, which is a concern for patients with WPW who are often young and may require many years of therapy. (See "Amiodarone: Adverse effects, potential toxicities, and approach to monitoring".) For recurrent antidromic AVRT Ablation of the accessory pathway is the preferred therapy for chronic prevention of antidromic AVRT. An important concern about long-term medical therapy of this arrhythmia is the potential for very rapid ventricular rates should AF develop, given that the accessory pathway is capable of antegrade preexcited conduction during AF. We suggest drug therapy for the prevention of recurrent antidromic AVRT only in patients who are not candidates for or who refuse ablation of the accessory pathway. (See 'Catheter ablation' above.) The selection of an effective antiarrhythmic drug should be based upon the effect of the drug on the electrophysiologic properties of the various parts of the reentrant circuit and on the ability to suppress the arrhythmia. The AV nodal blocking agents (beta blockers, calcium channel blockers, and digoxin) are contraindicated because of the possible occurrence of AF with accelerated conduction down the accessory pathway. (See 'When to avoid AV nodal blockers' above.) The class IC drugs flecainide and propafenone ( table 2) are the agents of choice in the absence of other contraindications such as underlying structural heart disease or myocardial ischemia ( table 1). These drugs may increase mortality in patients with known coronary disease due to proarrhythmia [77]. Class IA drugs and amiodarone are also effective but are less desirable because of side effects. For recurrent preexcited atrial fibrillation Ablation of the accessory pathway is the preferred therapy for the prevention of recurrent preexcited AF. While ablation of the accessory pathway will not directly impact the development of AF, it should prevent the possibility of very rapid ventricular rates due to antegrade conduction via the accessory pathway. We suggest https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 14/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate medical therapy for the prevention of recurrent preexcited AF only in patients who are not candidates for, or refuse, ablation of the accessory pathway. (See 'Catheter ablation' above.) The drug selected for prevention of intermittent AF in the WPW syndrome should possess antifibrillatory activity on the atrial myocardium, antiectopic activity to suppress both PACs and ventricular premature beats that can induce AF, and should prevent AVRT since the latter can subsequently degenerate into AF. The drug must also lengthen refractoriness in both the accessory pathway and the AV node and His-Purkinje system to provide adequate background protection against a rapid ventricular response should AF intermittently occur. (See "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations" and "Atrial fibrillation in adults: Use of oral anticoagulants".) The class IC drugs flecainide and propafenone ( table 2) possess the best electrophysiologic profile for achieving these goals if no cardiac contraindications exist [81,82]. Class IA drugs are less potent and have more noncardiac adverse effects as previously noted. Amiodarone may be useful for the prevention of recurrent AF when class IC and IA drugs are ineffective and/or not tolerated and when ablation therapy is inappropriate or has failed [83,84]. Amiodarone should not be used in the acute management of AF. (See 'When to avoid AV nodal blockers' above.) SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Atrial fibrillation" and "Society guideline links: Arrhythmias in adults" and "Society guideline links: Catheter ablation of arrhythmias" and "Society guideline links: Supraventricular arrhythmias".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 15/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topic (see "Patient education: Wolff-Parkinson-White syndrome (The Basics)") Beyond the Basics topic (see "Patient education: Wolff-Parkinson-White syndrome (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Patients requiring treatment Symptomatic patients Patients with the Wolff-Parkinson-White (WPW) syndrome with symptomatic arrhythmia are generally treated to manage the symptoms caused by the arrhythmia and reduce the risk of a life-threatening arrhythmia. (See 'Acute treatment of symptomatic arrhythmias' above and 'Treatment to prevent recurrent arrhythmias' above.) Asymptomatic patients For most asymptomatic patients with preexcitation, particularly those over age 35 to 40, we suggest observation rather than ablation or pharmacotherapy (Grade 2C). However, risk stratification is performed in certain asymptomatic patients who are felt to be at higher risk of an arrhythmia or sudden cardiac death (SCD; particularly children, individuals with congenital heart disease, and those with cardiomyopathy) to identify those who may benefit from treatment ( algorithm 2). (See 'Asymptomatic patients' above.) Treatment options These include nonpharmacologic therapies (ie, catheter ablation of the accessory pathway) as well as pharmacologic therapy (to slow ventricular heart rates or to prevent arrhythmias). The choice of the optimal therapy depends on the acuity of the arrhythmia(s) and the risk of sudden cardiac death. (See 'Acute treatment of symptomatic arrhythmias' above and 'Treatment to prevent recurrent arrhythmias' above.) Hemodynamic instability All patients with any arrhythmia (ie, orthodromic atrioventricular reciprocating tachycardia [AVRT], antidromic AVRT, atrial fibrillation/flutter) involving an accessory pathway should undergo prompt initial assessment of hemodynamic status. Patients who are felt to be hemodynamically unstable related to their arrhythmia should undergo urgent electrical cardioversion. (See 'Initial assessment of hemodynamic stability' above and "Cardioversion for specific arrhythmias".) https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 16/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate Acute orthodromic AVRT For patients with acute symptomatic orthodromic AVRT who are hemodynamically stable, our approach is as follows ( table 1) (see 'Orthodromic AVRT' above): Initial therapy We recommend initial treatment with one or more vagal maneuvers rather than pharmacologic therapy (Grade 1B). Pharmacologic therapy If vagal maneuvers are ineffective, pharmacologic therapy with an AV nodal blocking agent (ie, adenosine, verapamil, beta blockers) should be instituted. We suggest intravenous adenosine rather than intravenous verapamil as the initial choice based on its efficacy and short half-life (Grade 2B). If adenosine is ineffective, we proceed with intravenous verapamil as the second line agent. If orthodromic AVRT persists, intravenous procainamide and beta blockers approved for intravenous administration (eg, propranolol, metoprolol, and esmolol) are additional therapeutic options. Acute antidromic AVRT For patients with acute symptomatic antidromic AVRT who are hemodynamically stable, we treat with intravenous procainamide in an effort to terminate the tachycardia or, if the tachycardia persists, slow the ventricular response. (See 'Antidromic AVRT' above.) Acute atrial fibrillation For patients with acute symptomatic preexcited atrial fibrillation (AF) who are hemodynamically stable, our approach is as follows (see 'Atrial fibrillation with preexcitation' above): Recommended therapy We suggest initial medical therapy for rhythm control versus rate control (Grade 2C). This is based on the greater ease of controlling the ventricular rate in sinus rhythm. While there is no clear first-line medication for rhythm control, options include procainamide and ibutilide. Drugs to avoid For all patients with preexcited AF, we recommend against using standard AV nodal blocking medications (ie, beta blockers, non-dihydropyridine calcium channel blockers [verapamil and diltiazem], digoxin, adenosine, and amiodarone) (Grade 1A). Blocking the AV node may result in increased conduction of atrial impulses to the ventricle by way of the accessory pathway, increasing the ventricular rate and potentially resulting in hemodynamic instability. (See 'When to avoid AV nodal blockers' above.) Prevention of recurrent arrhythmias https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 17/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate First-line therapy For patients with an accessory pathway and symptomatic arrhythmias including orthodromic AVRT, antidromic AVRT, and preexcited AF or atrial flutter, we recommend catheter ablation (Grade 1A). (See 'Catheter ablation' above.) Alternate therapy For patients with an accessory pathway and symptomatic arrhythmias (including orthodromic AVRT, antidromic AVRT, and preexcited AF or atrial flutter) who are not candidates for, or refuse, ablation of the accessory pathway, we suggest pharmacologic therapy (Grade 2C). (See 'Medical therapy for arrhythmia prevention' above.) For prevention of recurrent orthodromic AVRT in the absence of underlying structural heart disease, class IC antiarrhythmic drugs (eg, flecainide, propafenone) are the drugs of choice, although beta blockers, class IA antiarrhythmic drugs, and amiodarone may also be considered. For prevention of recurrent antidromic AVRT and preexcited AF in the absence of underlying structural heart disease, class IC antiarrhythmic drugs (eg, flecainide, propafenone) are also the drugs of choice. However, the AV nodal blocking agents (beta blockers, calcium channel blockers, and digoxin) are contraindicated in these patients, so class IA antiarrhythmic drugs and amiodarone should be considered in patients with concurrent structural heart disease. Failed catheter ablation For patients with preexcitation and symptomatic arrhythmias or AF or atrial flutter who have failed catheter ablation of the accessory pathway, we typically perform a repeat attempt at catheter ablation or consider proceeding with surgical ablation. (See 'Catheter ablation' above and 'Surgical ablation' above.) Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2016; 133:e506. 2. Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 18/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2020; 41:655. 3. Walker S, Cutting P. Impact of a modified Valsalva manoeuvre in the termination of paroxysmal supraventricular tachycardia. Emerg Med J 2010; 27:287. 4. Belardinelli L, Linden J, Berne RM. The cardiac effects of adenosine. Prog Cardiovasc Dis 1989; 32:73. 5. diMarco JP, Sellers TD, Lerman BB, et al. Diagnostic and therapeutic use of adenosine in patients with supraventricular tachyarrhythmias. J Am Coll Cardiol 1985; 6:417. 6. DiMarco JP, Sellers TD, Berne RM, et al. Adenosine: electrophysiologic effects and therapeutic use for terminating paroxysmal supraventricular tachycardia. Circulation 1983; 68:1254. 7. Exner DV, Muzyka T, Gillis AM. Proarrhythmia in patients with the Wolff-Parkinson-White syndrome after standard doses of intravenous adenosine. Ann Intern Med 1995; 122:351. 8. Dougherty AH, Gilman JK, Wiggins S, et al. Provocation of atrioventricular reentry tachycardia: a paradoxical effect of adenosine. Pacing Clin Electrophysiol 1993; 16:8. 9. DiMarco JP, Miles W, Akhtar M, et al. Adenosine for paroxysmal supraventricular tachycardia: dose ranging and comparison with verapamil. Assessment in placebo-controlled, multicenter trials. The Adenosine for PSVT Study Group. Ann Intern Med 1990; 113:104. 10. Rinkenberger RL, Prystowsky EN, Heger JJ, et al. Effects of intravenous and chronic oral verapamil administration in patients with supraventricular tachyarrhythmias. Circulation 1980; 62:996. 11. Sung RJ, Elser B, McAllister RG Jr. Intravenous verapamil for termination of re-entrant supraventricular tachycardias: intracardiac studies correlated with plasma verapamil concentrations. Ann Intern Med 1980; 93:682. 12. Jackman WM, Friday KJ, Fitzgerald DM, et al. Use of intracardiac recordings to determine the site of drug action in paroxysmal supraventricular tachycardia. Am J Cardiol 1988; 62:8L. 13. Kowey PR, Friehling TD, Marinchak RA. Electrophysiology of beta blockers in supraventricular arrhythmias. Am J Cardiol 1987; 60:32D. 14. Anderson S, Blanski L, Byrd RC, et al. Comparison of the efficacy and safety of esmolol, a short-acting beta blocker, with placebo in the treatment of supraventricular tachyarrhythmias. The Esmolol vs Placebo Multicenter Study Group. Am Heart J 1986; 111:42. 15. Mandel WJ, Laks MM, Obayashi K, et al. The Wolff-Parkinson-White syndrome: pharmacologic effects of procaine amide. Am Heart J 1975; 90:744. https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 19/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate 16. Wellens HJ. The wide QRS tachycardia. Ann Intern Med 1986; 104:879. 17. Kang KT, Potts JE, Radbill AE, et al. Permanent junctional reciprocating tachycardia in children: a multicenter experience. Heart Rhythm 2014; 11:1426. 18. Dorostkar PC, Silka MJ, Morady F, Dick M 2nd. Clinical course of persistent junctional reciprocating tachycardia. J Am Coll Cardiol 1999; 33:366. 19. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:2071. 20. Glatter KA, Dorostkar PC, Yang Y, et al. Electrophysiological effects of ibutilide in patients with accessory pathways. Circulation 2001; 104:1933. 21. Bianconi L, Boccadamo R, Pappalardo A, et al. Effectiveness of intravenous propafenone for conversion of atrial fibrillation and flutter of recent onset. Am J Cardiol 1989; 64:335. 22. Suttorp MJ, Kingma JH, Jessurun ER, et al. The value of class IC antiarrhythmic drugs for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm. J Am Coll Cardiol 1990; 16:1722. 23. Suttorp MJ, Kingma JH, Lie-A-Huen L, Mast EG. Intravenous flecainide versus verapamil for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm. Am J Cardiol 1989; 63:693. 24. Krahn AD, Klein GJ, Yee R. A randomized, double-blind, placebo-controlled evaluation of the efficacy and safety of intravenously administered dofetilide in patients with Wolff- Parkinson-White syndrome. Pacing Clin Electrophysiol 2001; 24:1258. 25. Garratt C, Antoniou A, Ward D, Camm AJ. Misuse of verapamil in pre-excited atrial fibrillation. Lancet 1989; 1:367. 26. Gulamhusein S, Ko P, Carruthers SG, Klein GJ. Acceleration of the ventricular response during atrial fibrillation in the Wolff-Parkinson-White syndrome after verapamil. Circulation 1982; 65:348. 27. McGovern B, Garan H, Ruskin JN. Precipitation of cardiac arrest by verapamil in patients with Wolff-Parkinson-White syndrome. Ann Intern Med 1986; 104:791. 28. Boriani G, Biffi M, Frabetti L, et al. Ventricular fibrillation after intravenous amiodarone in Wolff-Parkinson-White syndrome with atrial fibrillation. Am Heart J 1996; 131:1214. 29. Simonian SM, Lotfipour S, Wall C, Langdorf MI. Challenging the superiority of amiodarone for rate control in Wolff-Parkinson-White and atrial fibrillation. Intern Emerg Med 2010; 5:421. https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 20/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate 30. Sellers TD Jr, Bashore TM, Gallagher JJ. Digitalis in the pre-excitation syndrome. Analysis during atrial fibrillation. Circulation 1977; 56:260. 31. Jackman WM, Wang XZ, Friday KJ, et al. Catheter ablation of accessory atrioventricular pathways (Wolff-Parkinson-White syndrome) by radiofrequency current. N Engl J Med 1991; 324:1605. 32. Kuck KH, Schl ter M, Geiger M, et al. Radiofrequency current catheter ablation of accessory atrioventricular pathways. Lancet 1991; 337:1557. 33. Calkins H, Sousa J, el-Atassi R, et al. Diagnosis and cure of the Wolff-Parkinson-White syndrome or paroxysmal supraventricular tachycardias during a single electrophysiologic test. N Engl J Med 1991; 324:1612. 34. Chen SA, Tai CT. Ablation of atrioventricular accessory pathways: current technique-state of the art. Pacing Clin Electrophysiol 2001; 24:1795. 35. Calkins H, Langberg J, Sousa J, et al. Radiofrequency catheter ablation of accessory atrioventricular connections in 250 patients. Abbreviated therapeutic approach to Wolff- Parkinson-White syndrome. Circulation 1992; 85:1337. 36. Scheinman MM, Huang S. The 1998 NASPE prospective catheter ablation registry. Pacing Clin Electrophysiol 2000; 23:1020. 37. Aguinaga L, Primo J, Anguera I, et al. Long-term follow-up in patients with the permanent form of junctional reciprocating tachycardia treated with radiofrequency ablation. Pacing Clin Electrophysiol 1998; 21:2073. 38. Rodriguez LM, Geller JC, Tse HF, et al. Acute results of transvenous cryoablation of supraventricular tachycardia (atrial fibrillation, atrial flutter, Wolff-Parkinson-White syndrome, atrioventricular nodal reentry tachycardia). J Cardiovasc Electrophysiol 2002; 13:1082. 39. Wellens HJ. Should catheter ablation be performed in asymptomatic patients with Wolff- Parkinson-White syndrome? When to perform catheter ablation in asymptomatic patients with a Wolff-Parkinson-White electrocardiogram. Circulation 2005; 112:2201. 40. Pappone C, Santinelli V. Should catheter ablation be performed in asymptomatic patients with Wolff-Parkinson-White syndrome? Catheter ablation should be performed in asymptomatic patients with Wolff-Parkinson-White syndrome. Circulation 2005; 112:2207. 41. Chevalier P, Cadi F, Scridon A, et al. Prophylactic radiofrequency ablation in asymptomatic patients with Wolff-Parkinson-White is not yet a good strategy: a decision analysis. Circ Arrhythm Electrophysiol 2013; 6:185. https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 21/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate 42. Todd DM, Klein GJ, Krahn AD, et al. Asymptomatic Wolff-Parkinson-White syndrome: is it time to revisit guidelines? J Am Coll Cardiol 2003; 41:245. 43. Etheridge SP, Escudero CA, Blaufox AD, et al. Life-threatening event risk in children with Wolff-Parkinson-White syndrome: a multicenter international study. J Am Coll Cardiol EP 2018; 4:433. 44. Pappone C, Vicedomini G, Manguso F, et al. Wolff-Parkinson-White syndrome in the era of catheter ablation: insights from a registry study of 2169 patients. Circulation 2014; 130:811. 45. Pediatric and Congenital Electrophysiology Society (PACES), Heart Rhythm Society (HRS), American College of Cardiology Foundation (ACCF), et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson- White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm 2012; 9:1006. 46. Crossen KJ, Lindsay BD, Cain ME. Reliability of retrograde atrial activation patterns during ventricular pacing for localizing accessory pathways. J Am Coll Cardiol 1987; 9:1279. 47. Jackman WM, Friday KJ, Yeung-Lai-Wah JA, et al. New catheter technique for recording left free-wall accessory atrioventricular pathway activation. Identification of pathway fiber orientation. Circulation 1988; 78:598. 48. Denes P, Wyndham CR, Amat-y-Leon F, et al. Atrial pacing at multiple sites in the Wolff- Parkinson-White syndrome. Br Heart J 1977; 39:506. 49. Mitchell LB, Mason JW, Scheinman MM, et al. Recordings of basal ventricular preexcitation from electrode catheters in patients with accessory atrioventricular connections. Circulation 1984; 69:233. 50. Chen X, Borggrefe M, Shenasa M, et al. Characteristics of local electrogram predicting successful transcatheter radiofrequency ablation of left-sided accessory pathways. J Am Coll Cardiol 1992; 20:656. 51. Scheinman MM. Catheter ablation for cardiac arrhythmias, personnel, and facilities. North American Society of Pacing and Electrophysiology Ad Hoc Committee on Catheter Ablation. Pacing Clin Electrophysiol 1992; 15:715. 52. Kay GN, Epstein AE, Dailey SM, Plumb VJ. Role of radiofrequency ablation in the management of supraventricular arrhythmias: experience in 760 consecutive patients. J Cardiovasc Electrophysiol 1993; 4:371. https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 22/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate 53. Calkins H, Yong P, Miller JM, et al. Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachycardia, and the atrioventricular junction: final results of a prospective, multicenter clinical trial. The Atakr Multicenter Investigators Group. Circulation 1999; 99:262. 54. Dagres N, Clague JR, Kottkamp H, et al. Radiofrequency catheter ablation of accessory pathways. Outcome and use of antiarrhythmic drugs during follow-up. Eur Heart J 1999; 20:1826. 55. Bravo L, Atienza F, Eidelman G, et al. Safety and efficacy of cryoablation vs. radiofrequency ablation of septal accessory pathways: systematic review of the literature and meta- analyses. Europace 2018; 20:1334. 56. Backhoff D, Klehs S, Muller MJ, et al. Long-term follow-up after radiofrequency catheter ablation of accessory atrioventricular pathways in children. J Am Coll Cardiol EP 2018; 4:448. 57. Chen SA, Hsia CP, Chiang CE, et al. Reappraisal of radiofrequency ablation of multiple accessory pathways. Am Heart J 1993; 125:760. 58. Huang JL, Chen SA, Tai CT, et al. Long-term results of radiofrequency catheter ablation in patients with multiple accessory pathways. Am J Cardiol 1996; 78:1375. 59. Schweikert RA, Saliba WI, Tomassoni G, et al. Percutaneous pericardial instrumentation for endo-epicardial mapping of previously failed ablations. Circulation 2003; 108:1329. 60. Langberg JJ, Calkins H, Kim YN, et al. Recurrence of conduction in accessory atrioventricular connections after initially successful radiofrequency catheter ablation. J Am Coll Cardiol 1992; 19:1588. 61. Dagres N, Clague JR, Lottkamp H, et al. Impact of radiofrequency catheter ablation of accessory pathways on the frequency of atrial fibrillation during long-term follow-up; high recurrence rate of atrial fibrillation in patients older than 50 years of age. Eur Heart J 2001; 22:423. 62. Liu J, Dole LR. Late complete atrioventricular block complicating radiofrequency catheter ablation of a left posteroseptal accessory pathway. Pacing Clin Electrophysiol 1998; 21:2136. 63. Seidl K, Hauer B, Zahn R, Senges J. Unexpected complete AV block following transcatheter ablation of a left posteroseptal accessory pathway. Pacing Clin Electrophysiol 1998; 21:2139. 64. Kessler DJ, Pirwitz MJ, Horton RP, et al. Intracardiac shunts resulting from transseptal catheterization for ablation of accessory pathways in otherwise normal hearts. Am J Cardiol 1998; 82:391. 65. Fitchet A, Turkie W, Fitzpatrick AP. Transeptal approach to ablation of left-sided arrhythmias does not lead to persisting interatrial shunt: a transesophageal echocardiographic study. https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 23/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate Pacing Clin Electrophysiol 1998; 21:2070. 66. Kocovic DZ, Harada T, Shea JB, et al. Alterations of heart rate and of heart rate variability after radiofrequency catheter ablation of supraventricular tachycardia. Delineation of parasympathetic pathways in the human heart. Circulation 1993; 88:1671. 67. Psychari SN, Theodorakis GN, Koutelou M, et al. Cardiac denervation after radiofrequency ablation of supraventricular tachycardias. Am J Cardiol 1998; 81:725. 68. Hamdan MH, Page RL, Wasmund SL, et al. Selective parasympathetic denervation following posteroseptal ablation for either atrioventricular nodal reentrant tachycardia or accessory pathways. Am J Cardiol 2000; 85:875. 69. Cox JL, Gallagher JJ, Cain ME. Experience with 118 consecutive patients undergoing operation for the Wolff-Parkinson-White syndrome. J Thorac Cardiovasc Surg 1985; 90:490. 70. Lawrie GM, Lin HT, Wyndham CR, DeBakey ME. Surgical treatment of supraventricular arrhythmias. Results in 67 patients. Ann Surg 1987; 205:700. 71. Johnson DC, Nunn GR, Richards DA, et al. Surgical therapy for supraventricular tachycardia, a potentially curable disorder. J Thorac Cardiovasc Surg 1987; 93:913. 72. Holman WL, Kay GN, Plumb VJ, Epstein AE. Operative results after unsuccessful radiofrequency ablation for Wolff-Parkinson-White syndrome. Am J Cardiol 1992; 70:1490. 73. Kim SS, Lal R, Ruffy R. Treatment of paroxysmal reentrant supraventricular tachycardia with flecainide acetate. Am J Cardiol 1986; 58:80. 74. Ward DE, Jones S, Shinebourne EA. Use of flecainide acetate for refractory junctional tachycardias in children with the Wolff-Parkinson-White syndrome. Am J Cardiol 1986; 57:787. 75. Ludmer PL, McGowan NE, Antman EM, Friedman PL. Efficacy of propafenone in Wolff- Parkinson-White syndrome: electrophysiologic findings and long-term follow-up. J Am Coll Cardiol 1987; 9:1357. 76. Musto B, D'Onofrio A, Cavallaro C, Musto A. Electrophysiological effects and clinical efficacy of propafenone in children with recurrent paroxysmal supraventricular tachycardia. Circulation 1988; 78:863. 77. Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991; 324:781. 78. Rosenbaum MB, Chiale PA, Ryba D, Elizari MV. Control of tachyarrhythmias associated with Wolff-Parkinson-White syndrome by amiodarone hydrochloride. Am J Cardiol 1974; 34:215. https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 24/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate 79. Wellens HJ, Lie KI, B r FW, et al. Effect of amiodarone in the Wolff-Parkinson-White syndrome. Am J Cardiol 1976; 38:189. 80. Feld GK, Nademanee K, Weiss J, et al. Electrophysiologic basis for the suppression by amiodarone of orthodromic supraventricular tachycardias complicating pre-excitation syndromes. J Am Coll Cardiol 1984; 3:1298. 81. Chouty F, Coumel P. Oral flecainide for prophylaxis of paroxysmal atrial fibrillation. Am J Cardiol 1988; 62:35D. 82. Antman EM, Beamer AD, Cantillon C, et al. Long-term oral propafenone therapy for suppression of refractory symptomatic atrial fibrillation and atrial flutter. J Am Coll Cardiol 1988; 12:1005. 83. Kappenberger LJ, Fromer MA, Steinbrunn W, Shenasa M. Efficacy of amiodarone in the Wolff-Parkinson-White syndrome with rapid ventricular response via accessory pathway during atrial fibrillation. Am J Cardiol 1984; 54:330. 84. Feld GK, Nademanee K, Stevenson W, et al. Clinical and electrophysiologic effects of amiodarone in patients with atrial fibrillation complicating the Wolff-Parkinson-White syndrome. Am Heart J 1988; 115:102. Topic 996 Version 48.0 https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 25/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate GRAPHICS ECG in Wolff-Parkinson-White The 12-lead ECG shows the typical features of Wolff-Parkinson-White; the PR interval is short (*) and the QRS duration prolonged as a result of a delta wave (arrow), indicating ventricular preexcitation. Courtesy of Martin Burke, DO. Graphic 67181 Version 3.0 Normal ECG https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 26/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate Normal electrocardiogram showing normal sinus rhythm at a rate of 75 beats/minute, a PR interval of 0.14 seconds, a QRS interval of 0.10 seconds, and a QRS axis of approximately 75 . Courtesy of Ary Goldberger, MD. Graphic 76183 Version 4.0 https://www.uptodate.com/contents/treatment-of-arrhythmias-associated-with-the-wolff-parkinson-white-syndrome/print 27/40 7/6/23, 3:09 PM Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome - UpToDate Medical therapy of arrhythmias associated with Wolff-Parkinson-White syndrome Arrhythmia Treatment options Contraindicated therapies Orthodromic AV reentrant tachycardia Acute termination* Unstable patients: Synchronized cardioversion Stable patients: First line: Vagal maneuvers Second line: IV adenosine Third line: IV verapamil OR IV diltiazem Other therapies: IV procainamide OR IV beta blocker; synchronized cardioversion if other therapies are ineffective or not feasible 