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Difficulties with invasive risk stratification performed under anesthesia in pediatric Wolff-Parkinson-White Syndrome
Mark H Shwayder1, Carolina A Escudero2, Susan P Etheridge1
1Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah.
Insights
Electrophysiology lab tests for Wolff-Parkinson-White Syndrome (WPW) in children do not reliably predict risk. Measurements taken under anesthesia may misclassify patients, questioning their use for risk stratification.
Area of Science:
- Pediatric Cardiology
- Electrophysiology
- Cardiac Arrhythmias
Background:
- Children with Wolff-Parkinson-White Syndrome (WPW) face risks of sudden cardiac death.
- The shortest pre-excited RR interval during atrial fibrillation (SPERRI) is the established standard for risk assessment in these patients.
Purpose of the Study:
- To compare electrophysiology laboratory measurements with the clinical gold standard (Clinical-SPERRI) for risk stratification in pediatric WPW patients.
- To evaluate the correlation between in-laboratory measurements and SPERRI obtained during actual clinical episodes of pre-excited atrial fibrillation.
Main Methods:
- A subgroup analysis of 49 children with WPW from a multicenter study.
- Inclusion criteria required measurement of Clinical-SPERRI alongside at least one surrogate: EP-SPERRI, accessory pathway effective refractory period (APERP), or shortest pre-excited paced cycle length (SPPCL).
- Seventy percent of electrophysiological measurements were performed under general anesthesia.
Main Results:
- Clinical-SPERRI showed moderate correlation with EP-SPERRI (r=0.495, P=.012).
- A significant 24% of patients with high-risk Clinical-SPERRI (≤250 ms) were misclassified as low-risk by EP-SPERRI (>250 ms).
- Clinical-SPERRI did not correlate with APERP or SPPCL (r<0.3, P>.1), and these parameters were consistently higher than Clinical-SPERRI.
Conclusions:
- Electrophysiology laboratory measurements, particularly those under general anesthesia, do not accurately reflect risk determined by Clinical-SPERRI.
- EP-SPERRI demonstrated only moderate correlation, while APERP and SPPCL showed poor correlation.
- The findings challenge the utility of invasive risk stratification using these in-anesthesia measurements due to potential misclassification of high-risk patients.
Background:
Children with Wolff-Parkinson-White Syndrome (WPW) are at risk for sudden death. The gold standard for risk stratification in this population is the shortest pre-excited RR interval during atrial fibrillation (SPERRI).
Objective:
The purpose of this study was to determine how closely measurements made in the electrophysiology laboratory in patients with WPW compared to SPERRI obtained during an episode of clinical pre-excited atrial fibrillation (Clinical-SPERRI).
Methods:
This was a subgroup analysis of a multicenter study of children with WPW. Subjects in our study (N = 49) were included if they had Clinical-SPERRI measured in addition to 1 or more of 3 surrogate measurements: SPERRI obtained during electrophysiological study (EP-SPERRI), accessory pathway effective refractory period (APERP), or shortest pre-excited paced cycle length with 1:1 conduction (SPPCL).
Results:
Seventy percent of electrophysiological measurements were made with patients under general anesthesia. Clinical-SPERRI moderately correlated with EP-SPERRI (r = 0.495; P = .012). However, 24% of our patients with Clinical-SPERRI ≤250 ms would have been misclassified as having a low-risk pathway based on EP-SPERRI >250 ms. Clinical-SPERRI did not correlate with APERP or SPPCL (r < 0.3; P >.1). Mean EP-SPERRI, APERP, and SPPCL all were greater than Clinical-SPERRI.
Conclusion:
Electrophysiology laboratory measurements of pathway characteristics made with patients under general anesthesia do not correlate well with Clinical-SPERRI. Of APERP, SPPCL, and EP-SPERRI, only EP-SPERRI had moderate correlation with Clinical-SPERRI. This study questions the predictive ability of invasive risk stratification with patients under general anesthesia, given that 24% of patients with high-risk Clinical-SPERRI (≤250 ms) had EP-SPERRI that may be considered low risk (>250 ms).
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