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Original article
Prevalence, causes of reappearance of symptoms or preexcitation syndrome after ablation of accessory pathway and management Prévalence et causes de la réapparition de symptômes ou d’un syndrome de préexcitation ventriculaire après ablation d’un faisceau accessoire et conduite à tenir C. Federspiel , B. Brembilla-Perrot ∗ Cardiology, CHU of Brabois, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France Received 1st October 2013; accepted 3 January 2014 Available online 15 January 2014
Abstract Aim. – The purpose of the study was to look for the prevalence, significance and management of preexcitation syndrome (PS) or symptoms reappearance after accessory pathway (AP) ablation. AP ablation actually is the first treatment of PS. Methods. – Successful AP ablation was performed in 261 patients; reappearance of symptoms or PS on ECG occurred in 47 patients (18%) from 20 minutes to several years. Their data were compared with remaining patients. Results. – Recurrences were more frequent in patients with spontaneous malignant form (34 vs. 21%), in congenital heart disease (4.2 vs. 0%) (P < 0.002), in case of complication (11 vs. 2%) (P < 0.007) and of a longer duration of applications (304 ± 209 vs. 188 ± 182 sec) (P < 0.019). Forty percent of patients had the same symptoms and electrophysiological data as before ablation. Twenty-four percent had an improvement of symptoms and/or electrophysiological data. However, 3 initially asymptomatic patients became symptomatic after ablation. Twenty-six percent had another AP or another rhythm disorder. We recommend transesophageal electrophysiological study for the control because only 40% of patients required second ablation. Conclusions. – Reappearance of symptoms or a PS on ECG after AP ablation was not rare (18%) and was inconsistently associated with the reappearance of all initial AP electrophysiological properties. Only 40% of patients required a second AP ablation. Another arrhythmia was possible. Non-invasive second evaluation should be preferred. However, asymptomatic patients before ablation could become symptomatic. © 2014 Elsevier Masson SAS. All rights reserved. Keywords: Accessory pathway; Ablation; Follow-up; Electrophysiological study
Résumé Le but de l’étude a été d’évaluer la prévalence, la signification et la conduite à tenir en cas de réapparition d’un syndrome de préexcitation ventriculaire (SPV) ou de symptômes après l’ablation d’un faisceau accessoire (FA), traitement de choix actuel du SPV. Méthodes. – L’ablation d’un FA a été réalisée avec succès chez 261 patients ; la réapparition de symptômes ou du SPV est survenue chez 47 patients (18 %) entre 20 minutes jusqu’à plusieurs années. Leurs données ont été comparées à celles des autres patients. Résultats. – Les récidives ont été plus fréquentes chez les sujets avec une forme maligne spontanée (34 vs 21 %), en cas de cardiopathie congénitale (4,2 vs 0 %) (p < 0,0002), en cas de complication (11 vs 2 %) (p < 0,007) et d’une plus grande longueur des applications (304 ± 209 vs 188 ± 182 sec) (p < 0,019). Quarante pour cent des patients avaient les mêmes symptômes et données électrophysiologiques qu’avant l’ablation. Vingt-quatre pour cent avaient une amélioration des symptômes et/ou des données électrophysiologiques. Cependant, 3 patients initialement asymptomatiques étaient devenus symptomatiques après l’ablation. Vingt-six pour cent avaient un autre FA ou un autre trouble du rythme. Nous recommandons une exploration électrophysiologique transœsophagienne pour le contrôle car seulement 40 % des patients nécessitaient une 2e ablation.
∗
Corresponding author. E-mail address: [email protected] (B. Brembilla-Perrot).
0003-3928/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.ancard.2014.01.009
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Conclusions. – La réapparition de symptômes ou d’un SPV après l’ablation d’un FA n’a pas été rare (18 %) mais était inconstamment associée à une réapparition des propriétés initiales du FA. Seulement 40 % des patients nécessitaient une seconde ablation. Une autre arythmie était possible. Une seconde exploration non invasive devrait être préférée. Cependant, des patients asymptomatiques avant l’ablation pouvaient devenir symptomatiques après. © 2014 Elsevier Masson SAS. Tous droits réservés. Mots clés : Faisceau accessoire ; Ablation ; Suivi ; Étude électrophysiologique
1. Introduction Radiofrequency ablation of the accessory pathway (AP) is the usual treatment of symptomatic preexcitation and of asymptomatic preexcitation with signs of malignancy at electrophysiological study [1,2]. However, a recurrence of symptoms and/or preexcitation on the electrocardiogram may occur in some patients. The main objective of the study was to evaluate the recurrence rate and the factors associated with recurrence of symptoms and/or preexcitation on the electrocardiogram after ablation of overt AP. The second objective was to evaluate the electrophysiological data after reappearance and to define the methods of risk assessment after recurrence. 2. Patients and methods
(n = 1), atrioventricular block (n = 4) with 2 permanent complete AV block requiring the implantation of a pace-maker and 2 regressive complete AV blocks, hematoma at the puncture site (n = 3) (Table 1). 2.2. Electrophysiological study (EPS) EPS was performed without sedation as previously described [3]. Briefly incremental atrial pacing until the highest rate conducted 1/1 through the AP and/or the atrioventricular (AV) node and programmed atrial stimulation were performed. When a fast supraventricular tachycardia was induced, the protocol was stopped. In absence of induction of a tachycardia conducted through the AP at a rate higher than 250 bpm, isoproterenol (0.02 to 1 g.min−1 ) was infused to increase the sinus rate to at least 130 bpm and the pacing protocol was repeated.
2.1. Patients
2.3. Definitions
Between 1994 and 2011, 297 patients, 181 males, 116 females; mean age 34 ± 16.5 years, with an overt AP were referred for accessory pathway radiofrequency ablation. They were issued from a group of 765 patients consecutively referred for the evaluation of a preexcitation syndrome. Patients with concealed AP and those with an indication of ablation which was not performed (patient refusal, anteroseptal accessory pathway with high-risk of atrioventricular block) were excluded from the study. Ablation was successful in 261 patients. The success was defined as the anterograde and retrograde conduction lost at least 20 minutes after the last radiofrequency application. The patients were from 10 to 76 years old (mean 36 ± 16 years). Twenty patients had an underlying heart disease: ischemic heart disease (n = 6), valvular heart disease (n = 4), tachycardiomyopathy (n = 3), alcoholic dilated cardiomyopathy (n = 1), hypertensive heart disease (n = 1), idiopathic dilated cardiomyopathy (n = 1), Fabry disease cardiomyopathy (n = 1), history of closure of the ductus artriosus (n = 1), Ebstein’s anomaly (n = 1), and left ventricular non-compaction (n = 1). Ablation was unsuccessful in 36 patients, aged from 12 to 76 years (mean 38 ± 20). Failure of ablation was related to several causes as inadequate contact of ablation’s catheter, a broad AP, the occurrence of a major complication as tamponade or complete atrioventricular block, the intermittent conduction in the AP, the induction of a sustained atrial fibrillation and/or an extended procedure. These patients refused a second ablation. Among the total population, 11 patients (3.7%) had a major complication: tamponade (n = 4), transitory ischemic stroke
The AP’s location was determined with the 12-lead ECG recorded in maximal preexcitation and then by the study of retrograde conduction over AP. The diagnosis of multiple accessory pathways was retained only if AP’s had different locations as left lateral and septal or right lateral and septal or left lateral and right lateral: in the left free wall location, the ablation could require the application of radiofrequency energy apparently at two sites, but it could be the same large accessory pathway. In the posteroseptal location left and right septal applications can be required to suppress the preexcitation. Table 1 Details on the AP ablation-related major complications. Complication
Number
Age
Sex
AP location
Tamponade
4 (1.3%)
22 31 66 51
M F F M
LPS AS LL LL
AV block
4 (1.3%)
50 49 42 49
F M M M
LPS AS LPS RPS
Stroke
1 (0.3%)
31
M
LL
Pseudoaneurysm requiring surgery
3 (1%)
61
F
LL
55 66
F M
LL LPS
AP: accessory pathway; AS: anteroseptal; LL: left lateral; LPS: left posteroseptal; RPS: right posteroseptal.
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Sustained AF or reciprocating tachycardia was defined as a tachycardia that lasted longer than 1 minute. Conduction over the AP was evaluated by the measurement of the shortest atrial cycle length at which there was 1 to 1 conduction over the AP and the shortest atrial tachycardia cycle length at which there was 1 to 1 conduction over the AP. AP effective refractory period was determined at a cycle length of 600 ms and 400 ms in control state and only 400 ms after isoproterenol. WPW syndrome was considered as malignant and at risk of sudden death when the shortest RR interval between preexcited beats was less than 250 ms in the control state or less than 200 ms after isoproterenol during induced sustained AF. Orthodromic tachycardia induction alone was not considered as a criterion for a high-risk form of preexcitation syndrome. 2.4. Ablation The clinical history associated with the information collected during the electrophysiological study has identified four indications of ablation:
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2.5. Follow-up Systematic electrocardiogram was recorded after ablation, the first day after ablation, and one month later. Then the follow-up varied from 6 months to 10 years (mean 5 ± 4 years). Second intracardiac and/or esophageal electrophysiologic study was performed in all patients with a recurrence of symptoms and/or preexcitation. The intracardiac route was only proposed in patients with recurrence of symptoms and reappearance of preexcitation (n = 20). Transesophageal study, previously shown as reliable as the intracardiac route [4], fast, of low-cost was performed in remaining patients. 2.6. Statistical analysis Variables were expressed in mean (± standard difference) or in percentage. A Chi2 test or Fisher was used for continuous variables and a Student’s test or Wilcoxon was used for the quantitative variables. A value of P < 0.05 was considered as significant. 3. Results
• spontaneous malignant form (rapid and poorly-tolerated atrial fibrillation or recovered cardiac arrest after ventricular fibrillation); • asymptomatic form with criteria of malignancy during the electrophysiological study, defined above [2]; • symptomatic form (atrioventricular reentrant tachycardia) without criteria of malignancy during the electrophysiological study; • symptomatic form (atrioventricular reentrant tachycardia) with criteria of malignancy during the electrophysiological study. The ablations were performed by the same senior operator with different fellows. To perform ablation, a 7F deflectable catheter with a 4 mm electrode was used. Accessory pathway ablation was made with conventional methods by the research of the site where atrioventricular conduction was the shortest in bipolar and unipolar recording. Left accessory pathway was approached by retrograde catheterism except in the case of patent foramen ovale. At this level, a radiofrequency current was applied with energy of 40 to 50 watts and a temperature of 65◦ . The application was stopped if preexcitation did not disappear within a maximum of 15 seconds; otherwise it was continued for 60 seconds. Exceptionally, an irrigated tip catheter was used to deliver a lower energy for rare posteroseptal accessory pathways identified in the coronary sinus. The disappearance of retrograde conduction over accessory pathway was verified by systematic ventricular pacing. If it was still present, a new application of radiofrequency current was performed by locating the site where retrograde atrial activation in tachycardia or during ventricular stimulation was the earliest. The catheters were removed 20 minutes after the disappearance of the anterograde and retrograde conduction in the accessory pathway.
3.1. Recurrence rate Symptoms and/or aspect of preexcitation recurred in 47 patients (18%) among 261 patients in whom ablation was initially considered as successful: • in 27 patients (57%), the aspect of preexcitation reappeared on the ECG; • in 20 patients (43%), the aspect of preexcitation did not reappear but these patients complained again of tachycardia. 3.2. Factors associated with recurrence of symptoms and/or preexcitation Statistically, there was no significant difference between the group “with recurrence” and the group “without recurrence” regarding the age, the gender, the indication of ablation except for the spontaneous malignant form, the location of the accessory pathway, the existence of an underlying heart disease and the number of radiofrequency energy applications (Table 2). Only 2 patients had 2 accessory pathway’s in our population and ablation was successful in these 2 patients. There was a tendency for more frequent posteroseptal AP location. Concerning the age, there was tendency for younger age that could favor the reappearance, but only 11 patients were younger than 19 years. Statistically, there was a significant difference between the group “with recurrence” and the group “without recurrence” regarding the presence of a congenital heart disease, the initial presentation as spontaneous malignant form, the occurrence of a minor complication (chest pain, haematoma, atrial fibrillation requiring intravenous drug) more frequent in case of recurrence and the longer duration of radiofrequency energy applications in case of recurrences.
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Table 2 Factors associated with recurrence of symptoms and/or preexcitation. With recurrence n = 47 (18%)
Without recurrence n = 214 (82%)
n
n
%/mean
Sex Male Female
26 21
55% 45%
Indication of ablation Spontaneous malignant form Symptomatic form Asymptomatic form with criteria of malignancy during EPS Symptomatic form with criteria of malignancy during EPS
16 23 4 4
34% 49% 8.5% 8.5%
Electrophysiological data Highest rate conducted 1/1 through AP in basal state (bpm) Anterograde refractory period in basal state (ms) Highest rate conducted1/1 through AP under isoproterenol Anterograde refractory period under Isoproterenol (ms) Location of AP Left lateral AP Posteroseptal AP Anteroseptal AP Right lateral AP Mahaim
%/mean
33 ± 16
Age
P
37 ± 16
0.075
135 79
63% 37%
0.322 0.322
44 112 26 32
21% 52% 12% 15%
0.047 0.673 0.479 0.247
211 ± 66 261 ± 60 263 ± 68 210 ± 40
0.6 0.6 0.5 0.1
217 ± 63 252 ± 84 252 ± 75 172 ± 54 18 27 1 1 0
14.5% 23% 14% 12.5% 0%
106 91 6 7 4
85% 77% 86% 87.5% 100%
Underlying HD Congenital HD
3 2
6% 4.2%
17 0
8% 0%
0.716 0.002
Occurrence of a complication
5
11%
5
2%
0.007
Number of applications
10 ± 7
8±8
0.191
Duration of applications (in ms)
304 ± 209
188 ± 182
0.019
EPS: electrophysiologic study; AP: accessory pathway; HD: heart disease.
3.3. Clinical and electrophysiological characteristics noted in case of recurrence Among patients in whom the aspect of preexcitation reappeared on the ECG (n = 27), 19 patients had a total recurrence of their symptoms and of the electrophysiological characteristics of the AP; one patient with symptomatic spontaneous malignant form became asymptomatic; 3 asymptomatic patients with a malignant form at electrophysiologic study and without inducible orthodromic tachycardia before ablation became symptomatic with the occurrence of spontaneous orthodromic atrioventricular reentrant tachycardia; 4 patients who had a spontaneous malignant form before ablation at electrophysiological study remained asymptomatic and had a benign form at the second electrophysiological study. At second electrophysiological study, one patient had a transitory reappearance of preexcitation just after ablation but there was no anterograde and retrograde conduction over AP at the control. In other patients, the anterograde conduction was not as good as during the study before ablation mainly in 7 patients, but the values were significant only for the highest rate conducted through AP in the basal state (Table 3). Among patients with recurrence of symptoms but ECG normal in sinus rhythm (n = 20), 10 patients had symptoms related to another arrhythmia: atrioventricular nodal reentrant (n = 2),
atrial fibrillation (n = 3), inappropriate sinus tachycardia (n = 5). The retrograde conduction reappeared in 5 patients (11%). All of them had inducible reentrant tachycardia. Two patients had a second AP that had only a retrograde conduction. Three patients were lost of view after one month and the cause of symptoms recurrence was not established. Finally, only 40% of patients had the same symptoms and electrophysiological data as before ablation. However, 3 initially asymptomatic patients, who had improved their electrophysiological data, became symptomatic after ablation. 3.4. Time of recurrence of symptoms and/or preexcitation Symptoms and/or a preexcitation reappeared within a time between few minutes after the end of the procedure and several years (Table 4). The maximal time was 14 years. A long delay was generally associated with another arrhythmia-related symptom. However, the delays of reappearance of a preexcitation syndrome at ECG were very variable. 3.5. Follow-up Among the 27 patients with always an indication of AP ablation, a second ablation procedure was performed in 24 patients with a persistent success in 21 patients (success rate
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Table 3 Electrophysiological data before and after ablation in patients with reappearance of preexcitation syndrome after ablation. Before ablation Highest rate conducted through AP in basal state (bpm) Anterograde refractory period basal state (ms) Highest rate conducted through AP under isoproterenol (bpm) Anterograde refractory period under isoproterenol (ms)
217 252 252 172
± ± ± ±
63 84 75 54
After ablation 170 288 223 227
± ± ± ±
75 32 97 41
P 0.02 0.161 0.436 0.07
AP: accessory pathway.
88%), a failure in 1 patient and a second recurrence in 2 patients. A second ablation procedure was not performed in 3 patients (patient refusal or little symptomatic patient). Remaining patients became asymptomatic or had lost the character of gravity of their preexcitation and were not treated. After a follow-up of 3.5 ± 2.5 years, they remained asymptomatic. 4. Discussion Ablation of accessory pathway is largely indicated in preexcitation syndrome. However, the recurrence rate varied from 7.8 to 9.6% in the literature [5–10]. In our study, the rate of reappearance of symptoms and/or preexcitation was 18% but only 10% of patients had a second indication of ablation of the AP. The overall success rate was relatively low, but these results concerned the first procedure of ablation and we have not used mapping software. The recurrence of symptoms was not always associated with a reappearance of the AP. Ten patients had in fact symptoms associated with another arrhythmia, atrioventricular nodal reentrant, atrial fibrillation, inappropriate sinus tachycardia. Similar findings were previously reported by Oddsson et al. [11]. The authors reported that 94% patients with a long history of tachyarrhythmias due to the WPW syndrome reported improved physical well-being after ablation, but palpitations were common during a 2-year follow-up period; 8% continued to use pharmacological antiarrhythmic treatment. Five percent had symptomatic relapses and in 6% atrial fibrillation episodes reoccurred, i.e., in half of those who had atrial fibrillation before ablation. Paradoxically, there were also 3 asymptomatic patients who initially had a malignant asymptomatic form and who became, after ablation, symptomatic with occurrence of orthodromic atrioventricular reentrant tachycardia. So the ablation procedure could transform the electrophysiological characteristics of AP
and cause the occurrence of symptoms in asymptomatic patients before ablation [12]. Moreover, a second indication of the AP was not always required in patients with a reappearance of the preexcitation syndrome at ECG. AP was probably damaged during ablation and anterograde conduction became less good. Anterograde conduction could have disappeared with persistence of isolated retrograde conduction. Only 40% of patients had a total recurrence of AP characteristics. Therefore, non-invasive testing as exercise test and transesophageal electrophysiological study, which can be performed in the out-clinic patients should be performed before the indication of a second ablation. Indications may be extended to symptomatic patients without reappearance of preexcitation syndrome on ECG or to asymptomatic patients with a reappearance of preexcitation syndrome [13]. In the present study, the occurrence of a complication, the initial presentation with malignant form and a high duration of applications were factors, which were associated with a higher recurrence rate. Generally, these factors were the results of a complicated procedure by the young age of the patient, the occurrence of frequent tachycardia or an unusual accessory pathway location. We could not demonstrate that children had more recurrence risks due to their small number. Langberg et al. [6] demonstrated that patients of “with recurrence” group were younger and received a higher number of radiofrequency applications. Regarding the AP location, some authors [5–7,9,14] have demonstrated that posteroseptal and right lateral locations of the accessory pathway were associated with a higher recurrence rate, probably. It was found in our study a tendency for less recurrence for left lateral AP. The absence of significant difference was probably due to their small number. As in the study of Schläpfer and Fromer [10], most of patients with reappearance of other disease-related symptoms had these symptoms more than one month after ablation. Unlike other
Table 4 Correlation between the recurrence time and the causes of recurrence. Another arrhythmia was related to atrioventricular nodal reentrant tachycardia (n = 2), atrial fibrillation (= 3), inappropriate sinus tachycardia (n = 5). Recurrence time
Anterograde or only retrograde conduction over AP or another AP (symptomatic or not) n = 37
Reappearance of symptoms associated with another arrhythmia n = 10
Greater than 1 month Between 48 hours and 1 month Below to 48 hours Unknown
14 (38%) 8 (22%) 13 (35%) 2 (5%)
8 (80%) 1 (10%) 1 (10%) 0
AP: accessory pathway.
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studies in which the reappearance of AP usually occurred rather early generally before the first month after ablation [10], but sometimes 2 or 3 months after ablation [5,7,9], in our study, patients had a recurrence of AP in an highly variable time which could range from some minutes to several years. Recurrence of symptoms or a PS on ECG after AP ablation was inconsistently associated with the reappearance of all initial AP electrophysiological properties. Only 40% of patients required a second AP ablation. Non-invasive second evaluation should be preferred. The study shows that the need for national guidelines dealing with clinical strategy in patients with PS is important [15,16]. Duration of applications was higher in patients with recurrence AP group. Irrigation system may be effective in these cases and was not used in the present study. Holter ECG was not systematic in asymptomatic patients after ablation. Some intermittent preexcitation could have been missed. We have excluded patients with a concealed AP. Some authors [7,8] found a higher recurrence rate in patients with a concealed AP compared with patients with an overt AP. The time of AP disappearance time after the beginning of effective application and the duration of this effective application have not been studied because we did not collect data for all patients. Finally, the relatively small number of patients who had recurrences did not allow demonstrating significant differences such as age of the patient. 5. Conclusion The reappearance rate of symptoms and/or preexcitation was high (18%) but only 10% of patients required a second ablation of their AP. Only 40% of patients had a total recurrence of AP characteristics. But there was also a risk of transformation of an asymptomatic form into a symptomatic form, reminding that an AP is not harmless. Factors associated with the reappearance of symptoms and/or preexcitation were a high duration of total number of radiofrequency applications, the presence of congenital heart disease and the initial presentation as a spontaneous malignant form. On the other hand, patients with left lateral AP had fewer recurrences. The reappearance of symptoms and/or preexcitation should lead to another electrophysiological study but inconstantly to another indication of ablation. Therefore, transesophageal study performed in the out-clinic patients should be preferred to evaluate the significance of symptoms or the properties of the preexcitation syndrome after an initial apparently successful AP ablation. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, et al. Writing committee to develop guidelines for the management of patients with supraventricular arrhythmias. Circulation 2003;108:1871–909. [2] 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;112:2201–7. [3] Brembilla-Perrot B, Tatar C, Suty-Selton C. Risk factors of adverse presentation as the first arrhythmia in Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol 2010;33:1074–81. [4] Samson RA, Deal BJ, Strasburger JF, Benson Jr DW. Comparison of transesophageal and intracardiac electrophysiologic studies in characterization of supraventricular tachycardia in pediatric patients. J Am Coll Cardiol 1995;26:159–63. [5] Timmermans C, Smeets JLRM, Rodriguez LM, Oreto G, Medina E, Notheis W, et al. Recurrence rate after accessory pathway ablation. Br Heart J 1994;72:571–4. [6] Langberg JJ, Calkins H, Kim YN, Sousa J, el-Atassi R, Leon A, et al. Recurrence of conduction in accessory atrioventricular connections after initially successful radiofrequency catheter ablation. J Am Coll Cardiol 1992;19:1588–92. [7] Twidale N, Wang X, Beckman KJ, McClelland JH, Moulton KP, Prior MI, et al. Factors associated with recurrence of accessory pathway conduction after radiofrequency catheter ablation. PACE 1991;14:2042–8. [8] Chen SA, Chiang CE, Tsang WP, Hsia CP, Wang DC, Yeh HI, et al. Recurrent conduction in accessory pathway and possible new arrhythmias after radiofrequency catheter ablation. Am Heart J 1993;125:381–7. [9] Calkins H, Yong P, Miller JM, Olshansky B, Carlson M, Saul JP, et al. Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachycardia, and the atrioventricular junction: final results of a prospective, multicenter clinical trial. Circulation 1999;99:262–70. [10] Schläpfer J, Fromer M. Late clinical outcome after successful radiofrequency catheter ablation of accessory pathway. Eur Heart J 2001;22:605–9. [11] Oddsson H, Walfridsson H, Edvardsson N. Perception and documentation of arrhythmias after successful radiofrequency catheter ablation of accessory pathways. Ann Noninvasive Electrocardiol 2001;6:216–21. [12] Brembilla-Perrot B, Carette B, Houriez P, Beurrier D. Transformation of asymptomatic Wolff-Parkinson-White into a symptomatic form as a result of the ablation of the bundle of Kent. Ann Cardiol Angeiol 2001;50:202–5. [13] Brembilla-Perrot B, Groben L, Chometon F, Lethor JP, Admant P, Cloez JL, et al. Rapid and low-cost method to prove the nature of no documented tachycardia in children and teenagers without preexcitation syndrome. Europace 2009;11:1083–9. [14] Van Hare G, Javitz H, Carmelli D, Saul JP, Tanel RE, Fischbach PS, et al. Prospective assessment after pediatric cardiac ablation: recurrence at 1 year after initially successful ablation of supraventricular tachycardia. Heart Rhythm 2004;1:188–96. [15] Svendsen JH, Dagres N, Dobreanu D, Bongiorni MG, Marinskis G, Blomström-Lundqvist C. Current strategy for treatment of patients with Wolff-Parkinson-White syndrome and asymptomatic preexcitation in Europe: European Heart Rhythm Association survey. Europace 2010;15:750–3. [16] Cohen MI, Triedman JK, Cannon BC, Davis AM, Drago F, Janousek J, 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;9:1006–24.
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Original article
Prevalence, causes of reappearance of symptoms or preexcitation syndrome after ablation of accessory pathway and management Prévalence et causes de la réapparition de symptômes ou d’un syndrome de préexcitation ventriculaire après ablation d’un faisceau accessoire et conduite à tenir C. Federspiel , B. Brembilla-Perrot ∗ Cardiology, CHU of Brabois, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France Received 1st October 2013; accepted 3 January 2014 Available online 15 January 2014
Abstract Aim. – The purpose of the study was to look for the prevalence, significance and management of preexcitation syndrome (PS) or symptoms reappearance after accessory pathway (AP) ablation. AP ablation actually is the first treatment of PS. Methods. – Successful AP ablation was performed in 261 patients; reappearance of symptoms or PS on ECG occurred in 47 patients (18%) from 20 minutes to several years. Their data were compared with remaining patients. Results. – Recurrences were more frequent in patients with spontaneous malignant form (34 vs. 21%), in congenital heart disease (4.2 vs. 0%) (P < 0.002), in case of complication (11 vs. 2%) (P < 0.007) and of a longer duration of applications (304 ± 209 vs. 188 ± 182 sec) (P < 0.019). Forty percent of patients had the same symptoms and electrophysiological data as before ablation. Twenty-four percent had an improvement of symptoms and/or electrophysiological data. However, 3 initially asymptomatic patients became symptomatic after ablation. Twenty-six percent had another AP or another rhythm disorder. We recommend transesophageal electrophysiological study for the control because only 40% of patients required second ablation. Conclusions. – Reappearance of symptoms or a PS on ECG after AP ablation was not rare (18%) and was inconsistently associated with the reappearance of all initial AP electrophysiological properties. Only 40% of patients required a second AP ablation. Another arrhythmia was possible. Non-invasive second evaluation should be preferred. However, asymptomatic patients before ablation could become symptomatic. © 2014 Elsevier Masson SAS. All rights reserved. Keywords: Accessory pathway; Ablation; Follow-up; Electrophysiological study
Résumé Le but de l’étude a été d’évaluer la prévalence, la signification et la conduite à tenir en cas de réapparition d’un syndrome de préexcitation ventriculaire (SPV) ou de symptômes après l’ablation d’un faisceau accessoire (FA), traitement de choix actuel du SPV. Méthodes. – L’ablation d’un FA a été réalisée avec succès chez 261 patients ; la réapparition de symptômes ou du SPV est survenue chez 47 patients (18 %) entre 20 minutes jusqu’à plusieurs années. Leurs données ont été comparées à celles des autres patients. Résultats. – Les récidives ont été plus fréquentes chez les sujets avec une forme maligne spontanée (34 vs 21 %), en cas de cardiopathie congénitale (4,2 vs 0 %) (p < 0,0002), en cas de complication (11 vs 2 %) (p < 0,007) et d’une plus grande longueur des applications (304 ± 209 vs 188 ± 182 sec) (p < 0,019). Quarante pour cent des patients avaient les mêmes symptômes et données électrophysiologiques qu’avant l’ablation. Vingt-quatre pour cent avaient une amélioration des symptômes et/ou des données électrophysiologiques. Cependant, 3 patients initialement asymptomatiques étaient devenus symptomatiques après l’ablation. Vingt-six pour cent avaient un autre FA ou un autre trouble du rythme. Nous recommandons une exploration électrophysiologique transœsophagienne pour le contrôle car seulement 40 % des patients nécessitaient une 2e ablation.
∗
Corresponding author. E-mail address: [email protected] (B. Brembilla-Perrot).
0003-3928/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.ancard.2014.01.009
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Conclusions. – La réapparition de symptômes ou d’un SPV après l’ablation d’un FA n’a pas été rare (18 %) mais était inconstamment associée à une réapparition des propriétés initiales du FA. Seulement 40 % des patients nécessitaient une seconde ablation. Une autre arythmie était possible. Une seconde exploration non invasive devrait être préférée. Cependant, des patients asymptomatiques avant l’ablation pouvaient devenir symptomatiques après. © 2014 Elsevier Masson SAS. Tous droits réservés. Mots clés : Faisceau accessoire ; Ablation ; Suivi ; Étude électrophysiologique
1. Introduction Radiofrequency ablation of the accessory pathway (AP) is the usual treatment of symptomatic preexcitation and of asymptomatic preexcitation with signs of malignancy at electrophysiological study [1,2]. However, a recurrence of symptoms and/or preexcitation on the electrocardiogram may occur in some patients. The main objective of the study was to evaluate the recurrence rate and the factors associated with recurrence of symptoms and/or preexcitation on the electrocardiogram after ablation of overt AP. The second objective was to evaluate the electrophysiological data after reappearance and to define the methods of risk assessment after recurrence. 2. Patients and methods
(n = 1), atrioventricular block (n = 4) with 2 permanent complete AV block requiring the implantation of a pace-maker and 2 regressive complete AV blocks, hematoma at the puncture site (n = 3) (Table 1). 2.2. Electrophysiological study (EPS) EPS was performed without sedation as previously described [3]. Briefly incremental atrial pacing until the highest rate conducted 1/1 through the AP and/or the atrioventricular (AV) node and programmed atrial stimulation were performed. When a fast supraventricular tachycardia was induced, the protocol was stopped. In absence of induction of a tachycardia conducted through the AP at a rate higher than 250 bpm, isoproterenol (0.02 to 1 g.min−1 ) was infused to increase the sinus rate to at least 130 bpm and the pacing protocol was repeated.
2.1. Patients
2.3. Definitions
Between 1994 and 2011, 297 patients, 181 males, 116 females; mean age 34 ± 16.5 years, with an overt AP were referred for accessory pathway radiofrequency ablation. They were issued from a group of 765 patients consecutively referred for the evaluation of a preexcitation syndrome. Patients with concealed AP and those with an indication of ablation which was not performed (patient refusal, anteroseptal accessory pathway with high-risk of atrioventricular block) were excluded from the study. Ablation was successful in 261 patients. The success was defined as the anterograde and retrograde conduction lost at least 20 minutes after the last radiofrequency application. The patients were from 10 to 76 years old (mean 36 ± 16 years). Twenty patients had an underlying heart disease: ischemic heart disease (n = 6), valvular heart disease (n = 4), tachycardiomyopathy (n = 3), alcoholic dilated cardiomyopathy (n = 1), hypertensive heart disease (n = 1), idiopathic dilated cardiomyopathy (n = 1), Fabry disease cardiomyopathy (n = 1), history of closure of the ductus artriosus (n = 1), Ebstein’s anomaly (n = 1), and left ventricular non-compaction (n = 1). Ablation was unsuccessful in 36 patients, aged from 12 to 76 years (mean 38 ± 20). Failure of ablation was related to several causes as inadequate contact of ablation’s catheter, a broad AP, the occurrence of a major complication as tamponade or complete atrioventricular block, the intermittent conduction in the AP, the induction of a sustained atrial fibrillation and/or an extended procedure. These patients refused a second ablation. Among the total population, 11 patients (3.7%) had a major complication: tamponade (n = 4), transitory ischemic stroke
The AP’s location was determined with the 12-lead ECG recorded in maximal preexcitation and then by the study of retrograde conduction over AP. The diagnosis of multiple accessory pathways was retained only if AP’s had different locations as left lateral and septal or right lateral and septal or left lateral and right lateral: in the left free wall location, the ablation could require the application of radiofrequency energy apparently at two sites, but it could be the same large accessory pathway. In the posteroseptal location left and right septal applications can be required to suppress the preexcitation. Table 1 Details on the AP ablation-related major complications. Complication
Number
Age
Sex
AP location
Tamponade
4 (1.3%)
22 31 66 51
M F F M
LPS AS LL LL
AV block
4 (1.3%)
50 49 42 49
F M M M
LPS AS LPS RPS
Stroke
1 (0.3%)
31
M
LL
Pseudoaneurysm requiring surgery
3 (1%)
61
F
LL
55 66
F M
LL LPS
AP: accessory pathway; AS: anteroseptal; LL: left lateral; LPS: left posteroseptal; RPS: right posteroseptal.
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Sustained AF or reciprocating tachycardia was defined as a tachycardia that lasted longer than 1 minute. Conduction over the AP was evaluated by the measurement of the shortest atrial cycle length at which there was 1 to 1 conduction over the AP and the shortest atrial tachycardia cycle length at which there was 1 to 1 conduction over the AP. AP effective refractory period was determined at a cycle length of 600 ms and 400 ms in control state and only 400 ms after isoproterenol. WPW syndrome was considered as malignant and at risk of sudden death when the shortest RR interval between preexcited beats was less than 250 ms in the control state or less than 200 ms after isoproterenol during induced sustained AF. Orthodromic tachycardia induction alone was not considered as a criterion for a high-risk form of preexcitation syndrome. 2.4. Ablation The clinical history associated with the information collected during the electrophysiological study has identified four indications of ablation:
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2.5. Follow-up Systematic electrocardiogram was recorded after ablation, the first day after ablation, and one month later. Then the follow-up varied from 6 months to 10 years (mean 5 ± 4 years). Second intracardiac and/or esophageal electrophysiologic study was performed in all patients with a recurrence of symptoms and/or preexcitation. The intracardiac route was only proposed in patients with recurrence of symptoms and reappearance of preexcitation (n = 20). Transesophageal study, previously shown as reliable as the intracardiac route [4], fast, of low-cost was performed in remaining patients. 2.6. Statistical analysis Variables were expressed in mean (± standard difference) or in percentage. A Chi2 test or Fisher was used for continuous variables and a Student’s test or Wilcoxon was used for the quantitative variables. A value of P < 0.05 was considered as significant. 3. Results
• spontaneous malignant form (rapid and poorly-tolerated atrial fibrillation or recovered cardiac arrest after ventricular fibrillation); • asymptomatic form with criteria of malignancy during the electrophysiological study, defined above [2]; • symptomatic form (atrioventricular reentrant tachycardia) without criteria of malignancy during the electrophysiological study; • symptomatic form (atrioventricular reentrant tachycardia) with criteria of malignancy during the electrophysiological study. The ablations were performed by the same senior operator with different fellows. To perform ablation, a 7F deflectable catheter with a 4 mm electrode was used. Accessory pathway ablation was made with conventional methods by the research of the site where atrioventricular conduction was the shortest in bipolar and unipolar recording. Left accessory pathway was approached by retrograde catheterism except in the case of patent foramen ovale. At this level, a radiofrequency current was applied with energy of 40 to 50 watts and a temperature of 65◦ . The application was stopped if preexcitation did not disappear within a maximum of 15 seconds; otherwise it was continued for 60 seconds. Exceptionally, an irrigated tip catheter was used to deliver a lower energy for rare posteroseptal accessory pathways identified in the coronary sinus. The disappearance of retrograde conduction over accessory pathway was verified by systematic ventricular pacing. If it was still present, a new application of radiofrequency current was performed by locating the site where retrograde atrial activation in tachycardia or during ventricular stimulation was the earliest. The catheters were removed 20 minutes after the disappearance of the anterograde and retrograde conduction in the accessory pathway.
3.1. Recurrence rate Symptoms and/or aspect of preexcitation recurred in 47 patients (18%) among 261 patients in whom ablation was initially considered as successful: • in 27 patients (57%), the aspect of preexcitation reappeared on the ECG; • in 20 patients (43%), the aspect of preexcitation did not reappear but these patients complained again of tachycardia. 3.2. Factors associated with recurrence of symptoms and/or preexcitation Statistically, there was no significant difference between the group “with recurrence” and the group “without recurrence” regarding the age, the gender, the indication of ablation except for the spontaneous malignant form, the location of the accessory pathway, the existence of an underlying heart disease and the number of radiofrequency energy applications (Table 2). Only 2 patients had 2 accessory pathway’s in our population and ablation was successful in these 2 patients. There was a tendency for more frequent posteroseptal AP location. Concerning the age, there was tendency for younger age that could favor the reappearance, but only 11 patients were younger than 19 years. Statistically, there was a significant difference between the group “with recurrence” and the group “without recurrence” regarding the presence of a congenital heart disease, the initial presentation as spontaneous malignant form, the occurrence of a minor complication (chest pain, haematoma, atrial fibrillation requiring intravenous drug) more frequent in case of recurrence and the longer duration of radiofrequency energy applications in case of recurrences.
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Table 2 Factors associated with recurrence of symptoms and/or preexcitation. With recurrence n = 47 (18%)
Without recurrence n = 214 (82%)
n
n
%/mean
Sex Male Female
26 21
55% 45%
Indication of ablation Spontaneous malignant form Symptomatic form Asymptomatic form with criteria of malignancy during EPS Symptomatic form with criteria of malignancy during EPS
16 23 4 4
34% 49% 8.5% 8.5%
Electrophysiological data Highest rate conducted 1/1 through AP in basal state (bpm) Anterograde refractory period in basal state (ms) Highest rate conducted1/1 through AP under isoproterenol Anterograde refractory period under Isoproterenol (ms) Location of AP Left lateral AP Posteroseptal AP Anteroseptal AP Right lateral AP Mahaim
%/mean
33 ± 16
Age
P
37 ± 16
0.075
135 79
63% 37%
0.322 0.322
44 112 26 32
21% 52% 12% 15%
0.047 0.673 0.479 0.247
211 ± 66 261 ± 60 263 ± 68 210 ± 40
0.6 0.6 0.5 0.1
217 ± 63 252 ± 84 252 ± 75 172 ± 54 18 27 1 1 0
14.5% 23% 14% 12.5% 0%
106 91 6 7 4
85% 77% 86% 87.5% 100%
Underlying HD Congenital HD
3 2
6% 4.2%
17 0
8% 0%
0.716 0.002
Occurrence of a complication
5
11%
5
2%
0.007
Number of applications
10 ± 7
8±8
0.191
Duration of applications (in ms)
304 ± 209
188 ± 182
0.019
EPS: electrophysiologic study; AP: accessory pathway; HD: heart disease.
3.3. Clinical and electrophysiological characteristics noted in case of recurrence Among patients in whom the aspect of preexcitation reappeared on the ECG (n = 27), 19 patients had a total recurrence of their symptoms and of the electrophysiological characteristics of the AP; one patient with symptomatic spontaneous malignant form became asymptomatic; 3 asymptomatic patients with a malignant form at electrophysiologic study and without inducible orthodromic tachycardia before ablation became symptomatic with the occurrence of spontaneous orthodromic atrioventricular reentrant tachycardia; 4 patients who had a spontaneous malignant form before ablation at electrophysiological study remained asymptomatic and had a benign form at the second electrophysiological study. At second electrophysiological study, one patient had a transitory reappearance of preexcitation just after ablation but there was no anterograde and retrograde conduction over AP at the control. In other patients, the anterograde conduction was not as good as during the study before ablation mainly in 7 patients, but the values were significant only for the highest rate conducted through AP in the basal state (Table 3). Among patients with recurrence of symptoms but ECG normal in sinus rhythm (n = 20), 10 patients had symptoms related to another arrhythmia: atrioventricular nodal reentrant (n = 2),
atrial fibrillation (n = 3), inappropriate sinus tachycardia (n = 5). The retrograde conduction reappeared in 5 patients (11%). All of them had inducible reentrant tachycardia. Two patients had a second AP that had only a retrograde conduction. Three patients were lost of view after one month and the cause of symptoms recurrence was not established. Finally, only 40% of patients had the same symptoms and electrophysiological data as before ablation. However, 3 initially asymptomatic patients, who had improved their electrophysiological data, became symptomatic after ablation. 3.4. Time of recurrence of symptoms and/or preexcitation Symptoms and/or a preexcitation reappeared within a time between few minutes after the end of the procedure and several years (Table 4). The maximal time was 14 years. A long delay was generally associated with another arrhythmia-related symptom. However, the delays of reappearance of a preexcitation syndrome at ECG were very variable. 3.5. Follow-up Among the 27 patients with always an indication of AP ablation, a second ablation procedure was performed in 24 patients with a persistent success in 21 patients (success rate
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Table 3 Electrophysiological data before and after ablation in patients with reappearance of preexcitation syndrome after ablation. Before ablation Highest rate conducted through AP in basal state (bpm) Anterograde refractory period basal state (ms) Highest rate conducted through AP under isoproterenol (bpm) Anterograde refractory period under isoproterenol (ms)
217 252 252 172
± ± ± ±
63 84 75 54
After ablation 170 288 223 227
± ± ± ±
75 32 97 41
P 0.02 0.161 0.436 0.07
AP: accessory pathway.
88%), a failure in 1 patient and a second recurrence in 2 patients. A second ablation procedure was not performed in 3 patients (patient refusal or little symptomatic patient). Remaining patients became asymptomatic or had lost the character of gravity of their preexcitation and were not treated. After a follow-up of 3.5 ± 2.5 years, they remained asymptomatic. 4. Discussion Ablation of accessory pathway is largely indicated in preexcitation syndrome. However, the recurrence rate varied from 7.8 to 9.6% in the literature [5–10]. In our study, the rate of reappearance of symptoms and/or preexcitation was 18% but only 10% of patients had a second indication of ablation of the AP. The overall success rate was relatively low, but these results concerned the first procedure of ablation and we have not used mapping software. The recurrence of symptoms was not always associated with a reappearance of the AP. Ten patients had in fact symptoms associated with another arrhythmia, atrioventricular nodal reentrant, atrial fibrillation, inappropriate sinus tachycardia. Similar findings were previously reported by Oddsson et al. [11]. The authors reported that 94% patients with a long history of tachyarrhythmias due to the WPW syndrome reported improved physical well-being after ablation, but palpitations were common during a 2-year follow-up period; 8% continued to use pharmacological antiarrhythmic treatment. Five percent had symptomatic relapses and in 6% atrial fibrillation episodes reoccurred, i.e., in half of those who had atrial fibrillation before ablation. Paradoxically, there were also 3 asymptomatic patients who initially had a malignant asymptomatic form and who became, after ablation, symptomatic with occurrence of orthodromic atrioventricular reentrant tachycardia. So the ablation procedure could transform the electrophysiological characteristics of AP
and cause the occurrence of symptoms in asymptomatic patients before ablation [12]. Moreover, a second indication of the AP was not always required in patients with a reappearance of the preexcitation syndrome at ECG. AP was probably damaged during ablation and anterograde conduction became less good. Anterograde conduction could have disappeared with persistence of isolated retrograde conduction. Only 40% of patients had a total recurrence of AP characteristics. Therefore, non-invasive testing as exercise test and transesophageal electrophysiological study, which can be performed in the out-clinic patients should be performed before the indication of a second ablation. Indications may be extended to symptomatic patients without reappearance of preexcitation syndrome on ECG or to asymptomatic patients with a reappearance of preexcitation syndrome [13]. In the present study, the occurrence of a complication, the initial presentation with malignant form and a high duration of applications were factors, which were associated with a higher recurrence rate. Generally, these factors were the results of a complicated procedure by the young age of the patient, the occurrence of frequent tachycardia or an unusual accessory pathway location. We could not demonstrate that children had more recurrence risks due to their small number. Langberg et al. [6] demonstrated that patients of “with recurrence” group were younger and received a higher number of radiofrequency applications. Regarding the AP location, some authors [5–7,9,14] have demonstrated that posteroseptal and right lateral locations of the accessory pathway were associated with a higher recurrence rate, probably. It was found in our study a tendency for less recurrence for left lateral AP. The absence of significant difference was probably due to their small number. As in the study of Schläpfer and Fromer [10], most of patients with reappearance of other disease-related symptoms had these symptoms more than one month after ablation. Unlike other
Table 4 Correlation between the recurrence time and the causes of recurrence. Another arrhythmia was related to atrioventricular nodal reentrant tachycardia (n = 2), atrial fibrillation (= 3), inappropriate sinus tachycardia (n = 5). Recurrence time
Anterograde or only retrograde conduction over AP or another AP (symptomatic or not) n = 37
Reappearance of symptoms associated with another arrhythmia n = 10
Greater than 1 month Between 48 hours and 1 month Below to 48 hours Unknown
14 (38%) 8 (22%) 13 (35%) 2 (5%)
8 (80%) 1 (10%) 1 (10%) 0
AP: accessory pathway.
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studies in which the reappearance of AP usually occurred rather early generally before the first month after ablation [10], but sometimes 2 or 3 months after ablation [5,7,9], in our study, patients had a recurrence of AP in an highly variable time which could range from some minutes to several years. Recurrence of symptoms or a PS on ECG after AP ablation was inconsistently associated with the reappearance of all initial AP electrophysiological properties. Only 40% of patients required a second AP ablation. Non-invasive second evaluation should be preferred. The study shows that the need for national guidelines dealing with clinical strategy in patients with PS is important [15,16]. Duration of applications was higher in patients with recurrence AP group. Irrigation system may be effective in these cases and was not used in the present study. Holter ECG was not systematic in asymptomatic patients after ablation. Some intermittent preexcitation could have been missed. We have excluded patients with a concealed AP. Some authors [7,8] found a higher recurrence rate in patients with a concealed AP compared with patients with an overt AP. The time of AP disappearance time after the beginning of effective application and the duration of this effective application have not been studied because we did not collect data for all patients. Finally, the relatively small number of patients who had recurrences did not allow demonstrating significant differences such as age of the patient. 5. Conclusion The reappearance rate of symptoms and/or preexcitation was high (18%) but only 10% of patients required a second ablation of their AP. Only 40% of patients had a total recurrence of AP characteristics. But there was also a risk of transformation of an asymptomatic form into a symptomatic form, reminding that an AP is not harmless. Factors associated with the reappearance of symptoms and/or preexcitation were a high duration of total number of radiofrequency applications, the presence of congenital heart disease and the initial presentation as a spontaneous malignant form. On the other hand, patients with left lateral AP had fewer recurrences. The reappearance of symptoms and/or preexcitation should lead to another electrophysiological study but inconstantly to another indication of ablation. Therefore, transesophageal study performed in the out-clinic patients should be preferred to evaluate the significance of symptoms or the properties of the preexcitation syndrome after an initial apparently successful AP ablation. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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