Wolff-Parkinson-White Apresentado como QRS Alternante e Outros Diagnósticos Diferenciais em uma Grande Coorte de Triagem de ECG Pré-Participação / Wolff-Parkinson-White Presenting as QRS Alternans and Other Differential Diagnoses in a Large Pre-Participation ECG Screening Cohort

Resumo Fundamento A síndrome de Wolff-Parkinson-White (WPW) é uma condição pró-arrítmica que pode exigir restrição de atividades extenuantes e é caracterizada por sinais de ECG, incluindo ondas delta. Observamos casos de padrões intermitentes de WPW apresentando-se como QRS alternante ('WPW alternante') em uma grande coorte de triagem de ECG pré-participação de homens jovens que se candidataram ao recrutamento militar. Objetivos Nosso objetivo foi determinar o padrão de WPW alternante, as características do caso e a prevalência de outros diagnósticos diferenciais relevantes apresentando-se como alternância de QRS em um ambiente de pré-participação. Métodos Cento e vinte e cinco mil cento e cinquenta e oito recrutas militares do sexo masculino prospectivos foram revisados de janeiro de 2016 a dezembro de 2019. Uma revisão de prontuários médicos eletrônicos identificou casos de WPW alternante e padrões ou síndrome de WPW. A revisão de prontuários médicos eletrônicos identificou casos de diagnósticos diferenciais relevantes que podem causar alternância de QRS. Resultados Quatro indivíduos (2,2%) apresentaram WPW alternante em 184 indivíduos com diagnóstico final de padrão ou síndrome de WPW. Dois desses indivíduos manifestaram sintomas ou achados eletrocardiográficos compatíveis com taquicardia supraventricular. A prevalência geral de WPW alternante foi de 0,003%, e a prevalência de WPW foi de 0,147%. As WPW alternantes representaram 8,7% dos indivíduos com QRS alternantes, e QRS alternantes tiveram prevalência de 0,037% em toda a população. Conclusões A WPW alternante é uma variante da WPW intermitente, que compreendeu 2,2% dos casos de WPW em nossa coorte de triagem pré-participação. Não indica necessariamente um baixo risco de taquicardia supraventricular. Deve ser reconhecido na triagem de ECG e distinguido de outras patologias que também apresentam QRS alternantes.

Abstract Background Wolff-Parkinson-White (WPW) syndrome is a proarrhythmic condition that may require restriction from strenuous activities and is characterized by ECG signs, including delta waves. We observed cases of intermittent WPW patterns presenting as QRS alternans ('WPW alternans') in a large pre-participation ECG screening cohort of young men reporting for military conscription. Objectives We aimed to determine the WPW alternans pattern, case characteristics, and the prevalence of other relevant differential diagnoses presenting as QRS alternans in a pre-participation setting. Methods One hundred twenty-five thousand one hundred fifty-eight prospective male military recruits were reviewed from January 2016 to December 2019. A review of electronic medical records identified cases of WPW alternans and WPW patterns or syndrome. Reviewing electronic medical records identified cases of relevant differential diagnoses that might cause QRS alternans. Results Four individuals (2.2%) had WPW alternans out of 184 individuals with a final diagnosis of WPW pattern or syndrome. Two of these individuals manifested symptoms or ECG findings consistent with supraventricular tachycardia. The overall prevalence of WPW alternans was 0.003%, and the prevalence of WPW was 0.147%. WPW alternans represented 8.7% of individuals presenting with QRS alternans, and QRS alternans had a prevalence of 0.037% in the entire population. Conclusions WPW alternans is a variant of intermittent WPW, which comprised 2.2% of WPW cases in our pre-participation screening cohort. It does not necessarily indicate a low risk for supraventricular tachycardia. It must be recognized at ECG screening and distinguished from other pathologies that also present with QRS alternans.

Decitabine combined with full鄄dose and long鄄term pre鄄excitation regimen for treatment of relapsed/refractory acute myeloid leukemia: a clinical study of 32 cases / 白血病·淋巴瘤

Objective To observe the clinical efficacy and adverse events of decitabine combined with full_dose and long_term pre_excitation regimen as a induction therapy for relapsed/refractory acute myeloid leukemia (AML). Methods A total of 32 patients with relapsed/refractory AML in Henan Provincial Cancer Hospital from May 2013 to February 2018 were enrolled. All the patients were treated with decitabine combined with full_dose and long_term pre_excitation regimen, including 15 patients who received decitabine combined with CAG regiemtn, and 17 patients who received decitabine combined with CHAG regimen: 25 mg decitabine, intravenous drip, from day 1 to day 3; cytarabine (10-15 mg/m2) administered subcutaneously every 12 h one time, from day 4 to day 17 or more; homoharringtonine (1 mg/m2) intravenous drip, administered intravenously from day 4 to day 10 or more; aclacinomycin (8-10 mg/m2), intravenous drip, administered intravenously from day 4 to day 11 or more; granulocyte colony_stimulating factor (G_CSF) (100-200 μg/m2), subcutaneous injection, and it began 1 day before chemotherapy, adjusted according to the blood cell count; the therapeutic effect and adverse reactions of the patients were observed. Results There were 29 patients (90.6% ) with complete remission (CR), 3 patients (9.4% ) with partial remission (PR), and the overall response (CR+PR) rate was 100.0% (32/32). In decitabine combined with CAG regimen group, 13 patients achieved CR; in decitabine combined with CHAG regimen group, 16 patients achieved CR, and there was no statistically significant difference in the efficacy between the two groups (P＝0.589). The main adverse reactions were agranulocytosis, thrombocytopenia, secondary infection and fever, and no serious adverse events occurred. Conclusion Decitabine combined with full_dose and long_term pre_excitation regimen has a favorable efficacy and safety, which provides a new therapy for relapsed/refractory AML.

Clinical and prognostic analysis of accessory pathway-induced dilated cardiomyopathy after catheter ablation in children / 中华心血管病杂志

Objective@#To investigate the clinical characteristics and prognostic factors after catheter ablation of accessory pathway (AP)-induced dilated cardiomyopathy (DCM) in children.@*Methods@#Data were collected and analyzed on 147 consecutive pediatric patients (81males and 66 females), who hospitalized in our pediatric heart center between January 2009 and August 2018 and received catheter ablation for ventricular pre-excitation (right AP). Thirty-one children were diagnosed as AP-induced DCM and 116 children with normal cardiac function served as control. Data including clinical characteristics, electrocardiogram (ECG), echocardiography, electrophysiological examination (EPS), successful ablation and follow up were analyzed.@*Results@#The median age at first examination was 3.07 (0.09, 5.83) years. The pre-hospital misdiagnosis rate was 87.1% (27/31). The incidence of the AP-induced DCM was 21.1% (31/147) and the rate of right anterior free wall accessory pathway (AP) was the highest (50.0%, 10/20). AP-induced DCM was more common in right free wall Aps (41.9%, 13/31) and right anterior free wall (32.3%, 10/31). 48.4% (15/31) cases had no supraventricular tachycardia (SVT). EPS showed that 29% (9/31) of the AP did not have retrograde conduction. The median follow-up time after successful catheter ablation was 8 (2, 36) months of AP-induced DCM group, LVDd was significantly decreased ((41.6±12.8)mm vs. (45.6±13.9)mm, P<0.01) and LVEF ((56.2±11.8)% vs. (40.8±12.5)%, P<0.01) was significantly increased after ablation. Cox regression analysis showed that LVEF was the predictor of the duration of cardiac function recovery (HR=1.08, 95%CI 1.01-1.15, P=0.03).@*Conclusions@#Misdiagnosis rate is high for children with AP-induced DCM, leading to the delayed treatment. All of the AP-induced DCM occurred in right APs and right anterior free wall APs is the highest. Right free wall APs and right anterior free wall are most common in AP-induced DCM. Catheter ablation is a safe and effective treatment option for these patients. The lower the LVEF, the longer the cardiac function recovery.

Accessory pathway induced dilated cardiomyopathy / 中华实用儿科临床杂志

Accessory pathway-induced dilated cardiomyopathy is a new diagnosis proposed recently.Pre-excitation of part of the myocardium may mediate electrical and mechanical dyssynchrony,which will result in decreased left ventricular systolic function and increased diameter of left ventricle in patients with right-sided overt accessory pathways (type B ventricular preexcitation).Its features are listed as follows:(1) Incessant and prolonged tachyarrhythmia never happened.Tachycardiomyopathy and other causes of dilated cardiomyopathy are excluded.(2) Right-sided overt accessory pathways are shown by electrocardiogram.(3)Echocardiography indicates dyssynchronous left ventricle contraction,decreased left ventricular systolic function and increased diameter of left ventricle.Normal interventricular septal motion,recovered left ventricular and reversed left ventricular remodeling can be realized by radiofrequency ablation with a good prognosis.To infant patients,taking anti arrhythmia drugs to inhibit the conduction of the accessory pathway was recommended.

Evaluation of left ventricular movement in patients with type B Wolff-Parkinson-White syndrome / 中华超声影像学杂志

Objective To investigate the left ventricular (LV) torsion parameters of type B WolffParkinson-White syndrome (B-WPW) and to explore alternation of the left ventricular motion pattern in patients with B-WPW.Methods Thirty-eight patients with B-WPW were studied.And 40 volunteers were selected as control.Two-dimensional speckle tracking imaging (2D-STI) was used to acquire left ventricular torsion parameters,including peak value and time to peak value of LV twist,LV apex rotation,and LV base rotation.Apical-basal rotation delay (RDA-B) was calculated.Biplane Simpson method was used to measure LV end-diastolic volume (LVEDV),end-systolic volume (LVESV) and ejection fraction (LVEF).All above parameters were measured in patients with B-WPW before (B-WPW-B group) and after (B-WPW-A group) radiofrequency catheter ablation and in control group.The QRS width of lead Ⅱ was recorded,and the relationships between all above parameters with the RDA-B or QRS width were analyzed.Results Compared with the contrd group,in patients with B-WPW,the peak value of LV apex rotation (RotA),LV base rotation (RotB) and LV twist (TwistLV) were lower(LV base was more obvious than LV apex)(P ＜0.05),the time to RotB (TTPB) was shorter (P =0.004),RDAB was longer(P =0.002),the left ventricular enlarged and the QRS prolonged (P =0.000).After radiofrequency catheter ablation,the left ventricular torsion parameters in patients with B-WPW recovered significantly(P ＜0.05),but still lower than those in the control group(P ＜0.05).Conclusions The left ventricular motion pattern of patients with B-WPW alters,including the changes of peak value and time to peak value in LV apex rotation,LV base rotation and LV twist,as well as LV myocardium dyssynchrony.The motion pattern of LV in patients with B-WPW is improved in acute stage after radiofrequency catheter ablation but not yet recover totally.

Left ventricular noncompaction and pre-excitation: an unusual finding in adults

Left ventricular noncompaction (LVNC) is a rare form of cardiomyopathy characterized by prominent left ventricular (LV) trabeculae, deep intertrabecular recesses, and the thin compacted layer. The disease is potentially associated with sudden cardiac death due to LV dysfunction and ventricular arrhythmias. The presence of accessory pathway and Wolff-Parkinson-White syndrome is particularly rare in adults. Here we describe the rare association of LVNC and ventricular pre-excitation in an 18-year-old female with neonatal hypoxic brain injury (AU)

Prevalence Survey of Pre-excitation and Wolff-Parkinson-White Syndrome in Adolescents in Beijing Area / 中国循环杂志

Objective:To study the prevalence of pre-excitation and Wolff-Parkinson-White (WPW) syndrome in adolescents in Beijing area. Methods: A total of 19 484 adolescents at the age of (15-20) years from Xicheng district of Beijing and the freshmen from Peking University were enrolled for our survey; 12-lead electrocardiography (ECG) screening was conducted and the diagnosis, classification of pre-excitation, WPW syndrome were recorded. The follow-up study was performed in relevant patients. Results: There were 19 389 qualiifed ECG obtained, among them, 30 (0.15%) patients with ventricular pre-excitation and WPW syndrome identiifed including 17 male (0.17%) and 13 (0.13%) female, the prevalence between male and female was similar (χ2=0.495,P>0.05). There were 6/19389 (0.03%) patients with palpitation and 2 (0.01%) documented by super-ventricular tachycardia. There were 16/30 (53.33%) patients with type A and 14(46.7%) with type B ventricular pre-excitation, the prevalence between male and female was similar (χ2=4.693,P>0.05). The patients were followed-up at the mean of 2.5 (1.5-3) years and no malignant arrhythmia events occurred. Conclusion: In this cohort survey, prevalence of pre-excitation and WPW syndrome is about 0.15% in adolescents from (15-20) years in Beijing area; the prevalence is similar between male and female subjects.

Intermittent Pre-Excitation-Syndrome in Facio-Scapulo-Humeral Muscular Dystrophy

Pre-excitation-syndrome has not been reported as a phenotypic feature of facio-scapulo-humeral muscular dystrophy (FSH-MD). In a 39-year-old male with FSH-MD due to a reduced tandem repeat size in the D4Z4-locus on chromosome 4q35, cardiac involvement, manifesting as an incomplete right bundle-branch-block, tall T-waves in V 3-5, ST-elevation in V 2-4, and mild thickening of the left ventricular myocardium, was first recognised 10 years earlier. Follow-up at age 39 years revealed mild myocardial thickening, two intra-ventricular aberrant bands, and, surprisingly, intermittent pre-excitation on a routine electrocardiography. Cardiac involvement in FSH-MD may manifest as hypertrophic cardiomyopathy or various arrhythmias, of which one may be pre-excitation-syndrome.

The correlation between wide QRS of transesophageal atrial pacing and implicit ventricular pre-excitation / 中国基层医药

Objective To explore the correlation between wide QRS of transesophageal atrial pacing (TEAP) and implicit ventricular pre-excitation.Methods 77 patients tested by TEAP were divided into two groups according to the ECG results .45 patients in group Ⅰhad normal electrocardiogram .32 patients in group Ⅱhad ven-tricular pre-excitation.In group Ⅰ,TEAP results showed that electric pulse wave (S wave) was followed by intermit-tent or continuous wide QRS complex .At the same time , the results of group Ⅰ were compared with the results of groupⅡ.Results (1)The patients of group Ⅰwere excluded the presence of concealed accessory pathway by intra-cavitary electrocardiographic test,among them 20 patients (group ⅠA) were ventricular pacing,the test results dis-played that S wave was followed by wide QRS complex exhibiting a pattern of right bundle branch block ( RBBB) ,SR interval was 0 s;SR intervals of 25 patients (groupⅠB) were not fixed,SR interval was (0.07 ±0.01)s,S wave had no concern with QRS wave ,the wide QRS complex was premature ventricular contraction ,QRS wave shapes were dif-ferent according to the different sites of pacing origin .(2)In groupⅡ,the test results displayed that S wave was close-ly followed by the atrial depolarization wave P ,and there was a wide QRS complex with pre-excitation wave at the be-ginning after a atrioventricular conduction time shorter than normal ,SR interval was fixed ,SR interval was (0.08 ±0. 03)s,at the same time,different parts of accessory pathway QRS complex had different morphological characteristics . (3) SR interval of ⅠA group compared with groupⅠB and groupⅡ,the differences were statistically significant ( t=2.97,3.02,all P0.05).Conclusion When TEAP displaying pacing wide QRS complex ,in order to avoid bringing misdiag-nosis,TEAP results should be analyzed comprehensively rather than blindly believing that the reason was concealed accessory pathway .

A Case of Left Ventricular Noncompaction Accompanying Fasciculo-Ventricular Accessory Pathway and Atrial Flutter

Left ventricular hypertrabeculation/noncompaction (LVHT) is an uncommon type of genetic cardiomyopathy characterized by trabeculations and recesses within the ventricular myocardium. LVHT is associated with diastolic or systolic dysfunction, thromboembolic complications, and arrhythmias, including atrial fibrillation, ventricular arrhythmias, atrioventricular block and Wolff-Parkinson-White syndrome. Herein, we describe a patient who presented with heart failure and wide-complex tachycardia. Echocardiography showed LVHT accompanied with severe mitral regurgitation. The electrophysiologic study revealed a fasciculo-ventricular accessory pathway and atrial flutter (AFL). The AFL was successfully treated with catheter ablation.

Anomalía de Ebstein en edad adulta / Ebstein anomaly in adulthood

La anomalía de Ebstein es una malformación congénita poco frecuente caracterizada por el adosamiento de los elementos de la válvula tricúspide en la cavidad del ventrículo derecho. Este adosamiento produce un desplazamiento del orificio fisiológico de la válvula tricúspide hacia la cavidad del ventrículo derecho. Generalmente se asocia a alteraciones propias de la válvula, como insuficiencia o estenosis tricuspídea, así con el desarrollo de insuficiencia cardiaca y la presencia de arritmias y síndrome de preexcitación. Aunque es un diagnóstico propio del neonato o del niño, se han descrito pacientes diagnosticados en la edad adulta. En estos últimos, la forma de presentación varía, y puede ir desde encontrarse asintomático hasta comenzar con arritmias. Se presenta el caso de una paciente de 70 años de edad que ingresó con el diagnóstico de flutter auricular, se decide cardioversión eléctrica retornando a ritmo sinusal. Al realizarle el ecocardiograma se diagnostica la anomalía de Ebstein. Se revisan las características clínicas, exámenes complementarios y tratamientos de esta entidad, así como la anatomía y embriología del aparato valvular tricuspídeo. El ecocardiograma continúa siendo el examen complementario de elección en esta entidad.

Ebstein anomaly is a non-frequent congenital malformation characterized by enclosing of tricuspid valve elements in right ventricle cavity. This enclosing produces a move of physiologic orifice of tricuspid valve within the right ventricle valve. Generally, it is associated with alterations typical of this valve, as insufficiency or tricuspid stenosis, as well as the development of heart insufficiency and the presence of arrhythmias and pre-excitation syndrome. Although it is a diagnosis characteristic of neonate or the children, has described patients diagnosed in adulthood. In past years, its presentation varies, and may be asymptomatic of start with arrhythmias. This is a female case presentation aged 70 admitted with a diagnosis of atrial flutter, thus the electric cardioversion to return to sinusal rhythm. In echocardiogram it is diagnosed an Ebstein anomaly. Clinical features, complementary examinations and treatment of this entity, as well as the anatomy and embryology of tricuspid valvular apparatus. Echocardiogram is the choice complementary examination in this entity.

Catheter Ablation of a Left Free-Wall Accessory Pathway via the Radial Artery Approach

Catheter ablation of the left free-wall accessory pathways (APs) is normally performed by the retrograde transaortic approach via a femoral artery or the transseptal approach. Here we report a case of an overt left free-wall AP, which was successfully ablated with a retrograde transaortic approach via the radial artery without any vascular complications. The patient has remained free of any symptoms or pre-excitation observed on the ECG during a 10-month post- ablation follow-up.

Applied research of Doppler tissue imaging technique in evaluating accessory pathways in pre-excitation syndrome / 中华超声影像学杂志

Objective To evaluate the accuracy,practical value and methods of Doppler tissue imaging(DTI) in localizing the ventricular emergence site of accessory atrioventricular pathways.Methods Forty patients with pre-excitation syndrome were examined by DTI before intracardiac electrophysiologic studies(EP) and radiofrequency catheter ablation(RFCA).The pre-excitation zone was determined as a zone of maximum acceleration with “DTI acceleration mode” at the time of the delta wave or before the onset of the QRS complex.At the same time,the contraction velocity was measured from subendocardium of corresponding myocardial segment by “pulsed wave Doppler imaging”.Results Assuming the results of EP and RFCA as a gold standard,the correct localization by DTI was 80% but was only 47.5% and 52.5% by eletrocardiographic algorithms( P