Risk Stratification for Prophylactic Ablation in Asymptomatic Wolff–Parkinson–White Syndrome
http://www.100md.com
《新英格兰医药杂志》
To the Editor: The most surprising finding in the article by Pappone et al. (Sept. 16 issue)1 is not that prophylactic ablation results in a low risk of life-threatening arrhythmias. It is that their control group had an extraordinarily high rate of such events. The authors enrolled asymptomatic children and considered them to be at high risk if they had inducible atrial fibrillation or atrioventricular reciprocating tachycardia. Neither criterion is widely accepted as a feature that defines a high risk for sudden death. Indeed, Pappone et al. did not consider pathway refractory periods or preexcited RR intervals among their inclusion criteria, making a comparison with published data impossible. After randomization, 3 of 27 control patients (11 percent) had life-threatening events — a very high rate. This finding is inconsistent with published observations2 and our experience.
How do the authors account for the high rate of attacks in the control group? The question is critical to their conclusions and has serious implications for the assessment of young patients with the Wolff–Parkinson–White syndrome. If the risks for the untreated patient are overstated, then the study is misleading, and the authors' conclusions might result in the unnecessary application of ablation in many asymptomatic children.
John Triedman, M.D.
Children's Hospital
Boston, MA 02115
john.triedman@cardio.chboston.org
James Perry, M.D.
Yale University Children's Hospital
New Haven, CT 06515
George Van Hare, M.D.
Lucile Packard Children's Hospital at Stanford
Palo Alto, CA 94304
References
Pappone C, Manguso F, Santinelli R, et al. Radiofrequency ablation in children with asymptomatic Wolff-Parkinson-White syndrome. N Engl J Med 2004;351:1197-1205.
Munger TM, Packer DL, Hammill SC, et al. A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989. Circulation 1993;87:866-873.
The authors reply: We thank Dr. Triedman and colleagues for raising fundamental questions about risk stratification for the accurate selection of asymptomatic persons with the Wolff–Parkinson–White syndrome who might benefit from prophylactic ablation. We understand that for many years, the identification of high-risk patients relied mainly on the finding of pathway refractory periods, preexcited RR intervals, or both — features that unfortunately are associated with very low specificity, despite a high negative predictive value. We empirically attempted to find other criteria to identify high-risk patients by using a specific protocol for inducibility, which demonstrated not only sensitivity but also specificity.1,2 Accurate risk stratification among asymptomatic persons with the Wolff–Parkinson–White syndrome is undoubtedly necessary3 and must be validated prospectively in a large cohort of untreated persons.
By preliminary analysis of pooled data from 477 untreated, asymptomatic persons with the Wolff–Parkinson–White syndrome, we found that inducibility, multiple pathways, and younger age predict future life-threatening events, including syncope, cardiac arrest, and sudden death. On the basis of these three variables, we propose a scheme for risk stratification into low-risk (<20 percent), intermediate-risk (20 to 50 percent), and high-risk (>50 percent) categories with possible implications for decisions concerning prophylactic ablation.
Carlo Pappone, M.D., Ph.D.
Vincenzo Santinelli, M.D.
University Hospital San Raffaele
20132 Milan, Italy
carlo.pappone@hsr.it
References
Pappone C, Santinelli V, Rosanio S, et al. Usefulness of invasive electrophysiologic testing to stratify the risk of arrhythmic events in asymptomatic patients with Wolff-Parkinson-White pattern: results of a large prospective long-term follow-up study. J Am Coll Cardiol 2003;41:239-244.
Pappone C, Santinelli V, Manguso F, et al. A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-Parkinson-White syndrome. N Engl J Med 2003;349:1803-1811.
Wellens HJJ. Catheter ablation for cardiac arrhythmias. N Engl J Med 2004;351:1172-1174.
How do the authors account for the high rate of attacks in the control group? The question is critical to their conclusions and has serious implications for the assessment of young patients with the Wolff–Parkinson–White syndrome. If the risks for the untreated patient are overstated, then the study is misleading, and the authors' conclusions might result in the unnecessary application of ablation in many asymptomatic children.
John Triedman, M.D.
Children's Hospital
Boston, MA 02115
john.triedman@cardio.chboston.org
James Perry, M.D.
Yale University Children's Hospital
New Haven, CT 06515
George Van Hare, M.D.
Lucile Packard Children's Hospital at Stanford
Palo Alto, CA 94304
References
Pappone C, Manguso F, Santinelli R, et al. Radiofrequency ablation in children with asymptomatic Wolff-Parkinson-White syndrome. N Engl J Med 2004;351:1197-1205.
Munger TM, Packer DL, Hammill SC, et al. A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989. Circulation 1993;87:866-873.
The authors reply: We thank Dr. Triedman and colleagues for raising fundamental questions about risk stratification for the accurate selection of asymptomatic persons with the Wolff–Parkinson–White syndrome who might benefit from prophylactic ablation. We understand that for many years, the identification of high-risk patients relied mainly on the finding of pathway refractory periods, preexcited RR intervals, or both — features that unfortunately are associated with very low specificity, despite a high negative predictive value. We empirically attempted to find other criteria to identify high-risk patients by using a specific protocol for inducibility, which demonstrated not only sensitivity but also specificity.1,2 Accurate risk stratification among asymptomatic persons with the Wolff–Parkinson–White syndrome is undoubtedly necessary3 and must be validated prospectively in a large cohort of untreated persons.
By preliminary analysis of pooled data from 477 untreated, asymptomatic persons with the Wolff–Parkinson–White syndrome, we found that inducibility, multiple pathways, and younger age predict future life-threatening events, including syncope, cardiac arrest, and sudden death. On the basis of these three variables, we propose a scheme for risk stratification into low-risk (<20 percent), intermediate-risk (20 to 50 percent), and high-risk (>50 percent) categories with possible implications for decisions concerning prophylactic ablation.
Carlo Pappone, M.D., Ph.D.
Vincenzo Santinelli, M.D.
University Hospital San Raffaele
20132 Milan, Italy
carlo.pappone@hsr.it
References
Pappone C, Santinelli V, Rosanio S, et al. Usefulness of invasive electrophysiologic testing to stratify the risk of arrhythmic events in asymptomatic patients with Wolff-Parkinson-White pattern: results of a large prospective long-term follow-up study. J Am Coll Cardiol 2003;41:239-244.
Pappone C, Santinelli V, Manguso F, et al. A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-Parkinson-White syndrome. N Engl J Med 2003;349:1803-1811.
Wellens HJJ. Catheter ablation for cardiac arrhythmias. N Engl J Med 2004;351:1172-1174.