Surgery for Wolff-Parkinson-White syndrome. Cuban experience

Surgery is a recent approach in the treatment of arrhythmias. The first successful surgery of this type was the interruption of the accessory pathway in a patient suffering from the Wolff Parkinson White syndrome. In 25 consecutive patients who underwent surgery, 28 accessory AV pathways were identified with classical endocardial and epicardial mapping. Only three patients experienced recurrence of preexcitation without symptoms; one patient had AV block; and another patient died. In all cases we successfully used either an endocardial or an epicardial approach. The purpose of this paper is to report the Cuban experience with this procedure.     

Surgery of Wolff-Parkinson-White: value of the epicardial approach. Apropos of 28 surgically treated cases

The authors report their experience of 28 cases of the Wolff-Parkinson-White (WPW) syndrome treated by surgery. Four patients had multiple accessory pathways; of the 32 bundles of Kent detected, 16 were in the postero-septal region. Surgery, performed under cardio-pulmonary bypass after epicardial mapping, consisted in atrioventricular disconnection using no special physical agent. With the exception of 2 cases, the left lateral accessory pathways were operated using a classical left intraatrial approach whereas in the right lateral and septal forms the main procedure of dissection of the right atrioventricular groove was carried out by an epicardial approach. There was one operative death due to haemodynamic and haemorrhagic problems in a top class athlete with two bundles of Kent, the interruption of which required two consecutive bypass procedures. In the 27 survivors, 29 of the 30 accessory pathways were successfully interrupted (96 p. 100). The only failure occurred in a patient with two bundles of Kent. On the other hand, in 2 patients, complete atrioventricular block was successfully obtained by surgical section of the His bundle during the same procedure in one case, and by postoperative catheter ablation in the other case in which surgery had failed. There were no cases of accidental permanent atrioventricular block. The results in this series confirm the value of surgery in the treatment of the WPW syndrome, especially in the septal forms which are reputed to be the most difficult but in which the approach is greatly simplified by the initial dissection of the tricuspid ring by an epicardial approach.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgery ablation of atrial fibrillation with epicardial and endocardial biauricular radiofrequency: initial experience

BACKGROUND: Atrial fibrillation is frequent in surgical patients with cardiac valvulopathies. Radiofrequency energy applied by means of surgical probes permits the reproduction of atriotomies described in the maze surgical procedure for the ablation of atrial fibrillation in a fast, safe and efficient way. This study presents our initial experience in treatment of chronic atrial fibrillation through radiofrequency performed in patients with surgical cardiac valvulopathies. PATIENTS AND METHOD: From June to November 2000, 10 patients, with surgical indications of valvulopathy, were intraoperatively treated through radiofrequency for its atrial fibrillation. Ablations were performed in the right auricle from the epicardium before starting extra corporeal circulation, and in the left auricle from the endocardium, while under circulation. Radiofrequency was applied through a surgical multielectrode probe. RESULTS: Eight patients (80%) presented some type of postoperative arrhythmia, with relapse of paroxysmal fibrillation in 3 patients and flutter in another one. At discharge, none of the patients presented relapse of chronic atrial fibrillation. There was no in-hospital mortality. After a mean follow-up of 3 months (range 1-6), 8 patients (80%) have recovered and maintained sinus rhythm. Only one patient has re-established echocardiographic biatrial contraction. CONCLUSIONS: Intraoperative radiofrequency has allowed us to perform the auricular lesions, in both auricles, in a simple way, with an initial effectiveness of 80%. Epicardial ablation of the right auricle was simple and safe. Although no patient presented relapse of chronic atrial fibrillation at hospital discharge, postoperative arrhythmias have continued to be the main postsurgical problem.     

Surgery for hilar cholangiocarcinoma: an Italian experience

From January 1980 to June 1997 we treated 159 patients with carcinoma of the hepatic duct confluence. Seventy‐five patients underwent surgical resection (overall resectability rate: 47.2%), and radical resection was attempted in 46 patients (radical resectability rate: 28.9%) classified in the first three stages of our staging system. Perioperative mortality was 10% (16 patients). The 5‐year survival rate for 46 patients with curative resection was 17.5% with a median survival of 19 months. The 5‐year survival rate for those patients who underwent combined caudate lobectomy (n = 17) was 25%, whereas the survival rate for those who did not was zero. The difference between these two groups' results was statistically significant. The importance of careful preoperative staging is stressed. Preoperative tests should be limited to investigations (ultrasound with Doppler scan, spiral computed tomography, percutaneous transhepatic cholangiography) supplying most information about intra‐ and extrabiliary diffusion of the tumoral mass. We conclude by highlighting the importance of resection as the only treatment potentially improving long‐term survival. On the basis of these results, caudate lobectomy is always recommended in association with resectional treatment of the neoplasm.     

Hypnotherapy in severe irritable bowel syndrome: further experience

Fifteen patients with severe intractable irritable bowel syndrome previously reported as successfully treated with hypnotherapy, have now been followed up for a mean duration of 18 months. All patients remain in remission although two have experienced a single relapse overcome by an additional session of hypnotherapy. Experience with a further 35 patients is reported giving a total group of 50. This group was divided into classical cases, atypical cases and cases exhibiting significant psychopathology. The response rates were 95%, 43%, and 60% respectively. Patients over the age of 50 years responded very poorly (25%) whereas those below the age of 50 with classical irritable bowel syndrome exhibited a 100% response rate. This study confirms the successful effect of hypnotherapy in a larger series of patients with irritable bowel syndrome and defines some subgroup variations.     

Encainide for atrial fibrillation associated with Wolff-Parkinson-White syndrome

Thirty-six patients with a history of atrial fibrillation and Wolff-Parkinson-White syndrome were treated with oral encainide, 175 ± 44 ing/day, after undergoing baseline drug-free electrophysiologic studies. The mean age was 38 ± 15 years, with structural heart disease present in only 3 patients. Nine patients had only paroxysmal atrial fibrillation and 27 patients had both atrial fibrillation and atrioventricular reciprocating tachycardia (AVRT). Symptoms were present for a mean of 195 ± 168 months and were treated with an average of 2.7 ± 1.6 drugs before encainide. Anterograde block in the accessory pathway occurred in 12 of 30 patients (40%) and retrograde block accessory pathway occurred in 10 of 24 patients in whom comparison could be made. AVRT was initiated in 29 of 36 patients during the control study and could be initiated in 19 of 29 patients while receiving encainide.

Drug efficacy was determined by the clinical response judged completely effective, partially effective or ineffective. During a mean follow-up of 30.1 ± 25 months, 24 patients (67%) continued to take encainide. Encainide was completely effective in 14 of 24 patients and partially effective in another 7 patients. Noncardiac side effects were mild and generally resolved, and required discontinuance in only 1 patient. More frequent AVRT occurred in 2 patients, but was managed with dose reduction and the addition of a β blocker. Three patients had ventricular tachycardia requiring discontinuance; however 2 of 3 patients had a history of ventricular tachycardia before receiving encainide. Encainide is an effective and safe agent for treating atrial fibrillation in patients with Wolff-Parkinson-White syndrome.     

Wolff-Parkinson-White syndrome: long follow-up and an Anglo-American historical note

A patient who developed palpitation in 1917 was later found to have the Wolff-Parkinson-White syndrome and survived to the age of 86, when he died of emphysema. Shortly before he first presented, a report of another patient had been published that can now retrospectively be recognized as containing the first tracings from a case of the Wolff-Parkinson-White syndrome; its coauthors were a distinguished American cardiologist, Alfred E. Cohn, who had worked with Sir Thomas Lewis, and his British research fellow, Francis R. Fraser.     

Fitness for sports of patients with Wolff-Parkinson-White syndrome

The fitness of patients with Wolff-Parkinson-White syndrome to indulge in sporting activities is a practical cardiology problem. The major risk is sudden death due to atrial fibrillation deteriorating to ventricular fibrillation. This risk is small or even theoretical, but signing a fitness certificate engages the clinician's responsibility. Non invasive complementary examinations are useful. Echocardiography may detect a heart disease that would preclude any sport. Exercise tests explore the behaviour of the accessory pathway and rarely trigger off arrhythmias. Holter recordings mainly investigate disorders of the atrial rhythm. The decision concerning fitness may be based on clinical symptoms. Exercise-induced tachycardia is a classical contra-indication to competitive sports. In patients whose tachycardia is unrelated to exercise, fitness may be discussed according to the results of exercise tests and of the electrophysiological study. A refractory period which would be considered as rather prolonged at rest does not protect against fast ventricular rate during passage to atrial fibrillation. If pre-excitation disappears during the exercise test in an asymptomatic patient, then competitive sports can be authorized without limitations. If not, only surgical excision or fulguration would provide full protection against a potentially dangerous fibrillation. It is concluded that Wolff-Parkinson-White syndrome contra-indicates competitive sports in most cases. Games played outside competitions remain possible in the absence of symptoms or when arrhythmias are well controlled by medical treatment.     

Wolff-Parkinson-White syndrome with 1:2 atrioventricular conduction

The QRS complex of the Wolff-Parkinson-White syndrome is thought to represent a fusion beat resulting from conduction over the normal pathway and an anomalous pathway. This report demonstrates utilization of both of these pathways resulting in two ventricular responses from a single supraventricular impulse. The presence of “1:2” atrioventricular conduction in this case firmly supports the fusion beat theory of the Wolff-Parkinson-White syndrome.     

Electrophysiology: the Wolff-Parkinson-White syndrome

Though tachyarrhythmias occur commonly in patients with the Wolff-Parkinson-White syndrome, many patients remain asymptomatic. Recent studies suggest that routine electrophysiologic testing in these individuals is of limited value. However, electrophysiologic testing remains very helpful in the symptomatic patient for predicting arrhythmia recurrence and for determining accessory pathway location and function. Unfortunately, noninvasive tests to predict high-risk WPW patients has not been proven helpful because of their low specificity. A number of recent studies have shown that autonomic function can markedly improve accessory pathway function and even counteract the effect of antiarrhythmic drugs. Given the frequent failure of antiarrhythmic therapy in the WPW syndrome, there has been increasing interest in nonpharmacologic therapies, including high-energy DC shock and radiofrequency catheter ablation of accessory pathways, which may prove to be more cost-effective than surgery.