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Cardiac arrest in concomitant Wolff-Parkinson-White syndrome and early repolarisation: is pathway ablation enough?
  1. Antonio Frontera,
  2. Glyn Thomas,
  3. Edward Duncan
  1. Department of Cardiology, Bristol Heart Institute, University Hospital Bristol NHS Trust, Bristol BS28HW, UK
  1. Correspondence to Dr Antonio Frontera, Electrophysiology Cath Lab, Bristol Heart Institute, University Hospitals Bristol BS28HW, UK; a.frontera{at}gmail.com

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A 24-year-old soldier suffered a cardiac arrest while shopping. Ventricular fibrillation was diagnosed and sinus rhythm restored with an external DC cardioversion. A 12-lead ECG confirmed sinus rhythm with evidence of ventricular pre-excitation (see Figure 1). Inpatient investigations including serum biochemistry, serum troponin, echocardiography and cardiac magnetic resonance scans revealed no abnormality. A diagnostic electrophysiological study confirmed a rapidly conducting (refractory period 340 msec) left lateral accessory pathway with no inducible arrhythmia. Successful radiofrequency catheter ablation (50 Watts, 50°C) was undertaken. However, loss of ventricular pre-excitation unmasked J-point elevation in the infero-lateral leads in keeping with a diagnosis of early repolarisation (ER) syndrome which is in turn associated with idiopathic ventricular fibrillation (see Figure 2).

Figure 1

Admission 12-lead ECG suggesting a left accessory pathway. In the box on the left, a zoom of D2, D3 lead.

Figure 2

ECG recorded after left accessory pathway ablation; J-point elevation appeared in infero-lateral leads as seen in the zoomed image.

ER is a common finding seen in greater than 10% of normal individuals. Its incidence is higher among survivors of cardiac arrest. Recent data have also demonstrated ER in up to 36% of patients after ablation of left lateral accessory pathways.1 The significance of ER postablation in survivors of cardiac arrest with ventricular pre-excitation is unclear. Early studies in this group of survivors suggest that prognosis is good after accessory pathway ablation.2 However, the available data are from small patient cohorts and predate the recognition of ER in this group and its s545ignificance after cardiac arrest.

The importance of ER in our patient remains unknown. He was offered an implantable defibrillator due to this uncertainty; however, he declined. Six months postablation he remains well. His ECG continues to show marked ER.

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Footnotes

  • Contributors AF wrote this paper and participated in ablation. GT participated in ablation. ED performed ablation.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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