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Increased Atrial Myocardium Vulnerability and Sudden Death in the Wolff-Parkinson-White Syndrome

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Increased Atrial Myocardium Vulnerability and Sudden Death in the Wolff-Parkinson-White Syndrome Journal of Cardiology & Current Research Increased Atrial Myocardium Vulnerability and Sudden Death in the Wolff-Parkinson-White Syndrome Editorial Editorial the most frequent, older, and forgotten arrhythmia last century, Volume 6 Issue 1 - 2016 to Historically,become the atrial more fibrillation investigated (AF) arrhythmia has passed in from this beingnew millennium. Atrial premature contractions (APC) occurring in a critical timing during the relative atrial refractory period, in the Department of Health Sciences’s Investigation, Sanatorio presence of a non-homogeneous dispersion of refractoriness Metropolitano, Fernando de la Mora, Paraguay and conduction, can trigger atrial responses that determine atrial vulnerability and susceptibility to develop AF [1-5]. These *Corresponding author: Osmar Antonio Centurión, Professor of Medicine, Asuncion National University, atrial responses to clinical spontaneous APC can be reproduced Department of Health Sciences’s Investigation, Sanatorio in the electrophysiological laboratory. Indeed, the recording of Metropolitano, Teniente Ettiene 215 c/ Ruta Mariscal abnormally prolonged and fractionated atrial electrograms by Estigarribia, Fernando de la Mora, Paraguay, the technique of atrial endocardial mapping during sinus rhythm, Email: as well as, the induction of electrophysiological responses by June 07, 2016 June 28, 2016 programmed atrial stimulation with single extra stimulus have Received: | Published: shed very interesting data for a better comprehension of the atrial myocardial substrate in the genesis of AF [6-13]. Patients with the Wolff-Parkinson-White (WPW) syndrome Induction of AF can be achieved by incremental atrial rapid are known to have an increased susceptibility to develop AF in pacing and by programmed atrial stimulation with single extra the course of their lives. It has been shown a clear association stimulus. With this latter approach certain electrophysiological between increased atrial vulnerability and the presence of a parameters of increased atrial vulnerability can be induced, Kent accessory pathway (AP). Since the initial publication of the WPW syndrome, the investigators recognized the existence of an (FAA), and inter-atrial conduction delay (IACD) [15-22]. association between this entity and AF [1]. Episodes of AF have Thesenamely, electrophysiological repetitive atrial firing responses (RAF), fragmentedin the site ofatrial stimulation activity been documented in one third of the patients with WPW syndrome reproduce in the laboratory the response of the atrial myocardium [2]. The AF in patients with this syndrome is associated with to clinical spontaneous APC that the patients may have in faster rates of the reciprocal tachycardia, with shorter effective their daily routine. The APC can induce an important delay in refractory periods of the accessory pathway, slower intra-atrial conduction of the impulses and non homogeneous dispersion of conduction times, structural heart disease and advancing age [2- atrial refractory periods developing an episode of sustained AF 4]. Patients with manifest pre-excitation that have spontaneous [20]. It is conceivable that these electrophysiological responses episodes of AF present a greater incidence of induction of AF by are the abnormal manifestation of cellular electrophysiology programmed atrial stimulation. because they are found in pathologic tissue. Repetitive atrial Not only the atrial vulnerability, but also the AP plays an atrial complexes with a return cycle of <250 ms, and a subsequent important role in the development of AF [14]. Therefore, it is cyclefiring lengthis defined of <300 as the ms occurrence[10]. The interval of two betweenor more thesuccessive longest and shortest coupling interval that elicited RAF is often referred presence of increased atrial vulnerability and the predisposition as the zone. Hence, the longest and shortest coupling interval tovery develop important AF. There to determine are certain the electrophysiological influence of the AP responses and the eliciting RAF are considered the outer and inner limits of the zone that can be induced by programmed atrial stimulation during of induction of RAF. Fragmented atrial activity elicited by atrial the electrophysiological study which can be utilized as indicators of increased atrial muscle vulnerability. The programmed atrial stimulation is performed using a programmable electric basicextra stimulusbeat recorded is defined in the as right the occurrenceatrium [21]. of The disorganized duration ofatrial the stimulator with rectangular current pulses of 2 ms duration at atrialactivity activity ≥150% in of FAA the isduration measured of the as local the time atrial interval electrogram comprised of the twice the diastolic threshold. Programmed single premature between the stimulus artifact and the end of the local electrogram atrial stimuli can be delivered after a train of eight atrial paced in the high right atrium of the basic stimulus (A1) and the early beats at two different cycle length from the high right atrium. The single extra stimulus (A2). The inter-atrial conduction time is coupling interval between S1 and S2 is decreased in 10 ms steps measured from the stimulus artifact to the atrial electrogram at until S2 is no longer captured, that is the atrial refractory period. the distal coronary sinus level. The inter-atrial conduction delay Reaching the relative atrial refractoriness at a critical coupling through A interval of the extra timing, atrial responses are elicited in patients with increased 2 2 stimulus 20 ms compared with the S through A of the basic drive. atrial vulnerability and predisposition to develop AF. 1 1 Theseis defined electrophysiological as an increase in theparameters S can be considered as a Submit Manuscript | http://medcraveonline.com J Cardiol Curr Res 2016, 6(1): 00194 Increased Atrial Myocardium Vulnerability and Sudden Death in the Wolff-Parkinson- Copyright: 2/3 White Syndrome ©2016 Centurión et al. clinical index in the AF prediction [23-26]. The slowing of intra- 7. Centurión OA, Isomoto S, Shimizu A, Konoe A, Kaibara M, et al. (2003) atrial conduction is considered to be one of the most important The effects of aging on atrial endocardial electrograms in patients requirements for the initiation of reentry and, thus, for AF to develop [26]. These electrophysiological parameters have been 8. withCenturi paroxysmalón OA, Fukatani atrial fibrillation. M, Konoe ClinA, Tanigawa Cardiol 26(9): M, Shimizu 435-438. A, et al. evaluated in an individual manner and in heterogeneous groups (1992) Electrophysiological abnormalities of the atrial muscle in of patients with multiple types of arrhythmias. patients with sinus node dysfunction without tachyarrhythmias. Int J Cardiol 37(1): 41-50. There is an important electrophysiological evidence of an underlying atrial disease in patients with the WPW syndrome. 9. Abnormally prolonged and fractionated atrial endocardial advancing age on fractionated right atrial endocardial electrograms. AmCenturión J Cardiol OA, 96(2): Shimizu 239-242. A, Isomoto S, et al. (2005) Influence of in WPW patients with documented episodes of AF. In addition, 10. Centurión OA, Shimizu A, Isomoto S, Konoe A, Hirata T, et al. (1994) electro grams are observed with a significantly higher incidence increased induction of RAF and FAA, and wider zones of induction, extrastimuli in the sick sinus syndrome with and without abnormal Repetitive atrial firing and fragmented atrial activity elicited by asthe well electrophysiological as, an increased inter-atrialfindings of conductionaltered atrial delay refractoriness, suggest an atrial electro grams. Am J Med Sciences 307(4): 247-254. intrinsic increased atrial vulnerability as the mechanism of PAF in 11. Centurión OA, Isomoto S, Shimizu A, Shimizu A, Konoe A, et al. (1994) certain patients with the WPW syndrome. Supernormal atrial conduction and its relation to atrial vulnerability Dreifus et al. [27] demonstrated a diffuse atrial destruction and a marked increased in connective tissue in the sinus node and the and atrial fibrillation in patients with sick sinus syndrome and atria of WPW patients that had AF before the episode of sudden 12. paroxysmalCenturión OA, atrial Isomoto fibrillation. S, Fukatani Am Heart M, J 128:et al. 88-95. (1993) Relationship between atrial conduction defects and fractionated atrial endocardial death [27]. Wyndham et al. [28] demonstrated that the shortening electrograms in patients with sick sinus syndrome. Pacing Clin of the atrial cycle length is related to the atrial vulnerability [28]. Electrophysiol 16(10): 2022-2033. Rinne et al. [29] observed that patients with WPW syndrome and AF had a higher incidence of atrial vulnerability than those WPW 13. Centurión OA (2009) Clinical implications of the P wave duration patients without AF [29]. Sung et al. [30] demonstrated that the and dispersion: Relationship between atrial conduction defects and abnormally prolonged atrial endocardial electrograms. Int J Cardiol development of AF in the WPW syndrome may be related to the 134(1): 6-8. presence of atrial vulnerability [30]. During AF in a WPW patient, the increasing rate of atrial depolarization in the presence of an AP 14. Centurión OA, Shimizu A, Isomoto S, Konoe A (2008) Mechanisms with fast conduction capacity, the ventricles are exposed to very fast rates that can easily degenerate into ventricular tachycardia Parkinson-White syndrome: Intrinsic atrial muscle vulnerability vs. electrophysiologicalfor
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