Una de las consultas más habituales en las consultas del cardiólogo del deporte es el deportista sin síntomas que trae un electrocardiograma con una imagen de preexcitación ventricular (onda delta). El síndrome de Wolff-Parkinson-White (WPW) afecta al 0,1-0,3% de la población general.
Una proporción significativa de pacientes con preexcitación ventricular permanecen asintomáticos pero corren el riesgo de sufrir arritmias potencialmente mortales.
Un mal desarrollo embriogénico del anillo aurículo-ventricular da lugar a restos de células miocárdicas funcionales que forman las vías accesorias (VAcc) que darán como resultado una rápida preexcitación ventricular anterógrada y arritmias potencialmente malignas.
En ausencia de una taquiarritmia documentada o síntomas relacionados, los hallazgos del electrocardiograma (ECG) por sí solos se denominan patrón WPW. El temor principal tanto del síndrome como del patrón de WPW es el riesgo de muerte súbita cardíaca (MSC), que se supone que es el resultado de una rápida preexcitación ventricular que precipita la fibrilación ventricular (FV).
El riesgo general de MSC en pacientes asintomáticos con WPW es de un 3-4 %, con la mayoría de los casos entre los 10-40 años de edad. Aunque los pacientes con WPW sintomático son los más susceptibles a la MSC, la MSC es la 1ª manifestación en el 65% de los pacientes con WPW asintomático. De los eventos que amenazan la vida, se ha informado que aproximadamente el 40% de los casos ocurren en reposo y alrededor del 45% de los casos ocurren durante la actividad.
Las características de alto riesgo incluyen:
– Varones.
– Patrón de WPW detectado en las dos primeras décadas de vida.
– Antecedentes de fibrilación auricular (FA).
– Síntomas arrítmicos (especialmente síncope).
– Cardiopatía congénita (p. ej., anomalía de Ebstein) o síndrome WPW familiar.
– Atención especial a los pacientes con ocupaciones de alto riesgo (p. ej., piloto, conductor de autobús) y aquellos que participan en deportes competitivos de intensidad moderada a alta.
Estratificación del riesgo de personas con patrón de WPW
a) Pruebas no invasivas
- ECG estándar de 12 derivaciones, Holter ECG y prueba de esfuerzo.
- En teoría, la pérdida completa de preexcitación ventricular con el tono simpático alto durante el ejercicio debería indicar una VA no rápida y presagia un bajo riesgo de FV.
- La persistencia de preexcitacion ventricular durante la prueba de esfuerzo es altamente sensible para predecir un período refractario efectivo anterógrado de via accesoria (APERP) ≤250 ms o un intervalo RR preexcitado más corto (SPERRI) ≤ 250 ms y, ante ello, deberemos realizar pruebas invasivas.
b) Pruebas invasivas
- Cuanto más largo sea el APERP, menor será el riesgo de inducción de arritmia mortal.
- APERP y SPERRI cortos sugieren conducción anterógrada rápida y se asocian con WPW de alto riesgo.
- Las mediciones basales de APERP ≤240 ms y SPERRI ≤250 ms durante la FA se consideran características de alto riesgo.
- La medición de SPERRI parece superior a la medición de APERP para discriminar a los pacientes con riesgo de MSC y que pueden beneficiarse de la ablación.
- La medición de APERP durante el uso de isoproterenol no es confiable en la estratificación del riesgo en pacientes con WPW asintomáticos y requiere más investigación.
- La inducción de taquicardia por reentrada AV durante la estimulación, especialmente con la degeneración espontánea en FA preexcitada, se considera una característica de alto riesgo.
- Una VAcc localizada en el tabique o la presencia de múltiples VAcc aumenta el riesgo de eventos arrítmicos, incluida la MSC.
- Los hombres tienden a tener APERP más cortos y VAcc del lado izquierdo, mientras que las mujeres tienen múltiples VAcc y del lado derecho.
- Las características de menor riesgo incluirían la falta de inducibilidad de taquiarritmia, la falta de conducción VAcc retrógrada y la ausencia de múltiples VAcc.
¿Cuándo se debe realizar la ablación en pacientes con WPW asintomáticos?
En general, si una VAcc contribuye a una arritmia clínica, si hay alguna característica de alto riesgo o si hay varias VAcc, se recomienda la ablación con catéter.
Las complicaciones graves de la ablación fueron menos del 1%.
Ubicaciones septales de VAcc se asociaron con una tasa más alta de bloqueos de rama relacionados con la ablación.
Conclusiones
- La ablación profiláctica con catéter es razonable para pacientes asintomáticos con características de alto riesgo.
- La preexcitación ventricular intermitente durante Holter-ECG o la terminación abrupta y completa de la conducción de la VAcc durante la prueba de esfuerzo sugiere una vía de bajo riesgo.
- El intervalo RR preexcitado más corto (<250 ms) durante la fibrilación auricular, o el período refractario efectivo de la vía accesoria <240 ms sugieren una vía de alto riesgo.
- La toma de decisiones compartida debe realizarse antes de ofrecer la ablación con catéter.
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