Case report
Aborted sudden cardiac death as first presentation of Wolff–Parkinson–White syndrome
Morte súbita cardíaca abortada como primeira manifestação da síndrome de Wolff–Parkinson–White
Guida Silva
, Gustavo Pires de Morais, João Primo, Olga Sousa, Eulália Pereira, Marta Ponte, Lino Simões, Vasco Gama
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Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho-EPE, Vila Nova de Gaia, Portugal
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Surface leads I, II, III, aVF, aVL, aVF and V1–V6 are shown, with intracardiac recordings from catheters in the right ventricle (HRVp and HRVd), distal (CS1) and proximal (CS5) coronary sinus, and proximal (RFp) and distal (RFd) ablation catheter. Atrial (A) and ventricular (V) electrical signals are shown. (A) Electrocardiographic and intracardiac signals immediately before catheter ablation, recorded at 200<span class="elsevierStyleHsp" style=""></span>mm/s. (B) Catheter accessory pathway ablation, recorded at 50<span class="elsevierStyleHsp" style=""></span>mm/s. Conduction over the AP disappeared within 3<span class="elsevierStyleHsp" style=""></span>s of radiofrequency energy application. The asterisk represents the beginning of radiofrequency energy application.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0070" class="elsevierStylePara elsevierViewall">WPW syndrome is a disorder characterized by the presence of one or more accessory pathways that predispose patients to frequent episodes of arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The 2003 ESC/ACC/AHA guidelines<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> recommend routine electrophysiological study (EPS) with liberal indications for catheter ablation in symptomatic patients. However, management of asymptomatic subjects with incidentally found pre-excitation patterns remains controversial. Prognosis is usually good, but there is a lifetime risk of malignant arrhythmias and sudden cardiac death (SCD), and the latter can be the first presentation of the disease. Although risk factors for fatal arrhythmic events are not well established, EPS can be a useful tool in risk stratification.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> A short accessory pathway anterograde effective refractory period (AP-AERP), inducibility of sustained tachyarrhythmias (atrioventricular reciprocating tachycardia [AVRT] and/or atrial fibrillation [AF]) and the presence of multiple accessory pathways are the strongest predictors of life-threatening arrhythmias and SCD.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0075" class="elsevierStylePara elsevierViewall">A 17-year-old male with no history of cardiovascular disease or familial SCD presented to the emergency department (ED) with palpitations. No medication or drug abuse was reported. Symptoms had started three hours earlier at rest. The physical examination revealed normal blood pressure (130/70<span class="elsevierStyleHsp" style=""></span>mmHg) and an irregular pulse approaching 200<span class="elsevierStyleHsp" style=""></span>bpm. The rest of the physical evaluation was unremarkable, with no cardiac murmurs or signs of pulmonary edema. An electrocardiogram (ECG) showed a wide-complex irregular tachycardia with rapid ventricular rate (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), suggesting pre-excited AF. Continuous heart monitoring was initiated and two venous lines were inserted.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">A few minutes after admission to the ED, the rhythm degenerated into ventricular fibrillation (VF) (checked on the monitor) and the patient collapsed without pulse. Cardiopulmonary resuscitation was promptly started. Recovery of regular pulse and rhythm was confirmed after defibrillation with two electrical shocks (2× 150<span class="elsevierStyleHsp" style=""></span>J, biphasic). The ECG then obtained revealed sinus rhythm with ventricular pre-excitation (shortened PR interval, widened QRS complex with delta wave and secondary ventricular repolarization abnormalities) (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The patient was admitted to the coronary care unit (CCU). No rhythm abnormalities were recorded during CCU monitoring. Serum potassium and magnesium levels were normal and transthoracic echocardiography excluded structural heart disease.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">EPS was scheduled and performed within 12<span class="elsevierStyleHsp" style=""></span>hours of admission. Two catheters were positioned via the right femoral vein: a deflectable decapolar catheter in the coronary sinus, and a nondeflectable quadripolar catheter in the right ventricle for His activity tracing and ventricular stimulation. Atrial stimulation was performed using the decapolar catheter. A short AP-AERP was recorded (210<span class="elsevierStyleHsp" style=""></span>ms) using programmed atrial stimulation, indicating a high-risk AP.</p><p id="par0090" class="elsevierStylePara elsevierViewall">A 4-mm ablation catheter (RF Mariner™, Medtronic Inc., Minneapolis, USA) was advanced retrogradely via the right femoral artery and placed in the mitral ring.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Radiofrequency energy (50<span class="elsevierStyleHsp" style=""></span>W/70<span class="elsevierStyleHsp" style=""></span>°C) was applied for 60<span class="elsevierStyleHsp" style=""></span>s to the atrial side of the left lateral mitral ring. Conduction over the AP was successfully interrupted within 3<span class="elsevierStyleHsp" style=""></span>s of energy delivery (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). During the procedure, AF without pre-excitation was triggered, and sinus rhythm was spontaneously recovered. Total procedure time was 90<span class="elsevierStyleHsp" style=""></span>min, and total fluoroscopy time was 17<span class="elsevierStyleHsp" style=""></span>min. The ECG tracing after catheter ablation showed PR and QRS intervals within normal limits (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). No procedural complications ensued and the patient was discharged three days after admission. Six months after catheter ablation the patient was asymptomatic with a normal ECG tracing. No tachyarrhythmias were documented during this period.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">WPW is a cardiac conduction disorder characterized by the presence of one or multiple APs that predispose patients to frequent episodes of arrhythmia. A Wolff–Parkinson–White pattern is present in 0.1–0.2% of the general population,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> most of whom will never be aware of the issue unless it is discovered incidentally. Symptomatic patients generally experience a good outcome, with either no recurrent arrhythmias or only benign recurrences. Risk of SCD is low, with annual estimates of 0.1% for asymptomatic<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and 0.15–0.39% for symptomatic patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The ECG features of WPW include a PR interval of <0.12<span class="elsevierStyleHsp" style=""></span>s, slurring and slow rise of the initial QRS complex (delta wave), a widened QRS complex with a total duration greater than 0.12<span class="elsevierStyleHsp" style=""></span>s, and secondary repolarization abnormalities that are generally directed in an opposite direction to the major delta and QRS vectors. Diagnosis of WPW syndrome requires typical ECG findings with a documented dysrhythmia. The most frequently encountered dysrhythmia in patients with WPW is atrioventricular reciprocating tachycardia (AVRT), which occurs in 80% of cases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> AF is not uncommon, occurring in 15–30% of patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This is a potentially life-threatening arrhythmia in patients with WPW syndrome and may lead to SCD. If an AP has a short anterograde refractory period, rapid repetitive conduction to the ventricles during AF can result in rapid ventricular response with subsequent degeneration to VF.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Predicting clinical outcome is one of the major issues in asymptomatic WPW subjects. Risk assessment is not well defined and remains a considerable clinical challenge.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Risk factors for potentially life-threatening arrhythmic events in WPW<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> include: (1) short AP-AERP (<250<span class="elsevierStyleHsp" style=""></span>ms) allowing a rapid ventricular response in AF; (2) inducibility of tachyarrhythmia during EPS (AVRT and/or AF); (3) short pre-excited RR interval during AF (<250<span class="elsevierStyleHsp" style=""></span>ms); (4) multiple APs; (5) male gender; (6) age; and (7) syncope.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Invasive EPS most accurately assesses the electrophysiological properties of the AP and its role in the patient's clinical arrhythmia, although no single factor has high sensitivity, specificity and positive predictive value.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Pappone et al.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5,10</span></a> reported that a particular subgroup of asymptomatic patients may be at risk for a malignant arrhythmic event and demonstrated the value of EPS in stratifying asymptomatic patients into high- and low-risk groups.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Noninvasive markers of lower risk such as intermittent loss of pre-excitation, loss of AP conduction on exercise stress testing, and sudden loss of AP conduction after treatment with the antiarrhythmic drugs procainamide or flecainide are limited by insufficient sensitivity and specificity, and currently play little role in patient management.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In our case of a previously healthy 17-year-old patient there were no past ECG records and thus the existence of an AP was not known. A malignant arrhythmia with degeneration to VF was the first presentation and could have resulted in SCD. The first-line therapeutic option was EPS before hospital discharge, resulting in successful ablation of the high-risk AP. However, had the WPW pattern been incidentally found before symptoms, how should we have proceeded?</p><p id="par0135" class="elsevierStylePara elsevierViewall">The 2003 ESC/ACC/AHA guidelines<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> are restrictive regarding the management of an asymptomatic WPW pattern, and recommend routine invasive EPS and catheter ablation only in symptomatic patients. This may be questionable: catheter ablation is now routinely and safely performed by skilled operators, and asymptomatic patients are more commonly referred for invasive risk stratification and prophylactic AP ablation. Pappone et al.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,10</span></a> reported that prophylactic AP catheter ablation performed at the time of initial EPS improved the long-term outcome of patients at high risk for malignant arrhythmias, and the risk significantly and persistently decreased over time after ablation. Furthermore, the efficacy of catheter AP ablation approaches 100%, and overall procedure-related mortality is less than 0.2%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,12</span></a> Accordingly, radiofrequency catheter ablation (RFA) is now widely accepted as a therapy for WPW and is frequently considered the first-line therapy. However, different AP locations still represent challenges for ablation. Parahisian and midseptal APs, which account for only a minority of cases, pose a significant challenge to RFA due to their proximity to the His bundle and AV node, increasing the risk of AV block. A possibly safer approach for elimination of these challenging APs is cryoablation, which creates homogeneous and smaller lesions and is less thrombogenic than RFA, reducing the risk of inadvertent AV block.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The potential risk of AV block due to RFA of parahisian and midseptal APs must always be discussed with the patient, particularly in the younger, and balanced against the benefits of ablation. In conclusion, the benefits of prophylactic catheter ablation (RFA or cryoablation) can outweigh the procedural risks when performed by a skilled operator, and the issue of the management of asymptomatic WPW patients could be readdressed.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Our case illustrates how a WPW pattern may not be as benign as thought. Sudden cardiac death is a dramatic occurrence, particularly in young healthy subjects, and is a real-life event and not merely an item on the reference list of a report on the natural history of the disease. If our patient had had a previous ECG tracing showing a WPW pattern, and if the guidelines had been followed, his fate would have been SCD in the absence of prompt medical assistance. This scenario must be always taken into consideration in each patient with an incidental WPW pattern.</p><p id="par0145" class="elsevierStylePara elsevierViewall">WPW-associated deaths are preventable given the availability of a permanent treatment that is safe and effective, and the benefits of catheter ablation are likely to outweigh the procedural risks when performed by a skilled operator.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The latest guidelines<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> were published over nine years ago. The authors consider that it is currently unacceptable that even one asymptomatic patient with WPW pattern should die or experience a life-threatening arrhythmic event due to a high-risk accessory pathway.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres251178" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec238777" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres251177" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec238776" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-03-25" "fechaAceptado" => "2012-08-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec238777" "palabras" => array:3 [ 0 => "Wolff–Parkinson–White" 1 => "Sudden cardiac death" 2 => "Catheter ablation" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec238776" "palabras" => array:3 [ 0 => "Wolff–Parkinson–White" 1 => "Morte súbita cardíaca" 2 => "Ablação por catéter" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sudden cardiac death (SCD) can be the first clinical manifestation of Wolff–Parkinson–White (WPW) syndrome.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Catheter ablation of accessory pathways is now a safe and effective procedure, and is widely recommended in patients with WPW syndrome. However, management of the asymptomatic WPW patient remains controversial. Recent studies have readdressed the issue of risk stratification and prophylactic catheter ablation.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We describe a case of malignant arrhythmia and aborted SCD as first presentation of WPW syndrome in a previously asymptomatic 17-year-old patient.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A morte súbita cardíaca (MSC) pode ser a primeira manifestação da síndrome de Wolff–Parkinson–White (WPW).</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A ablação por cateter da via acessória é atualmente um tratamento seguro e eficaz, estando liberalmente recomendado em doentes sintomáticos. Já na presença de padrão electrocardiográfico de WPW, a orientação terapêutica é alvo de controvérsia. Alguns estudos vieram reativar a discussão relativamente à estratificação de risco e benefício da ablação profilática.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Descrevemos o caso clínico de um jovem de 17 anos previamente assintomático, com arritmia maligna e morte súbita cardíaca abortada como primeira manifestação da doença.</p>" ] ] "nomenclatura" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleSectionTitle">Abbreviations</span>" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:13 [ 0 => array:2 [ "termino" => "AF" "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">atrial fibrillation</p>" ] 1 => array:2 [ "termino" => "AP" "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">accessory pathway</p>" ] 2 => array:2 [ "termino" => "AP-AERP" "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">accessory pathway antegrade effective refractory period</p>" ] 3 => array:2 [ "termino" => "AV" "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">atrioventricular</p>" ] 4 => array:2 [ "termino" => "AVRT" "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">atrioventricular reciprocating tachycardia</p>" ] 5 => array:2 [ "termino" => "CCU" "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">coronary care unit</p>" ] 6 => array:2 [ "termino" => "ECG" "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">electrocardiogram</p>" ] 7 => array:2 [ "termino" => "ED" "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">emergency department</p>" ] 8 => array:2 [ "termino" => "EPS" "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">electrophysiological study</p>" ] 9 => array:2 [ "termino" => "RFA" "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">radiofrequency ablation</p>" ] 10 => array:2 [ "termino" => "SCD" "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">sudden cardiac death</p>" ] 11 => array:2 [ "termino" => "VF" "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">ventricular fibrillation</p>" ] 12 => array:2 [ "termino" => "WPW" "descripcion" => "<p id="par0065" class="elsevierStylePara elsevierViewall">Wolff–Parkinson–White</p>" ] ] ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1607 "Ancho" => 2918 "Tamanyo" => 1574017 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Presenting 12-lead ECG. A wide-complex irregular tachycardia is shown consistent with pre-excited AF. The ventricular response is very rapid, and the shortest pre-excited RR interval is nearly 200<span class="elsevierStyleHsp" style=""></span>ms.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1665 "Ancho" => 2918 "Tamanyo" => 1486367 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Twelve-lead ECG after conversion to sinus rhythm. Shortened PR interval, delta wave, widened QRS complex and secondary repolarization abnormalities are seen. This ECG is indicative of WPW syndrome, and a left lateral AP is suggested (positive delta wave in V1 and inferior leads and negative delta wave in aVL and DI).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1523 "Ancho" => 3333 "Tamanyo" => 406052 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Accessory pathway ablation. Surface leads I, II, III, aVF, aVL, aVF and V1–V6 are shown, with intracardiac recordings from catheters in the right ventricle (HRVp and HRVd), distal (CS1) and proximal (CS5) coronary sinus, and proximal (RFp) and distal (RFd) ablation catheter. Atrial (A) and ventricular (V) electrical signals are shown. (A) Electrocardiographic and intracardiac signals immediately before catheter ablation, recorded at 200<span class="elsevierStyleHsp" style=""></span>mm/s. (B) Catheter accessory pathway ablation, recorded at 50<span class="elsevierStyleHsp" style=""></span>mm/s. Conduction over the AP disappeared within 3<span class="elsevierStyleHsp" style=""></span>s of radiofrequency energy application. The asterisk represents the beginning of radiofrequency energy application.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1507 "Ancho" => 2917 "Tamanyo" => 1420364 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Twelve-lead ECG after catheter ablation. PR and QRS intervals are within normal limits.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atrial fibrillation in the Wolff–Parkinson–White syndrome: ECG recognition and treatment in the ED" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.T. Fengler" 1 => "W.J. Brady" 2 => "C.U. 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| 2023 Agosto | 63 | 26 | 89 |
| 2023 Julho | 69 | 12 | 81 |
| 2023 Junho | 50 | 15 | 65 |
| 2023 Maio | 79 | 26 | 105 |
| 2023 Abril | 48 | 11 | 59 |
| 2023 Maro | 57 | 28 | 85 |
| 2023 Fevereiro | 66 | 31 | 97 |
| 2023 Janeiro | 69 | 36 | 105 |
| 2022 Dezembro | 94 | 36 | 130 |
| 2022 Novembro | 85 | 45 | 130 |
| 2022 Outubro | 73 | 21 | 94 |
| 2022 Setembro | 63 | 38 | 101 |
| 2022 Agosto | 50 | 33 | 83 |
| 2022 Julho | 70 | 49 | 119 |
| 2022 Junho | 61 | 30 | 91 |
| 2022 Maio | 33 | 23 | 56 |
| 2022 Abril | 51 | 31 | 82 |
| 2022 Maro | 56 | 42 | 98 |
| 2022 Fevereiro | 40 | 30 | 70 |
| 2022 Janeiro | 54 | 29 | 83 |
| 2021 Dezembro | 30 | 38 | 68 |
| 2021 Novembro | 46 | 41 | 87 |
| 2021 Outubro | 47 | 44 | 91 |
| 2021 Setembro | 31 | 30 | 61 |
| 2021 Agosto | 41 | 34 | 75 |
| 2021 Julho | 27 | 27 | 54 |
| 2021 Junho | 25 | 17 | 42 |
| 2021 Maio | 34 | 30 | 64 |
| 2021 Abril | 53 | 33 | 86 |
| 2021 Maro | 92 | 28 | 120 |
| 2021 Fevereiro | 95 | 14 | 109 |
| 2021 Janeiro | 43 | 14 | 57 |
| 2020 Dezembro | 39 | 6 | 45 |
| 2020 Novembro | 37 | 16 | 53 |
| 2020 Outubro | 46 | 21 | 67 |
| 2020 Setembro | 45 | 12 | 57 |
| 2020 Agosto | 43 | 12 | 55 |
| 2020 Julho | 61 | 9 | 70 |
| 2020 Junho | 45 | 7 | 52 |
| 2020 Maio | 49 | 2 | 51 |
| 2020 Abril | 56 | 14 | 70 |
| 2020 Maro | 45 | 7 | 52 |
| 2020 Fevereiro | 136 | 25 | 161 |
| 2020 Janeiro | 47 | 10 | 57 |
| 2019 Dezembro | 53 | 5 | 58 |
| 2019 Novembro | 50 | 6 | 56 |
| 2019 Outubro | 51 | 6 | 57 |
| 2019 Setembro | 112 | 10 | 122 |
| 2019 Agosto | 73 | 5 | 78 |
| 2019 Julho | 88 | 11 | 99 |
| 2019 Junho | 73 | 7 | 80 |
| 2019 Maio | 83 | 7 | 90 |
| 2019 Abril | 74 | 20 | 94 |
| 2019 Maro | 167 | 12 | 179 |
| 2019 Fevereiro | 140 | 14 | 154 |
| 2019 Janeiro | 165 | 8 | 173 |
| 2018 Dezembro | 153 | 14 | 167 |
| 2018 Novembro | 144 | 12 | 156 |
| 2018 Outubro | 164 | 15 | 179 |
| 2018 Setembro | 63 | 10 | 73 |
| 2018 Agosto | 151 | 16 | 167 |
| 2018 Julho | 62 | 6 | 68 |
| 2018 Junho | 83 | 9 | 92 |
| 2018 Maio | 69 | 9 | 78 |
| 2018 Abril | 68 | 6 | 74 |
| 2018 Maro | 68 | 10 | 78 |
| 2018 Fevereiro | 34 | 9 | 43 |
| 2018 Janeiro | 45 | 8 | 53 |
| 2017 Dezembro | 84 | 14 | 98 |
| 2017 Novembro | 74 | 8 | 82 |
| 2017 Outubro | 61 | 8 | 69 |
| 2017 Setembro | 81 | 10 | 91 |
| 2017 Agosto | 81 | 13 | 94 |
| 2017 Julho | 72 | 7 | 79 |
| 2017 Junho | 149 | 15 | 164 |
| 2017 Maio | 217 | 20 | 237 |
| 2017 Abril | 73 | 3 | 76 |
| 2017 Maro | 181 | 16 | 197 |
| 2017 Fevereiro | 200 | 14 | 214 |
| 2017 Janeiro | 88 | 4 | 92 |
| 2016 Dezembro | 88 | 14 | 102 |
| 2016 Novembro | 99 | 13 | 112 |
| 2016 Outubro | 139 | 14 | 153 |
| 2016 Setembro | 181 | 16 | 197 |
| 2016 Agosto | 106 | 3 | 109 |
| 2016 Julho | 41 | 9 | 50 |
| 2016 Junho | 7 | 15 | 22 |
| 2016 Maio | 19 | 0 | 19 |
| 2016 Abril | 122 | 10 | 132 |
| 2016 Maro | 189 | 23 | 212 |
| 2016 Fevereiro | 198 | 44 | 242 |
| 2016 Janeiro | 177 | 25 | 202 |
| 2015 Dezembro | 170 | 22 | 192 |
| 2015 Novembro | 181 | 14 | 195 |
| 2015 Outubro | 191 | 30 | 221 |
| 2015 Setembro | 172 | 26 | 198 |
| 2015 Agosto | 185 | 21 | 206 |
| 2015 Julho | 222 | 17 | 239 |
| 2015 Junho | 158 | 10 | 168 |
| 2015 Maio | 172 | 10 | 182 |
| 2015 Abril | 149 | 32 | 181 |
| 2015 Maro | 178 | 12 | 190 |
| 2015 Fevereiro | 182 | 13 | 195 |
| 2015 Janeiro | 148 | 15 | 163 |
| 2014 Dezembro | 136 | 11 | 147 |
| 2014 Novembro | 167 | 13 | 180 |
| 2014 Outubro | 226 | 25 | 251 |
| 2014 Setembro | 191 | 12 | 203 |
| 2014 Agosto | 132 | 18 | 150 |
| 2014 Julho | 168 | 15 | 183 |
| 2014 Junho | 166 | 17 | 183 |
| 2014 Maio | 186 | 20 | 206 |
| 2014 Abril | 164 | 12 | 176 |
| 2014 Maro | 204 | 23 | 227 |
| 2014 Fevereiro | 178 | 21 | 199 |
| 2014 Janeiro | 193 | 19 | 212 |
| 2013 Dezembro | 169 | 18 | 187 |
| 2013 Novembro | 153 | 17 | 170 |
| 2013 Outubro | 143 | 23 | 166 |
| 2013 Setembro | 104 | 27 | 131 |
| 2013 Agosto | 127 | 30 | 157 |
| 2013 Julho | 128 | 33 | 161 |
| 2013 Junho | 112 | 34 | 146 |
| 2013 Maio | 120 | 55 | 175 |
| 2013 Abril | 41 | 23 | 64 |
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