Do You Need Ablation for WPW Syndrome? Can You Fly Safely?

Does Wolff-Parkinson-White (WPW) syndrome require catheter ablation (can one fly)?

Hello, Director He.
I would like to consult you regarding issues related to WPW syndrome.
First, please review my examination results below:
1.
I have undergone two 24-hour Holter ECGs (the first one was in December last year, and the second one was just done in July).
2.
Doppler echocardiography.
3.
Exercise ECG.
(a) Holter ECG recording on 2022/12/14 [Report Content & Impression]:
1.
Basically sinus rhythm with short PR interval and pre-excitation.
Minimal HR: 57/min (04:34), Average HR: 81/min, Maximal HR: 130/min (11:38).
The longest pause: 1.4 sec (03:17).
2.
Occasional ventricular ectopic beats (41) with 2 episodes of ventricular tachycardia (22:49, 19:00).
Rare supraventricular ectopic beats (6).
3.
ST changes with T wave alterations correlated to pre-excitation.
Diagnosis:
- Premature Ventricular Contractions (PVCs)
- Premature Atrial Contractions (PACs)
- 2-VT, Paroxysmal Supraventricular Tachycardia (PSVT) with WPW and AV Reentrant Tachycardia (AVRT) / Non-sustained WPW syndrome.
(b) Holter ECG recording on 2023/07/03 [Report Content & Impression]:
1.
Basically sinus rhythm with short PR interval and pre-excitation.
2.
Minimal HR: 46/min (03:18).
3.
Average HR: 76/min.
4.
Maximal HR: 145/min (09:52).
5.
The longest pause: 1.4 sec (03:18).
6.
Frequent ventricular ectopic beats (442 - 0.4%) with 418-bigeminy.
Occasional supraventricular ectopic beats (70).
ST changes with T wave alterations correlated to pre-excitation.
Diagnosis:
- Premature Ventricular Contractions (PVCs), 0.4%, bigeminy, especially between 02:00-06:00.
- Premature Atrial Contractions (PACs).
- WPW syndrome.
- Sinus tachycardia (09:52 - 145/min).
Doppler Echocardiography:
The left ventricle is grossly normal in size and shape.
The left ventricular systolic function is normal.

- Aortic regurgitation trace.
- Mild mitral regurgitation.
- Mild tricuspid regurgitation.
- Mild pulmonic regurgitation.
M-mode/2D Measurements & Calculations:
- IVSd: 0.76 cm
- LVIDd: 4.6 cm
- FS: 39.5%
- LV mass (C)d: 121.2 grams
- LVIDs: 2.8 cm
- EDV (Teich): 99.2 ml
- LVPWd: 0.85 cm
- ESV (Teich): 29.7 ml
- RWT: 0.37
- EF (M 52% F 54%): 70.0%
- Ao root diameter: 2.8 cm
- Ascending aorta diameter: 2.6 cm
- Ao root area: 6.3 cm
- ACS: 1.9 cm
- LA dimension: 3.5 cm
Doppler Measurements & Calculations:
- MV E max velocity: 61.1 cm/sec
- Ao V2 max: 148.0 cm/sec
- PA V2 max: 82.5 cm/sec
- MV deceleration slope: 275.5 cm/sec
- MV A max velocity: 70.3 cm/sec
- Ao max pressure gradient: 8.8 mmHg
- PA max pressure gradient: 2.7 mmHg
- MV deceleration time: 0.22 sec
- MV E/A: 0.87
- PA acceleration time: 0.17 sec
- TR max velocity: 220.6 cm/sec
- TR max pressure gradient: 19.5 mmHg
Left Ventricle: The left ventricle is grossly normal in size and shape.
The left ventricular systolic function is normal.
No regional wall motion abnormalities were noted.
Left Atrium: The left atrial size is normal.
Aortic Valve: Aortic regurgitation trace.
Mitral Valve: Mild mitral regurgitation.
Right Heart: Mild tricuspid regurgitation.
Mild pulmonic regurgitation.
Exercise ECG Report (2023/04/17):
The patient exercised according to the Bruce protocol for 06:14 minutes, achieving a maximum MET level of 7.7.
The resting heart rate of 109 bpm rose to a maximal heart rate of 170 bpm, which represents 98% of the maximal age-predicted heart rate.
The resting blood pressure of 144/75 mmHg rose to a maximum blood pressure of 192/55 mmHg.
The test was stopped due to dyspnea.
Interpretation:
- Resting: WPW syndrome.
- Chest pain: NONE.
- Functional Capacity: Normal.
- HR response to exercise: Appropriate.
- BP response to exercise: Resting hypertension with exaggerated response.
- Arrhythmias: No arrhythmia.
- ST Changes: ST-depression, horizontal/reaching criteria.
Conclusion:
Overall impression: Inconclusive stress test.
I would like to ask the doctor several questions:
1.
Regarding the two 24-hour Holter ECGs, why were there different findings? The number of ventricular ectopic beats increased, and there was a 418-bigeminy, which seems to be a different arrhythmia from WPW.
The first test showed VT and PSVT, but they were absent in the second test.
Is this concerning? I have been consistently doing spinning exercises for the past six months, and my heart rate seems to have stabilized; could this be the reason?
2.
Is my echocardiogram normal? Are there any issues with contraction?
3.
Why is the conclusion of my exercise ECG inconclusive? I did not experience any discomfort during the test, yet it was stopped due to dyspnea.
I noticed my blood pressure was quite high during exercise; is this normal? I have had low blood pressure for a long time, often below 90/50 before bed; is this normal?
4.
I have known about my extra electrical pathway since high school but was unaware it was formally called WPW.
After experiencing frequent palpitations post-pandemic, I underwent these tests and learned about WPW and some risk factors.
Do I need to undergo catheter ablation?
5.
I read online that WPW can pose a risk of tachycardia during episodes.
Given my WPW symptoms, is it safe for me to fly? I used to travel frequently for work, but now I hesitate and wonder if I should have ablation before flying.
Thank you very much for your guidance, Director He.

Ms. Zhang, 40~49 year old female. Ask Date: 2023/07/06

Dr. He Dongjin reply Cardiology

Hello, the echocardiogram and exercise electrocardiogram both appear normal.
An inconclusive result means there is nothing wrong.
It is normal for blood pressure to increase during exercise.
In the case of Wolff-Parkinson-White (WPW) syndrome, ablation is recommended unless you never experience episodes.
If you frequently fly and are concerned about potential issues, it is advisable to address it promptly rather than carrying around a ticking time bomb and worrying all day.
Some fluctuations over 24 hours are acceptable.
Please take care of it.
Changhua Hospital cares about you.

Reply Date: 2023/07/06

More Info

WPW syndrome, or Wolff-Parkinson-White syndrome, is a condition characterized by an extra electrical pathway in the heart, which can lead to episodes of rapid heart rate (tachycardia). Your concerns regarding the management of WPW syndrome, the necessity of ablation, and the safety of flying are valid and important to address.

1. Variability in ECG Results: The differences observed in your two 24-hour ECG recordings can be attributed to several factors. The presence of more ventricular ectopic beats (VE) and the occurrence of bigeminy (a pattern where every other heartbeat is a premature beat) in the second test may indicate changes in your heart's electrical activity or response to stressors, such as exercise or anxiety. It is not uncommon for arrhythmias to fluctuate over time, especially with lifestyle changes, such as increased physical activity. Regular exercise, like spinning, can improve cardiovascular health and potentially stabilize heart rhythms, but it’s essential to monitor how your body responds to such activities.

2. Echocardiogram Findings: Your echocardiogram results indicate that your left ventricle is normal in size and function, which is reassuring. Mild regurgitation in the aortic and mitral valves is common and often does not pose significant health risks unless symptomatic. The normal left ventricular function suggests that your heart is pumping effectively, which is a positive sign.

3. Inconclusive Exercise ECG: The inconclusive result from your exercise ECG could be due to several factors, including the presence of ST changes during exercise, which may indicate ischemia or other cardiac stress. The dyspnea you experienced could have been a response to exertion, especially if you have underlying issues like low blood pressure. It’s not unusual for individuals with a history of low blood pressure to experience higher readings during exercise due to the body’s compensatory mechanisms. However, consistently low blood pressure readings at rest, especially below 90/50 mmHg, should be discussed with your healthcare provider to ensure that it’s not causing any adverse effects.

4. Need for Ablation: The decision to proceed with catheter ablation for WPW syndrome typically depends on the frequency and severity of your symptoms. If you experience frequent episodes of tachycardia that significantly impact your quality of life, ablation may be recommended. This procedure aims to eliminate the extra electrical pathway and can be very effective. However, if your symptoms are infrequent and manageable, your physician may suggest a conservative approach with regular monitoring.

5. Flying with WPW Syndrome: Regarding air travel, many individuals with WPW syndrome fly without issues. However, if you have experienced recent episodes of tachycardia or other concerning symptoms, it may be wise to consult with your cardiologist before flying. They can provide personalized advice based on your current health status and the frequency of your symptoms. If you are considering ablation, it may be prudent to wait until after the procedure, as this could reduce your risk of tachycardia during flights.

In conclusion, while WPW syndrome can pose risks, many individuals manage their condition effectively with lifestyle modifications and medical supervision. Regular follow-ups with your cardiologist are essential to monitor your heart health and make informed decisions about your treatment options. If you have any further questions or concerns, do not hesitate to reach out to your healthcare provider for guidance tailored to your specific situation.

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