Non-invasive versus invasive risk stratification of paediatric patients with ventricular pre-excitation

Abstract

Introduction and Objectives: Ventricular pre-excitation (VPE) relates to the presence of an accessory pathway that bypasses the atrioventricular-His-Purkinje conduction system. Despite being a rare event, these patients can present sudden cardiac death (SCD) as the first manifestation of VPE. Risk stratification to identify which individuals are at a higher risk for SCD has classically been performed using non-invasive methods (electrocardiogram, 24-hour Holter monitoring and exercise stress test), although recent studies show that low-risk markers in these exams do not exactly correlate with a low risk for SCD invasively determined by electrophysiological study (EPS). The purpose of this study was to evaluate how non-invasive risk stratification correlates with SCD risk assessed by EPS. Methods: This single-centre retrospective cohort study included all paediatric patients with VPE who underwent EPS from January 2016 to July 2023 at our institution. Patient data was collected from electronical clinical records. Results: Among 85 patients, 30 were asymptomatic, 12 of whom had low-risk non-invasive markers. Considering EPS data, 49 patients (33 symptomatic and 16 asymptomatic) presented high-risk accessory pathways. Sensitivity and specificity of non-invasive methods as surrogates for SCD risk on EPS were 83.7% and 11.1%, respectively. Conclusion: Our study demonstrates that relying solely on non-invasive tests is not the most effective method for accurately predicting the risk of SCD in VPE patients. Invasive risk stratification should be considered for all patients, irrespective of their symptoms.