Atrial fibrillation with Wolff-Parkinson-White syndrome in epilepsy: A potentially fatal combination

During epileptic seizures, cardiac arrhythmias are not uncommon findings. Most of them are benign, although sometimes they can be a life-threatening situation. The combination of a Wolff-Parkinson-White syndrome with atrial fibrillation is a potentially lethal situation but can be definitively treated. A 44-year-old woman with epilepsy since youth and no previous cardiovascular event, was admitted to the epilepsy unit for a thorough study with video-EEG. She usually had several complex partial seizures every month, although occasionally presented generalized episodes. Antiepileptic drugs were tapered off before the study. Previous ECGs showed sinus rhythm with a short PR interval (100 ms) and a narrow QRS complex without delta wave. During the video-EEG she had a partial seizure that secondarily generalized. Sinus tachycardia without any abnormality in the ECG was noticed at the beginning of the episode, but in the post-ictal state she developed a regular wide QRS complex tachycardia at a rate of 180 bpm (Fig. 1) that spontaneously changed to an irregular one. The QRS complexes were very broad and showed a right bundle branch block configuration suggesting an atrial fibrillation (AF) with preexcitation (Fig. 2). The arrhythmia was well tolerated and spontaneously terminated after the seizure. The ECG after this episode was similar to the initial one. An electrophysiological study was performed and revealed an AH (Atrium to His) interval of 38 ms, slightly below the normal limits. By programmed atrial stimulation, an atrial tachycardia was induced but immediately degenerated into AF, which was finished by electrical cardioversion. Both of them showed a preexcitation pattern similar to the clinical episode. The HV (His to Ventricle) interval was 37 ms and shortened with incremental pacing at distal coronary sinus and the high right atrium, with the appearance of a clear preexcitation pattern. Anterograde refractory period was 240 ms. A left posterior accessory pathway (AP) was demonstrated and successfully ablated. After ablation, the AH interval remained unchanged. After one-year follow-up with antiepileptic drugs but without antiarrhythmic treatment, the patient had several partial seizures, none of them generalized and was free of arrhythmic events. Epileptic patients have a higher incidence of arrhythmias within the peri-ictal period. The incidence of epilepsy-related arrhythmias has been described in up to 56% of seizures including sinus tachycardia, bradycardia, asystole, ectopic beats, conduction disturbances, atrial fibrillation, supraventricular and ventricular arrhythmias. Uncontrolled electrical discharges during an epileptic episode concerning autonomic control system areas (insular cortex, amygdala, cingulated gyrus, thalamus and hypothalamus) may disturb both sympathetic and/or parasympathetic system, resulting in any kind of arrhythmia [[1]Sevcencu C. Struijk J. Autonomic alterations and cardiac changes in epilepsy.Epilepsia. 2005; 51: 725-737Crossref Scopus (207) Google Scholar]. Although most of the time it results in benign arrhythmias, life-threatening events, such as atrioventricular block or ventricular arrhythmias have been described. Peri-ictal atrial fibrillation cases have been described, most of them in males and tonic-clonic seizures. The duration of these episodes has been described from less than 2 min to up to more than 24 h and none of them has ever been described in a patient with Wolff-Parkinson-White (WPW) syndrome [[2]Surges R. Moskau S. Viebahn B. Schoene-Bake J.C. Schwab J.O. Elger C.E. Prolonged atrial fibrillation following generalized tonic-clonic seizures.Seizure. 2012; 21: 643-645Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. The combination of AF and WPW syndrome entails a risk for sudden cardiac death. The mechanism is based on the very fast conduction of the atrial impulses to the ventricles through the AP, which can degenerate into ventricular fibrillation [[3]Pappone C. Videdomini G. Manguso F. Baldi M. Pappone A. Petretta A. et al.Risk of malignant arrhythmias in initially symptomatic patients with Wolff-Parkinson-White syndrome: results of a prospective long-term electrophysiological follow-up study. Clinical perspective.Circulation. 2012; 125: 661-668Crossref PubMed Scopus (82) Google Scholar]. Our patient did not have an evident preexcitation in the ECG, likely because of AP's anatomical situation (left posterior, far away from the sinus node) and the presence of a facilitated nodal conduction, proved as a short AH interval. Sudden unexpected death has been described in epileptic patients, the so called SUDEP, but the direct mechanism is not very well known [[4]Tomson T. Nashef L. Ryvlin P. Sudden unexpected death in epilepsy: current knowledge and future directions.Lancet Neurol. 2008; 7: 1021-1031Abstract Full Text Full Text PDF PubMed Scopus (514) Google Scholar]. Although central apnea has been postulated as the most likely responsible, the high incidence of arrhythmias in these patients has raised the hypothesis of arrhythmic events as a potential underlying mechanism. The combination in our patient of epilepsy, WPW syndrome and seizure-induced atrial fibrillation attached an increased risk of sudden death. The elective treatment for WPW syndrome is AP ablation, which eliminates the risk of sudden death in the case of AF recurrence. This is an isolated case report and its main limitation is the absence of a genetic test that could prove a biological or structural association between epilepsy and atrial fibrillation. None declared.