Class II and III: Applicant or Designated
1. Asymptomatic WPW pattern requires cardiology consultation, echocardiogram, 24-hour Holter monitor, and exercise stress testing.
a. WPW pattern alone with normal studies is CD/WR.
b. If cardiology studies determine EPS is indicated, and EPS does NOT cause inducible dysrhythmias, the individual is CD/WR.
c. If cardiology studies determine that EPS is indicated and the EPS causes inducible dysrhythmias, then ablation is required. During ablation procedure, retesting is required to demonstrate that the dysrythmia is non-inducible. The condition is CD/WR. Waiver requests are considered immediately; Class II and III do not have a six-month post-ablation waiting period.
2. WPW syndrome (WPW pattern with symptoms) and LGL (short PR with palpitations) are both CD. Waiver requirements are the same as for Class I personnel with symptomatic dysrhythmias (See Class I Paragraph 2).
3.
Very short PR (< 0.1) without Delta wave, symptoms or dysrhythmia requires a non-invasive cardiology evaluation (24 hour Holter, echocardiogram, stress test). If all tests are negative/normal, then the individual is NCD. If any of the tests are positive/abnormal, then the individual is CD, requires a cardiology evaluation, and may require EPS and/or ablation. Waivers are considered on a case-by-case basis.
4. Short PR (> or = 0.1) without symptoms or dysrhythmias is NCD, and requires no further evaluation, treatment, or waiver.
Follow-Up Reports Required for Waivered Personnel (All Classes):
1. Notation on report of annual flight physical examination indicating no signs or symptoms of dysrhythmia recurrences.
2. An electrocardiogram will be completed and compared to prior studies. In some cases, a Holter U.S. Navy Aeromedical Reference and Waiver Guide Cardiology - 32
monitor may be substituted.
3. If dysrhythmias or symptoms recur, personnel are NPQ and waivers are terminated.
TREATMENT: Radio Frequency Ablation (RFA) is currently the definitive treatment (95-99% immediate success rate), with few complications (0.006-6.9%, but very low in young, healthy patients), and a low risk of recurrence (1-5%, most within 6 months post-RFA). Cryoablation is also acceptable for waiver requests, but is not used as commonly as RFA.
DISCUSSION: Pre-Excitation Syndromes (WPW and LGL) occur in 0.1-0.3% of the population. The lowest incidence of dysrhythmia is in young adults without histories of signs or symptoms. However, 20-35% of asymptomatic individuals with WPW pattern that are inducible via EPS will develop SVT within 10 years, and 1-6% of those will experience sudden death. It is not possible to predict which EPS-inducible patients will develop SVT with or without catastrophic rapid ventricular responses. EPS immediately after RFA is a valid indicator of RFA success and is the current standard of care; EPS weeks, months or years after the RFA is not medically indicated and entails unneeded risks and costs.
