An 18-Year-Old Basketball Player With Pre-Excitation on an Electrocardiogram

An 18-year-old woman, who is a basketball player on a scholarship at a local university and has no significant past medical history, presents with chest pain and palpitations. Symptoms are described as dull, burning, retrosternal chest pain and tachypalpitations. She denies any syncope or near-syncope. She undergoes an initial evaluation for the chest discomfort, which includes an electrocardiogram (ECG) and an echocardiogram. This reveals a structurally normal heart; however, her ECG reveals the presence of a delta wave consistent with presumed Wolff-Parkinson-White (WPW) syndrome. She undergoes a treadmill myocardial perfusion imaging study that demonstrates normal perfusion and cardiac function on imaging, and there is no inducible tachyarrhythmia on the exercise portion. However, her delta wave remains manifest throughout the exercise period.

She is referred to electrophysiology (EP) for consultation. A 24-hour Holter monitor also reveals the presence of persistent pre-excitation. She is taken to the EP lab where a standard three-catheter EP study reveals pre-excitation with a short his-ventricular (H-V) interval of 25 milliseconds. When on high-dose isoproterenol, supraventricular tachycardia (SVT) cannot be induced; however, a brief episode of atrial fibrillation (AF) is induced without rapid ventricular response. Finally, catheter movement induces a temporary 2:1 atrioventricular (AV) block with persistent pre-excitation on the conducted beats.

Which of the following describes the next most appropriate step in management?

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