Wolff-Parkinson-White syndrome classification scheme: Difference between revisions

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__NOTOC__
{{Wolff-Parkinson-White syndrome}}
{{Wolff-Parkinson-White syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} {{CZ}}; {{Rim}}
==EKG Classification==
# Type A:
#* Prominent R wave in lead V1 and V2.
#* It has been found at EP studies that these patients have early activation of the [[left ventricle]].
#* Generally V1 shows either a notched R wave or RS or Rsr' deflection
#* Mimics a posterior MI, RVH
# Type B: 
#* Prominent S wave deflection in the right precordial leads, and upright R waves in the lateral precordial leads.
#* EP studies have showed that this form of [[WPW syndrome]]s is due to early activation of the lateral aspect of the [[right ventricle]]
#* This form is more common.
#* May resemble an abnormal Q wave in the right precordial leads and be mistaken for an [[Acute MI|anterior MI]]
#* In both type A and B there may be abnormal q waves in leads 2, 3 and aVF.


==Overview==
Wolff-Parkinson-White ([[WPW]]) syndrome is the occurrence of [[arrhythmia]] in the presence of an [[accessory pathway]].  WPW can be classified according to the site of origin, location in the [[mitral]] or [[tricuspid]] annulus except at the aortomitral continuity (left anteroseptal region), type of conduction (antegrade vs retrograde), and characteristics of the conduction (decremental vs nondecremental).  In addition, WPW can be classified based on the type of [[atrioventricular reciprocating tachycardia]] ([[AVRT]]) it causes, which can be either orthodromic (~95% of the cases) or antidromic.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref>


==Variants of WPW==
==Classification==
#LGL: Lown-Ganong-Levine Syndrome
#* there is a short PR, but no delta wave
#* due to intranodal bypass tracts (i.e. there is conduction down James fibers) 
#* normal QRS duration
#* PR less than 0.12 seconds
#* normal P wave
# Mahaim Type of Preexcitation
#* nodoventricular, nodofascicular or fasciculoventricular connections
#* the impulse may travel through the AV node normally and this may then be followed by premature conduction to the basal ventricular myocardium
#* there is a delta wave with a normal PR interval
#* is rarer than WPW or LGL
#* in older patients there can be a prolonged conduction down the accessory pathway resulting in a normal PR interval in the presence of WPW which is tough to distinguish from Mahaim fibers


* Findings of  [[ECG]] in [[sinus rhythm]] during [[ventricular preexcitation]] include:
* Short [[PR interval]]≤120 milliseconds
* [[Delta wave]] ( slurring of the initial forces of the QRS complex
* QRS>100 milliseconds
* Secondary [[ST-T wave]] abnormalities
** [[Wolf Parkinson White syndrome]] may be classified according to the localization of [[accessory pathway]] on [[ECG]] into four subtypes:<ref name="CainLuke1992">{{cite journal|last1=Cain|first1=Michael E.|last2=Luke|first2=Robert A.|last3=Lindsay|first3=Bruce D.|title=Diagnosis and Localization of Accessory Pathways|journal=Pacing and Clinical Electrophysiology|volume=15|issue=5|year=1992|pages=801–824|issn=0147-8389|doi=10.1111/j.1540-8159.1992.tb06847.x}}</ref><ref name="GoldreyerDamato1971">{{cite journal|last1=Goldreyer|first1=Bruce N.|last2=Damato|first2=Anthony N.|title=The Essential Role of Atrioventricular Conduction Delay in the Initiation of Paroxysmal Supraventricular Tachycardia|journal=Circulation|volume=43|issue=5|year=1971|pages=679–687|issn=0009-7322|doi=10.1161/01.CIR.43.5.679}}</ref>
*Left lateral free wall (common type)
*Posteroseptal
*Right free wall
*Antroseptal wall
The accessory pathway may be localized on [[ ECG ]] during preexcitation based on the delta wave axis and [[P-wave]] axis.
=== Delta-wave axis ===
* Negative delta in V1 indicates a left-sided accessory pathway<ref name="pmid1382283">{{cite journal |vauthors=Cain ME, Luke RA, Lindsay BD |title=Diagnosis and localization of accessory pathways |journal=Pacing Clin Electrophysiol |volume=15 |issue=5 |pages=801–24 |date=May 1992 |pmid=1382283 |doi=10.1111/j.1540-8159.1992.tb06847.x |url=}}</ref><ref name="SzaboKlein1989">{{cite journal|last1=Szabo|first1=Tibor S.|last2=Klein|first2=George J.|last3=Guiraudon|first3=Gerard M.|last4=Yee|first4=Raymond|last5=Sharma|first5=Arjun D.|title=Localization of Accessory Pathways in the Wolff-Parkinson-White Syndrome|journal=Pacing and Clinical Electrophysiology|volume=12|issue=10|year=1989|pages=1691–1705|issn=0147-8389|doi=10.1111/j.1540-8159.1989.tb01848.x}}</ref>
*Negative delta in lead 1 and avl or 2,3,avf indicates left free wall or left posterior accessory pathway
*rsR` or QR complexes in V1 in the absent of incomplete RBBB, indicates left-sided septal accessory pathway
*Negative delta in lead 2, the positive delta in Avr ,deep s wave in V6 indicates postroseptal accessory pathway within the coronary sinus
*LBBB pattern, transitioning zone before V4, the positive delta in 2,3,avf indicates an anteroseptal accessory pathway
===  P-wave axis ===
* Positive P wave in AVR, negative P wave in AVL indicates left-sided accessory pathway<ref name="pmid8617084">{{cite journal |vauthors=Tai CT, Chen SA, Chiang CE, Lee SH, Chang MS |title=Electrocardiographic and electrophysiologic characteristics of anteroseptal, midseptal, and para-Hisian accessory pathways. Implication for radiofrequency catheter ablation |journal=Chest |volume=109 |issue=3 |pages=730–40 |date=March 1996 |pmid=8617084 |doi=10.1378/chest.109.3.730 |url=}}</ref>
* Positive P wave in AVL, negative P wave in AVR indicates right-sided accessory pathway
* Superior axis in P waves  indicates a posteroseptal accessory pathway
* Inferior axis in P waves  indicates the anteroseptal accessory pathway
===Classification Based on the Type of Conduction===
The [[accessory pathway]] in [[ WPW]] may be classified into:<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref>
* Antegrade conduction: also known as manifest, responsible for the "pre-excitation" finding on [[ECG]]
* Retrograde conduction: also known as concealed
Most commonly, the accessory pathways conduct in both directions. Isolated retrograde conduction is less common.  Isolated antegrade conduction is the least common and is usually associated with accessory pathways in the right side of the [[heart]].
===Classification Based on the Characteristics of Conduction===
* Decremental conduction (8% of the cases)
** Decremental conduction is the progressive delay in the conduction through the accessory pathway following an increase in the paced rates.
* Non-decremental conduction (92% of the cases)<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref>
===Classification Based on the Type of AVRT===
The most common arrhythmia in WPW syndrome is atrioventricular reciprocating tachycardia (AVRT).  AVRT in WPW can be classified into:<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref>
* Orthodromic (most common): the antegrade electrical signal moves from the [[atria]] to the [[ventricle]]s through the [[AV node]], whereas the retrograde electrical signal moves from the [[ventricle]]s to the [[atria]] through the accessory pathway.
* Antidromic: the antegrade electrical signal moves from the [[atria]] to the [[ventricle]]s through the [[accessory pathway]], whereas the retrograde electrical signal moves from the [[ventricle]]s to the [[atria]] through either the [[AV node]] or a second [[accessory pathway]].
===Variants of WPW===
====[[Lown-Ganong-Levine Syndrome]] ([[LGL]])====
* Short [[PR interval]], but no [[delta wave]]
* Intranodal bypass tracts (conduction down the [[James fibers]]) 
* Normal [[QRS duration]]
* [[PR]] less than 0.12 seconds
* Normal [[P wave]]
====[[Mahaim type preexcitation|Mahaim Type Preexcitation]]====
* Antidromic atrioventricular reentry [[tachycardia]] pattern
* Cause: Atriofascicular pathway or  Insertion of [[right ventricle]] free wall [[accessory pathway]] into the  [[right bundle branch]]
* No preexcitation during [[sinus rhythm]]
* Induction of preexcitation with [[premature atrial contraction]] or [[rapid atrial pacing]]
Pattern of preexcitation:
* [[LBBB]] morphology,
* Long [[atrioventricular interval]] because of long conduction time over the [[accessory pathway]]
* Normal or short [[PR interval]]
* Anterograde conduction over the [[accessory pathway]] and retrograde conduction over the [[right bundle branch]]-[[His bundle-AV node]]<ref name="pmid28507744">{{cite journal |vauthors=Katritsis DG, Wellens HJ, Josephson ME |title=Mahaim Accessory Pathways |journal=Arrhythm Electrophysiol Rev |volume=6 |issue=1 |pages=29–32 |date=April 2017 |pmid=28507744 |pmc=5430943 |doi=10.15420/aer.2016:35:1 |url=}}</ref>


==References==
==References==
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Disease]]
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Latest revision as of 19:36, 9 November 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Rim Halaby, M.D. [4]

Overview

Wolff-Parkinson-White (WPW) syndrome is the occurrence of arrhythmia in the presence of an accessory pathway. WPW can be classified according to the site of origin, location in the mitral or tricuspid annulus except at the aortomitral continuity (left anteroseptal region), type of conduction (antegrade vs retrograde), and characteristics of the conduction (decremental vs nondecremental). In addition, WPW can be classified based on the type of atrioventricular reciprocating tachycardia (AVRT) it causes, which can be either orthodromic (~95% of the cases) or antidromic.[1]

Classification

The accessory pathway may be localized on ECG during preexcitation based on the delta wave axis and P-wave axis.

Delta-wave axis

  • Negative delta in V1 indicates a left-sided accessory pathway[4][5]
  • Negative delta in lead 1 and avl or 2,3,avf indicates left free wall or left posterior accessory pathway
  • rsR` or QR complexes in V1 in the absent of incomplete RBBB, indicates left-sided septal accessory pathway
  • Negative delta in lead 2, the positive delta in Avr ,deep s wave in V6 indicates postroseptal accessory pathway within the coronary sinus
  • LBBB pattern, transitioning zone before V4, the positive delta in 2,3,avf indicates an anteroseptal accessory pathway

P-wave axis

  • Positive P wave in AVR, negative P wave in AVL indicates left-sided accessory pathway[6]
  • Positive P wave in AVL, negative P wave in AVR indicates right-sided accessory pathway
  • Superior axis in P waves indicates a posteroseptal accessory pathway
  • Inferior axis in P waves indicates the anteroseptal accessory pathway

Classification Based on the Type of Conduction

The accessory pathway in WPW may be classified into:[1]

  • Antegrade conduction: also known as manifest, responsible for the "pre-excitation" finding on ECG
  • Retrograde conduction: also known as concealed

Most commonly, the accessory pathways conduct in both directions. Isolated retrograde conduction is less common. Isolated antegrade conduction is the least common and is usually associated with accessory pathways in the right side of the heart.

Classification Based on the Characteristics of Conduction

  • Decremental conduction (8% of the cases)
    • Decremental conduction is the progressive delay in the conduction through the accessory pathway following an increase in the paced rates.
  • Non-decremental conduction (92% of the cases)[1]

Classification Based on the Type of AVRT

The most common arrhythmia in WPW syndrome is atrioventricular reciprocating tachycardia (AVRT). AVRT in WPW can be classified into:[1]

Variants of WPW

Lown-Ganong-Levine Syndrome (LGL)

Mahaim Type Preexcitation

Pattern of preexcitation:

References

  1. ↑ 1.0 1.1 1.2 1.3 Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ; et al. (2003). "ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society". J Am Coll Cardiol. 42 (8): 1493–531. PMID 14563598.
  2. ↑ Cain, Michael E.; Luke, Robert A.; Lindsay, Bruce D. (1992). "Diagnosis and Localization of Accessory Pathways". Pacing and Clinical Electrophysiology. 15 (5): 801–824. doi:10.1111/j.1540-8159.1992.tb06847.x. ISSN 0147-8389.
  3. ↑ Goldreyer, Bruce N.; Damato, Anthony N. (1971). "The Essential Role of Atrioventricular Conduction Delay in the Initiation of Paroxysmal Supraventricular Tachycardia". Circulation. 43 (5): 679–687. doi:10.1161/01.CIR.43.5.679. ISSN 0009-7322.
  4. ↑ Cain ME, Luke RA, Lindsay BD (May 1992). "Diagnosis and localization of accessory pathways". Pacing Clin Electrophysiol. 15 (5): 801–24. doi:10.1111/j.1540-8159.1992.tb06847.x. PMID 1382283.
  5. ↑ Szabo, Tibor S.; Klein, George J.; Guiraudon, Gerard M.; Yee, Raymond; Sharma, Arjun D. (1989). "Localization of Accessory Pathways in the Wolff-Parkinson-White Syndrome". Pacing and Clinical Electrophysiology. 12 (10): 1691–1705. doi:10.1111/j.1540-8159.1989.tb01848.x. ISSN 0147-8389.
  6. ↑ Tai CT, Chen SA, Chiang CE, Lee SH, Chang MS (March 1996). "Electrocardiographic and electrophysiologic characteristics of anteroseptal, midseptal, and para-Hisian accessory pathways. Implication for radiofrequency catheter ablation". Chest. 109 (3): 730–40. doi:10.1378/chest.109.3.730. PMID 8617084.
  7. ↑ Katritsis DG, Wellens HJ, Josephson ME (April 2017). "Mahaim Accessory Pathways". Arrhythm Electrophysiol Rev. 6 (1): 29–32. doi:10.15420/aer.2016:35:1. PMC 5430943. PMID 28507744.

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