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

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{{Wolff-Parkinson-White syndrome}}
{{Wolff-Parkinson-White syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; {{Rim}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} {{CZ}}; {{Rim}}


==Overview==
==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, type of conduction (antegrade vs retrograde), and characteristics of the conduction (decremental vs non decremental).  In addition, WPW can be classified based of 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>
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>


==Classification==
==Classification==
* 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===
===Classification Based on the Type of Conduction===
The accessory pathway 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>
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
* Antegrade conduction: also known as manifest, responsible for the "pre-excitation" finding on [[ECG]]
* Retrograde conduction: also known as concealed
* 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.
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===
===Classification Based on the Characteristics of Conduction===
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** Decremental conduction is the progressive delay in the conduction through the accessory pathway following an increase in the paced rates.
** 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>
* 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 ECG Findings===
WPW syndrome can be classified based on the location of the accessory pathway, right-sided vs left-sided.  In 1945, Rosenbaum classified WPW syndrome into type A and type B based on the characteristic electrocardiographic findings of the right-sided and left-sided accessory pathway.<ref name="pmid24252285">{{cite journal| author=Suzuki T, Nakamura Y, Yoshida S, Yoshida Y, Shintaku H| title=Differentiating fasciculoventricular pathway from Wolff-Parkinson-White syndrome by electrocardiography. | journal=Heart Rhythm | year= 2014 | volume= 11 | issue= 4 | pages= 686-90 | pmid=24252285 | doi=10.1016/j.hrthm.2013.11.018 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24252285  }} </ref>
*Type A: Pre-excitation of the left side of the heart (the accessory pathway communicates the left [[atrium]] with the left [[ventricle]])
** Presence of upright [[delta wave]] in the precordial leads
** Small or absent S waves
** Generally V1 shows either a notched R wave or RS or Rsr' deflection
** Mimics a posterior [[MI]], [[RVH]]
* Type B: Pre-excitation of the right side of the heart (the accessory pathway communicates the right [[atrium]] with the right [[ventricle]])
** Negative delta wave
** Prominent S wave deflection in the right precordial leads, and upright R waves in the lateral precordial leads
** More common than type A
** May resemble an abnormal Q wave in the right precordial leads and be mistaken for an [[Acute MI|anterior MI]]


===Classification Based on the Type of AVRT===
===Classification Based on the Type of AVRT===
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===Variants of WPW===
===Variants of WPW===
====[[Lown-Ganong-Levine Syndrome]] ([[LGL]])====
====[[Lown-Ganong-Levine Syndrome]] ([[LGL]])====
* There is a short [[PR interval]], but no delta wave
* Short [[PR interval]], but no [[delta wave]]
* LGL is due to intranodal bypass tracts (i.e. there is conduction down the [[James fibers]])   
* Intranodal bypass tracts (conduction down the [[James fibers]])   
* Normal [[QRS duration]]
* Normal [[QRS duration]]
* [[PR]] less than 0.12 seconds
* [[PR]] less than 0.12 seconds
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====[[Mahaim type preexcitation|Mahaim Type Preexcitation]]====
====[[Mahaim type preexcitation|Mahaim Type Preexcitation]]====
* This form of pre-excitation is due to nodoventricular, nodofascicular or fasciculoventricular connections
* Antidromic atrioventricular reentry [[tachycardia]] pattern
* The impulse may travel through the [[AV node]] normally and this may then be followed by premature conduction to the basal ventricular myocardium
* Cause: Atriofascicular pathway or  Insertion of [[right ventricle]] free wall [[accessory pathway]] into the [[right bundle branch]]
* There is a delta wave with a normal [[PR interval]]
* No preexcitation during [[sinus rhythm]]
* Rarer than [[WPW]] or [[LGL]]
* Induction of preexcitation with [[premature atrial contraction]] or [[rapid atrial pacing]]
* 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
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==

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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