Wolff-Parkinson-White syndrome classification scheme
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Rim Halaby, M.D. [3]
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 antroseptal region), 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.[1]
Classification
- the finding on ECG in normal sinus rhythm during ventricular preexcitation include:
- short PR interval≤120 milliseconds
- delta wave ( slurring of the initial forces of the QRS complex
- secondary ST-T wave abnormalities
- Left lateral free wall
- Posteroseptal
- Right free wall
- Antroseptal wall
- The accessory pathway may be localized on ECG based on: delta wave axis during preexcitation; P-wave axis during orthodromic AVRT
Delta-wave axis
- Negative delta in V1 indicates a left-sided accessory pathway
- 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
- positive P wave in avl, negative P wave in AVR indicates right sided accessory pathway
- axis superior in P waves indicates posteroseptal accessory pathway
- axis inferior in P waves indicates the anteroseptal accessory pathway
Classification Based on the Type of Conduction
The accessory pathway in WPW can 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 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.[4]
- 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 myocardial infraction (MI) or right ventricular hypertrophy (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 anterior MI
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]
- Orthodromic (most common): the antegrade electrical signal moves from the atria to the ventricles through the AV node, whereas the retrograde electrical signal moves from the ventricles to the atria through the accessory pathway.
- Antidromic: the antegrade electrical signal moves from the atria to the ventricles through the accessory pathway, whereas the retrograde electrical signal moves from the ventricles to the atria through either the AV node or a second accessory pathway.
Variants of WPW
Lown-Ganong-Levine Syndrome (LGL)
- There is a short PR interval, but no delta wave
- LGL is due to intranodal bypass tracts (i.e. there is conduction down the James fibers)
- Normal QRS duration
- PR less than 0.12 seconds
- Normal P wave
Mahaim Type Preexcitation
- This form of pre-excitation is due to 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
- 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
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Suzuki T, Nakamura Y, Yoshida S, Yoshida Y, Shintaku H (2014). "Differentiating fasciculoventricular pathway from Wolff-Parkinson-White syndrome by electrocardiography". Heart Rhythm. 11 (4): 686–90. doi:10.1016/j.hrthm.2013.11.018. PMID 24252285.