Pre-excitation syndrome: Difference between revisions

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*[[File:Wolf-parkinson-white.jpg|thumb|WPW Syndrome was given in 1930 by Wolf- Parkinson- white. [https://en.ecgpedia.org/index.php?title=File:Wolffparkinsonwhite.jpg]|alt=|254x254px]][[WPW syndrome]] was described in 1930 and named for the [[John Parkinson]], [[Paul Dudley White]], and [[Louis Wolff]].
*[[File:Wolf-parkinson-white.jpg|thumb|WPW Syndrome was given in 1930 by Wolf- Parkinson- white. [https://en.ecgpedia.org/index.php?title=File:Wolffparkinsonwhite.jpg]|alt=|254x254px]][[WPW syndrome]] was described in 1930 and named for the [[John Parkinson]], [[Paul Dudley White]], and [[Louis Wolff]].
*They successfully interpreted a series of 11 [[healthy]] young [[patients]] who had repeated attacks of [[tachycardia]] in the presence of [[short PR interval]] and [[bundle branch block]] pattern on the [[ECG]] findings<ref>https://doi.org/10.1016/j.eupc.2004.09.005</ref>.
*They successfully interpreted a series of 11 [[healthy]] young [[patients]] who had repeated attacks of [[tachycardia]] in the presence of [[short PR interval]] and [[bundle branch block]] pattern on the [[ECG]] findings.
*British physiologist "Albert Frank Stanley Kent" (1863 - 1958), first described the lateral branches of [[AV grove]] of the [[monkey]] [[heart]], which was later named accessory [[bundle of Kent]].
*British physiologist "Albert Frank Stanley Kent" (1863 - 1958), first described the lateral branches of [[AV grove]] of the [[monkey]] [[heart]], which was later named accessory [[bundle of Kent]].
*In 1915, [[Frank Norman Wilson]] became the first to describe the [[condition]] which would later be referred to as [[Wolff–Parkinson–White syndrome]].
*In 1915, [[Frank Norman Wilson]] became the first to describe the [[condition]] which would later be referred to as [[Wolff–Parkinson–White syndrome]].
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==Classification==
==Classification==


*Based on conduction pathway or fiber subtype [[ pre-excitation syndrome]] may be classified into sub-types<ref name="pmid1111564">{{cite journal |vauthors=Lowe KG, Emslie-Smith D, Ward C, Watson H |title=Classification of ventricular pre-excitation. Vectorcardiographic study |journal=Br Heart J |volume=37 |issue=1 |pages=9–19 |date=January 1975 |pmid=1111564 |pmc=484149 |doi=10.1136/hrt.37.1.9 |url=}}</ref>
*Based on conduction pathway or fiber subtype [[ pre-excitation syndrome]] may be classified into sub-types


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*Based on their [[conduction]] properties, three types of [[Accessory pathways]] are there<ref name="pmid4561817">{{cite journal |vauthors=Kuramoto K, Matsushita S |title=[Classification and interpretation of WPW syndrome] |language=Japanese |journal=Nippon Rinsho |volume=30 |issue=8 |pages=1770–8 |date=August 1972 |pmid=4561817 |doi= |url=}}</ref>:
*Based on their [[conduction]] properties, three types of [[Accessory pathways]] are there:
*#[[Accessory pathway|Manifest Accessory Pathways]]: [[Conducts]] more rapidly as compared to [[AV nodal conduction]]. [[Delta waves]] will commonly be seen on [[ECG]].
*#[[Accessory pathway|Manifest Accessory Pathways]]: [[Conducts]] more rapidly as compared to [[AV nodal conduction]]. [[Delta waves]] will commonly be seen on [[ECG]].
*#[[Concealed]] [[Accessory Pathways]]: [[Conducts]] in the [[retrograde direction]]. As its name represents, the changes in [[ECG]] will be [[concealed]]. No [[delta waves]] will be seen.
*#[[Concealed]] [[Accessory Pathways]]: [[Conducts]] in the [[retrograde direction]]. As its name represents, the changes in [[ECG]] will be [[concealed]]. No [[delta waves]] will be seen.
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==Pathophysiology==
==Pathophysiology==
[[File: Pathophysiology of WPW- Pre-excitation syndrome.jpg|thumb|Pathophysiology of WPW / Pre-excitation syndrome.[https://www.slideshare.net/smcmedicinedept/ecg-wpw-syndrome?next_slideshow=3]]]
[[File: Pathophysiology of WPW- Pre-excitation syndrome.jpg|thumb|Pathophysiology of WPW / Pre-excitation syndrome.[https://www.slideshare.net/smcmedicinedept/ecg-wpw-syndrome?next_slideshow=3]]]
Normally the [[electrical]] activity in the [[heart]] starts with [[SA node]]. The [[impulse]] generation usually happens in the right [[atrium]] near the [[entrance]] of [[superior vena cava]]<ref name="urlWolff-Parkinson-White pattern - Conditions - GTR - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/gtr/conditions/C0043202/ |title=Wolff-Parkinson-White pattern - Conditions - GTR - NCBI |format= |work= |accessdate=}}</ref>. The [[impulse]] from the [[SA node]] travels to the [[AV node]]. The [[AV node ]] modulates the rate and number of [impulses]] to be conducted to the [[ventricles]]. The [[AV node]] also modulates the speed of transmission from [[atria]] to [[ventricles]] represents the [[PR interval]] on ECG. From the [[AV node]], an [[electrical]] [[impulse]] is transmitted to the [[bundle of His]], to left and right branches extending to the [[ventricular]] [[myocardium]]. 


[[WPW]]<ref name="urlWhat is the pathophysiology of Wolff-Parkinson-White (WPW) syndrome?">{{cite web |url=https://www.medscape.com/answers/159222-53990/what-is-the-pathophysiology-of-wolff-parkinson-white-wpw-syndrome |title=What is the pathophysiology of Wolff-Parkinson-White (WPW) syndrome? |format= |work= |accessdate=}}</ref> is another word for [[pre-excitation]] of the [[ventricle]] through the [[accessory]] [[pathway]] instead of going through the usual pathway of [[AV node]] which usually slows down the [[speed]] of [[conduction]] of [[impulses]] transmitting to [[ventricles]]. The [[accessory]] pathway creates a channel directly to [[conduct]] the [[impulses]] to [[ventricles]] resulting in [[premature]] [[excitation]]. In "Type A [[Pre-excitation]]" [[accessory]] pathway lies between [[Left atria]] [[ventricles]] and in Type B [[pre-excitation]] fibers carry impulses between [[right atria]] and [[ventricles]]<ref name="urlAmerican Heart Association | To be a relentless force for a world of longer, healthier lives">{{cite web |url=https://www.heart.org/?identifier=563 |title=American Heart Association &#124; To be a relentless force for a world of longer, healthier lives |format= |work= |accessdate=}}</ref><ref name="urlWolff-Parkinson-White (WPW) Syndrome ECG Review - Criteria and Examples | LearntheHeart.com">{{cite web |url=https://www.healio.com/cardiology/learn-the-heart/ecg-review/ecg-topic-reviews-and-criteria/wpw-review |title=Wolff-Parkinson-White (WPW) Syndrome ECG Review - Criteria and Examples &#124; LearntheHeart.com |format= |work= |accessdate=}}</ref>.   
* Normally the [[electrical]] activity in the [[heart]] starts from [[SA node]]. 
* The [[impulse]] generation usually happens in the right [[atrium]] near the [[entrance]] of [[superior vena cava]] and it travels from [[SA node]] to the [[AV node]].<ref name="urlWolff-Parkinson-White pattern - Conditions - GTR - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/gtr/conditions/C0043202/ |title=Wolff-Parkinson-White pattern - Conditions - GTR - NCBI |format= |work= |accessdate=}}</ref>
* The [[AV node ]] modulates the rate and number of [impulses]] to be conducted to the [[ventricles]]. The [[AV node]] also modulates the speed of transmission from [[atria]] to [[ventricles]] represents the [[PR interval]] on ECG. From the [[AV node]], an [[electrical]] [[impulse]] is transmitted to the [[bundle of His]], to left and right branches extending to the [[ventricular]] [[myocardium]]. 
 
[[WPW]] is another word for [[pre-excitation]] of the [[ventricle]] through the [[accessory]] [[pathway]] instead of going through the usual pathway of [[AV node]] which usually slows down the [[speed]] of [[conduction]] of [[impulses]] transmitting to [[ventricles]]. The [[accessory]] pathway creates a channel directly to [[conduct]] the [[impulses]] to [[ventricles]] resulting in [[premature]] [[excitation]]. In "Type A [[Pre-excitation]]" [[accessory]] pathway lies between [[Left atria]] [[ventricles]] and in Type B [[pre-excitation]] fibers carry impulses between [[right atria]] and [[ventricles]].   


Basic concept of Pathophysiology in [[pre-excitation syndrome]] lies in the concept of bypassing the [[AV node]] [[conduction]] and letting the [[impulse conduct]] faster through [[atria]] to [[ventricles]] via [[accessory pathways]]. These [[accessory pathways]] Usually called [[Bundle of Kent]] in [[WPW syndrome]], [[James fiber]] in [[LGL syndrome]] and [[Mahaim fibers]] in Mahaim type [[pre-excitation syndrome]]. These conducts [[impulses]] in forward (not common), backward ( around 15-20%) and in both directions ( Most common type) as well.   
Basic concept of Pathophysiology in [[pre-excitation syndrome]] lies in the concept of bypassing the [[AV node]] [[conduction]] and letting the [[impulse conduct]] faster through [[atria]] to [[ventricles]] via [[accessory pathways]]. These [[accessory pathways]] Usually called [[Bundle of Kent]] in [[WPW syndrome]], [[James fiber]] in [[LGL syndrome]] and [[Mahaim fibers]] in Mahaim type [[pre-excitation syndrome]]. These conducts [[impulses]] in forward (not common), backward ( around 15-20%) and in both directions ( Most common type) as well.   


The [[accessory pathways]] mediate the occurrence of [[tachyarrhythmia]] by forming a [[re-entry]] circuit and commonly known as [[AVRT]]. The direct [[conduction]] of [[impulses]] from [[atria]] to [[ventricles]] can also result in the development of [[tachyarrhythmia's]] when there is a development of [[Atrial Fibrillation]] with [[RVR]]<ref name="pmid28328711">{{cite journal |vauthors=Moskowitz A, Chen KP, Cooper AZ, Chahin A, Ghassemi MM, Celi LA |title=Management of Atrial Fibrillation with Rapid Ventricular Response in the Intensive Care Unit: A Secondary Analysis of Electronic Health Record Data |journal=Shock |volume=48 |issue=4 |pages=436–440 |date=October 2017 |pmid=28328711 |pmc=5603354 |doi=10.1097/SHK.0000000000000869 |url=}}</ref>
The [[accessory pathways]] mediate the occurrence of [[tachyarrhythmia]] by forming a [[re-entry]] circuit and commonly known as [[AVRT]]. The direct [[conduction]] of [[impulses]] from [[atria]] to [[ventricles]] can also result in the development of [[tachyarrhythmia's]] when there is a development of [[Atrial Fibrillation]] with [[RVR]]


[[WPW syndrome]] is a combination of [[WPW]] pattern on [[ECG]] + [[Paroxysmal arrhythmias]]. The [[accessory pathways]] are usually named as [[Bundle of Kent]] or [[AV]] [[bypass tracts]]. [[Accessory pathways|The accessory pathways]] here are named as [[James fibers]], also known as [[Atrionodal fibers]] connecting the [[Atrium (heart)|atrium]] to the distal [[Atrioventricular node|AV node]]. These usually [[conduct]] the [[impulses]] from [[atria]] to the initial portion of the [[AV node]]. [[Accessory pathways|The accessory pathways]] named as [[Mahaim fibers]] connect the [[Atrium (heart)|Atrium]], [[AV node]], or [[bundle of His]] to the [[Purkinje fibers]] or [[ventricular myocardium]]. <br />
[[WPW syndrome]] is a combination of [[WPW]] pattern on [[ECG]] + [[Paroxysmal arrhythmias]]. The [[accessory pathways]] are usually named as [[Bundle of Kent]] or [[AV]] [[bypass tracts]]. [[Accessory pathways|The accessory pathways]] here are named as [[James fibers]], also known as [[Atrionodal fibers]] connecting the [[Atrium (heart)|atrium]] to the distal [[Atrioventricular node|AV node]]. These usually [[conduct]] the [[impulses]] from [[atria]] to the initial portion of the [[AV node]]. [[Accessory pathways|The accessory pathways]] named as [[Mahaim fibers]] connect the [[Atrium (heart)|Atrium]], [[AV node]], or [[bundle of His]] to the [[Purkinje fibers]] or [[ventricular myocardium]]. <br />
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! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Co-existing Conditions}}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Co-existing Conditions}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Atrial fibrillation|Atrial Fibrillation]]<ref name="pmid22518390">{{cite journal |vauthors=Harris K, Edwards D, Mant J |title=How can we best detect atrial fibrillation? |journal=J R Coll Physicians Edinb |volume=42 Suppl 18 |issue= |pages=5–22 |date=2012 |pmid=22518390 |doi=10.4997/JRCPE.2012.S02 |url=}}</ref><ref name="pmid24837984">{{cite journal |vauthors=Lankveld TA, Zeemering S, Crijns HJ, Schotten U |title=The ECG as a tool to determine atrial fibrillation complexity |journal=Heart |volume=100 |issue=14 |pages=1077–84 |date=July 2014 |pmid=24837984 |doi=10.1136/heartjnl-2013-305149 |url=}}</ref> (AFib)
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Atrial fibrillation|Atrial Fibrillation]] (AFib)
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*[[Irregularly irregular]]
*[[Irregularly irregular]]
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*Left chamber enlargement
*Left chamber enlargement
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Atrial Flutter]]<ref name="pmid28835836">{{cite journal |vauthors=Cosío FG |title=Atrial Flutter, Typical and Atypical: A Review |journal=Arrhythm Electrophysiol Rev |volume=6 |issue=2 |pages=55–62 |date=June 2017 |pmid=28835836 |pmc=5522718 |doi=10.15420/aer.2017.5.2 |url=}}</ref>'''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Atrial Flutter]]'''
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*[[Regular]] or [[Irregular]]
*[[Regular]] or [[Irregular]]
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*[[Alcohol]]
*[[Alcohol]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Atrioventricular nodal reentry tachycardia]]<ref name="pmid20458824">{{cite journal |vauthors=Letsas KP, Weber R, Siklody CH, Mihas CC, Stockinger J, Blum T, Kalusche D, Arentz T |title=Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway |journal=Acta Cardiol |volume=65 |issue=2 |pages=171–6 |date=April 2010 |pmid=20458824 |doi=10.2143/AC.65.2.2047050 |url=}}</ref><ref name="pmid27617092">{{cite journal |vauthors=Katritsis DG, Josephson ME |title=Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia |journal=Arrhythm Electrophysiol Rev |volume=5 |issue=2 |pages=130–5 |date=August 2016 |pmid=27617092 |pmc=5013176 |doi=10.15420/AER.2016.18.2 |url=}}</ref><ref name="pmid25196716">{{cite journal |vauthors=Schernthaner C, Danmayr F, Strohmer B |title=Coexistence of atrioventricular nodal reentrant tachycardia with other forms of arrhythmias |journal=Med Princ Pract |volume=23 |issue=6 |pages=543–50 |date=2014 |pmid=25196716 |pmc=5586929 |doi=10.1159/000365418 |url=}}</ref> ([[AV nodal reentrant tachycardia|AVNRT]])<nowiki>''''</nowiki>'''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Atrioventricular nodal reentry tachycardia]] ([[AV nodal reentrant tachycardia|AVNRT]])<nowiki>''''</nowiki>'''
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*[[Regular]]
*[[Regular]]
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*[[Atrial tachyarrhythmias]]
*[[Atrial tachyarrhythmias]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Multifocal atrial tachycardia|Multifocal Atrial Tachycardia]]<ref name="pmid11884328">{{cite journal |vauthors=Goodacre S, Irons R |title=ABC of clinical electrocardiography: Atrial arrhythmias |journal=BMJ |volume=324 |issue=7337 |pages=594–7 |date=March 2002 |pmid=11884328 |pmc=1122515 |doi=10.1136/bmj.324.7337.594 |url=}}</ref><ref name="pmid2570520">{{cite journal |vauthors=Scher DL, Arsura EL |title=Multifocal atrial tachycardia: mechanisms, clinical correlates, and treatment |journal=Am. Heart J. |volume=118 |issue=3 |pages=574–80 |date=September 1989 |pmid=2570520 |doi=10.1016/0002-8703(89)90275-5 |url=}}</ref>
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Multifocal atrial tachycardia|Multifocal Atrial Tachycardia]]
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*Irregular
*Irregular
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*[[Wolff-Parkinson-White syndrome]]
*[[Wolff-Parkinson-White syndrome]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Premature atrial contraction|Premature Atrial Contractrions]] ([[Premature atrial contraction|PAC]])<ref name="pmid18063110">{{cite journal |vauthors=Strasburger JF, Cheulkar B, Wichman HJ |title=Perinatal arrhythmias: diagnosis and management |journal=Clin Perinatol |volume=34 |issue=4 |pages=627–52, vii–viii |date=December 2007 |pmid=18063110 |pmc=3310372 |doi=10.1016/j.clp.2007.10.002 |url=}}</ref><ref name="pmid26316525">{{cite journal |vauthors=Lin CY, Lin YJ, Chen YY, Chang SL, Lo LW, Chao TF, Chung FP, Hu YF, Chong E, Cheng HM, Tuan TC, Liao JN, Chiou CW, Huang JL, Chen SA |title=Prognostic Significance of Premature Atrial Complexes Burden in Prediction of Long-Term Outcome |journal=J Am Heart Assoc |volume=4 |issue=9 |pages=e002192 |date=August 2015 |pmid=26316525 |pmc=4599506 |doi=10.1161/JAHA.115.002192 |url=}}</ref>'''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Premature atrial contraction|Premature Atrial Contractrions]] ([[Premature atrial contraction|PAC]])'''
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*Regular except when disturbed by [[premature beat(s)]]
*Regular except when disturbed by [[premature beat(s)]]
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*[[Hypercholesterolemia]]
*[[Hypercholesterolemia]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White Syndrome]]<ref name="pmid10597097">{{cite journal |vauthors=Rosner MH, Brady WJ, Kefer MP, Martin ML |title=Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues |journal=Am J Emerg Med |volume=17 |issue=7 |pages=705–14 |date=November 1999 |pmid=10597097 |doi=10.1016/s0735-6757(99)90167-5 |url=}}</ref><ref name="pmid24982705">{{cite journal |vauthors=Rao AL, Salerno JC, Asif IM, Drezner JA |title=Evaluation and management of wolff-Parkinson-white in athletes |journal=Sports Health |volume=6 |issue=4 |pages=326–32 |date=July 2014 |pmid=24982705 |pmc=4065555 |doi=10.1177/1941738113509059 |url=}}</ref>
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White Syndrome]]
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*[[Tuberous sclerosis]]
*[[Tuberous sclerosis]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Ventricular fibrillation|Ventricular Fibrillation]]<ref name="pmid20142817">{{cite journal |vauthors=Adabag AS, Luepker RV, Roger VL, Gersh BJ |title=Sudden cardiac death: epidemiology and risk factors |journal=Nat Rev Cardiol |volume=7 |issue=4 |pages=216–25 |date=April 2010 |pmid=20142817 |pmc=5014372 |doi=10.1038/nrcardio.2010.3 |url=}}</ref><ref name="pmid27899944">{{cite journal |vauthors=Glinge C, Sattler S, Jabbari R, Tfelt-Hansen J |title=Epidemiology and genetics of ventricular fibrillation during acute myocardial infarction |journal=J Geriatr Cardiol |volume=13 |issue=9 |pages=789–797 |date=September 2016 |pmid=27899944 |pmc=5122505 |doi=10.11909/j.issn.1671-5411.2016.09.006 |url=}}</ref><ref name="pmid11334828">{{cite journal |vauthors=Samie FH, Jalife J |title=Mechanisms underlying ventricular tachycardia and its transition to ventricular fibrillation in the structurally normal heart |journal=Cardiovasc. Res. |volume=50 |issue=2 |pages=242–50 |date=May 2001 |pmid=11334828 |doi=10.1016/s0008-6363(00)00289-3 |url=}}</ref> (VF)'''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Ventricular fibrillation|Ventricular Fibrillation]] (VF)'''
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*Irregular
*Irregular
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*[[Stroke]]
*[[Stroke]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Ventricular tachycardia|Ventricular Tachycardia]]<ref name="pmid21505622">{{cite journal |vauthors=Levis JT |title=ECG Diagnosis: Monomorphic Ventricular Tachycardia |journal=Perm J |volume=15 |issue=1 |pages=65 |date=2011 |pmid=21505622 |pmc=3048638 |doi=10.7812/tpp/10-130 |url=}}</ref><ref name="pmid19252119">{{cite journal |vauthors=Koplan BA, Stevenson WG |title=Ventricular tachycardia and sudden cardiac death |journal=Mayo Clin. Proc. |volume=84 |issue=3 |pages=289–97 |date=March 2009 |pmid=19252119 |pmc=2664600 |doi=10.1016/S0025-6196(11)61149-X |url=}}</ref>'''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Ventricular tachycardia|Ventricular Tachycardia]]'''


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==Epidemiology and Demographics==
==Epidemiology and Demographics==


*[[WPW]] is commonly found with an [[incidence]] of around 0.1-3.0 per thousand [[population]]<ref name="pmid22579340">{{cite journal |vauthors=Cohen MI, Triedman JK, Cannon BC, Davis AM, Drago F, Janousek J, Klein GJ, Law IH, Morady FJ, Paul T, Perry JC, Sanatani S, Tanel RE |title=PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS) |journal=Heart Rhythm |volume=9 |issue=6 |pages=1006–24 |date=June 2012 |pmid=22579340 |doi=10.1016/j.hrthm.2012.03.050 |url=}}</ref>.
*[[WPW]] is commonly found with an [[incidence]] of around 0.1-3.0 per thousand [[population]].
*More common in the [[male]] [[population]] as compared to [[females]]<ref>http://www.cardiology.sk/casopis/606/pdf/04.pdf</ref>.
*More common in the [[male]] [[population]] as compared to [[females]].
*[[Familial studies]] are done to found its association proved that around .55% more commonly found in first degree relatives.
*[[Familial studies]] are done to found its association proved that around .55% more commonly found in first degree relatives.
*More common in [[young]] and [[healthy]] [[individuals]] and as the [[age]] advances the [[prevalence]] of [[disease]] [[decreases]] because of loss of [[pre-excitation]].
*More common in [[young]] and [[healthy]] [[individuals]] and as the [[age]] advances the [[prevalence]] of [[disease]] [[decreases]] because of loss of [[pre-excitation]].
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==Risk Factors==
==Risk Factors==
High-risk [[population]] for development of [[atrial fibrillation]] or [[sudden cardiac death]] include<ref name="pmid22532593">{{cite journal |vauthors=Obeyesekere MN, Leong-Sit P, Massel D, Manlucu J, Modi S, Krahn AD, Skanes AC, Yee R, Gula LJ, Klein GJ |title=Risk of arrhythmia and sudden death in patients with asymptomatic preexcitation: a meta-analysis |journal=Circulation |volume=125 |issue=19 |pages=2308–15 |date=May 2012 |pmid=22532593 |doi=10.1161/CIRCULATIONAHA.111.055350 |url=}}</ref>:
High-risk [[population]] for development of [[atrial fibrillation]] or [[sudden cardiac death]] include:


*[[Pilots]]
*[[Pilots]]
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===Complications===
===Complications===


*Most common [[complications]] studied in patients having [[accessory pathway]] [[Conduction basics|conduction]] are [[Arrhythmias]] and [[Sudden cardiac death]]<ref>https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/hospital-medicine/pre-excitation-syndrome-wpw/</ref>
*Most common [[complications]] studied in patients having [[accessory pathway]] [[Conduction basics|conduction]] are [[Arrhythmias]] and [[Sudden cardiac death]]
*[[Tachyarrhythmias]]:
*[[Tachyarrhythmias]]:
**If there is a development of [[atrial fibrillation]] or flutter then there is [[fast conduction]] across the [[tracts]] leads to an increased risk of dangerous [[ventricular arrhythmias]].
**If there is a development of [[atrial fibrillation]] or flutter then there is [[fast conduction]] across the [[tracts]] leads to an increased risk of dangerous [[ventricular arrhythmias]].
**[[AV nodal block|AV nodal]] blocking agents may also be the factor responsible for the [[increased]] [[Conduction System|conduction]] through [[accessory pathways]] causing life-threatening [[ventricular arrhythmias]] or [[hemodynamic]] instability resulting and with a worse [[prognosis]].
**[[AV nodal block|AV nodal]] blocking agents may also be the factor responsible for the [[increased]] [[Conduction System|conduction]] through [[accessory pathways]] causing life-threatening [[ventricular arrhythmias]] or [[hemodynamic]] instability resulting and with a worse [[prognosis]].
*[[Sudden cardiac death]]<ref name="urlWolff-Parkinson-White Syndrome. WPW syndrome info | Patient">{{cite web |url=https://patient.info/doctor/wolff-parkinson-white-syndrome-pro#:~:text=Wolff-Parkinson-White%20%28WPW%29%20syndrome%20is%20the%20most%20common%20of,result%20in%20serious%20cardiovascular%20complications%20and%20sudden%20death. |title=Wolff-Parkinson-White Syndrome. WPW syndrome info &#124; Patient |format= |work= |accessdate=}}</ref>:
*[[Sudden cardiac death]]:
**[[Sudden cardiac death]] as a [[complication]] in patients with [[AP conduction]] is more common in a young [[male]] with age less than 35, history of [[arrhythmias]] in the past, [[Anatomical|anatomical location]] of [[accessory pathway]]- that is the [[septal]] location of the [[accessory pathway]], having multiple accessory pathways.
**[[Sudden cardiac death]] as a [[complication]] in patients with [[AP conduction]] is more common in a young [[male]] with age less than 35, history of [[arrhythmias]] in the past, [[Anatomical|anatomical location]] of [[accessory pathway]]- that is the [[septal]] location of the [[accessory pathway]], having multiple accessory pathways.
**The studies proved the risk of [[sudden cardiac death]] related to the [[pre-excitation syndrome]] is around 1.5% in childhood with the highest [[risk]] in the first two decades of life.
**The studies proved the risk of [[sudden cardiac death]] related to the [[pre-excitation syndrome]] is around 1.5% in childhood with the highest [[risk]] in the first two decades of life.
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===WPW Syndrome===
===WPW Syndrome===


*[[WPW syndrome]] is a combination of [[WPW]] pattern on [[ECG]] + [[Paroxysmal arrhythmias]]. The [[accessory pathways]] are usually named as [[Bundle of Kent]] or [[AV]] [[bypass tracts]]<ref name="urlWolff-Parkinson-White (WPW) syndrome - Diagnosis and treatment - Mayo Clinic">{{cite web |url=https://www.mayoclinic.org/diseases-conditions/wolff-parkinson-white-syndrome/diagnosis-treatment/drc-20354630 |title=Wolff-Parkinson-White (WPW) syndrome - Diagnosis and treatment - Mayo Clinic |format= |work= |accessdate=}}</ref>.
*[[WPW syndrome]] is a combination of [[WPW]] pattern on [[ECG]] + [[Paroxysmal arrhythmias]]. The [[accessory pathways]] are usually named as [[Bundle of Kent]] or [[AV]] [[bypass tracts]].


*[[ECG]] features of [[WPW]] syndrome are
*[[ECG]] features of [[WPW]] syndrome are
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**Episodic [[Paroxysmal supraventricular tachycardia|paroxysmal SVT]]
**Episodic [[Paroxysmal supraventricular tachycardia|paroxysmal SVT]]


===Mahaim-Type Pre-excitation<ref name="pmid15489095">{{cite journal |vauthors=Sternick EB, Timmermans C, Sosa E, Cruz FE, Rodriguez LM, Fagundes MA, Gerken LM, Wellens HJ |title=The electrocardiogram during sinus rhythm and tachycardia in patients with Mahaim fibers: the importance of an "rS" pattern in lead III |journal=J. Am. Coll. Cardiol. |volume=44 |issue=8 |pages=1626–35 |date=October 2004 |pmid=15489095 |doi=10.1016/j.jacc.2004.07.035 |url=}}</ref>===
===Mahaim-Type Pre-excitation===


*The [[accessory pathways]] named as [[Mahaim fibers]] connect the [[Atrium (heart)|Atrium]], [[AV node]], or [[bundle of His]] to the [[Purkinje fibers]] or [[ventricular myocardium]].
*The [[accessory pathways]] named as [[Mahaim fibers]] connect the [[Atrium (heart)|Atrium]], [[AV node]], or [[bundle of His]] to the [[Purkinje fibers]] or [[ventricular myocardium]].
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[[HEMODYNAMICALLY]] STABLE [[PATIENTS]]  -- THE FOLLOWING ALGORITHM CAN BE FOLLOWED
[[HEMODYNAMICALLY]] STABLE [[PATIENTS]]  -- THE FOLLOWING ALGORITHM CAN BE FOLLOWED


<u>GENERAL PROTOCOL<ref name="pmid30056397">{{cite journal |vauthors=Stasiak A, Niewiadomska-Jarosik K, Kędziora P |title=Clinical course and treatment of children and adolescents with the preexcitation syndrome - own studies |journal=Dev Period Med |volume=22 |issue=2 |pages=113–122 |date=2018 |pmid=30056397 |doi= |url=}}</ref></u>
<u>GENERAL PROTOCOL</u>


*[[Antiarrhythmic drug]]  
*[[Antiarrhythmic drug]]  
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**IV [[Verapamil]]- this is a [[calcium]] [[channel blocker]] and commonly used as 5-10 mg.
**IV [[Verapamil]]- this is a [[calcium]] [[channel blocker]] and commonly used as 5-10 mg.


<u>[[ATRIAL FLUTTER]]/[[FIBRILLATION]]<ref name="pmid23545139">{{cite journal |vauthors=Wann LS, Curtis AB, Ellenbogen KA, Estes NA, Ezekowitz MD, Jackman WM, January CT, Lowe JE, Page RL, Slotwiner DJ, Stevenson WG, Tracy CM, Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey J, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS |title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines |journal=Circulation |volume=127 |issue=18 |pages=1916–26 |date=May 2013 |pmid=23545139 |doi=10.1161/CIR.0b013e318290826d |url=}}</ref></u>  
<u>[[ATRIAL FLUTTER]]/[[FIBRILLATION]]</u>  


*If [[wide complex]] [[tachycardia]] is present
*If [[wide complex]] [[tachycardia]] is present
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Class 3 [[Antiarrhythmics]] and class IC drugs are used with [[AV nodal block|AV nodal]] blocking [[agents]] in patients with a history of [[atrial flutter]] or [[Atrial fibrillation|A.Fib]]. [[Sotalol]] and [[Flecainide]] would be the safe options to use in [[pregnancy]].
Class 3 [[Antiarrhythmics]] and class IC drugs are used with [[AV nodal block|AV nodal]] blocking [[agents]] in patients with a history of [[atrial flutter]] or [[Atrial fibrillation|A.Fib]]. [[Sotalol]] and [[Flecainide]] would be the safe options to use in [[pregnancy]].


===Surgical management<ref name="urlSurgical treatment of patients with Wolff-Parkinson-White syndrome and associated acquired valvular heart disease - ScienceDirect">{{cite web |url=https://www.sciencedirect.com/science/article/pii/S0022522394702209#:~:text=The%20surgical%20technique%20used%20for%20the%20treatment%20of,of%20the%20involved%20valve%20anulus%2C%20and%20%283%29%20cryoablation. |title=Surgical treatment of patients with Wolff-Parkinson-White syndrome and associated acquired valvular heart disease - ScienceDirect |format= |work= |accessdate=}}</ref>===
===Surgical management===


*[[Endocardial|ENDOCARDIAL]] SURGICAL APPROACH
*[[Endocardial|ENDOCARDIAL]] SURGICAL APPROACH

Revision as of 16:13, 23 September 2020


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4], Associate Editor-In-Chief: Shivam Singla, M.D.[5]

Synonyms and keywords: Pre Excitation Syndromes; Pre-Excitation Syndrome; Preexcitation Syndrome; Preexcitation Syndromes; Lown-Ganong-Levine Syndrome; Pre-Excitation, Mahaim-Type; Wolff-Parkinson-White Syndrome

Overview

Pre-excitation syndrome is a condition where ventricles of the heart depolarize earlier than expected via some accessory pathway conduction the normal leading to premature contraction. Normally the atria and the ventricles interconnected through AV node (Atrioventricular node). But in all pre-excitation syndromes, there is present an accessory pathway that conducts impulses to ventricles besides the AV node. The accessory pathway electrical impulses pass to the ventricles before the normal impulse of depolarization through the AV node. The phenomenon of depolarizing ventricles through the accessory pathway earlier than the usual depolarization supposed to happen through the AV node is referred to as "Pre- Excitation". WPW syndrome was described in 1930 and named for the John Parkinson, Paul Dudley White, and Louis Wolff. The accessory pathways are named depending upon the regions of atria and ventricles they are connecting as Bundle of His, Mahaim fibers, James fibers.

The typical ECG findings associated with WPW syndrome are shortened PR interval, widened QRS complex and Delta wave- which is slurring in the upstroke of QRS complex due to preexcitation of ventricles via the accessory pathway. ECG findings along with symptomatic tachyarrhythmias is referred to as Wolff-Parkinson-White syndrome. Although it is more common in the adult males with an incidence rate of 0.1-0.3 %, WPW can be considered as a congenital anomaly in some cases where it is usually present since birth and in others and it is regarded as a developmental anomaly. Studies proved it's lower prevalence in children aged between 6-13 than those in the age group of 14-15 years of age. Hemodynamically unstable patients should be managed on direct cardioversion. For stable patients, medical management should be tried first before going for other acceptable options of catheter ablation or surgical intervention. Although Catheter ablation has widely replaced the surgical option due to less invasive technique and better outcomes still in cases where catheter ablation cannot be done or doesn't prove to be effective the surgical option is worth considering with curative rate of nearly 100%.

Historical Perspective

Classification

Type Conduction pathway QRS interval PR interval Delta wave
Wolff-Parkinson-White syndrome Bundle of Kent Wide/long Usually short yes
Lown-Ganong-Levine syndrome "James bundle" (atria to bundle of His) Normal/Unaffected Short no
Mahaim-type Mahaim fibers long normal


Pathophysiology

Pathophysiology of WPW / Pre-excitation syndrome.[2]

WPW is another word for pre-excitation of the ventricle through the accessory pathway instead of going through the usual pathway of AV node which usually slows down the speed of conduction of impulses transmitting to ventricles. The accessory pathway creates a channel directly to conduct the impulses to ventricles resulting in premature excitation. In "Type A Pre-excitation" accessory pathway lies between Left atria ventricles and in Type B pre-excitation fibers carry impulses between right atria and ventricles.

Basic concept of Pathophysiology in pre-excitation syndrome lies in the concept of bypassing the AV node conduction and letting the impulse conduct faster through atria to ventricles via accessory pathways. These accessory pathways Usually called Bundle of Kent in WPW syndrome, James fiber in LGL syndrome and Mahaim fibers in Mahaim type pre-excitation syndrome. These conducts impulses in forward (not common), backward ( around 15-20%) and in both directions ( Most common type) as well.

The accessory pathways mediate the occurrence of tachyarrhythmia by forming a re-entry circuit and commonly known as AVRT. The direct conduction of impulses from atria to ventricles can also result in the development of tachyarrhythmia's when there is a development of Atrial Fibrillation with RVR

WPW syndrome is a combination of WPW pattern on ECG + Paroxysmal arrhythmias. The accessory pathways are usually named as Bundle of Kent or AV bypass tracts. The accessory pathways here are named as James fibers, also known as Atrionodal fibers connecting the atrium to the distal AV node. These usually conduct the impulses from atria to the initial portion of the AV node. The accessory pathways named as Mahaim fibers connect the Atrium, AV node, or bundle of His to the Purkinje fibers or ventricular myocardium.

Differentiating Pre-excitation Syndrome from other Diseases

Arrhythmia Rhythm Rate P wave PR Interval QRS Complex Response to Maneuvers Epidemiology Co-existing Conditions
Atrial Fibrillation (AFib)
  • Absent
  • Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
  • 2.7–6.1 million people in the United States have AFib
  • 2% of people younger than age 65 have AFib, while about 9% of people aged 65 years or older have AFib
Atrial Flutter
  • 75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) beats per minute (bpm), but 150 is more common
  • Varies depending upon the magnitude of the block, but is short
  • Less than 0.12 seconds, consistent, and normal in morphology
  • Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm
Atrioventricular nodal reentry tachycardia (AVNRT)''''
  • 140-280 bpm
Multifocal Atrial Tachycardia
  • Irregular
  • Atrial rate is > 100 beats per minute
  • Less than 0.12 seconds, consistent, and normal in morphology
Paroxysmal Supraventricular Tachycardia
  • Regular
  • 150 and 240 bpm
  • Absent
  • Hidden in QRS
  • Absent
  • Narrow complexes (< 0.12 s)
Premature Atrial Contractrions (PAC)
  • 80-120 bpm
  • Upright
  • Usually narrow (< 0.12 s)
Wolff-Parkinson-White Syndrome
  • Regular
  • Atrial rate is nearly 300 bpm and the ventricular rate is at 150 bpm
  • Less than 0.12 seconds
Ventricular Fibrillation (VF)
  • Irregular
  • 150 to 500 bpm
  • Absent
  • Absent
  • Absent (R on T phenomenon in the setting of ischemia)
Ventricular Tachycardia
  • Regular
  • > 100 bpm (150-200 bpm common)
  • Absent
  • Absent
  • Initial R wave in V1, initial r > 40 ms in V1/V2, notched S in V1, initial R in aVR, lead II R wave peak time ≥50 ms, no RS in V1-V6, and atrioventricular dissociation
  • Wide complex, QRS duration > 120 milliseconds
  • 5-10% of patients presenting with AMI

Epidemiology and Demographics

Risk Factors

High-risk population for development of atrial fibrillation or sudden cardiac death include:

Natural History, Complications and Prognosis

Natural History

Complications

Prognosis

Diagnosis

AVRT ( Orthodromic and Antidromic)

WPW Syndrome

Lown-Ganong-Levine(LGL) Syndrome

Mahaim-Type Pre-excitation

  • ECG findings are usually normal

History and Symptoms

People with Pre- Excitation syndromes may be asymptomatic, however, the individuals commonly experience the following symptoms:

Treatment

Medical Treatment

HEMODYNAMICALY UNSTABLE PATIENT -- DIRECT SYNCHRONIZED CARDIOVERSION, BIPHASIC ( INITIAL 100 J, LATER ON- 200J OR 360J).

WPW Treatment Algorithm. Brief flow chart describing the various treatment options that can be selected depending upon the underlying scenario. [https://media.thecardiologyadvisor.com/images/dsm/ch6154.fig11.JPG

]

HEMODYNAMICALLY STABLE PATIENTS -- THE FOLLOWING ALGORITHM CAN BE FOLLOWED

GENERAL PROTOCOL

IN CASE OF ACUTE AVRT/AVNRT

ATRIAL FLUTTER/FIBRILLATION

Catheter Ablation- Surgical Approach in WPW. Image showing catheter ablation of right free wall accessory pathway. The first successful ablation was performed by Morady and Scheinman. [3]

RADIOFREQUENCY ABLATION[3]

Class 3 Antiarrhythmics and class IC drugs are used with AV nodal blocking agents in patients with a history of atrial flutter or A.Fib. Sotalol and Flecainide would be the safe options to use in pregnancy.

Surgical management

Prevention

References

  1. "Wolff-Parkinson-White pattern - Conditions - GTR - NCBI".
  2. Obeyesekere MN, Leong-Sit P, Massel D, Manlucu J, Modi S, Krahn AD, Skanes AC, Yee R, Gula LJ, Klein GJ (May 2012). "Risk of arrhythmia and sudden death in patients with asymptomatic preexcitation: a meta-analysis". Circulation. 125 (19): 2308–15. doi:10.1161/CIRCULATIONAHA.111.055350. PMID 22532593.
  3. Cohen MI, Triedman JK, Cannon BC, Davis AM, Drago F, Janousek J, Klein GJ, Law IH, Morady FJ, Paul T, Perry JC, Sanatani S, Tanel RE (June 2012). "PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS)". Heart Rhythm. 9 (6): 1006–24. doi:10.1016/j.hrthm.2012.03.050. PMID 22579340.