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: 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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