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
- 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:[2][3]
- 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 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]
- 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)
- 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
- 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[7]
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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.