ECG: WPW Syndrome


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ECG: WPW Syndrome

  2. 2. HISTORY <ul><li>A 45 YR old female presented with </li></ul><ul><ul><li>Difficulty in breathing </li></ul></ul><ul><ul><li>Palpitation </li></ul></ul><ul><ul><li>Sweating </li></ul></ul><ul><ul><ul><li>for past 4 hours </li></ul></ul></ul>
  3. 3. ECG
  4. 4. FINDINGS <ul><li>Normal sinus rhythm </li></ul><ul><li>Rate 80 / min </li></ul><ul><li>Axis normal </li></ul><ul><li>PR shortened 0.08 sec </li></ul><ul><li>Broad QRS complex </li></ul><ul><li>QRS duration 0.12 sec </li></ul><ul><li>QTC 0.40 sec </li></ul><ul><li>Delta wave noticed(slurred QRS upstroke) </li></ul><ul><li>Terminal QRS normal </li></ul><ul><li>Secondary ST/T changes seen </li></ul>
  5. 5. DIAGNOSIS <ul><li>WPW SYNDROME </li></ul><ul><ul><li>POSSIBLE PATHWAYS </li></ul></ul><ul><ul><ul><li>Right posteroseptal </li></ul></ul></ul><ul><ul><ul><li>anteroseptal </li></ul></ul></ul>
  6. 6. PATHWAYS
  7. 7. HISTORY <ul><li>Named after three scientists </li></ul><ul><ul><li>WOLFF </li></ul></ul><ul><ul><li>PARKINSON </li></ul></ul><ul><ul><li>WHITE </li></ul></ul><ul><ul><ul><li>In the year 1930 </li></ul></ul></ul>
  8. 8. DEFINITION <ul><li>WPW is a electrocardiographic syndrome it is the expression of anomalous atrio ventricular conduction pathway congenital in origin </li></ul><ul><li>This pathway forms a bypass which enables supraventricular impulse to bypass AV node , bundle of HIS and distal conducting system and so activate or pre exite the ventricles </li></ul><ul><li>This anomalous bypass, most commonly bundle of kent situated any where along AV node </li></ul>
  9. 9. ECG PRESENTATION <ul><li>Short PR interval </li></ul><ul><li>Slurred initial upstroke of QRS – delta wave </li></ul><ul><li>Relatively normal , narrow terminal QRS –main QRS deflection </li></ul><ul><li>Slight widening of QRS </li></ul><ul><li>Secondary STT changes </li></ul>
  10. 10. CARDIAC ACTIVATION <ul><li>PHASE 1 </li></ul><ul><ul><li>Atrial activation- normal </li></ul></ul><ul><ul><li>PHASE 2: </li></ul></ul><ul><ul><li>Ventricular pre-exitation </li></ul></ul><ul><ul><li>sinus activation occurs through both normal , anomalous pathway </li></ul></ul><ul><ul><li>anomalous pathway lacks AV nodal conduction delay </li></ul></ul><ul><ul><li>so sinus impulse conducted at a rapid rate </li></ul></ul><ul><ul><li>this enables ventricles to be activated or pre exited- short PR interval , delta wave </li></ul></ul><ul><ul><li>Further activation through normal pathway </li></ul></ul><ul><ul><li>PHASE 3: </li></ul></ul><ul><ul><li>Narrow terminal QRS </li></ul></ul>
  11. 12. OLD CLASSIFICATION <ul><li>Type A </li></ul><ul><li>In this type of WPW syndrome, the delta wave and QRS complex are predominantly upright in the precordial leads. The dominant R wave in lead V1 may be misinterpreted as right bundle branch block. </li></ul><ul><li>Type B </li></ul><ul><li>The delta wave and QRS complex are predominantly negative in leads V1 and V2 and positive in the other precordial leads, resembling left bundle branch block. </li></ul>
  12. 13. PATHWAY
  13. 15. ORTHODROMIC <ul><li>DESCEND- NORMAL PATHWAY </li></ul><ul><li>ASCEND- ACCESSORY PATHWAY </li></ul><ul><li>In orthodromic tachycardia, the normal pathway is used for ventricular depolarization and the accessory tract is used for reentry. </li></ul><ul><li>VPC’s can initiate orthodromic tachycardia </li></ul><ul><li>On ECG findings, </li></ul><ul><ul><li>the delta wave is absent, </li></ul></ul><ul><ul><li>QRS complex is normal, </li></ul></ul><ul><ul><li>P waves are inverted in the inferior and lateral leads </li></ul></ul>
  14. 17. ANTIDROMIC <ul><li>LESS COMMON PATHWAY. </li></ul><ul><li>DESCEND- ACCESSORY PATHWAY. </li></ul><ul><li>ASCEND – NORMAL PATHWAY </li></ul><ul><li>On ECG findings, </li></ul><ul><ul><li>the QRS is wide, which is an exaggeration of the delta wave during sinus rhythm (ie, wide-QRS tachycardia). </li></ul></ul><ul><ul><li>Such tachycardias are difficult to differentiate from ventricular tachycardia </li></ul></ul>
  15. 20. PATHWAYS
  16. 21. FIBRES <ul><li>KENT PATHWAY : ATRIO-VENTRICULAR </li></ul><ul><li>JAMES PATHWAY : ATRIO-HIS </li></ul><ul><li>MAHAIM PATHWAY: HISO- VENTRICULAR </li></ul>
  17. 22. <ul><li>MAHAIM FIBRE: </li></ul><ul><li>Orgin- distal to AV node </li></ul><ul><li>Ends in the venricular myocardium </li></ul><ul><li>ECG : </li></ul><ul><li>normal PR interval </li></ul><ul><li>delta waves </li></ul><ul><li>JAMES FIBRE </li></ul><ul><li>(LGL SYNDROME) </li></ul><ul><li>Origin- atria </li></ul><ul><li>Bypass AV node </li></ul><ul><li>Ends in bundle of HIS </li></ul><ul><li>ECG : </li></ul><ul><li>Short PR </li></ul><ul><li>Normal QRS </li></ul>
  18. 24. COMPLICATION <ul><li>Tachyarrhythmia </li></ul><ul><li>Syncopal attacks </li></ul><ul><li>Sudden cardiac death </li></ul><ul><li>Complications of drug therapy (eg, proarrhythmia, organ toxicity) </li></ul><ul><li>Complications associated with invasive procedures and surgery </li></ul><ul><li>Recurrence </li></ul>
  19. 25. TREATMENT <ul><li>ANTIARRYTHMICS– class 1c, 3 </li></ul><ul><li>RADIOFREQUENCY ABLATION ( TOC) </li></ul><ul><li>SURGICAL ABLATION ( OUTDATED) </li></ul>
  20. 26. CAUTION <ul><li>Usual presentation is SVT </li></ul><ul><li>Sudden cadiac death possible </li></ul><ul><li>Digoxin, beta blockers,verapamil are contraindicated </li></ul><ul><li>Underlying Ebstein’s anomaly, hypertrophic cardiomyopathy should be evaluated </li></ul>
  21. 27. THANK YOU