A 45-year-old female presented with difficulty breathing, palpitations, and sweating for 4 hours. An ECG showed Wolff-Parkinson-White (WPW) syndrome, characterized by a short PR interval, delta wave, and widened QRS complex. WPW is a congenital condition involving an accessory pathway that allows supraventricular impulses to bypass the AV node and activate the ventricles early. Treatment options include antiarrhythmic drugs or radiofrequency ablation to destroy the accessory pathway.

1. PROF .Dr G.SUNDARAMURTY ‘S UNIT M6 S.DHANRAJ Ist YEAR PG

2. HISTORY A 45 YR old female presented with Difficulty in breathing Palpitation Sweating for past 4 hours

3. ECG

4. FINDINGS Normal sinus rhythm Rate 80 / min Axis normal PR shortened 0.08 sec Broad QRS complex QRS duration 0.12 sec QTC 0.40 sec Delta wave noticed(slurred QRS upstroke) Terminal QRS normal Secondary ST/T changes seen

5. DIAGNOSIS WPW SYNDROME POSSIBLE PATHWAYS Right posteroseptal anteroseptal

6. PATHWAYS

7. HISTORY Named after three scientists WOLFF PARKINSON WHITE In the year 1930

8. DEFINITION WPW is a electrocardiographic syndrome it is the expression of anomalous atrio ventricular conduction pathway congenital in origin 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 This anomalous bypass, most commonly bundle of kent situated any where along AV node

9. ECG PRESENTATION Short PR interval Slurred initial upstroke of QRS – delta wave Relatively normal , narrow terminal QRS –main QRS deflection Slight widening of QRS Secondary STT changes

10. CARDIAC ACTIVATION PHASE 1 Atrial activation- normal PHASE 2: Ventricular pre-exitation sinus activation occurs through both normal , anomalous pathway anomalous pathway lacks AV nodal conduction delay so sinus impulse conducted at a rapid rate this enables ventricles to be activated or pre exited- short PR interval , delta wave Further activation through normal pathway PHASE 3: Narrow terminal QRS

12. OLD CLASSIFICATION Type A 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. Type B 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.

13. PATHWAY

15. ORTHODROMIC DESCEND- NORMAL PATHWAY ASCEND- ACCESSORY PATHWAY In orthodromic tachycardia, the normal pathway is used for ventricular depolarization and the accessory tract is used for reentry. VPC’s can initiate orthodromic tachycardia On ECG findings, the delta wave is absent, QRS complex is normal, P waves are inverted in the inferior and lateral leads

17. ANTIDROMIC LESS COMMON PATHWAY. DESCEND- ACCESSORY PATHWAY. ASCEND – NORMAL PATHWAY On ECG findings, the QRS is wide, which is an exaggeration of the delta wave during sinus rhythm (ie, wide-QRS tachycardia). Such tachycardias are difficult to differentiate from ventricular tachycardia

20. PATHWAYS

21. FIBRES KENT PATHWAY : ATRIO-VENTRICULAR JAMES PATHWAY : ATRIO-HIS MAHAIM PATHWAY: HISO- VENTRICULAR

22. MAHAIM FIBRE: Orgin- distal to AV node Ends in the venricular myocardium ECG : normal PR interval delta waves JAMES FIBRE (LGL SYNDROME) Origin- atria Bypass AV node Ends in bundle of HIS ECG : Short PR Normal QRS

24. COMPLICATION Tachyarrhythmia Syncopal attacks Sudden cardiac death Complications of drug therapy (eg, proarrhythmia, organ toxicity) Complications associated with invasive procedures and surgery Recurrence

25. TREATMENT ANTIARRYTHMICS– class 1c, 3 RADIOFREQUENCY ABLATION ( TOC) SURGICAL ABLATION ( OUTDATED)

26. CAUTION Usual presentation is SVT Sudden cadiac death possible Digoxin, beta blockers,verapamil are contraindicated Underlying Ebstein’s anomaly, hypertrophic cardiomyopathy should be evaluated

27. THANK YOU