WPW

1. CASE PRESENTATION
Dr. ADEEL AHMAD.
PGR WMW.

2. Name Sobia
Age 35 years
 Sex Female
Resident Faisal Abad
Presented
“Palpitation and SOB 6 hours”.
 Patient HTN+ 3 months (on regular medication) nonDM
presented in emergency with H/O palpitation that started
6hrs back. She complains of such a palpitation for last 3
months on and off, palpitation can occur any time that
have no relation to exercise or work load.She, along with
palpitation, also complains of SOB for up to a similiar
period. SOB can occur any time,no diurnal variation,no
seasonal history. There is no H/O orthopnea and PND.

3. Past History: Except HTN not significant
Personal History: Not significant
Family History: She is married and living a
happy life.
Treatment History:
She was on
Losartan 50 mg 1 po OD and
Tenormin 50 mg BD

4. Vitals
BP 170/100 mmHg
Pulse 120 beat/m
RR 20/M
Fever A/F

5. GPE
 Pallor -ve
 Cyanosis -ve
 Clubbing -ve
 Koilonychia -ve
 S /hemorrhage -ve
 Osler nodes absent
 Heberden nodes absent
 Boucard nodes absent
 Palmer erythema -ve
 Dupuytren contrature -ve
 Skin rash -ve
 Axillary nodes not palpable
 JVP not raised
 Thyroid normal
 Ankle edema absent
 Sign of dehyration -ve

6. CVS
On inspection; Shape of chest is normal.
On palpation; Apex beat in 5th intercostal space
just medial to mid clavicular line,no other sound is
palpable,no thrill,no murmur.
On auscultation; Both sound normal,no thrill,no
murmur.

7. Respiratory system
On inspection; Rate 20/m thoraco abdominal.
On palpation; Trachea is central,apex beat in 5th
medial to midclavicular line,chest movement and
expansion within normal range,no vocal fremitus.
On purcussion; upper border of liver is in 5th
intercostal space.
On auscultation; Breath sounds are normal,no
ronchi,no crepts.

8. GIT
On Inspection; Oral hygiene is good,
On Palpation; Not done
On Purcusion; Not done.
On Auscultation; B/S are audible,no bruit is
present.

9. CNS
HMF Normal.
Speech Normal
Cranial nerves Intact.
Motor Intact
Sensory Intact
Cerebellar Intact

13. Diagnostic criteria:
The QRS complex duration is >0.11 second; in
approximately 20% of individuals, the QRS complex
may not be >0.11 second.
PR is <0.12 second.
A delta wave is prominent, often in V3 through V6,
In type A WPW syndrome, a tall R wave present in V1
In type B WPW , the QRS complex is predominately
negative in V1 through V3 and upright in V5 and V6.

18. History
In 1930, Wolff, Parkinson and White described a
distinct (ECG) pattern in healthy young people with
short bursts of tachycardia.
In 1944, doctors confirmed the presence of extra
pathways

19. Prevalence:
WPW is a congenital heart abnormality
WPW occurs randomly in the general population
1 to 3 per 1,000 persons.
Men have a higher incidence of WPW than women.
Some cases of WPW are inherited.
7 to 20 percent of patients with WPW also have
congenital defects within the heart.

20. Symptoms of WPW
Any age, from infancy to adult years.
Heart palpitations
Racing feeling in your chest
Dizziness
Shortness of breath (dyspnea)
Anxiety
Rarely, cardiac arrest (sudden death)
Some people have WPW without any symptoms at all.

21. Types of WPW
Practical concept is that a negative delta wave usually
signals where the AP is:
A negative delta wave in a left-side, I and aVL
indicates a left-side AP.
A negative delta in a right-side lead such as V1 predicts
a right-side AP.
A negative delta in the inferior leads (II, III, and aVF)
indicates a posteroseptal AP.
A positive delta in the inferior leads predicts an
anteroseptal AP.
An isoelectric delta in V1 predicts an anteroseptal AP.

22. Left lateral wall - Negative delta waves in lead I
and aVL; positive or isoelectric in II, III, aVF and V1-4;
and negative or isoelectric delta waves in V5-6
Right free wall - Positive delta waves in I and II,
negative delta waves in aVR, isoelectric or negative
delta wave in aVF, isoelectric delta wave in V1,
isoelectric or positive delta waves in V2-3, and positive
delta waves in V4-6

23. Left posterior free wall - Positive delta waves in lead I
and aVL; negative delta waves in II, III, and aVF; positive
delta waves in V1-5; and negative or isoelectric delta wave
in V6
Posteroseptal - Positive delta waves in lead I and aVL
with negative delta waves in II, III, and aVF; isoelectric
waves in V1; and positive delta waves in the rest of the
precordial leads
Left anteroseptal - Positive delta waves in I, II, and
aVF; negative delta wave in aVR; isoelectric or positive
delta wave in V1; and positive delta waves in V2-6
Right anteroseptal - Positive delta waves in I, II, and
aVF; negative delta wave in aVR; negative or isoelectric
delta waves in V1-3; and positive delta waves in V4-6

24. Treatment
DD
AVNRT
Orthodromic AVRT
Antidromic AVRT

26. Narrow complex
Orthodromic AVRT and AVNRT blocking AV node
conduction
Vagal maneuvers (eg, Valsalva maneuver, carotid sinus
massage, splashing cold water or ice water on the face)
IV adenosine 6-12 mg via a large-bore
IV verapamil 5-10 mg or diltiazem 10 mg

27. Wide complex
Antidromic AVRT
Procainamide or
Amiodarone or
Flecainide if wide-complex tachycardia is present, if
patient hemodynamically stable
Ibutilide

28. Unstable patient
Synchronized electrical cardioversion,
A level of 100 J initially
If necessary, a second shock with higher energy (200 J
or 360 J)
Pregnancy Sotalol

29. Radiofrequency Ablation
Indication
Patients with symptomatic AVRT
Patients with AF
Patients with AVRT or AF with rapid ventricular rates
found incidentally during EPS,RR interval during AF
<250 ms
Asymptomatic patients who would endanger the
public safety
Patients with WPW and a family history of sudden
cardiac death

30. RFA
In RF ablation, platinum-tipped 3.5- to 8-mm
steerable multielectrode catheters are advanced via the
femoral artery or vein to locate and ablate the AP by
delivering thermal RF energy

31. Surgical treatment
Surgical treatment is replaced by RFA
Patients in whom RF catheter ablation (with repeated
attempts) fails
Patients undergoing concomitant cardiac surgery

32. Long-term antiarrhythmic therapy
Oral medication is the mainstay of therapy in patients
not undergoing RFA. Choices include the following:
Dual-drug therapy (eg, procainamide and verapamil
[class Ia and IV])
Class Ic drugs (eg, flecainide, propafenone), typically
used with an AV nodal blocking agent
Class III drugs (eg, amiodarone, sotalol)
In pregnancy, sotalol (class B) or flecainide (class C)

33. WHAT IS DIAGNOSIS

34. WHAT IS DIAGNOSIS

36. WHAT IS DIAGNOSIS

38. THANKS