ECG: Wolff-Parkinson-White syndrome
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Transcript of ECG: Wolff-Parkinson-White syndrome
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Prof. Dr.TITO’S unit M6
Dr.Rakesh.Pinninti
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Ullas R 22yrs of age came with
C/O
palpitations since childhood
Palpitations are triggered by exertion(minimal), fever, emotional disturbances and few occasions at rest.
No H/O RHD, CTD, DM2, Hypertension, TB, epilepsy.
Patient referred for abnormal ECG by local doctor.
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O/E
VITALS : PR 117 bpm, regular rhythm, normal character.
BP 110/80 mm Hg Temp Afebrile Resp. rate 20 bpm SP O2 96% with out O2 C.V.S. S1S2 heard, no murmurs heard R.S. NVBS heard, no added sounds heard.
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A standard 12 lead ECG showing Sinus rhythm Heart rate 117 bpmRegular rhythm without significant variation
in R-R intervalPR interval 0.06 secQRS duration 0.12 secQTc interval 0.38 sec P wave axis 40* to 60* QRS axis -40*to -30*
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Diagnosis
Wolff-Parkinson-White Syndrome (right posteroseptal/ right
lateral) (accessory pathway)
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The Wolff- Parkinson- White synd is an electrocardiographic syndrome which is an expression of an anomalous atrioventricular conduction pathway, congenital in origin.
The anomalous bypass, also known as the Bundle of Kent, is a thin filamentous structure ectopically anywhere along the atrioventricular ring.
Main sites of Bypass tracts Right lateral pathway 18%
Left lateral pathway 45%
Posteroseptal pathway(r/l) 26%
Anteroseptal pathway(r/l) 9%
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The basic electrocardiographic presentation in WPW: A short P-R interval A slurred, thickened, initial upstroke of QRS
complex “DELTA
wave”A relatively normal –narrow – ensuing terminal QRS
defluxion but slightly widened QRS as a whole.
Secondary S-T segment and T wave changes
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ECG simulation by WPWRight ventricular hypertrophy.Anterior / Post myocardial infarction. (left
lateral)
Inferior wall myocardial infarction. (right posteriorseptal)
Bundle branch blocks.Ventricular tachycardia. Primary myocardial disease.
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LOCALIZATION OF BYPASS TRACT IN THE PRESENT ECGRosenbaum and associates first attempted
the localization of bypass tracts, separating them into
Type A --- a left bypass tract (QRS dominantly upright in RPL)
Type B --- a right bypass tract ( ” ” ” ” ” ” downward in RPL)
SO, taking these into consideration the presented ECG is a
Type B
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Localization of BPT can be divided into 3 parts :
Part 1 : analysis of main QRS defluxion.
Part 2: analysis of the delta waves.
Part 3 : comparison of main QRS polarity in the frontal
& horizontal leads.
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1.Analysis of the main QRS deflexion 1) Frontal plane axis of main QRS deflexion
Right lateral pathways LAD upto -60*
Posteroseptal pathways ® LAD 0* to -30* cc
Left lateral pathways +60* to +90*
Anterior paraseptal pathways normal axis
So, empirically it is evident that right lateral pathway has a LAD and left lat pathway tends to have RAD of the main QRS deflexion.
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2) The polarity of the main QRS complex in Horizontal plane leads
a)Polarity in leads V4toV6Leads V4toV6 reflect positive/dominantly positive QRS
complexes, irrespective of site of accessory pathway.
b)Polarity in lead V2 Its a important diagnostic feature for localization of BPT, If main QRS complex is dominantly positive –Rs/R Left lateral
If main QRS complex is dominantly negative – rS Right lateral If main QRS complex is isoelectric or positive Right
posteroseptal with dominantly negative QRS in V1
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Polarity of main QRSPathway V1 V2 V3 QRS
DELTA
Anteroseptal - - - N N
Right lateral - - - L L
Right postsept - + + L L
Left postsept + + + L L
Left lateral + + + INF INF
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ive
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2.Analysis of the Delta waves
A) The Frontal plane delta wave axis
Right lateral & posteroseptal LAD -30*to-60*cc (negative delta waves in II III AVF)Left lateral
+90*to+120*cc (negative delta waves in I AVL V5 V6)Right anterior para septal +30* to +60*
c (positive delta waves in I II III AVL AVF)
A right sided pathway can be excluded in presence of negative delta waves in leads I & AVL.
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Pathway V1 delta V1 V2
QRSRight postseptal isoelectric/ dominantly positive negative negative
Left postseptal positive dominantly positive (always) positive
QRS negativity in V1 to V3, when associated with leftward QRS & delta waves connotes a right lateral pathway, when associated with normal QRS & delta wave, connotes an anteroseptal pathway
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SUMMARY• The present ECG is most likely having an
accessory Right posteroseptal pathway suggestive features
1) Main frontal QRS axis around -30*2) Frontal delta wave axis -30* to -60*3) Delta wave in V1 is isoelectric or negative 4) Lead V1 dominantly negative QRS defluxion
(rS ) Lead V2,V3 dominantly positive QRS
defluxion (Rs/R)
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Complications of WPW
A) RECIPROCATING TACHYCARDIA
B) ATRIAL FIBRILLATION
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Lown-Ganong-Levine SYDThis syndrome is characterized by A)Normal P waveB) Short PR interval C)Normal QRS complex
Individuals with this syndrome are prone to attacks of paroxysmal tachycardia.
This synd is due to a James bypass(ATRIOHISIAN), a pathway which arises in atria and bypasses the main region of bundle of His.May facilitate reciprocal return to atria.
But unlike in WPW, this bypass does not end in/activate the myocardium directly; hence absence of bizarre anomalous activation(delta wave)
Other similar synd is Mahaim fibre pre-excitation
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