WPW SYNDROME power p oint presentation

presentation

1. WPW SYNDROME DR.SIVA PRASAD DrNB CARDIOLOGY

2. Historical perspective The earliest description of an accessory pathway was reported by Stanley Kent in 1893. Cohn and Fraser reported the first case of pre-excitation syndrome in 1913

3. In 1930, Louis Wolff, Sir John Parkinson, and Paul Dudley White published a seminal article describing 11 young patients who suffered from attacks of tachycardia associated with an electrocardiographic pattern of bundle branch block with a short PR interval

4. Ohnell was the first to use the term “pre-excitation,” Seters described the slurred initial component of the QRS complex as a “delta” wave.

5. Curative therapy of WPW syndrome was demonstrated in 1967 when Cobb et al successfully ablated an accessory pathway during open-heart surgery The first successful catheter ablation of an accessory pathway by delivering direct current energy was reported by Morady and Scheinman in 1984 . In 1987, Borggrefe et al. successfully ablated a right-sided pathway by delivering RF current .

6. DEFINITION A Pre-excitation syndrome Expression of anamolus AV conduction pathway(By-pass tract connecting Atria to Ventricle) Congential in origin It’s an electrocardiographic diagnosis

7. BASIC ECG PRESENTATION

8. ECG CHANGES 1.Short PR interval.(PR INTERVAL-<120MS) 2.Slurred thickened,intial upstroke of QRS complex-DELTA WAVE 3.A relatively narrow ensuing terminal QRS deflection 4.Secondary ST segment and T wave changes 5.Pseudo-infarction pattern in up to 70% of patients — due to negatively deflected delta waves in inferior/anterior leads (“pseudo-Q waves”), or prominent R waves in V1-3 (mimicking posterior infarction)

9. MODIFICATIONS OF TERMINAL QRS COMPONENT -A change in QRS axis-either right or left,although it is not always so. -A change in QRS amplitude-Maximal QRS amplitude increases.

10. Delta waves detectable on an ECG have been reported to be present in 0.15% to 0.25% of the general population. WPW syndrome is more commonly diagnosed in men than in women, although this sex difference is not observed in children. Among those with the WPW, 3.4% have first-degree relatives with preexcitation. The familial form is usually inherited as a mendelian autosomal dominant trait Associated with a small risk of sudden cardiac death

11. WPW PATTERN-Pre- existation on ecg without symptoms WPW SYNDROME-Pre- existation on ecg with symptoms

12. LOCALISATION OF BYPASS TRACT - Depends on DELTA,QRS WAVE AXIS and POLARITY OF QRS WAVE FROM V1-V3 -Rosenbaum and associates first attempted the localization of tracts TYPE A-QRS predominately upright in right precordial leads TYPE B-QRS predominately downward in right precordial leads -12 lead ECG localization of bypass tract using criteria have become increasing apparent -Accurate localization done by EP studies

13. POTENTIAL SITES OF BYPASS TRACT -Can occur any where along AV ring -10 such locations have been described -90% of bypass tract occur in 4 main sites LEFT LATERAL PATHWAY 45% POSTERIO SEPTAL ( Rt&Lt ) 26% RIGHT LATERAL PATHWAY 18% ANTERIO SEPTAL ( Rt&Lt ) 9%

14. ANALYSIS OF MAIN QRS AXIS -FRONTAL PLANE QRS AXIS RIGHT LATERAL PATHWAY -60 POSTERIO SEPTAL 0 TO -30 ANTERIO SEPTAL 0 TO 60 LEFT LATERAL PATHWAY +60 TO +90 -These are only approximation to indicate general direction of frontal plane QRS axis -Actual range for each region may be wider than depicted

15. POLARITY OF QRS IN HORIZANTAL PLANE Polarity in Leads V4-V6 always reflected positive or dominantly positive irrespective of accessory pathway location Polarity in Leads V1-V3 It is a important for location of bypass sites

16. The polarity of the delta wave was measured within the initial 20 msec of the preexcitation and was classified as positive (+), negative (-), or isoelectric (±),

17. Arruda Algorithm

18. Europace , Volume 25, Issue 2, February 2023, Pages 600–609, https://doi.org/10.1093/europace/euac216 The content of this slide may be subject to copyright: please see the slide notes for details. Graphical Abstract

19. Europace , Volume 25, Issue 2, February 2023, Pages 600–609, https://doi.org/10.1093/europace/euac216 The content of this slide may be subject to copyright: please see the slide notes for details. Figure 3 Left-sided accessory pathways. Schematic representation of the MV junction region as viewed in the left ...

20. Europace , Volume 25, Issue 2, February 2023, Pages 600–609, https://doi.org/10.1093/europace/euac216 The content of this slide may be subject to copyright: please see the slide notes for details. Figure 4 Right-sided accessory pathways with QRS transition ≤ V3. Schematic representation of the TV junction region ...

21. Europace , Volume 25, Issue 2, February 2023, Pages 600–609, https://doi.org/10.1093/europace/euac216 The content of this slide may be subject to copyright: please see the slide notes for details. Figure 5 Right-sided accessory pathways with QRS transition > V3. Schematic representation of the TV junction region ...

22. VA conduction indices : Using ventricular-induced atrial pre-excitation, Miles  et al  devised pre-excitation index Progressively premature right ventricular extrastimuli were introduced during tachycardia and the difference between the TCL(Tachycardia cycle length) and the longest stimulation interval at which atrial pre-excitation occurred is taken as pre-excitation index If PEI is <25 then Anteroseptal or Right Free Wall If PEI is > 75 then Left Lateral or AVNRT pre-excitation index

23. Indications of Electrophysiological Studies in WPW 1) Sudden deaths have the peculiarity to occur during exercise, hence all competitive athletes with WPW syndrome should be studied. 2) Patient with high responsibility profession such as professional pilot (plane, truck, bus, train) 3) The indications in children are more controversial. The indications should be liberal in children who are competitive athletes and in all children above the age of 10 years. 4) In elderly, the propensity for atrial fibrillation increases hence the risk of occurrence of a potentially severe arrhythmia in an asymptomatic WPW patient should not be underestimated.

24. The WPW syndrome and risk of sudden death : -sustained atrial fibrillation is induced -the shortest RR interval between preexcited beats is < 250 ms in the control state in adults, < 220 ms in children or < 200 ms during isoproterenol infusion

25. Variants Concealed Accessory Pathways Defined as pathways that are capable of conduction only in the retrograde (VA) direction at rates similar or greater than the sinus rate. The concealed accessory pathways are noted in between 15% to 42% of patients with accessory pathway. Concealed pathways are more frequently localized to the left free wall (64%), and less frequently in Septal (31%) and right free wall locations.

26. Variants INTERMITTENT WPW SYNDROME -It may be intermittent or relatively permanent -Intermittence may be periodic and hapzard or regular like 2:1 wpw conduction mechanism(every alternate beat reflects the wpw fusion complex)

27. COMPLICATIONS 1.RECIPROCATING TACHYCARDIA

28. 2.ATRIAL FIBRILLATION

29. AV JUNCTIONAL PATHWAYS

30. TREATMENT (1) EPS with RF catheter ablation. EPS with ablation is the first-line treatment for symptomatic WPW syndrome (2) pharmacotherapy

31. Agents acting on atrioventricular node Verapamil and diltiazem (calcium channel blockers), metoprolol and atenolol (beta-blockers), and digitalis all prolong conduction time and refractoriness in the AV node. Agents acting on accessory pathway -Class Ia drugs ( eg , quinidine) and class Ic drugs ( eg , flecainide, propafenone) slow conduction velocity in the AP and prolong the AP refractory period in the bypass tract. -Amiodarone , dofetilide , and sotalol prolong refractoriness in myocardial tissue, including AV bypass tracts

32. Termination of Acute Episodes - Narrow-complex atrioventricular reentrant tachycardia IV adenosine , IV verapamil , adenosine -Atrial flutter/fibrillation or wide-complex tachycardia drugs that prolong the refractory period of the bypass tract should be used, including procainamide (class Ia agent). i f VT cannot be excluded, the drugs of choice are IV procainamide or amiodarone

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