Prof. Dr.TITO’S unit M6

Dr.Rakesh.Pinninti

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.

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.

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*

Diagnosis

Wolff-Parkinson-White Syndrome (right posteroseptal/ right

lateral) (accessory pathway)

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%

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

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.

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

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.

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.

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

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

ive

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.

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

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)

Complications of WPW

A) RECIPROCATING TACHYCARDIA

B) ATRIAL FIBRILLATION

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

THANK YOU

THANK YOU