ecg: wpw syndrome
TRANSCRIPT
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PROF .Dr G.SUNDARAMURTY ‘S UNITM6
S.DHANRAJ Ist YEAR PG
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HISTORYA 45 YR old female presented with
Difficulty in breathing
Palpitation
Sweating for past 4 hours
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ECG
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FINDINGSNormal sinus rhythmRate 80 / minAxis normalPR shortened 0.08 secBroad QRS complexQRS duration 0.12 secQTC 0.40 secDelta wave noticed(slurred QRS upstroke)Terminal QRS normalSecondary ST/T changes seen
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DIAGNOSISWPW SYNDROME
POSSIBLE PATHWAYS Right posteroseptal anteroseptal
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PATHWAYS
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HISTORY
Named after three scientists WOLFF PARKINSONWHITE
In the year 1930
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DEFINITIONWPW 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
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ECG PRESENTATIONShort PR intervalSlurred initial upstroke of QRS – delta waveRelatively normal , narrow terminal QRS –
main QRS deflectionSlight widening of QRS Secondary STT changes
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CARDIAC ACTIVATIONPHASE 1
Atrial activation- normal PHASE 2:
Ventricular pre-exitationsinus activation occurs through both normal ,
anomalous pathwayanomalous pathway lacks AV nodal conduction
delayso sinus impulse conducted at a rapid ratethis enables ventricles to be activated or pre
exited- short PR interval , delta waveFurther activation through normal pathway
PHASE 3:Narrow terminal QRS
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OLD CLASSIFICATIONType 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 BThe 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.
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PATHWAY
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ORTHODROMICDESCEND- NORMAL PATHWAYASCEND- ACCESSORY PATHWAYIn orthodromic tachycardia, the normal
pathway is used for ventricular depolarization and the accessory tract is used for reentry.
VPC’s can initiate orthodromic tachycardiaOn ECG findings,
the delta wave is absent, QRS complex is normal, P waves are inverted in the inferior and lateral
leads
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ANTIDROMICLESS COMMON PATHWAY.DESCEND- ACCESSORY PATHWAY.ASCEND – NORMAL PATHWAYOn 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
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PATHWAYS
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FIBRES
KENT PATHWAY : ATRIO-VENTRICULAR
JAMES PATHWAY : ATRIO-HIS
MAHAIM PATHWAY: HISO- VENTRICULAR
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MAHAIM FIBRE:Orgin- distal to AV nodeEnds in the venricular myocardiumECG:•normal PR interval•delta wavesJAMES FIBRE(LGL SYNDROME)•Origin- atria•Bypass AV node•Ends in bundle of HIS•ECG:•Short PR•Normal QRS
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COMPLICATIONTachyarrhythmiaSyncopal attacksSudden cardiac deathComplications of drug therapy (eg,
proarrhythmia, organ toxicity)Complications associated with invasive
procedures and surgeryRecurrence
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TREATMENT
ANTIARRYTHMICS– class 1c, 3
RADIOFREQUENCY ABLATION ( TOC)
SURGICAL ABLATION ( OUTDATED)
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CAUTIONUsual presentation is SVT
Sudden cadiac death possible
Digoxin, beta blockers,verapamil are contraindicated
Underlying Ebstein’s anomaly, hypertrophic cardiomyopathy should be evaluated
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THANK YOU