Preexcitation Syndromes

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Abstract

The classic electrocardiogram in Wolff-Parkinson-White (WPW) syndrome is characterized by a short PR interval and prolonged QRS duration in the presence of sinus rhythm with initial slurring. The clinical syndrome associated with above electrocardiogram finding and the history of paroxysmal supraventricular tachycardia is referred to as Wolff-Parkinson-White syndrome. Various eponyms describing accessory or anomalous conduction pathways in addition to the normal pathway are collectively referred to as preexcitation syndromes. The latter form and associated eponyms are frequently used in literature despite controversy and disagreements over their actual anatomical existence and electrophysiological significance. This communication highlights inherent deficiencies in the knowledge that has existed since the use of such eponyms began. With the advent of curative ablation, initially surgical, and then catheter based, the knowledge gaps have been mostly filled with better delineation of the anatomic and electrophysiological properties of anomalous atrioventricular pathways. It seems reasonable, therefore, to revisit the clinical and electrophysiologic role of preexcitation syndromes in current practice.

Introduction

The classic electrocardiographic (ECG) finding of preexcitation consists of a short PR interval and prolonged QRS (inscribing a “delta” wave causing an initial slurring of the QRS complex) in the presence of sinus rhythm.

The term Wolff-Parkinson-White (WPW) syndrome consists of the above ECG findings with coexistence of paroxysmal supraventricular tachycardia (PSVT). During the course of the last century, the concept of preexcitation syndrome, with its variants, has fascinated and intrigued physiologists, anatomists, and clinicians. The discovery of several anomalous conduction pathways and the various eponyms used, however, has also created controversies with disagreements over their actual anatomic existence, locations, clinical, and electrophysiological significance. This communication updates the contemporary understanding regarding the various preexcitation syndromes and the corresponding eponyms.

Section snippets

Historical Perspective

In 1883, Gaskell1 showed that auricular impulse spread to the ventricles by passing over the muscular connections that exist between the 2 parts of the heart. Paladino2 described numerous myocardial atrioventricular (AV) connections near the base of AV valves. The above findings were followed by the pioneering work of Tawara,3 who detailed the morphology of the AV bundle and its communication with Purkinje fibers distally and origin in AV node proximally in humans. Kent4 reported muscular

AVNRT With Bystander Conduction Over AFP

The common variety of AVNRT is found in less than 10% of patients with AFP-related tachycardias. The clinical and ECG presentation can be indistinguishable from antidromic tachycardia from AVNRT with bystander preexcitation via AFP. During electrophysiology study, a block in the AFP is achieved with using premature atrial or ventricular extra stimuli, evidence of a narrow QRS tachycardia with identical cycle length would suggest that possibility. In addition, finding of fusion beats during

Nonreentrant Preexcited Tachycardia Associated With AFP

Very much akin to nonreentrant tachycardia involving the AV node, so-called 1:2 response,87 during which simultaneous conduction over slow and fast pathway is noted, a similar phenomenon has been reported involving AFP with resultant incessant tachycardia with 1:2 (P: QRS).88 This patient did exhibit absence of V-A conduction and ablation of the AFP was successful in abolition of dual conduction.

Conclusion

Based upon experience it is evident that most of the preexcitation syndromes are the result of antegrade conduction over AV-AP that course across the right and left AV annuli and directly inserting into the myocardium. The preferred name for such connections is AV-AP which would suffice for routine use and avoid confusion by using multiple terminologies and the eponym Kent bundle should be reserved for historical purposes only.

It has also become clear that the so-called Mahaim tachycardia, that

Acknowledgments

The authors gratefully acknowledge Susan Nord and Jennifer Pfaff of Aurora Cardiovascular Services for the editorial preparation of the manuscript, Laurel Landis at the office of Masood Akhtar, and Brian Miller and Brian Schurrer of Aurora Research Institute for their help in preparing figures.

Warren M (Sonny) Jackman, MD, FACC, FHRS: This is a unique and valuable manuscript, detailing the evolution of the preexcitation syndromes and the multiple eponyms, which have been a source of confusion.

References (98)

  • J.J. Gallagher et al.

    The preexcitation syndromes

    Prog Cardiovasc Dis

    (1978)
  • E.B. Sternick et al.

    The electrocardiogram during sinus rhythm and tachycardia in patients with Mahaim fibers: the importance of an rS pattern in lead III

    J Am Coll Cardiol

    (2004)
  • P.C. Gillette et al.

    Prolonged and decremental antegrade conduction properties in right anterior accessory connections: wide QRS antidromic tachycardia of left bundle branch block pattern without Wolff-Parkinson-White configuration in sinus rhythm

    Am Heart J

    (1982)
  • A. Bhandari et al.

    Catheter-induced His bundle ablation in a patient with reentrant tachycardia associated with a nodoventricular tract

    J Am Coll Cardiol

    (1984)
  • G.J. Klein et al.

    Nodoventricular accessory pathway: evidence for a distinct accessory atrioventricular pathway with atrioventricular node-like properties

    J Am Coll Cardiol

    (1988)
  • G.H. Bardy et al.

    Surface electrocardiographic clues suggesting presence of a nodofascicular Mahaim fiber

    J Am Coll Cardiol

    (1984)
  • M. Akhtar et al.

    Antegrade and retrograde conduction characteristics in three patterns of paroxysmal atrioventricular junctional reentrant tachycardia

    Am Heart J

    (1978)
  • G. Csapo

    Paroxysmal nonreentrant tachycardias due to simultaneous conduction in dual atrioventricular nodal pathways

    Am J Cardiol

    (1979)
  • L. Sherf et al.

    A new electrocardiographic concept: synchronized sinoventricular conduction

    Dis Chest

    (1969)
  • W.H. Gaskell

    On the innervation of the heart, with especial reference to the Heart of the Tortoise

    J Physiol

    (1883)
  • G. Paladino

    Contribuzone all anatomia, istolgia e fisiologia del cuore

    Mov Med-Chir (Napoli)

    (1876)
  • S. Tawara

    Das Reizleitungssystem des Säugetierherzens: eine anatomisch-histologische Studie über das Atrioventrikularbündel und der Purkinjeschen Fäden

    Jena, Germany: Verslag Gustav Fischer

    (1906)
  • A.F. Kent

    Researches on the structure and function of the mammalian heart

    J Physiol

    (1893)
  • W. His

    Die Tätigkeit des embryonalen Herzens und deren Bedeutung für die lehre von Herzbewegung beiss Erwachsenen

    Ar Med Kiln Leip

    (1893)
  • A. Keith et al.

    The form and nature of the muscular connections between the primary divisions of the vertebrate heart

    J Anat Physiol

    (1907)
  • A.F.S. Kent

    Observations on the auriculo-ventricular junction of the mammalian heart

    Q J Exp Physiol

    (1913)
  • A.F.S. Kent

    The structure of the cardiac tissue at the auriculo-ventricular junction

    J Physiol

    (1913)
  • A.E. Cohn et al.

    Paroxysmal tachycardia and the effect of stimulation of the vagus nerve by pressure

    Heart

    (1913)
  • A.F.S. Kent

    The right lateral auriculo-ventricular junction of the heart

    J Physiol

    (1914)
  • A.F.S. Kent

    A conducting path between the right atrium and the external wall of the right ventricle in the heart of the mammal

    J Physiol

    (1914)
  • A.F.S. Kent

    Illustrations of the right lateral auriculo-ventricular junction in the heart

    J Physiol

    (1914)
  • G.R. Mines

    On Circulating excitations in heart muscles and their possible relation to tachycardia and fibrillation

    Trans R Soc Can

    (1914)
  • F.N. Wilson

    A case in which the vagus influenced the form of the ventricular complex of the electrocardiogram

    Ann Noninvasive Electrocardiol

    (2002)
  • A.M. Wedd

    Paroxysmal tachycardia with reference to monotonic tachycardia and the role of the extrinsic cardiac nerves

    Arch Int Med

    (1921)
  • W.W. Hamburger

    Bundle branch block: four cases of intraventricular block showing some interesting and unusual clinical features

    Med Clin North Am

    (1929)
  • T. Lewis

    The Mechanism and Graphic Registration of the Heartbeat

    (1925)
  • M. Holzmann et al.

    Uber electrokardigramme mit verkurzter Vohof-kammer-Distanz und positive P. Zacken

    Z kiln Med

    (1932)
  • M. Segers et al.

    L’activation ventriculare precoce de certain coeurs hyperexcitables etude de l’onde de l’electrocardiogrammee

    Cardiologia

    (1944)
  • R.F. Ohnell

    Pre excitation, a cardiac abnormality

    Acta Med Scan

    (1944)
  • M. Lev

    The pre excitation syndrome; anatomic considerations of anomalous A-V pathways

  • I. Mahaim et al.

    Nouvelles Recherches sur les connections superieures de la Branche Gauche du faisceau de His-Tawara avec la cloison Interventriculare

    Cardiologia

    (1937)
  • R.H. Anderson et al.

    Development of atrioventricular specialized tissue in human heart

    Br Heart J

    (1972)
  • R.H. Anderson et al.

    Atrioventricular ring specialized tissue in the normal heart

    Eur J Cardiol

    (1974)
  • A.E. Becker et al.

    The anatomical substrates of wolff-parkinson-white syndrome. A clinicopathologic correlation in seven patients

    Circulation

    (1978)
  • C. Brechenmacher

    Atrio-His bundle tracts

    Br Heart J

    (1975)
  • R.H. Anderson et al.

    Ventricular preexcitation. A proposed nomenclature for its substrates

    Eur J Cardiol

    (1975)
  • J.N. Ruskin et al.

    Abnormal Q waves in Wolff-Parkinson-White syndrome. Incidence and clinical significance

    J Am Med Assoc

    (1976)
  • E.K. Chung

    Electrocardiography

    Practical Applications With Vectorial Principles

    (1974)
  • G.A. Sears et al.

    Wolf-Parkinson-White pattern in routine electrocardiography

    Can Med Assoc J

    (1962)
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    The authors have no conflicts of interest to disclose.

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