Preexcitation Syndromes
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.
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2021, Journal of ElectrocardiologyCitation Excerpt :In 1930, Wolff, Parkinson, and White reported on a series of young patients who had paroxysmal tachycardia with characteristic abnormalities detected on an electrocardiogram (ECG), such as a short PR/PQ interval and broad QRS-complexes similar to a bundle branch block pattern [1]. Currently, the ECG abnormalities they had been advocated are recognized as pre-excitation syndrome, which is defined as a group of disorders in which the electrical activation of the accessory pathway (AP) bypasses the atrioventricular node and causes ventricular pre-excitation [2]. Early ventricular excitation causes a delta wave on a 12‑lead ECG, and it is useful to make a diagnosis of the localization of the AP [3].
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The authors have no conflicts of interest to disclose.