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Updated: Dec 10 2020

Wolff-Parkinson-White (WPW) Syndrome

  • Snapshot
    • A 10-year-old boy presents to the pediatrician’s office for an electrocardiogram. His family history includes Wolff-Parkinson-White syndrome and sudden cardiac death. His parents are adamant about an electrocardiogram at this visit. Results show a widened QRS, a delta wave, and a shortened PR interval, confirming the diagnosis.
  • Introduction
    • Clinical definition
      • a ventricular pre-excitation syndrome resulting in an aberrant conduction tract that bypasses the atrioventricular (AV) node
    • Epidemiology
      • risk factors
        • family history
    • Etiology
      • can be familial
    • Pathogenesis
      • ventricular pre-excitation results from an aberrant conduction tract from the atria to the ventricle, known as the bundle of Kent
        • this fast accessory tract bypasses the AV node
        • ventricles then depolarize earlier than normal
        • this causes the classic delta wave and widened QRS
      • administration of calcium channel blockers or digoxin will worsen a supraventricular tachycardia (SVT) caused by WPW syndrome
        • these medications block conduction in the AV node and will force more conduction down the aberrant tract, worsening WPW syndrome
    • Associated conditions
      • Ebstein anomaly
      • hypertrophic cardiomyopathy
    • Prognosis
      • can present with
        • atrioventricular reentrant tachycardia (AVRT)
          • most commonly as orthodromic AVRT
            • narrow QRS complexes
          • less commonly as (5%) antidromic AVRT
            • wide QRS complexes (> 120 ms)
        • atrial fibrillation
        • atrial flutter
        • ventricular tachycardia
        • ventricular fibrillation and sudden death
  • Presentation
    • Symptoms
      • can be asymptomatic
      • if symptomatic, patients will present with
        • palpitations
        • lightheadedness
        • syncope
        • dizziness
        • chest pain
    • Physical exam
      • tachycardia
  • Studies
    • Electrocardiogram (ECG)
      • delta wave
      • short PR interval
      • widened QRS complex
      • may have supraventricular tachycardia if symptomatic
    • Making the diagnosis
      • based on clinical presentation and ECG
  • Differential
    • Bundle branch block
      • distinguishing factor
        • widened and abnormal terminal portion of QRS portion on ECG
  • Treatment
    • Management approach
      • drugs that delay AV node conduction is typically contraindicated in these patients unless patients have confirmed orthodromic AVRT
    • Medical
      • procainamide
        • indications
          • for patients who are hemodynamically stable
          • for patients with antidromic AVRT or atrial fibrillation due to WPW syndrome
      • adenosine or calcium channel blocker
        • indication
          • for patients with orthodromic AVRT (narrow QRS complexes)
    • Non-operative
      • electrical cardioversion
        • indication
          • for all patients who are hemodynamically unstable due to arrhythmia
      • radiofrequency catheter ablation
        • indication
          • long-term definitive therapy for patients with WPW syndrome
  • Complications
    • Sudden cardiac death
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