[Wolff--Parkinson--White syndrome: classification, clinical manifestations, diagnosis, and treatment].

Main etiological factors, mechanisms of arrhythmogenesis, and classification of Wolff-Parkinson-White (WPW) syndrome are presented and clinico-electrocardiographical and electrophysiological peculiarities of atrioventricular reciprocal tachycardia in this syndrome are described. Main diagnostic measures, principles of their correct interpretation are specified and principles of tactical approach to management of patients are presented. Indications to electrophysiological investigation and radiofrequency catheter ablation, physical characteristics of radiofrequency action in regions of optimal mapping of supplementary atrioventricular junction are discussed. Data of analysis of efficacy of pharmacological and interventional approaches to the treatment of patients with WPW syndrome are also presented.

Fasciculoventricular pathways: clinical and electrophysiologic characteristics of a variant of preexcitation.

UNLABELLED: Fasciculoventricular Fibers. INTRODUCTION: Fasciculoventricular tracts are considered a rare form of ventricular preexcitation. Few fasciculoventricular pathways have been reported, and none have been linked to a reentrant tachycardia. METHODS AND RESULTS: Four patients with fasciculoventricular bypass tracts underwent electrophysiologic evaluation. Two patients had a single fasciculoventricular pathway, one that inserted anteroseptally and the other in the left ventricle. Two patients also had an AV bypass tract, with anterograde conduction over the fasciculoventricular pathway during orthodromic AV reentrant tachycardia. After ablation of the AV pathways, the ECG during sinus rhythm and the electrophysiologic study showed ventricular preexcitation due to a fasciculoventricular bypass tract inserting into the right ventricle. Adenosine triphosphate was helpful in the diagnostic process. CONCLUSION: Electrophysiologists should be able to make the differential diagnosis between a fasciculoventricular bypass tract and an anteroseptal accessory pathway to preclude potential harm to the AV conduction system if a fasciculoventricular pathway is targeted for catheter ablation.

[The clinico-electrocardiographic classification of the early ventricular repolarization syndrome]. / Kliniko-élektrokardiograficheskaia klassifikatsiia sindroma rannei repoliarizatsii zheludochkov.

Based on an analysis of 4980 ECGs of patients, the authors could distinguish and classify the clinico-electrocardiographic versions of the early ventricular repolarization syndrome (EVRS): permanent, occurring for the first time, suddenly disappearing, intermittent with a gigantic T wave; with a negative T wave, with a short-term T wave inversion, marked by the combination with Wolff-Parkinson-White syndrome, and additional chordae of the left ventricle. The clinico-electrocardiographic classification of the EVRS is of paramount importance for practitioners owing to an assumption that the EVRS is not only a version of the normal ECG but also can be a marker of CHD. The authors view the EVRS as an independent version of the preexcitation syndrome along with Wolff-Parkinson-White and CLK syndromes, with the manifestations of which it may combine.

Pre-excited RR intervals during atrial fibrillation in the Wolff-Parkinson-White syndrome: influence of the atrioventricular node refractory period.

The ventricular rate and percent of pre-excited QRS complexes during atrial fibrillation were compared in two groups of patients with the Wolff-Parkinson-White syndrome. Group A consisted of 22 patients whose anterograde effective refractory period of the accessory pathway was longer than that of the atrioventricular (AV) node. Group B consisted of 23 patients in whom this relation was reversed. No patient had organic heart disease. Both groups had a similar effective refractory period of the accessory pathway (288 +/- 37 vs. 280 +/- 26 ms), whereas that of the AV node was shorter in group A than group B (242 +/- 25 vs. 285 +/- 27 ms, p = 0.0001). Patients in group A had a lower percent of pre-excited QRS complexes during atrial fibrillation (39 +/- 43% vs. 93 +/- 20%, p = 0.0001). In the 21 patients whose refractory period was measured, the difference was plotted against the percent of pre-excited QRS complexes; there was a significant correlation between the two (r = -0.83, p less than 0.001). In patients in whom pre-excited RR intervals were present, the pre-excited RR intervals were compared between the two groups. Both groups had similar effective refractory periods of the accessory pathway (265 +/- 22 vs. 280 +/- 27 ms) and ventricle (200 +/- 17 vs. 211 +/- 26 ms). The effective refractory period of the AV node was shorter in group A (248 +/- 22 vs. 285 +/- 28 ms, p = 0.0005). The shortest pre-excited RR interval did not show any difference (244 +/- 37 vs. 265 +/- 41 ms). However, both the average (328 +/- 39 vs. 397 +/- 56 ms, p = 0.001) and longest (495 +/- 109 vs. 666 +/- 205 ms, p = 0.02) pre-excited RR intervals were shorter in group A.(ABSTRACT TRUNCATED AT 250 WORDS)

Criteria for intraventricular conduction disturbances and pre-excitation. World Health Organizational/International Society and Federation for Cardiology Task Force Ad Hoc.

In an effort to standardize terminology and criteria for clinical electrocardiography, and as a follow-up of its work on definitions of terms related to cardiac rhythm, an Ad Hoc Working Group established by the World Health Organization and the International Society and Federation of Cardiology reviewed criteria for the diagnosis of conduction disturbances and pre-excitation. Recommendations resulting from these discussions are summarized for the diagnosis of complete and incomplete right and left bundle branch block, left anterior and left posterior fascicular block, nonspecific intraventricular block, Wolff-Parkinson-White syndrome and related pre-excitation patterns. Criteria for intraatrial conduction disturbances are also briefly reviewed. The criteria are described in clinical terms. A concise description of the criteria using formal Boolean logic is given in the Appendix. For the incorporation into computer electrocardiographic analysis programs, the limits of some interval measurements may need to be adjusted.

Wolff-Parkinson-White syndrome type B and left bundle-branch block: electrophysiologic and radionuclide study.

Coinciding left bundle-branch block and Wolff-Parkinson-White syndrome type B, a very rare electrocardiographic occurrence, was found in a patient with dilated cardiomyopathy. Electrophysiologic study revealed eccentric retrograde atrial activation during ventricular pacing, suggesting right-sided accessory pathway. At programmed atrial pacing, effective refractory period of the accessory pathway was 310 ms; at shorter pacing coupling intervals, normal atrioventricular conduction with left bundle-branch block was seen. Left bundle-branch block was seen also with His bundle pacing. Radionuclide phase imaging demonstrated right ventricular phase advance and left ventricular phase delay; both right and left ventricular phase images revealed broad phase distribution histograms. Combined electrophysiologic and radionuclide investigations are useful to disclose complex conduction abnormalities and their mechanical correlates.

Wolff-Parkinson-White syndrome with gradual transition from type A to type B.

This report documents a case which showed type A, type B and intermediate patterns of pre-excitation on different days. A vagotonic maneuver and digitalis induced a type A pattern, while exercise, atropine and isoproterenol caused a type B pattern of activity. A gradual transition from type A to B was demonstrated with vectorcardiograms. Despite the variations in the QRS morphology, the direction of the initial vector was not altered and was directed straight anteriorly. In this case, an accessory pathway may be located in the posterior paraseptal region or the lateral free wall of the left ventricle, and a variable size of pre-excited area may have caused type A and type B patterns of pre-excitation.

The Wolff-Parkinson-White pattern in health aircrew.

The Wolff-Parkinson-White syndrome has been studied in a group of healthy aviation personnel over the past 15 years. The incidence of this electrocardiographic pattern has been determined in 22,500 healthy individuals and found to be 0.25%. The prevalence of documented tachyarrhythmias in this group of individuals was found to be only 1.8% while in a group of referred patients the prevalence was 20%. The limitations of the widely accepted classification into Type A and Type B patterns was borne out by our inability to categorize 45% of subjects with the WPW pattern. Q waves as QS or QR complexes in the inferior limb leads were found in 16.7% of subjects, but in all there was Q wave-T wave vector discordance. The limited value of stress testing in these individuals was reflected by 30% of our patients who demonstrated false positive signs of ischaemic heart disease. A discussion of the incidence, classification, differential diagnosis, mechanism of tachyarrhythmias, associated cardiovascular anomalies, and treatment follows.

Wolff-Parkinson-White syndrome: T wave abnormalities during normal pathway conduction.

Forty-five patients with Wolff-Parkinson-White syndrome (WPW) were reviewed. The preexcitation using Boineau's classification was: right anterior (six patients), left lateral (nine patients), right posterior (15 patients) and left posterior (15 patients). Normal pathway conduction was observed to occur either spontaneously or after administration of ajmaline, procainamide, or by eye-ball pressure. Disappearance of preexcitation was associated with T wave abnormalities in 39 patients (86.6%). The orientation of the T spatial vector (SAT), after suppression of the WPW aspect, varied according to the site of ventricular preexcitation. In eight patients with left lateral ventricular preexcitation (LLVP), the frontal T wave axis was between +70 degrees and +120 degrees (mean +92 degrees) and the horizontal T wave axis was located in the left anterior quadrant. In the five patients with right anterior ventricular preexcitation (RAVP), the frontal axis was between + 40 degrees and - 10 degrees (mean + 26 degrees) and the horizontal axis was in the left posterior quadrant. The 26 cases with right posterior ventricular preexcitation (RPVP) and left posterior ventricular preexcitation (LPVP) had a frontal axis between - 10 degrees and - 70 degrees (mean -39 degrees) and the horizontal T wave axis in the left anterior quadrant. This study suggests that the T wave anomalies observed after suppression of the WPW aspect are in direct relation to the localization of the preexcitation according to Boineau's classification. The analogy between the abnormalities of the T wave and those which are observed after right ventricular pacing (VP) or after disappearance of left bundle branch block (LBBB) is discussed.

Non-invasive localization of the pre-excitation site in patients with the Wolff-Parkinson-White syndrome. Vectorcardiographic and echocardiographic correlations.

Vectorcardiographic and echocardiographic correlations were made in 160 patients with no clinical evidence of cardiovascular diseases except for the Wolff-Parkinson-White syndrome. Frank vectorcardiographic classifications of the patients were based on both the morphology of the delta loop and the direction of the mean delta vector in the horizontal plane as follows; group I (93 patients) with a delta loop inscribed nearly straightly anteriorly and either to the left or right and a mean delta vector directed more anteriorly than +20 degrees, group II (31 patients) with a hook-shaped delta loop inscribed initially anteriorly but soon posteriorly and to the left, and group III (36 patients) with a delta loop inscribed nearly linearly to the left and either posteriorly or slightly anteriorly and a mean delta vector directed more posteriorly than +20 degrees. Abnormal echocardiographic patterns of ventricular contractions in the syndrome were seen at the left ventricular posterior wall (LVPW), the interventricular septum (IVS), and the right ventricular anterior wall (RVAW). In group I abnormal LVPW motions were observed in 91 patients (98%), and both abnormal LVPW and IVS motions in 1. The remaining 1 showed no echocardiographic abnormalities either at LVPW or IVS. In contrast, abnormal IVS motions were observed in 29 patients (94%) of group II. No patient of group II showed abnormal LVPW motions. In 17 patients (47%) of group III abnormal LVPW motions alone were observed. Two patients showed both abnormal LVPW and IVS motions. In the remaining 17 patients (47%), no abnormal motions were noted either at LVPW or IVS. Abnormal RVAW motions were invariably observed in 19 patients of group II with satisfactory RVAW echograms, but never seen in groups I and III. Above findings could be explained by the pre-excitation at LVPW in group I, RVAW in group II, and posterior right ventricle in group III. In 19 patients (8 in group I and 11 in group III) frontal QRS loops were very similar to that in left anterior hemiblock. All of these patients except for 1 showed abnormal LVPW motions, so that the site of pre-excitation was presumably located at the posterior paraseptal region or the posterior IVS. Three cases with a combination of a frontal QRS loop of left anterior hemiblock pattern and abnormal IVS motions in addition to abnormal LVPW motions may be explained by the pre-excitation at the right-sided IVS near LVPW. We feel that combinations of vectorcardiographic and echocardiographic approaches are clinically quite useful as an auxiliary non-invasive means of locating the pre-excitation site.