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WolfWolf--ParkinsonParkinson--WhiteWhite

S ndromeS ndromeRight or Left?Right or Left?

Dr. Hatem KholeifDr. Hatem Kholeif

-Azhar University; Cairo

Professor of CardiologyProfessor of Cardiology

AlAl-Azhar University; Cairo

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Aim ..Aim ..

lead ECG without-lead ECG withoutTo Know how to localize the accessoryTo Know how to localize the accessorypathway from 12pathway from 12-usin an al orithm.usin an al orithm.

during electrophysiological study.during electrophysiological study.Localization of accessory pathwayLocalization of accessory pathway

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WPWWPW

from the ventricles exceheart the A are isolated electricallyheart the A are isolated electricallyNormally during development of theNormally during development of the

from the ventricles exce t at AVN.t at AVN.

mitral connection).-mitral connection).(except at aorto-(except at aortoA to V anywhere across the AV ringA to V anywhere across the AV ringSometimes a muscle bundle attach theSometimes a muscle bundle attach the

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Localization of bypass tractLocalization of bypass tractin the WPW from the ECGin the WPW from the ECG

Rosenbaum (1945) .. Type A & BRosenbaum (1945) .. Type A & B

QRS > 120 msQRS > 120 ms

Analysis of delta wave in the frontal &Analysis of delta wave in the frontal &

frontal & horizontal planes.frontal & horizontal planes.

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StepsSteps ....

as delta wave in V1as delta wave in V.Look at main QRS deflection in V11.Look at main QRS deflection in V1 1--33 as wellas well

1

Positive with Left sidedPositive with Left sided

Ne ative with ri ht sidedNe ative with ri ht sided

. Transitional zone3. Transitional zone

negative .. Posteriornegative .. Posterior

2. Inferior leads; LII, III & aVF2. Inferior leads; LII, III & aVF

Positive .. AnteriorPositive .. Anterior3

before Vbefore V3 .. Ri3 ght Septal.. Rig

.. Right lateral4 .. Right lateral

ht Septal

after Vafter V4

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Differentiating right from left posteroseptal ..Differentiating right from left posteroseptal ..

MM--mode echomode echo

A dominant septal notch .. Right sidedA dominant septal notch .. Right sided

pos er or wa no c .. e s epos er or wa no c .. e s e

These notches disappear .. AblationThese notches disappear .. Ablation

[Hina et al.([Hina et al.(19991999) Heart;) Heart; 8282::731731--739739]]

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Localization of the accessoryLocalization of the accessorypathway during EPSpathway during EPS

From atrial sideFrom atrial side

Distal or mid CS .. Left sidedDistal or mid CS .. Left sided

Shortest VA during tachycardiaShortest VA during tachycardia

His .. Right anteroseptalHis .. Right anteroseptal

HRA .. Right free wallHRA .. Right free wall

Proximal CS .. Posteroseptal.Proximal CS .. Posteroseptal.

Unipolar recording (if manifested)Unipolar recording (if manifested)

CS precedes His > 25CS precedes His > 25 ms .. Left sidedms .. Left sided

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Localization of the accessory pathway during EPSLocalization of the accessory pathway during EPSContinuedContinued

From ventricular sideFrom ventricular side

Earliest V in relation to delta wave.Earliest V in relation to delta wave.

. .

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AP prolongs the CL of tachycardiaAP prolongs the CL of tachycardia

Development of BBB ipsilateral to theDevelopment of BBB ipsilateral to the

3030 ms.ms.

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