Review Article

Atrioventricular Accessory Pathways: Mechanisms, Electrocardiograms, and Associated Arrhythmias

Authors: Eliana Hanna Deschamps, MD, Elias B. Hanna, MD

Abstract

An atrioventricular accessory pathway (AP) may be manifest or concealed. When manifest, it leads to preexcitation on the baseline electrocardiogram, which is called the Wolff-Parkinson-White pattern. The degree of preexcitation varies according to the relative conduction speed of the atrioventricular node versus the AP, the AP location, and the AP refractory period. This explains that even a manifest AP may lead to only intermittent preexcitation. The AP conducts faster than the atrioventricular node but has a longer refractory period, which allows the initiation of a reentrant arrhythmia called atrioventricular reciprocating tachycardia. In addition to re-entry, a manifest AP may allow the fast antegrade conduction of an atrial tachyarrhythmia, leading to a small risk of sudden death; the latter depends on the AP refractory period (ie, the number of atrial waves it can conduct back to back) rather than the AP conduction speed. This can be assessed invasively and noninvasively and allows risk stratification of asymptomatic individuals.

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References

1. Jackman WM, Wang XZ, Friday KJ, et al. Catheter ablation of accessory atrioventricular pathways (Wolff-Parkinson-White syndrome) by radiofrequency current. N Engl J Med 1991;324:1605-1611.
 
2. Kuck KH, Friday KJ, Kunze KP, et al. Sites of conduction block in accessory atrioventricular pathways. Basis for concealed accessory pathways. Circulation 1990;82:407-417.
 
3. Surawicz B, Childers R, Deal BJ, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances. Circulation 2009;119:e235-e240.
 
4. Chung KY, Walsh TJ, Massie E. Wolff-Parkinson-White syndrome. Am Heart J 1965;69:116-133.
 
5. Ruskin JN, Akhtar M, Damato AN, et al. Abnormal Q waves in Wolff-Parkinson-White syndrome. Incidence and clinical significance. JAMA 1976;235:2727-2730.
 
6. Grant RP, Tomlinson FB, Van Buren JK. Ventricular activation in the pre-excitation syndrome (Wolff-Parkinson-White). Circulation 1958;18:355-366.
 
7. Massumi RA, Vera Z. Patterns and mechanisms of QRS normalization in patients with Wolff-Parkinson-White syndrome. Am J Cardiol 1971;28:541-554.
 
8. Klein GJ, Gulamhusein SS. Intermittent preexcitation in the Wolff-Parkinson-White syndrome. Am J Cardiol 1983;52:292-296.
 
9. Nalos PC, Deng Z, Gang ES, et al. Intermittent preexcitation: clinical recognition and management. Pract Cardiol 1985;11:49-67.
 
10. Reddy GV, Schamroth L. The localization of bypass tracts in the Wolff-Parkinson-White syndrome from the surface electrocardiogram. Am Heart J 1987;113:984-993.
 
11. Fananapazir L, German LD, Gallagher JJ, et al. Importance of preexcited QRS morphology during induced atrial fibrillation to the diagnosis and localization of multiple accessory pathways. Circulation 1990;81:578-585.
 
12. Cain ME, Luke RA, Lindsay BD. Diagnosis and localization of accessory pathways. Pacing Clin Electrophysiol 1992;15:801-824.
 
13. Arruda MS, McClelland JH, Wang X, et al. Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-White syndrome. J Cardiovasc Electrophysiol 1998;9:2-12.
 
14. Gillette PC. Concealed anomalous cardiac conduction pathways: a frequent cause of supraventricular tachycardia. Am J Cardiol 1977;40:848-852.
 
15. Knight BP, Ebinger M, Oral H, et al. Diagnostic value of tachycardia features and pacing maneuvers during paroxysmal supraventricular tachycardia. J Am Coll Cardiol 2000;36:574-582.
 
16. Pieper SJ, Stanton MS. Narrow QRS complex tachycardias. Mayo Clin Proc 1995;70:371-375.
 
17. Chung EK. Tachyarrhythmias in Wolff-Parkinson-White syndrome. Antiarrhythmic drug therapy. JAMA 1977;237:376-379.
 
18. Bogun F, Kalusche D, Li YG, et al. Septal Q waves in surface electrocardiographic lead V6 exclude minimal ventricular preexcitation. Am J Cardiol 1999;84:101-104.
 
19. Fitzsimmons PJ, McWhirter PD, Peterson DW, et al. The natural history of Wolff-Parkinson-White syndrome in 228 military aviators: a longterm follow-up of 22 years. Am Heart J 2001;142:530-536.
 
20. Chung EK. Tachyarrhythmias in Wolff-Parkinson-White syndrome. Antiarrhythmic drug therapy. JAMA 1977;237:376-379.
 
21. Man KC, Brinkman K, Bogun F, et al. 2:1 atrioventricular block during atrioventricular node reentrant tachycardia. J Am Coll Cardiol 1996;28:1770-1774.
 
22. Kerr CR, Gallagher JJ, German LD. Changes in ventriculoatrial intervals with bundle branch block aberration during reciprocating tachycardia in patients with accessory atrioventricular pathways. Circulation 1982;66:196-201.
 
23. Meiltz A, Weber R, Halimi F, et al. Permanent form of junctional reciprocating tachycardia in adults: peculiar features and results of radiofrequency catheter ablation. Europace 2006;8:21-28.
 
24. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm 2012;9:1006-1024.
 
25. Pappone C, Santinelli V, Rosanio S, et al. Usefulness of invasive electrophysiologic testing to stratify the risk of arrhythmic events in asymptomatic patients with Wolff-Parkinson-White pattern: results from a large prospective long-term follow-up study. J Am Coll Cardiol 2003;41:239-244.
 
26. Pietersen AH, Andersen ED, Sandoe E. Atrial fibrillation in the Wolff-Parkinson-White syndrome. Am J Cardiol 1992;70:38A-43A.
 
27. Santinelli V, Radinovic A, Manguso F, et al. The natural history of asymptomatic ventricular pre-excitation a long-term prospective follow- up study of 184 asymptomatic children. J Am Coll Cardiol 2009;53:275-280.
 
28. Santinelli V, Radinovic A, Manguso F, et al. Asymptomatic ventricular preexcitation: a long-term prospective follow-up study of 293 adult patients. Circ Arrythmia Electrophysiol 2009;2:102-107.
 
29. Klein GJ, Yee R, Sharma AD. Longitudinal electrophysiologic assessment of asymptomatic patients with the Wolff-Parkinson-White electrocardiographic pattern. N Engl J Med 1989;320:1229-1233.
 
30. Klein GJ, Prystowsky EN, Yee R, et al. Asymptomatic Wolff-Parkinson-White. Should we intervene? Circulation 1989;80:1902-1905.
 
31. Blomström-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias-executive summary. a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. J Am Coll Cardiol 2003;42:1493-1531.