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Highlights & Basics
- Wolff-Parkinson-White (WPW) syndrome occurs when myocardial fibers connect the atrium to the ipsilateral ventricle across the mitral or tricuspid annulus (accessory pathway), pre-exciting the ventricle.
- Patients often present with atrioventricular re-entrant tachycardia, less commonly atrial fibrillation, and, rarely, sudden cardiac death.
- Asymptomatic patients can either be monitored or screened to determine whether they have a "high-risk" accessory pathway, in which case catheter ablation is typically performed. Screening to determine whether a patient has a high-risk accessory pathway is recommended for patients who have high-risk occupations, such as school bus drivers or pilots, and also for competitive athletes. In patients with asymptomatic pre-excitation who have an accessory pathway demonstrating low risk features on invasive or noninvasive screening, an electrophysiology study and ablation can be considered.
- Symptomatic patients usually undergo catheter ablation as first-line therapy. Pharmacologic therapy can be considered for patients in whom catheter ablation fails and also for patients who prefer a noninvasive approach.
- Catheter ablation is highly effective with low risk and can be used either as initial therapy or for patients experiencing side effects or arrhythmia recurrences despite medical treatment.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Manifest versus concealed accessory pathway. AP, accessory pathway; AV, atrioventricular; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SA, sinoatrial
Orthodromic atrioventricular reciprocating tachycardia in a patient with left-sided accessory pathway. AP, accessory pathway; APC, atrial premature complex; AV, atrioventricular; AVRT, atrioventricular re-entrant tachycardia; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SA, sinoatrial
Orthodromic reciprocating tachycardia induced in a patient with left lateral accessory pathway
Antidromic atrioventricular reciprocating tachycardia in a patient with left-sided accessory pathway. AP, accessory pathway; APC, atrial premature complex; AV, atrioventricular; AVRT, atrioventricular re-entrant tachycardia; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SA, sinoatrial; SVT, supraventricular tachycardia
Antidromic reciprocating tachycardia in a patient with right posteroseptal accessory pathway
Anatomic location of accessory pathways across the valve annuli
Common locations of accessory pathways across the mitral and tricuspid annuli
Right lateral accessory pathway in a patient with Ebstein anomaly
WPW syndrome in a patient with hypertrophic obstructive cardiomyopathy
Collision (fusion) of wave fronts down the atrioventricular node and accessory pathway
Orthodromic and antidromic atrioventricular reciprocating tachycardia circuits. WCT, wide complex tachycardia
Atrial fibrillation in a patient with WPW syndrome with rapid ventricular rate; resulted in aborted sudden cardiac death
Atrial flutter with pre-excitation
A simplified algorithm for localizing an accessory pathway
Left posteroseptal accessory pathway
Right anteroseptal accessory pathway
Resting ECG shows delta waves (red arrows) in the inferior and lateral leads
Loss of pre-excitation (delta waves) in inferior and lateral leads during exercise
Persistent loss of pre-excitation during the recovery period of exercise testing, suggestive of low-risk ECG for sudden cardiac death
Intermittent pre-excitation
Rare forms of accessory pathways occur due to various anatomic substrates with different ECG manifestations
Citations
Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2020 Feb 1;41(5):655-720.[Abstract][Full Text]
Zeppenfeld K, Tfelt-Hansen J, de Riva M, et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2022 Oct 21;43(40):3997-4126.[Abstract][Full Text]
Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016 Apr 5;67(13):e27-115.[Abstract][Full Text]
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