Wolff–Parkinson–White syndrome

Wolff-Parkinson-White (WPW) Syndrome is a combination of the presence of a congenital accessory pathway and episodes of tachyarrhythmia.

WPW syndrome is characterized by a double stimulation of the ventricles. A premature conduction wave via accessory pathways (pre-excitation) stimulates the portions of the ventricles nearest the atrium; then the ventricles depolarize as a result of the conduction wave which proceeds normally through the atrioventricular (AV) node.

The clinical significance of this syndrome depends on the appearance of (supraventricular) reentry tachycardias.

History of Wolff–Parkinson–White syndrome

1909 – Retrospective review of published case reports looking for evidence of ventricular preexcitation shows the earliest example of WPW published is from August Hoffmann (1862-1929) published in MMW 1909; 56(2): 2259-2262

Remastered ECG from original white on black images via Von Knorre GH. The earliest published electrocardiogram showing ventricular preexcitation. Pacing Clin Electrophysiol. 2005 Mar;28(3):22830 [PMID 15733183]

The short PR interval and slurred initial portion of the QRS complex were first noted by:

• Cohn and Fraser [Heart, 1913];
• Frank Norman Wilson (1890–1952) [Arch Intern Med, 1915];
• Alfred M. Wedd (1887–1967) [Arch Intern Med, 1921];
• Francis Bach (1900-1975) [Proc R Soc Med, 1929];
• and Walter Wile Hamburger [Med Clin North Am, 1929]

1928 – On April 2 a young man was referred to Paul Dudley White because his physician was perplexed by the occurrence of paroxysmal atrial fibrillation in a healthy individual. White was preparing for visits to overseas medical centers and took the ECGs with him.

• Vienna: the tracing was deemed to represent nothing more unusual than bundle-branch block and atrioventricular (AV) nodal rhythm
• London: Parkinson was interested and found a further seven cases to add to the four from Boston.

1930 – Wolff L, Parkinson J, and White PD publish the eleven cases as definitive description of the syndrome – ‘Bundle Branch Block with Short P-R Interval in Healthy Young People Prone to Paroxysmal Tachycardia.’ A review of the literature confirmed and acknowledged the previously described cases as above. Wolff, Parkinson, and White erroneously thought that the wide QRS complex was caused by a type of bundle-branch block.

1933 – Wolferth and Wood suggested that the abnormal slurring of the initial part of the QRS complex, and prolongation of the QRS complex were not due to bundle-branch block but by:

an actual acceleration of the passage of the impulse from the auricle to a section of the ventricle…in keeping with the possibility that an accessory pathway of AV conduction such as described by Kent between the right auricle and right ventricle could be responsible for the phenomenon manifested by these cases

Wolferth CC, Wood FC. 1933

1944 – Segers PM, Lequime J and Denolin proposed the symbol Δ to represent the triangle shape at the base of the upsloping QRS complex. They described the ‘… deformation of the PQ segment is the result of a supplementary electrical deflection that we propose to call Δ‘ . This became more commonly described as the ‘delta wave‘

Associated Persons

• Louis Wolff (1898-1972)
• Sir John Parkinson (1885-1976)
• Paul Dudley White (1886-1973)

References

• Kent AFS. A conducting path between the right auricle and the external wall of the right ventricle in the heart of the mammal. J Physiol. 1914;48:57. [PMC2299573]
• His W. Die Thatigkeit des embryonalen Herzens und deren Bedeutung fur die Lehre von der Herzbewegung beim Erwachsenen. Med Klinik in Leipzig. 1893;I:14.
• Hoffmann A. Die Arythmie des Herzens im Elektrokardiogramm. Münchener medizinische Wochenschrift. 1909; 56: 2259-2262
• Hoffmann A. Die Elektrographie als Untersuchungsmethode des Herzens und ihre Ergebnisse: insbesondere für die Lehre. 1914
• Cohn AE, Fraser FR. Paroxysmal tachycardia and the effect of stimulation of the vagus nerve by pressure. Heart. 1913; 14(5): 93-105.
• Wilson FN. A case in which the vagus influenced the form of the ventricular complex of the electrocardiogram. 1915. Ann Noninvasive Electrocardiol. 2002 Apr;7(2):153-73. [PMID 12085794]
• Wedd, A.M. Paroxysmal tachycardia with reference to nomotopic tachycardia and role of extrinsic cardiac nerves. Arch Intern Med. 1921;27:571–590. [JAMA]
• Bach F. Paroxysmal Tachycardia of Forty-eight years’ Duration and right Branch Bundle Block. Proc R Soc Med. 1929 Feb;22(4):412-4. [PMC2102934]
• Hamburger WW. Bundle branch block. Four cases of intraventricular block showing some interesting and unusual clinical features. Med Clin North Am 1929; 13: 343-362
• Wolff L, Parkinson J, White PD. Bundle-branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia. American Heart Journal. 1930; 5: 685-704 [Reprint: Ann Noninvasive Electrocardiol. 2006 Oct;11(4):340-53. PMID 17040283]
• Wolferth CC, Wood FC. The mechanism of production of short P-R intervals and prolonged QRS complexes in patients with presumably undamaged hearts: hypothesis of an accessory pathway of auriculoventricular conduction (bundle of Kent). American Heart Journal. 1933; 8: 297-311.
• Segers PM, Lequime J, Denolin H. L’activation ventriculaire précoce de certains cœurs hyperexeitables. Étude de I’onde Δ de I’électrocardiogramme. Cardiologia. 1944; 8(3-4):113-167.
• Wellens HJ, Schuilenberg RM, Durrer D. Electrical stimulation of the heart in patients with Wolff-Parkinson-White syndrome, type A. Circulation. 1971 Jan;43(1):99-114. [PMID 5540856]
• Hurst JW. Naming of the waves in the ECG, with a brief account of their genesis. Circulation. 1998 Nov 3;98(18):1937-42. [PMID 9799216]
• Von Knorre GH. The earliest published electrocardiogram showing ventricular preexcitation. Pacing Clin Electrophysiol. 2005 Mar;28(3):22830 [PMID 15733183]
• Moss, AJ. History of Wolff-Parkinson-White Syndrome: Introductory Note to a Classic Article by Louis Wolff, M.D., John Parkinson, M.D., and Paul D. White, M.D. Ann Noninvasive Electrocardiol. 2006 Oct;11(4):338-9. [PMID 17040282]
• Scheinman MM. The History of the Wolff–Parkinson–White Syndrome. Rambam Maimonides Med J. 2012 Jul; 3(3): e0019. [PMC3678820]
• Gaskell WH. On the Innervation of the Heart, with especial reference to the Heart of the Tortoise. J Physiol. 1883 Aug; 4(2-3): [43]-127, 230-1-230-14. [PMC1484944]
• ECG Library – Pre-excitation Syndromes. LITFL

Advanced Reading

Online

• Wiesbauer F, Kühn P. ECG Yellow Belt online course: Become an ECG expert. Medmastery
• Wiesbauer F, Kühn P. ECG Blue Belt online course: Learn to diagnose any rhythm problem. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.

Textbooks

• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Hampton J. The ECG Made Practical 7e, 2019
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography 1e, 2009
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

LITFL Further Reading

• ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
• ECG A to Z by diagnosis – ECG interpretation in clinical context
• ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
• 100 ECG Quiz – Self-assessment tool for examination practice
• ECG Reference SITES and BOOKS – the best of the rest