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Accessory pathways between the atria and the ventricle that avoid the conduction delay of the AV node predispose to reentrant arrhythmias, such as AVRT, atrial flutter, and atrial fibrillation These may be wholly or partly within the node (Mahaim fibers), yielding a short PR interval and normal QRS morphology (Lown-Ganong-Levine syndrome) More commonly, they make direct connections between the atria and ventricle through Kent bundles (Wolff-Parkinson-White syndrome) This produces a short PR interval but an early delta wave at the onset of the wide, slurred QRS complex owing to early ventricular depolarization of the region adjacent to the pathway Although the morphology and polarity of the delta wave can suggest the location of the bypass tract, mapping by intracardiac recordings is required for precise anatomic localization Accessory pathways occur in 01 03% of the population and facilitate reentrant arrhythmias owing to the disparity in refractory periods of the AV node and accessory pathway Whether the tachycardia is associated with a narrow or wide QRS complex is determined by whether antegrade conduction is through the node (narrow) or the bypass tract (wide) Many patients with Wolff-Parkinson-White syndrome never conduct in an antegrade direction through the bypass tract In these cases, the bypass tract is termed concealed Orthodromic tachycardia is a reentrant rhythm that conducts antegrade down the AV node and retrograde up the accessory pathway, resulting in a narrow QRS complex unless an underlying bundle branch block or interventricular conduction delay is present Antidromic tachycardia conducts down the accessory pathway and retrograde through the AV node, resulting in a wide QRS complex Because accessory pathways are less refractory than specialized conduction tissue, tachycardias proceeding in this direction have the potential to be more rapid Up to 30% of patients with Wolff-Parkinson-White syndrome will develop atrial fibrillation or flutter with antegrade conduction down the accessory pathway and a rapid ventricular response If this conduction is very rapid, it can potentially degenerate to ventricular fibrillation.

Narrow-complex reentry rhythms involving a bypass tract can be managed as discussed for AVNRT Atrial fibrillation and flutter must be managed differently, since agents such as digoxin, calcium channel blockers, and even blockers may decrease the refractoriness of the accessory pathway or increase that of the AV node, leading to sometimes faster ventricular rates Therefore, these agents should be avoided The class Ia, class Ic, and class III antiarrhythmic agents will increase the refractoriness of the bypass tract and are the drugs of choice for widecomplex tachycardias If hemodynamic compromise is present, electrical cardioversion is warranted Long-term therapy often involves a combination of agents that increases refractoriness in the bypass tract (class Ia or Ic agents) and in the AV node (verapamil, digoxin, and -blockers), provided that atrial fibrillation or flutter with short RR cycle lengths is not present (see above) The class III agents sotalol and amiodarone are effective in refractory cases Patients who are difficult to manage should undergo electrophysiologic evaluation

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Antz M et al Risk of sudden death after successful accessory atrioventricular pathway ablation in resuscitated patients with Wolff-Parkinson-White syndrome J Cardiovasc Electrophysiol 2002 Mar;13(3):231 6 [PMID: 11942588] Hamada T et al Mechanisms for atrial fibrillation in patients with Wolff-Parkinson-White syndrome J Cardiovasc Electrophysiol 2002 Mar;13(3):223 9 [PMID: 11942586] Jezior MR et al Exercise testing in Wolff-Parkinson-White syndrome: case report with ECG and literature review Chest 2005 Apr;127(4):1454 7 [PMID: 15821231] Keating L et al Electrocardiographic features of Wolff-ParkinsonWhite syndrome Emerg Med J 2003 Sep;20(5):491 3 [PMID: 12954704] Pappone C et al A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-ParkinsonWhite syndrome N Engl J Med 2003 Nov 6;349(19):1803 11 [PMID: 14602878]

Some patients have a delta wave found incidentally on ECG In the absence of palpitations, light-headedness, or syncope, these patients do not require specific therapy

TABLE 3-1

Irregular heart rhythm Usually tachycardic Often associated with palpitations (acute onset) or fatigue (chronic) ECG shows erratic atrial activity with irregular ventricular response High incidence and prevalence in the elderly population

Table 10 9 Risk factors for ischemic stroke and systemic embolism in patients with nonvalvular atrial fibrillation

Risk Factors1 Previous stroke or TIA Diabetes mellitus History of hypertension Congestive heart failure Advanced age (continuous, per decade)

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