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Electrocardiogram(ECG)showingLownGanongLevine
syndrome

ThissyndromeischaracterizedbyashortPRinterval(<0.12seconds)anda
normalQRScomplexduetorapidatrioventricularconduction.
Graphic76652Version3.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsince
activationoftherightatriumprecedesthatoftheleftatrium.TheP
waveisuprightinapositivedirectioninleadsIandII.APwave
withauniformmorphologyprecedeseachQRScomplex.Therateis
between60and100beatsperminuteandthecyclelengthis
uniformbetweensequentialPwavesandQRScomplexes.In
addition,thePwavemorphologyandPRintervalsareidenticalfrom
beattobeat.
Graphic69872Version2.0

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12leadelectrocardiogram(ECG)showingtheWolff
ParkinsonWhitepattern

ThetwomainelectrocardiographicfeaturesofWolffParkinsonWhite(WPW)
patternincludeashortPRinterval(<0.12seconds)andadeltawave(redarrows).
TheQRScomplexiswide(>0.12seconds)andrepresentsafusionbeattheinitial
portion(deltawave)resultsfromrapidventricularactivationviatheaccessory
pathway(preexcitation),whiletheterminationofventricularactivationisviathe
normalconductionsystemleadingtoafairlynormalterminalportionoftheQRS.
Graphic75578Version4.0

NormalECG

Normalsinusrhythmatarateof71beats/min,aPwaveaxisof45,
andaPRintervalof0.15sec.
CourtesyofMortonArnsdorf,MD.
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Graphic58149Version3.0

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12leadelectrocardiogram(ECG)ofapatientinsinusrhythm
withWolffParkinsonWhite(WPW)pattern

Nearlyfullpreexcitationismanifestinnormalsinusrhythmonthe12leadECGin
thispatientwithashortaccessorypathwayrefractoryperiod.Theventricular
complexinpreexcitationisafusionoftheimpulsethatpreexcitestheventricles
duetorapidconductionthroughanaccessorypathwayandoftheimpulsethat
takestheusualroutethroughtheAVnodethisfusioncreatesthedeltawavethat
ischaracteristicofWolffParkinsonWhiteECGpattern.
CourtesyofMortonFArnsdorf,MD.
Graphic76226Version5.0

NormalECG

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Normalsinusrhythmatarateof71beats/min,aPwaveaxisof45,
andaPRintervalof0.15sec.
CourtesyofMortonArnsdorf,MD.
Graphic58149Version3.0

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ECGinWolffParkinsonWhite

The12leadECGshowsthetypicalfeaturesofWolffParkinsonWhitethePR
intervalisshort(*)andtheQRSdurationprolongedasaresultofadeltawave
(arrow),indicatingventricularpreexcitation.
CourtesyofMartinBurke,DO.
Graphic67181Version2.0

NormalECG

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Normalelectrocardiogramshowingnormalsinusrhythmatarateof75beats/min,aPR
intervalof0.14sec,aQRSintervalof0.10sec,andaQRSaxisofapproximately75.
CourtesyofAryGoldberger,MD.
Graphic76183Version3.0

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Orthodromicatrioventricularreentranttachycardia
(AVRT)inthesettingofanaccessoryAVpathway

Therhythmstripshowsasinus(S)beatthathasashortPRinterval
andawideQRScomplexasaresultofadeltawave(d).PanelA
showsanatrialprematurebeat(APB,*)thatisblockedinthe
accessorypathway(AP)whichhasalongrefractoryperiodbutis
conductedantegradelythroughtheatrioventricularnode(N)andthe
HisPurkinjesystem,resultinginanormalPRintervalandanarrow
andnormalQRScomplex,asseenontherhythmstrip.Afternormal
myocardialactivation,theimpulseisconductedretrogradelyalongthe
AP,activatingtheatriuminaretrogradefashion(panelB)which
resultsinanegativePwave.Ifthisactivationsequencerepeatsitself
(panelC),anorthodromicatrioventricularreentrant(orreciprocating)
tachycardia(AVRT)isestablished.
Graphic71302Version5.0

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Electrocardiogram(ECG)showingorthodromic
atrioventricularreentranttachycardia(AVRT)

Atrioventricularreentranttachycardia(AVRT)isasupraventricular
tachycardiaassociatedwithanaccessorypathwayconnectionbetween
theatriaandventricles.Thepathwaymayconductantegradeonly,
retrogradeonly,orbithantegradeandretrograde.AVRTisusually
initiatedbyanatrialprematurebeat(arrow).Themostcommontype
ofAVRT,termedorthodromicAVRT,usestheAVnodeandHis
Purkinjesystem(whichhasarelativelyshortrefractoryperiod)for
antegradeconductiontotheventriclesandtheaccessoryAVpathway
(whichinthesepatientshasarelativelylongantegraderefractory
periodwhencomparedtothenode)forretrogradeconduction.During
orthodromicAVRT,QRScomplexesarenarrow.Duringsinusrhythm,
however,wideandbizarreQRScomplexes(indicativeoftheWPW
pattern)arecausedbyconductionoverboththeaccessoryandnormal
pathways,resultinginafusionbeat.Sincethereis1:1retrograde
activationoftheatrium,anegativePwavemaybepresentfollowing
theQRScomplex.
Graphic54720Version4.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsince
activationoftherightatriumprecedesthatoftheleftatrium.TheP
waveisuprightinapositivedirectioninleadsIandII.APwave
withauniformmorphologyprecedeseachQRScomplex.Therateis
between60and100beatsperminuteandthecyclelengthis
uniformbetweensequentialPwavesandQRScomplexes.In
addition,thePwavemorphologyandPRintervalsareidenticalfrom
beattobeat.
Graphic69872Version2.0

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12leadelectrocardiogram(ECG)showingorthodromic
atrioventricularreentranttachycardia(AVRT)inapatient
withanaccessoryAVpathway

The12leadECGfromapatientwithWolffParkinsonWhiteshowsaregular
tachycardia.However,incontrasttotheQRSpatternduringsinusrhythm,theQRS
complexesarenarrow,withoutevidenceofadeltawaveorpreexcitationthisis
duetothefactthatantegradeventricularactivationoccursviathenormal
atrioventricularnodeHisPurkinjepathwaywhileretrogradeatrialactivationisvia
theaccessorypathway.Therefore,thisiscalledanorthodromicatrioventricular
reentranttachycardia(OAVRT).
CourtesyofMartinBurke,DO.
Graphic68804Version4.0

ECGinWolffParkinsonWhite

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The12leadECGshowsthetypicalfeaturesofWolffParkinsonWhitethePR
intervalisshort(*)andtheQRSdurationprolongedasaresultofadeltawave
(arrow),indicatingventricularpreexcitation.
CourtesyofMartinBurke,DO.
Graphic67181Version2.0

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Antidromicatrioventricularreentranttachycardia
(AVRT)inthesettingofanaccessoryAVpathway

Therhythmstripshowsasinus(S)beatthathasashortPRinterval
andawideQRScomplexasaresultofadeltawave(d).PanelA
showstheactivationsequencewithanatrialprematurebeat(APB,*).
Theimpulsereachestheatrioventricularnode(N)beforeithas
repolarizedandhenceisblockedinthisstructure.However,the
accessorypathway(AP),whichhasashortrefractoryperiod,isable
toconducttheimpulseantegradely,resultinginanAPBwitha
widenedQRSmorphologysimilartothesinusbeat.Asseeninpanel
B,followingmyocardialactivation,theimpulseisconducted
retrogradelyalongtheHisPurkinjesystemandAVnode,resultingin
retrogradeatrialactivation,seenontherhythmstripasaninvertedP
wave.Ifthisactivationsequencerepeatsitself(panelC),awideQRS
complexantidromicatrioventricularreentrant(orreciprocating)
tachycardia(AVRT)isestablished.
Graphic50433Version3.0

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12leadelectrocardiogram(ECG)showingantidromic
atrioventricularreentranttachycardia(AVRT)inapatient
withanaccessoryAVpathway

The12leadECGofapatientwithWolffParkinsonWhiteshowsaregular
tachycardia.TheQRScomplexesarewidenedandareidenticaltotheQRS
complexesseeninsinusrhythmtheantegradeconductiontotheventricleisvia
theaccessorypathwayandretrogradeconductionisviathenormalHis
atrioventicularnodepathway.Thisisthereforeanantidromicatrioventricular
reentanttachycardia(AAVRT).
CourtesyofMartinBurke,DO.
Graphic54484Version17.0

ECGinWolffParkinsonWhite

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The12leadECGshowsthetypicalfeaturesofWolffParkinsonWhitethePR
intervalisshort(*)andtheQRSdurationprolongedasaresultofadeltawave
(arrow),indicatingventricularpreexcitation.
CourtesyofMartinBurke,DO.
Graphic67181Version2.0

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12leadelectrocardiogram(EG)showingantidromic
atrioventricularreentranttachycardia(AVRT)

The12leadECGshowsawidecomplextachycardiainapatientwithWolff
ParkinsonWhitesyndromeandaleftlateralaccessorypathway.TheQRS
complexesarewideandhaveamorphologythatissimilartothatduringsinus
rhythm,confirmingthatthisisanantidromicatrioventricularreentranttachycardia.
Graphic71410Version4.0

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12leadelectrocardiogram(ECG)showingatrial
fibrillationandpreexcitationintheWolff
ParkinsonWhite(WPW)syndrome

Thesurface12leadECGshowsatrialfibrillationwitharapid
ventricularresponse.TheQRScomplexesarewideneddueto
antegradeconductionoveraleftlateralaccessorypathway.However,
theQRScomplexesvaryinmorphologyanddurationbecauseof
variabilityinthedegreeofpreexcitationthereisoneQRScomplex
(*)thatisconductedwithoutpreexcitation.
Graphic60790Version4.0

NormalECG

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Normalelectrocardiogramshowingnormalsinusrhythmatarateof75beats/min,aPR
intervalof0.14sec,aQRSintervalof0.10sec,andaQRSaxisofapproximately75.
CourtesyofAryGoldberger,MD.
Graphic76183Version3.0

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12leadelectrocardiogramshowingatrialfibrillationwith
preexcitationinWolffParkinsonWhite(WPW)syndrome

The12leadECGinthispatientwithWolffParkinsonWhitesyndromeshowsatrial
fibrillationwitharapidventricularresponseofover300beatsperminuteandfully
aberrantQRScomplexes.Thisresultsfromrapidatrioventriculartransmissionof
impulsesviaarapidlyconductingaccessorypathway.
CourtesyofMortonFArnsdorf,MD.
Graphic75523Version6.0

NormalECG

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Normalelectrocardiogramshowingnormalsinusrhythmatarateof75beats/min,aPR
intervalof0.14sec,aQRSintervalof0.10sec,andaQRSaxisofapproximately75.
CourtesyofAryGoldberger,MD.
Graphic76183Version3.0

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Atrialfibrillationinpreexcitation

Thetransmissionofatrialimpulsestotheventricleisviaaatriofascicular(Mahaim)
fiber,resultinginaventicularratethataverages350beats/min.TheQRS
complexesarewideoraberrantandhavealeftbundlebranchblockmorphology
andaleftaxisdeviation,suggestinganinsertionattherightventricularapex.
CourtesyofMortonArnsdorf,MD.
Graphic62450Version2.0

NormalECG

Normalsinusrhythmatarateof71beats/min,aPwaveaxisof45,
andaPRintervalof0.15sec.
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CourtesyofMortonArnsdorf,MD.
Graphic58149Version3.0

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12leadelectrocardiogram(ECG)showingatrialflutterin
preexcitationsyndrome

Atrialflutterisgeneratedwithintherightatriumandtheatrialimpulsesinthiscase
areconductedtotheventriclebyanaccessorypathway.Thereis1:1conduction
withaventricularrateof300beats/min.TheQRScomplexesarewidenedor
aberrantandhaveabundlebranchblockmorphologyandaleftaxisdeviation,
suggestingthepresenceofaatriofascicular(Mahaim)accessorypathway.
CourtesyofMortonArnsdorf,MD.
Graphic78602Version2.0

NormalECG

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Normalelectrocardiogramshowingnormalsinusrhythmatarateof75beats/min,aPR
intervalof0.14sec,aQRSintervalof0.10sec,andaQRSaxisofapproximately75.
CourtesyofAryGoldberger,MD.
Graphic76183Version3.0

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