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Poster WPW

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									A Wolf in a Sheeps’ Clothing: Wolff-Parkinson White Syndrome (WPW), an OMMC experience
Noriel S. Dimaandal, MD*, Vincent Paul Filio, MD**, Camilo Oliver Aquino, MD, FPCP, FPCC*** (* Resident, Department of Internal Medicine,OMMC; **Senior Resident; *** Consutant in Cardiology)
ABSTRACT The paper presents a case of Wolff- Parkinson- White syndrome; approached to diagnosis and treatment of WPW syndrome with Atrial Septal defect (ASD). This is a case of 35 year old female who came in due to palpitation with associated shortness of breath 30 minutes prior to admission. There was no loss of consciousness or dizziness. No chest pain, no paroxysmal nocturnal dyspnea, no easy fatigability, no orthopnea, no fever. Patient had neither tremors nor abdominal pain. She had no known thyroid disease. There was no family history of heart disease. There was no history of malignancy. She is a housewife. On physical examination, patient is conscious, coherent, elevated BP, tachycardic, afebrile. Patient had no neck vein distention, no exophthalmos nor anterior neck mass. Patient had adynamic precordium, no cardiomegaly, regular rhythm, and no murmur. ECG revealed tachycardia with narrow QRS complexes interpreted as supraventricular tachycardia (SVT), a repeat ECG showed short PR interval, normal P wave vector, presence of delta wave, and QRS duration > 0.10 sec (WPW pattern) . She had normal chest x-ray. 2d echo with Doppler studies showed normal size left ventricle with good wall motion contractility and preserved systolic function, atrial septal defect, secundum type and mild mitral regurgitation. Stress test revealed maximal exercise stress test with good exercise capacity and negative for exercise diffuse ischemia. TSH, FT4, FT3, serum sodium, potassium, and calcium were normal. Initially vagal maneuver was done. Then, patient was given Amiodarone 150mg intravenously. BACKGROUND AND SIGNIFICANCE • In 1930, Wolff, Parkinson and White described a distinct electrocardiograph (ECG) pattern in healthy young people with short bursts of tachycardia.2 • In general population, men have a higher incidence of WPW than women do because of a higher incidence of multiple accessory pathways in men.3 • About 7 to 20 percent of patients with WPW also have congenital defects within the heart.4 • Most people experience symptoms between the ages of 11 and 50 years old.2,3 • The incidence of WPW in the Philippines has not been fully reported. • Presenting symptoms include palpitations, dizziness, and shortness of breath.5 • This report describes a case of Wolff- Parkinson White syndrome in a 35- year old female presented with palpitation and an atrial septal defect. CLINICAL HISTORY AND PE • This is a case of 35 year old female who came in due to palpitation with associated shortness of breath 30 minutes prior to admission. • There was no loss of consciousness or dizziness. • No chest pain, no paroxysmal nocturnal dyspnea, no easy fatigability, no orthopnea, no fever, nor cough. • Patient had neither tremors nor abdominal pain. • She is non hypertensive and non diabetic. • She had no known thyroid disease. • There was no family history of heart disease. • There was no history of malignancy. • She is a housewife. • Patient is conscious, coherent, BP- 140/100 cardiac rate- 230, afebrile. • Patient had no neck vein distention, no exophthalmos nor anterior neck mass. • Patient had adynamic precordium, no cardiomegaly, regular rhythm, and no murmur. Figure 4. The atrial septum is parallel to the ultrasound waves and a false "Drop out" in the thin septum primum which may simulate a secundum atrial septal defect.  Stress test revealed maximal exercise stress test with good exercise capacity and negative for exercise diffuse ischemia. DISCUSSION •Accessory connections between the atrium and ventricle are the result of anomalous embryonic development of myocardial tissue bridging the fibrous tissues that separate the two chambers. •This allows for electrical conduction between the atria and ventricles at sites other than the atrioventricular node (AVN). •Passage through this accessory pathway circumvents the usual conduction delay between the atria and ventricles, which normally occurs at the AVN and predisposes the patient to develop tachydysrhythmias. •The classic ECG morphology of Wolff-Parkinson-White (WPW) syndrome is described as a shortened PR interval and a widened QRS complex with a delta wave. •The QRS interval is widened because the ventricles are initially activated via the accessory pathway, which lies outside the normal conducting system, producing an early, albeit relatively slow initial propagation of depolarization forces through the ventricular tissue. •This produces the delta wave. •The delta wave makes the QRS appear wider than expected and the PR interval somewhat shortened. •This is known as a revealed accessory pathway because it is easily identifiable on ECG.6 •EP studies can be used in patients with WPW syndrome to determine: (1) the mechanism of the clinical arrhythmia, (2) EP properties (eg, conduction capability, refractory periods) of the accessory pathway and the normal conduction system, (3) the number and location of accessory pathways (which is necessary for catheter ablation), and (4) the response to pharmacological or ablation therapy. •The 3 main treatment modalities for WPW syndrome are drug therapy, electrical (ie, RF) ablation, and surgical ablation. Ablation is the first-line treatment for symptomatic WPW syndrome.11,12 It has replaced surgical treatment and most drug treatment.

Figure3. The left to right shunting at the atrial level will cause increase blood volume in the right atrium and right ventricle resulting in cardiomegaly, in addition the increase pulmonary blood flow causes the pulmonary vasculature to be more prominent.

IMPORTANT DIAGNOSTIC WORK UP

CONCLUSION Presented a 35year old female with palpitation, ECG revealed WPW pattern and was given antiarrhythmic drugs (amiodarone) and advised for EPS for further diagnostic and therapeutic studies. Patients with only preexcitation on their ECG findings who are asymptomatic generally have a very good prognosis. Most of these patients do not develop symptoms in their lifetime. REFERENCES Figure 2. WPW pattern: Short PR interval, normal P wave vector, presence of delta wave, and QRS duration > 0.10 sec. Al-Khatib SM, Pritchet ELC. (1999) Clinical features of Wolff-Parkinson-White Syndrome, AM Heart J,138, 403-13. Jezior et al. Chest journal 2005;127;1454-1457 Soria, et al. Mal Coeur Vaiss. 1982 Dec;75(12):1389-99 Steven et al. Chest 2005;127;1454-1457

Figure 1. Supraventricular Tachycardia: Narrow QRS


								
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