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Variants of Ventricular Preexcitation RECOGNITION AND TREATMENT Eduardo Back Sternick, MD, PhD BiocorInstituto ArrhythmiaandElectrophysiologyUnit BeloHorizonte MinasGerais,Brazil Hein JJ Wellens, MD, PhD, FACC, FESC, FAHA, FRCP UniversityofMaastricht ProfessorofCardiology Maastricht,Netherlands This Page Intentionally Left Blank Variants of Ventricular Preexcitation RECOGNITION AND TREATMENT This Page Intentionally Left Blank Variants of Ventricular Preexcitation RECOGNITION AND TREATMENT Eduardo Back Sternick, MD, PhD BiocorInstituto ArrhythmiaandElectrophysiologyUnit BeloHorizonte MinasGerais,Brazil Hein JJ Wellens, MD, PhD, FACC, FESC, FAHA, FRCP UniversityofMaastricht ProfessorofCardiology Maastricht,Netherlands (cid:1)C 2006EduardoBackSternickandHeinJ.Wellens PublishedbyBlackwellPublishing BlackwellFuturaisanimprintofBlackwellPublishing BlackwellPublishing,Inc.,350MainStreet,Malden,Massachusetts02148-5020,USA BlackwellPublishingLtd,9600GarsingtonRoad,OxfordOX42DQ,UK BlackwellScienceAsiaPtyLtd,550SwanstonStreet,Carlton,Victoria3053,Australia Allrightsreserved.Nopartofthispublicationmaybereproducedinanyformorbyanyelectronic ormechanicalmeans,includinginformationstorageandretrievalsystems,withoutpermission inwritingfromthepublisher,exceptbyareviewerwhomayquotebriefpassagesinareview. Firstpublished2006 1 2006 ISBN-13:978-1-4051-48436 ISBN-10:1-4051-48438 LibraryofCongressCataloging-in-PublicationData Sternick,EduardoBack. Variantsofventricularpreexcitation:recognitionandtreatment/EduardoBackSternick, HeinJ.Wellens. p. ; cm. Includesbibliographicalreferencesandindex. ISBN-13:978-1-4051-4843-6(alk.paper) ISBN-10:1-4051-4843-8(alk.paper) 1.Wolff-Parkinson-Whitesyndrome. 2.Excitation(Physiology) [DNLM:1.Pre-Excitation,Mahaim-Type. 2.Myocardium–pathology.WG330S839v2006] I.Wellens,H.J.J. II.Title. RC685.W6S74 2006 616.1(cid:2)24–dc22 2006007279 AcataloguerecordforthistitleisavailablefromtheBritishLibrary Acquisitions:GinaAlmond Development:SimoneDudziakandJulieElliott Setin9.5/12PalatinobyTechBooks,NewDelhi,India PrintedandboundbyReplikaPressPvt.Ltd,India ForfurtherinformationonBlackwellPublishing,visitourwebsite: www.blackwellcardiology.com Thepublisher’spolicyistousepermanentpaperfrommillsthatoperateasustainableforestry policy,andwhichhasbeenmanufacturedfrompulpprocessedusingacid-freeandelementary chlorine-freepractices.Furthermore,thepublisherensuresthatthetextpaperandcoverboard usedhavemetacceptableenvironmentalaccreditationstandards. Notice:Theindicationsanddosagesofalldrugsinthisbookhavebeenrecommendedinthe medicalliteratureandconformtothepracticesofthegeneralcommunity.Themedications describeddonotnecessarilyhavespecificapprovalbytheFoodandDrugAdministrationfor useinthediseasesanddosagesforwhichtheyarerecommended.Thepackageinsertforeach drugshouldbeconsultedforuseanddosageasapprovedbytheFDA.Becausestandardsfor usagechange,itisadvisabletokeepabreastofrevisedrecommendations,particularlythose concerningnewdrugs. Contents Foreword,vii Acknowledgements,ix 1 Historicalnotesandclassificationofthevariants ofventricularpreexcitation,1 2 Theanatomyofdecrementallyconductingfibers,7 3 Atriofascicularpathwaysanddecrementallyconductinglong atrioventricularpathways,15 4 TheshortAVdecrementallyconductingfibers,59 5 NodoventricularandNodofascicularfibers,75 6 Fasciculoventricularfibers,83 7 Conductiondisturbancesinaccessorypathways,103 8 Automaticityindecrementallyconductingfibers,117 9 Differentialdiagnosisofleftbundlebranchblock-shaped tachycardias,131 Index,149 Acolourplatesectionfacesp.22 v This Page Intentionally Left Blank Foreword Preexcitationsyndromeshavefascinatedphysiciansfordecades.Mostofthe interestisfocusedontheWolff–Parkinson–Whitesyndrome,whichhasbeen anatomicallyandpathophysiologicallycharacterizedingreatdetail.Thisbook, titledVariantsofVentricularPreexcitation:RecognitionandTreatment,byEduardo SternickandHeinWellensoffersinsightintothemanyvariantformsofpreex- citationthatarenotwellrecognized. Afterreviewingthehistoryofthesevariantsanddiscussingtheirpatholog- icalaspects,theseauthorshaveputtogetheracompendiumofwell-described electrocardiographically and extremely well characterized electrophysiolog- ically variant accessory pathways with which electrophysiologists still lack experience.Theinitialchapterreviewingthehistoryandanatomyofthepath- waysisveryusefulinplacinginperspectivethedifferencesbetweenthepatho- logicandclinicalaspectsofthesevariantforms.Adifferentclassificationofpre- excitation syndromes is proposed, with the most important characteristic of themajorityofthesevariantsbeingdecrementalconduction.WhiletheWolff– Parkinson–Whitesyndromeinvolvesshortatrioventricularbypasstractswith rapid conduction, the variants that have been described in this volume in- cludeshortandlongdecrementallyconductingatrioventricularbypasstracts anddecrementallyconductingatriofascicularbypasstracts.Theoutlyerinthe grouparethefasciculoventricularbypasstracts,whichhavenodecremental propertiesandnoparticipationinactivereentrantarrhythmiasbutleadtocuri- ouselectrocardiographicabnormalitiesthatmustberecognizedbyclinicians. Extensivediscussionsoftheelectrophysiologicalcharacteristicsofallofthese formsofpreexcitationarewellpresented.Awealthofinformationexistsinthis textthatcanbefoundnowhereelse.Examplesofthesevariantsandtheirelec- trophysiologicalfeaturesareclearlydepictedandprovideinsightsthatcannot be found in any single source. The treatment of the decrementally conduct- ingbypasstractsisdescribedandis,asexpected,primarilyablative.Howto define the presence of these bypass tracts and distinguish them from others isandremainsaverydifficultbutnecessarytestifoneistohaveasuccessful ablativetherapy.Theexplanationsofhowtoevaluateeachoftheseformsof preexcitation in the laboratory and make the diagnosis correctly is a major featureofthetext.Insomeways,VariantsofVentricularPreexcitation:Recogni- tionandTreatmentprovidesauniqueopportunityforgeneralcardiologistsand vii viii Foreword electrophysiologiststofindinonetexttheintricaciesofrecognizingandtreat- ingagroupofdisordersthathasintriguedphysiciansformorethan100years. MarkE.Josephson,MD Chief,CardiovascularDivision BethIsraelDeaconessMedicalCenter Boston,USA

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“ Variants of Ventricular Preexcitation: Recognition and Treatment provides a unique opportunity for general cardiologists and electrophysiologists to find in one text the intricacies of recognizing and treating a group of disorders that has intrigued physicians for more than 100 years.” -
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Variants of Ventricular Preexcitation RECOGNITION AND TREATMENT Eduardo Back Sternick, MD, PhD BiocorInstituto ArrhythmiaandElectrophysiologyUnit BeloHorizonte MinasGerais,Brazil Hein JJ Wellens, MD, PhD, FACC, FESC, FAHA, FRCP UniversityofMaastricht ProfessorofCardiology Maastricht,Netherlands This Page Intentionally Left Blank Variants of Ventricular Preexcitation RECOGNITION AND TREATMENT This Page Intentionally Left Blank Variants of Ventricular Preexcitation RECOGNITION AND TREATMENT Eduardo Back Sternick, MD, PhD BiocorInstituto ArrhythmiaandElectrophysiologyUnit BeloHorizonte MinasGerais,Brazil Hein JJ Wellens, MD, PhD, FACC, FESC, FAHA, FRCP UniversityofMaastricht ProfessorofCardiology Maastricht,Netherlands (cid:1)C 2006EduardoBackSternickandHeinJ.Wellens PublishedbyBlackwellPublishing BlackwellFuturaisanimprintofBlackwellPublishing BlackwellPublishing,Inc.,350MainStreet,Malden,Massachusetts02148-5020,USA BlackwellPublishingLtd,9600GarsingtonRoad,OxfordOX42DQ,UK BlackwellScienceAsiaPtyLtd,550SwanstonStreet,Carlton,Victoria3053,Australia Allrightsreserved.Nopartofthispublicationmaybereproducedinanyformorbyanyelectronic ormechanicalmeans,includinginformationstorageandretrievalsystems,withoutpermission inwritingfromthepublisher,exceptbyareviewerwhomayquotebriefpassagesinareview. Firstpublished2006 1 2006 ISBN-13:978-1-4051-48436 ISBN-10:1-4051-48438 LibraryofCongressCataloging-in-PublicationData Sternick,EduardoBack. Variantsofventricularpreexcitation:recognitionandtreatment/EduardoBackSternick, HeinJ.Wellens. p. ; cm. Includesbibliographicalreferencesandindex. ISBN-13:978-1-4051-4843-6(alk.paper) ISBN-10:1-4051-4843-8(alk.paper) 1.Wolff-Parkinson-Whitesyndrome. 2.Excitation(Physiology) [DNLM:1.Pre-Excitation,Mahaim-Type. 2.Myocardium–pathology.WG330S839v2006] I.Wellens,H.J.J. II.Title. RC685.W6S74 2006 616.1(cid:2)24–dc22 2006007279 AcataloguerecordforthistitleisavailablefromtheBritishLibrary Acquisitions:GinaAlmond Development:SimoneDudziakandJulieElliott Setin9.5/12PalatinobyTechBooks,NewDelhi,India PrintedandboundbyReplikaPressPvt.Ltd,India ForfurtherinformationonBlackwellPublishing,visitourwebsite: www.blackwellcardiology.com Thepublisher’spolicyistousepermanentpaperfrommillsthatoperateasustainableforestry policy,andwhichhasbeenmanufacturedfrompulpprocessedusingacid-freeandelementary chlorine-freepractices.Furthermore,thepublisherensuresthatthetextpaperandcoverboard usedhavemetacceptableenvironmentalaccreditationstandards. Notice:Theindicationsanddosagesofalldrugsinthisbookhavebeenrecommendedinthe medicalliteratureandconformtothepracticesofthegeneralcommunity.Themedications describeddonotnecessarilyhavespecificapprovalbytheFoodandDrugAdministrationfor useinthediseasesanddosagesforwhichtheyarerecommended.Thepackageinsertforeach drugshouldbeconsultedforuseanddosageasapprovedbytheFDA.Becausestandardsfor usagechange,itisadvisabletokeepabreastofrevisedrecommendations,particularlythose concerningnewdrugs. Contents Foreword,vii Acknowledgements,ix 1 Historicalnotesandclassificationofthevariants ofventricularpreexcitation,1 2 Theanatomyofdecrementallyconductingfibers,7 3 Atriofascicularpathwaysanddecrementallyconductinglong atrioventricularpathways,15 4 TheshortAVdecrementallyconductingfibers,59 5 NodoventricularandNodofascicularfibers,75 6 Fasciculoventricularfibers,83 7 Conductiondisturbancesinaccessorypathways,103 8 Automaticityindecrementallyconductingfibers,117 9 Differentialdiagnosisofleftbundlebranchblock-shaped tachycardias,131 Index,149 Acolourplatesectionfacesp.22 v This Page Intentionally Left Blank Foreword Preexcitationsyndromeshavefascinatedphysiciansfordecades.Mostofthe interestisfocusedontheWolff–Parkinson–Whitesyndrome,whichhasbeen anatomicallyandpathophysiologicallycharacterizedingreatdetail.Thisbook, titledVariantsofVentricularPreexcitation:RecognitionandTreatment,byEduardo SternickandHeinWellensoffersinsightintothemanyvariantformsofpreex- citationthatarenotwellrecognized. Afterreviewingthehistoryofthesevariantsanddiscussingtheirpatholog- icalaspects,theseauthorshaveputtogetheracompendiumofwell-described electrocardiographically and extremely well characterized electrophysiolog- ically variant accessory pathways with which electrophysiologists still lack experience.Theinitialchapterreviewingthehistoryandanatomyofthepath- waysisveryusefulinplacinginperspectivethedifferencesbetweenthepatho- logicandclinicalaspectsofthesevariantforms.Adifferentclassificationofpre- excitation syndromes is proposed, with the most important characteristic of themajorityofthesevariantsbeingdecrementalconduction.WhiletheWolff– Parkinson–Whitesyndromeinvolvesshortatrioventricularbypasstractswith rapid conduction, the variants that have been described in this volume in- cludeshortandlongdecrementallyconductingatrioventricularbypasstracts anddecrementallyconductingatriofascicularbypasstracts.Theoutlyerinthe grouparethefasciculoventricularbypasstracts,whichhavenodecremental propertiesandnoparticipationinactivereentrantarrhythmiasbutleadtocuri- ouselectrocardiographicabnormalitiesthatmustberecognizedbyclinicians. Extensivediscussionsoftheelectrophysiologicalcharacteristicsofallofthese formsofpreexcitationarewellpresented.Awealthofinformationexistsinthis textthatcanbefoundnowhereelse.Examplesofthesevariantsandtheirelec- trophysiologicalfeaturesareclearlydepictedandprovideinsightsthatcannot be found in any single source. The treatment of the decrementally conduct- ingbypasstractsisdescribedandis,asexpected,primarilyablative.Howto define the presence of these bypass tracts and distinguish them from others isandremainsaverydifficultbutnecessarytestifoneistohaveasuccessful ablativetherapy.Theexplanationsofhowtoevaluateeachoftheseformsof preexcitation in the laboratory and make the diagnosis correctly is a major featureofthetext.Insomeways,VariantsofVentricularPreexcitation:Recogni- tionandTreatmentprovidesauniqueopportunityforgeneralcardiologistsand vii viii Foreword electrophysiologiststofindinonetexttheintricaciesofrecognizingandtreat- ingagroupofdisordersthathasintriguedphysiciansformorethan100years. MarkE.Josephson,MD Chief,CardiovascularDivision BethIsraelDeaconessMedicalCenter Boston,USA

Description:
“ Variants of Ventricular Preexcitation: Recognition and Treatment provides a unique opportunity for general cardiologists and electrophysiologists to find in one text the intricacies of recognizing and treating a group of disorders that has intrigued physicians for more than 100 years.” -
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