Review

Wolff-Parkinson-White syndrome: Diagnostic and management strategies

Masihullah Barat, MD, David Torres Barba, MD, PhD and Gordon Ho, MD
Cleveland Clinic Journal of Medicine February 2025, 92 (2) 119-127; DOI: https://doi.org/10.3949/ccjm.92a.24059

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Left, normal conduction pathway with normal sinus rhythm generated by the sinus node and conducted through the atrioventricular node, bundle of His, and subsequently through the left and right bundle branches, leading to normal PR duration (120–200 ms), normal QRS duration (< 120 ms), and no preexcitation. Right, normal electrocardiogram with clear upright P waves (yellow arrow), normal PR interval, and narrow QRS pattern.

  • Figure 2
    Figure 2

    Electrical conduction system with a left lateral accessory pathway. An accessory pathway provides an alternate atrioventricular (AV) conduction pathway, bypassing both the atrioventricular node and the His-Purkinje system, predisposing to malignant tachyarrhythmias. A left lateral accessory pathway leads to the characteristic type A Wolff-Parkinson-White pattern on electrocardiography (Figure 3).

    aAccessory pathways are capable of bidirectional flow, predisposing to retrograde conduction (conduction from ventricular to atrial tissue).

  • Figure 3
    Figure 3

    Characteristic Wolff-Parkinson-White type A pattern, including a short PR interval (blue arrows), wide QRS, and delta waves (red arrows). Positive delta waves in V1–V3 suggest a left-sided accessory pathway (Figure 2).

  • Figure 4
    Figure 4

    Characteristic Wolff-Parkinson-White type B pattern, including a short PR interval (blue arrows), wide QRS, and delta waves (red arrows). Precordial transition after V2 suggests a right-sided accessory pathway.

  • Figure 5
    Figure 5

    Our proposed diagnostic and management guideline for patients with high clinical suspicion, Wolff-Parkinson-White (WPW) pattern, and WPW syndrome.

    aHigh-risk features: male sex, age less than 30, history of atrial fibrillation, family history of WPW syndrome, congenital heart disease, competitive athlete, high-risk occupation.

    bHigh risk of sudden cardiac death: multiple accessory pathways; preexcitation persists during induced atrial fibrillation; shortest RR interval < 250 ms during incremental atrial pacing, premature atrial contraction, or when in atrial fibrillation.

  • Figure 6
    Figure 6

    The most reported accessory atrioventricular pathway location is the left lateral mitral valve annulus (30% to 58% of reported cases), followed by the posteroseptal region (about 25% of reported cases.25,26 The remainder of reported accessory pathway locations surround both the tricuspid annulus and the mitral valve annulus. Success rates of accessory pathway ablation vary by location, with highest success rates reported in those localized in the anterior, posterior, and lateral distribution (success rate of 90% and above), and lowest in those surrounding the coronary sinus (50%) and in the septal (50%) and midseptal distribution (73%).26

  • Figure 7
    Figure 7

    Catheter ablation of a left anterolateral accessory pathway in a 21-year-old patient. Open window mapping localized the accessory pathway (AP) to the anterolateral mitral annulus, where ablation (purple ball) eliminated the accessory pathway, with surface (white) and intracardiac electrocardiograms (red) showing loss of preexcitation and Kent potential (*) from the first to the second beat.

    LA = left atrium; LV = left ventricle

Tables

  • TABLE 1

    Type A vs type B Wolff-Parkinson-White patterns

    Type A (associated with left-sided accessory pathway)Type B (associated with right-sided accessory pathway)
    Short PR interval (< 120 ms)Short PR interval (< 120 ms)
    Delta wave: broad QRS complex with slurred R waveDelta wave: broad QRS complex with slurred S wave
    May mimic right bundle branch blockMay mimic left bundle branch block
    Dominant R wave in V1Dominant S wave in V1
    Tall R waves and inverted T waves in leads V1–V3Tall S waves and inverted T waves in leads V4–V6

    • Based on information from reference 1.

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