Lown-Ganong-Levine syndrome

Background

• Poorly understood pre-excitation condition
• Atrioventricular re-entrant tachycardia (AVRT) due to James fibers
  • Bundle of James accessory pathway creates atrio-hisian bypass tract
    • Convincing existence of the James accessory pathway has not been conclusively demonstrated

Clinical Features

• Palpitations
• Paroxysmal supraventricular tachycardia
• Short PR interval on ECG

Differential Diagnosis

Palpitations

• Arrhythmias:
  • Narrow-complex tachycardias
  • Wide-complex tachycardias
  • AV blocks
    • Second Degree AV Block Type I (Wenckeback)
    • Second Degree AV Block Type II
    • Third Degree AV Block
  • Premature atrial contraction
  • Premature junctional contraction
  • Premature ventricular contraction
  • Sick sinus syndrome
  • Wandering atrial pacemaker
• Non-arrhythmic cardiac causes:
  • Acute coronary syndrome
  • Cardiomyopathy
  • Congenital heart disease
  • Congestive heart failure (CHF)
  • Mitral valve prolapse
  • Pacemaker complication
  • Pericarditis
  • Myocarditis
  • Valvular disease
• Psychiatric causes:
  • Panic attack
  • Anxiety
  • Somatic Symptom Disorder
• Drugs and Medications:
  • Alcohol
  • Caffeine
  • Drugs of abuse (e.g. cocaine)
  • Medications (e.g. digoxin, theophylline)
  • Tobacco
• Misc
  • Anemia
  • Hyperthyroidism
    • Thyroid storm
  • Pulmonary embolism
  • Dehydration
  • Sepsis
  • Pheochromocytoma

Evaluation

• ECG
  • Short PR interval
  • Normal QRS
  • No delta wave
  • May have ventricular premature complexes
• May appear similar to:
  • WPW
  • AV junctional rhythm

Management

• Vagal manoeuvres may terminate episodes of SVT
• Counsel to avoid alcohol, coffee, and other stimulants
• Patients with demonstrated accessory pathways on electrophysiological study may benefit from ablation

Disposition

• Home with cardiology follow up
• Consider referral for Holter monitor, echo to rule out structural disease, and electrophysiologic studies