eMedicine Specialties > Cardiology > Arrhythmias

Lown-Ganong-Levine Syndrome: Differential Diagnoses & Workup

Author: Daniel M Beyerbach, MD, PhD,, Consulting Staff, Florida Electrophysiology Associates; Affiliate Clinical Assistant Professor of Biomedical Science, Florida Atlantic University, Regional Campus of University of Miami Miller School of Medicine
Coauthor(s): Christopher Cadman, MD, Director of Arrhythmia Service, Assistant Professor, Department of Internal Medicine, Division of Cardiology, University of New Mexico
Contributor Information and Disclosures

Updated: Sep 4, 2009

Differential Diagnoses

Atrial Fibrillation
Supraventricular tachycardia
Atrial Flutter
Ventricular Fibrillation
Atrial Tachycardia
Ventricular Tachycardia
Atrioventricular Nodal Reentry Tachycardia (AVNRT)
Wolff-Parkinson-White Syndrome
Paroxysmal Supraventricular Tachycardia

Other Problems to Be Considered

Sinoatrial reentrant tachycardia
Mahaim-type preexcitation
Sinus tachycardia
Atypical AV nodal reentrant tachycardia
Persistent form of juvenile reentrant tachycardia

Workup

Laboratory Studies

  • Workup is directed at determining the cause of tachycardia. LGL is an outdated diagnosis, and as such no workup is directed at making this diagnosis. However, identification of a short PR interval during sinus rhythm in a patient with paroxysmal supraventricular tachycardia (PSVT) should raise suspicion of a possible underlying bypass tract (ie, WPW). In the case of isolated short PR interval with no history of tachycardia or symptoms suggestive of paroxysms of tachycardia, no further workup is indicated.
  • Patients may present in an acute episode of tachycardia or with a history of symptoms suggestive of paroxysms of tachycardia.
    • In the acute setting, institute a standard workup for tachycardia, including an ECG to document the rhythm, serum electrolytes, calcium, magnesium levels, and serum thyroid-stimulating hormone (TSH) levels.
    • For a history suggestive of recurrent paroxysms of tachycardia, a Holter monitor or event recorder may prove useful for documenting the rhythm during acute symptomatic episodes. Less commonly, particularly when paroxysms of tachycardia are more rare, an implantable loop recorder may prove helpful.

Imaging Studies

  • In the case of shortness of breath, posteroanterior and lateral chest films are indicated.

Other Tests

  • To meet criteria for LGL, the 12-lead ECG taken during a period of normal sinus rhythm must demonstrate a PR interval less than or equal to 0.12 second and a normal QRS upstroke and duration (see Media file 1).

    ECG demonstrating a short PR interval of approxim...

    ECG demonstrating a short PR interval of approximately 100 ms and normal QRS.

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    ECG demonstrating a short PR interval of approxim...

    ECG demonstrating a short PR interval of approximately 100 ms and normal QRS.

  • One of the most useful diagnostic tools is a 12-lead ECG recorded during a paroxysm of tachycardia. Such documentation satisfies the LGL criterion of tachycardia.
  • A delta wave on the QRS complex precludes the diagnosis of LGL, because one of the criteria for LGL is a normal QRS complex. A delta wave suggests the presence of an accessory pathway; occurrence of supraventricular tachycardia in the presence of an accessory pathway suggests WPW, another preexcitation syndrome (see Media file 2).

    ECG demonstrating ventricular preexcitation. A de...

    ECG demonstrating ventricular preexcitation. A delta wave, which corresponds to initial myocardial depolarization via a bypass tract, appears at the beginning of each QRS complex.

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    ECG demonstrating ventricular preexcitation. A de...

    ECG demonstrating ventricular preexcitation. A delta wave, which corresponds to initial myocardial depolarization via a bypass tract, appears at the beginning of each QRS complex.

Procedures

  • If tachycardia is present, diagnostic workup to determine the cause may include Valsalva maneuvers.
  • If blood pressure is stable, the patient has no angina, is not presyncopal, and no carotid bruits are present, carotid massage may provide diagnostic information. Ideally, carotid massage should be performed during continuous 12-lead rhythm strip monitoring. The result of carotid massage may be termination of the tachycardia, or transient AV block that may provide a ventricular pause long enough to reveal an underlying atrial arrhythmia.
  • If these maneuvers fail to terminate the tachycardia, a trial of intravenous adenosine administration, again with simultaneous rhythm strip recording, may reveal the rhythm.  Adenosine should not be administered if there is any indication of pre-excitation on the surface ECG.
  • In cases of recurrent tachycardia, an invasive electrophysiology study is warranted.  This is particularly true when symptoms become intolerable, medical therapy is failing to prevent episodes of tachycardia, or when a ventricular arrhythmia is suspected.

More on Lown-Ganong-Levine Syndrome

Overview: Lown-Ganong-Levine Syndrome
Differential Diagnoses & Workup: Lown-Ganong-Levine Syndrome
Treatment & Medication: Lown-Ganong-Levine Syndrome
Follow-up: Lown-Ganong-Levine Syndrome
Multimedia: Lown-Ganong-Levine Syndrome
References
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References

  1. Clerc A, Levy R, Critesco C. A propos du raccourcissement permanent de l'espace P-R de l'electrocardiogramme sans deformation du complex ventriculaire. Arch Mal Coeur. 1938;31:569.

  2. LOWN B, GANONG WF, LEVINE SA. The syndrome of short P-R interval, normal QRS complex and paroxysmal rapid heart action. Circulation. May 1952;5(5):693-706. [Medline].

  3. Burch GE, Kimball JL. Notes on the similarity of QRS complex configuration in Wolff-Parkinson-White syndrome. Am Heart J. 1946;32:560.

  4. James TN. Morphology of the human atrioventricular node, with remarks pertinent to its electrophysiology. Am Heart J. 1961;62:756-71.

  5. Brechenmacher C, Laham J, Iris L, et al. [Histological study of abnormal conduction pathways in the Wolff-Parkinson-White syndrome and Lown-Ganong-Levine syndrome]. Arch Mal Coeur Vaiss. May 1974;67(5):507-19. [Medline].

  6. Josephson ME, Kastor JA. Supraventricular tachycardia in Lown-Ganong-Levine syndrome: atrionodal versus intranodal reentry. Am J Cardiol. Oct 1977;40(4):521-7. [Medline].

  7. Chou TC. Wolff-Parkinson-White syndrome and its variants. In: Electrocardiography in Clinical Practice, Adult and Pediatric. 4th ed. Philadelphia:. WB Saunders Co;1996.

  8. Moller P. Letter: Criteria for the LGL syndrome. Am Heart J. Apr 1976;91(4):539-41. [Medline].

  9. Jackman WM, Prystowsky EN, Naccarelli GV, et al. Reevaluation of enhanced atrioventricular nodal conduction: evidence to suggest a continuum of normal atrioventricular nodal physiology. Circulation. Feb 1983;67(2):441-8. [Medline].

  10. Ward DE, Camm AJ, Spurrell RA. Re-entrant tachycardia using two bypass tracts and excluding AV node in short PR interval, normal QRS syndrome. Br Heart J. Oct 1978;40(10):1127-33. [Medline].

  11. Zipes DP, DeJoseph RL, Rothbaum DA. Unusual properties of accessory pathways. Circulation. Jun 1974;49(6):1200-11. [Medline].

  12. Ward DE, Camm AJ, Spurrell RAJ. Dual AH pathways in patients with and without the Lown-Ganong-Levine syndrome. Br Heart J. 1981;45:356.

  13. Benditt DG, Pritchett LC, Smith WM, et al. Characteristics of atrioventricular conduction and the spectrum of arrhythmias in lown-ganong-levine syndrome. Circulation. Mar 1978;57(3):454-65. [Medline].

  14. Denes P, Wu D, Dhingra RC, et al. Demonstration of dual A-V nodal pathways in patients with paroxysmal supraventricular tachycardia. Circulation. Sep 1973;48(3):549-55. [Medline].

  15. Mandel WJ, Danzig R, Hayakawa H. Lown-Ganong-Levine syndrome. A study using His bundle electrograms. Circulation. Oct 1971;44(4):696-708. [Medline].

  16. Douglas JE, Mandel WJ, Danzig R, Hayakawa H. Lown-Ganong-Levine syndrome. Circulation. May 1972;45(5):1143-4. [Medline].

  17. Durrer D, Schuilenburg RM, Wellens HJ. Pre-excitation revisited. Am J Cardiol. Jun 1970;25(6):690-7. [Medline].

  18. Mahaim I. Kent fibers and the A-V paraspecific conduction through the upper connections of the bundle of His-Tawara. Am Heart J. 1947;33:651.

  19. Ometto R, Thiene G, Corrado D, et al. Enhanced A-V nodal conduction (Lown-Ganong-Levine syndrome) by congenitally hypoplastic A-V node. Eur Heart J. Nov 1992;13(11):1579-84. [Medline].

  20. Caracta AR, Damato AN, Gallagher JJ, et al. Electrophysiologic studies in the syndrome of short P-R interval, normal QRS complex. Am J Cardiol. Feb 1973;31(2):245-53. [Medline].

  21. Wiener I. Syndromes of Lown-Ganong-Levine and enhanced atrioventricular nodal conduction. Am J Cardiol. Sep 1 1983;52(5):637-9. [Medline].

  22. Bauernfeind RA, Ayres BF, Wyndham CC, et al. Cycle length in atrioventricular nodal reentrant paroxysmal tachycardia with observations on the Lown-Ganong-Levine syndrome. Am J Cardiol. Jun 1980;45(6):1148-53. [Medline].

  23. Bauernfeind RA, Swiryn S, Strasberg B, et al. Analysis of anterograde and retrograde fast pathway properties in patients with dual atrioventricular nodal pathways: observations regarding the pathophysiology of the Lown-Ganong-Levine syndrome. Am J Cardiol. Feb 1 1982;49(2):283-90. [Medline].

  24. Ward DE, Camm J. Mechanisms of junctional tachycardias in the Lown-Ganong-Levine syndrome. Am Heart J. Jan 1983;105(1):169-75. [Medline].

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Further Reading

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Keywords

Lown-Gangong-Levine syndrome, LGL syndrome, Clerc-Levy-Critesco syndrome, enhanced atrioventricular nodal conduction, accelerated atrioventricular nodal conduction, short PR/normal QRS syndrome, short PR/narrow QRS syndrome, accessory pathway, WPW syndrome, Wolff-Parkinson-White syndrome

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Contributor Information and Disclosures

Author

Daniel M Beyerbach, MD, PhD,, Consulting Staff, Florida Electrophysiology Associates; Affiliate Clinical Assistant Professor of Biomedical Science, Florida Atlantic University, Regional Campus of University of Miami Miller School of Medicine
Daniel M Beyerbach, MD, PhD, is a member of the following medical societies: American College of Cardiology
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher Cadman, MD, Director of Arrhythmia Service, Assistant Professor, Department of Internal Medicine, Division of Cardiology, University of New Mexico
Christopher Cadman, MD is a member of the following medical societies: American College of Cardiology and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Justin D Pearlman, MD, PhD, ME, MA, Director of Advanced Cardiovascular Imaging, Professor of Medicine, Professor of Radiology, Adjunct Professor, Thayer Bioengineering and Computer Science, Dartmouth-Hitchcock Medical Center
Justin D Pearlman, MD, PhD, ME, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Frank M Sheridan, MD, Cardiology, Providence Everett Medical Center
Frank M Sheridan, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD, Professor of Medicine and Pharmacology, Director, Clinical Cardiac Electrophysiology Fellowship Program, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center
Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)
Disclosure: Nothing to disclose.

 
 
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