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History of Medicine |

The Wenckebach Phenomenon: A Salute and Comment on the Centennial of Its Original Description

Charles B. Upshaw Jr., MD; and Mark E. Silverman, MD
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From Piedmont Hospital and Emory University School of Medicine, Atlanta, Georgia.


Ann Intern Med. 1999;130(1):58-63. doi:10.7326/0003-4819-130-1-199901050-00011
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In 1899, Karel F. Wenckebach unraveled the complicated arrhythmia that bears his name—one of the most famous eponyms in medicine. He reported his findings before the benefit of clinical electrocardiography or the discovery of the sinoatrial and atrioventricular nodes. Born and educated in the Netherlands, Wenckebach first worked in Utrecht in the physiology laboratory of T.W. Engelmann, his respected mentor, where he became familiar with kymographic recordings and rhythm disturbances in frog experiments. He then entered country practice in 1891, where he gained great respect for practicing physicians as well as the importance of clinical experience. In 1896, he returned to Utrecht to work again in the laboratory with Engelmann. In 1898, a woman consulted Wenckebach about her irregular pulse. His investigation of her irregular heart action by using radial arterial pulse tracings and experimental atrial and ventricular pulse tracings from the heart of a frog enabled him to discover the mechanism of partial heart block. In later years, he continued to be a leader in academic medicine, chairing the departments of medicine in Groningen, Strasbourg, and Vienna. He achieved fame for investigating cardiac arrhythmias and other contributions and is considered to be one of the founders of modern cardiology. He is remembered for his insight into atrioventricular conduction, which is as valid today as it was a century ago.

Figures

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Figure 2.
Selected segment of a single-channel radial arterial pulse tracing from the patient.

Pauses are seen every three to four beats, each pause is less than twice the preceding pulse interval, and the first pulse interval after each pause is longer than the other intervals. The numbers below the pulse curve refer to the intervals between beats; the numbers above the pulse curve measure the pulse upstroke time from baseline to the greatest upward displacement of the pulse curve (measurements were made by Wenckebach). The pulse upstroke time is shortest after a pause, suggesting maximum rate of left ventricular ejection. All numbers are expressed in tenths of a second; the timeline beneath the pulse curve has a frequency of one notch every 1/10th of a second; and the paper speed, by our measurement, is 15 mm/s (range, 13 to 16 mm/s). Sinus and ventricular rates are 83 and 63 beats/min, respectively. This figure has been lightly retouched for clarity.

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Grahic Jump Location
Figure 3.
Polygraph tracing from the left atrium and ventricle of a frog with our measurements and labeling of the laddergram.AVSAAV

The following phenomena are seen: beats occur in groups, the atrioventricular ( ) pulse intervals gradually increase until the pause, the pause is less than twice the preceding ventricular pulse interval; and the first AV interval is shortest after the pause. These findings are consistent with type I second-degree atrioventricular block. In addition, the intervals between the firing of the cardiac pacemaker and the atrial pulse waves ( ) gradually increase until the pause; the atrial pulse ( ) pause is less than twice the preceding atrial pulse interval; the first SA interval is shortest after the pause; the atrial pulse intervals gradually shorten after the pause; and the atrial pulse wave is absent during the pause, indicating the additional presence of type I second-degree sinoatrial block. Numbers 1 through 14 above the top line of the laddergram refer to sequential sinus impulses; numbers under the atrial pulse waves and the numbered s above the ventricular pulse waves refer to connected atrial and ventricular pulses, respectively. Arrows on the laddergram point in the direction of impulse propagation. Intervals are expressed in 1/25th of a second, and diminutive notches on the timeline above the laddergram have a frequency of one notch every 1/25th of a second; paper speed by our measurement is 12 mm/s (range, 11 to 13 mm/s). Sinus, atrial, and ventricular rates are 44, 38, and 32 beats/min, respectively. This figure has been lightly retouched for clarity. V = ventricular pulse waves.

Grahic Jump Location
Grahic Jump Location
Figure 4.
Selected segment of polygraph tracing from the left atrium and ventricle of a frog with our laddergram added, showing simultaneous type I second-degree atrioventricular block and type I second-degree sinoatrial block.V

Numbers 1 through 15 above the top line of the laddergram refer to sequential sinus impulses; numbers above the atrial pulse waves and the numbered s under the ventricular pulse waves refer to connected atrial and ventricular pulses, respectively. Numbers below the notched timeline and those above the ventricular waves are measurements made by Wenckebach of intervals between atrial and ventricular pulse waves and intervals between ventricular pulse waves, respectively. Intervals are expressed as 1/25th of a second; diminutive notches on the timeline above the laddergram have a frequency of one notch every 1/25th of a second. Paper speed by our measurement is 9 mm/s. Sinus, atrial, and ventricular rates are 34, 28, and 28 beats/min, respectively. This figure has been lightly retouched for clarity. A = atrial pulse waves; AV = intervals between atrial and ventricular pulse waves; SA = intervals between the firing of the cardiac pacemaker and the atrial pulse waves; V = ventricular pulse waves.

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Grahic Jump Location
Figure 5.
Schematic “model of heart action” drawn by Wenckebach showing type I second-degree atrioventricular block.

The numbers above the lowest horizontal line represent the delay in conduction at the atrioventricular border; the shortest interval occurs after a pause; the greatest increment occurs with the next beat; the intervals gradually increase to the maximum; and the pause is less than twice the preceding ventricular pulse interval. Time is shown on the abscissa, and paper speed is not specified. Numbers 1 through 7 at the top and bottom of the laddergram refer to sequential heart beats; all other numbers are intervals in unspecified time units. This figure has been lightly retouched for clarity. ρ = cardiac pacemaker at the root of the heart; A = conduction through the atria (the middle horizontal line represents the atrioventricular border); TV = time between ventricular complexes; V = conduction through the ventricles.

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