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LETTER TO EDITOR
Year : 2013 | Volume
: 7
| Issue : 3 | Page : 354-356
Anesthesia for Wolff-Parkinson-White syndrome: A report of two cases
Viraj Namshikar, Sidhesh Bharne
Department of Anaesthesiology, Goa Medical College, Bambolim, Goa, India
Correspondence Address:
Sidhesh Bharne
F1/A2, Kurtarkar Vatika, Shantinagar, Ponda, Goa
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1658-354X.115342
| Date of Web Publication | 20-Jul-2013 |
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How to cite this article:
Namshikar V, Bharne S. Anesthesia for Wolff-Parkinson-White syndrome: A report of two cases. Saudi J Anaesth 2013;7:354-6 |
Sir,
Wolff-Parkinson-White syndrome is a preexcitation syndrome, which results from an abnormal accessory pathway connecting the atria and ventricles, predisposing to supraventricular arrhythmias and even sudden death. [1] We report the anesthetic management of two patients with this syndrome under combined spinal-epidural anesthesia.
Case 1: A 30-year-old gravida 2, para 1 at 36.5 weeks gestation with cephalopelvic disproportion was posted for an elective cesarean section. She gave no history of any medical illness. She only complained of occasional palpitations, which were self-limiting. Physical examination was unremarkable. During preoperative testing, an electrocardiogram (ECG) was performed, which showed short PR interval with slurred upstroke of the QRS complex, the delta wave. A diagnosis of Wolff-Parkinson-White syndrome was made. Because the patient was hemodynamically stable and comfortable, no treatment was advised.
On the day of surgery, after securing an 18G intravenous line, the patient was premedicated with intravenous (IV) metoclopramide 10 mg and IV ranitidine 50 mg. A defibrillator along with anti-arrhythmic agents like adenosine, esmolol and amiodarone were kept ready. ECG, non-invasive blood pressure and pulse oximeter were used for monitoring. It was decided to use a combined spinal-epidural technique. She was preloaded with 500 mL of lactated Ringer's solution. An 18G Tuohy needle was passed in the L2-L3 epidural space by loss of resistance to air. An epidural catheter was passed and fixed at 8 cm at the skin. After lumbar puncture in the L3-L4 space with a 25G Quincke needle, 1.7 mL of 0.5% hyperbaric bupivacaine was injected. A wedge was placed under the right buttock. T6 level was attained. A baby boy weighing 2.3 kg was delivered, with Apgar score of 8, and 10 at 5 min. Twenty units of oxytocin were given slowly by infusion. She received 1 L of lactated Ringer's solution intraoperatively. Intraoperative vitals were stable. A 100 mg diclofenac per rectal suppository was given for postoperative analgesia at the end of surgery. Postoperatively, she was given 0.1% bupivacaine and 50 mcg fentanyl for analgesia, and was monitored for any arrhythmias. She was discharged on the 8 th postoperative day and made an uneventful recovery.
Case 2: A 28-year-old woman, who was a known case of WPW syndrome, was posted for elective cesarean section. Indication for cesarean was heart disease itself and there was no obstetric indication per se. The anesthetic management was similar to that of case 1, except for the following differences. The dose of heavy bupivacaine used for subarachnoid block was 2.0 mL of 0.5% solution. Postoperatively, the patient received 0.125% bupivacaine epidurally for analgesia.
In patients with Wolff-Parkinson-White syndrome, there is an accessory conduction pathway between the atria and the ventricles, called the bundle of Kent. This pathway bypasses the atrioventicular (AV) node and results in earlier activation of the ventricles compared with impulses conducted through the AV node. Patients may present with palpitations and syncope, or may be asymptomatic. ECG findings include a short PR interval (<0.12 s), slurred slow rising onset of QRS complex (called delta wave) and prolonged QRS complexes (>0.12 s). [2] There can be arrhythmias such as AV nodal re-entrant tachycardias and atrial fibrillation. There is also a risk of ventricular fibrillation and sudden death. [1] Definitive treatment is by radiofrequency catheter ablation or surgical ablation of the accessory pathway.
Patients with WPW syndrome have been successfully managed under both regional [3] and general anesthesia. [4] Regional anesthesia would avoid polypharmacy and the noxious stimuli and sympathetic stimulation associated with intubation during general anesthesia, and could be employed whenever possible. If general anesthesia is required, one should avoid tachycardia and drugs that have a negative inotropic effect on the heart. Etomidate would be an ideal agent for induction in view of its cardiostable properties. Cardiostable relaxants such as vecuronium should be employed. Isoflurane [5] has been shown to increase the refractory period of both the AV node and the accessory pathway and thus may reduce the incidence of intraoperative tachyarrhythmias; therefore, it may be a better choice for anesthesia than sevoflurane and propofol for maintenance. Anticholineesterase drugs should be carefully used at the end of surgery as they can precipitate arrhythmias. [6] Adequate postoperative analgesia has to be ensured to prevent sympathetic stimulation and arrhythmias.
Drugs such as adenosine, phenylephrine and beta blockers can be used to treat supraventricular tachycardias occurring under anesthesia. If the arrhythmia results in hemodynamic instability, direct cardioversion is indicated.
To conclude, WPW syndrome can be managed effectively and safely under combined spinal-epidural anesthesia, taking adequate precautions to prevent and manage arrhythmias that can occur. Combined spinal and epidural anesthesia has its own specific advantages in the management of such patients. Low-dose intrathecal bupivacaine helps to prevent profound hypotension and respiratory distress as a result of a high level of autonomic and motor blockade. In case the subarachnoid block is inadequate, supplementation with epidural local anesthetics can be done. Also, adequate postoperative analgesia given epidurally prevents any adverse sympathetic stimulation due to pain that could trigger dangerous arrhythmias.
| References | |  |
| 1. | Klein GJ, Bashore TM, Sellers TD, Pritchett EL, Smith WM, Gallagher JJ. Ventricular fibrillation in the Wolff-Parkinson-White syndrome. N Engl J Med 1979;301:1080-5. 
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| 2. | Al-Khatib SM, Pritchett EL. Clinical features of Wolff-Parkinson- White syndrome. Am Heart J 1999;138:403-13.
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| 3. | Kabade SD, Sheikh S, Periyadka B. Anaesthetic management of a case of Wolff-Parkinson Parkinson-White syndrome. Indian J Anaesth 2011;55:381-3.
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| 4. | Hussainkhan Z, Saffarian N. Cesarean section in a patient with Wolfe-Parkinson-White syndrome. Middle East J Anesthesiol 2003;17:467-75.
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| 5. | Sharpe MD, Dobkowski WB, Murkin JM, Klein G, Guiraudon G, Yee R. The electrophysiologic effects of volatile anesthetics and sufentanil on the normal atrioventricular conduction system and accessory pathways in Wolff-Parkinson-White syndrome. Anesthesiology 1994;80:63-70.
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| 6. | Kadoya T, Seto A, Aoyama K, Takenaka I. Development of rapid atrial fibrillation with a wide QRS complex after neostigmine in a patient with intermittent Wolff-Parkinson-White syndrome. Br J Anaesth 1999;83:815-8.
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