Correspondence Address:
Deepti Srinivas
Department of Neuroanaesthesia and Critical Care, Apollo Hospitals, BG Road, Bangalore - 560 029, Karnataka
India

Full Text



Wolff–Parkinson–White (WPW) syndrome is characterized by the presence of an accessory pathway (AP) between the atria and ventricles (bypassing atrioventricular node) resulting in pre-excitation of the ventricles displaying classical findings of a shortened PR interval, delta waves, and a widened QRS complex on the electrocardiogram (ECG). Early radiofrequency catheter ablation (RFCA) of the AP as a curative modality has emerged as the treatment of choice.[1] Consequently, post-RFCA patients coming for surgery have escalated.

A 59-year old-female presented with Pott's spine for lumbar decompression and fusion (L4–L5 level) in the prone position under general anesthesia. She was hypertensive and a known case of WPW syndrome with RFCA done 9 years back. Her effort tolerance was moderate. Preoperatively, serum electrolytes and electrocardiogram were normal. A 2D echocardiogram showed grade 1 diastolic dysfunction. She was taken up for surgery with a moderate risk for cardiac events.

Induction and intubation were accomplished with intravenous (IV) fentanyl 2 mcg/kg, propofol 2 mg/kg, and rocuronium 1 mg/kg. Fifteen minutes later, she developed ventricular bigeminy on the ECG accompanied by bronchospasm. Her end-tidal CO2 surged to 45–48 mmHg. However, both findings were transient and consequently, arterial blood gases were normal. Therefore, it was decided to proceed with the surgery. The ventricular bigeminy reappeared on positioning her prone [Figure 1]. She also developed hypertension and acute pulmonary edema evidenced by copious endotracheal secretions, fine crepts on auscultation, and oxygen desaturation to 88%. IV furosemide 40 mg and IV metoprolol 5 mg were administered. Reversion to sinus rhythm occurred after 20 min which comprised four episodes of ventricular bigeminy. The surgical procedure was postponed until stabilization, and she was extubated when pulmonary edema subsided and was fully conscious.{Figure 1}

Suspecting an acute cardiac event, serial troponin I values were done. The first sample sent from the operation theater was 21.9 ng/mL. Subsequently, it was 452.1 ng/mLat 6 h and 22.2 ng/mL at 12 h. N-terminal pro-brain natriuretic peptide (NT-proBNP) was 39 pg/mL. She was started on IV heparin 5000 twice a day. A coronary angiogram performed the following day revealed diffuse disease in distal right coronary artery branches. She was taken up for surgery under high-risk consent for a perioperative cardiac event. The surgery and postoperative period proceeded uneventfully.

WPW syndrome is an infrequent condition, and there is limited data regarding management under general anesthesia,[2] more so on post-RFCA anesthetic management. Our patient developed ventricular arrhythmia, acute pulmonary edema, and non-ST-elevation myocardial infarction after the induction of anesthesia.

A prospective cohort study[3] reported that although ablation-treated WPW patients were associated with a lower incidence of long-term mortality compared with nonablated patients, they had a higher incidence of hospitalization for coronary artery disease. The increase in this long-term risk was attributed to coronary artery injury during radiofrequency ablation. The risk of atrial fibrillation (AF) is significantly higher in WPW postablation compared with the no ablation group.[4],[5] Furthermore, the inducibility of AF correlates with a higher risk of symptomatic supraventricular and ventricular arrhythmias.[4]

Anesthesia and perioperative care of patients with WPW syndrome can be challenging. As evidenced by the literature, the risk of coronary events and life-threatening arrhythmias in a post-RFCA patient are surprisingly higher than a nonablated one. Working in association with a cardiologist, increased vigilance, and perioperative cardiovascular monitoring will facilitate prompt therapeutic intervention in case of arrhythmias.

Informed consent was obtained from the patient before writing this report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References