Table 2.
Case reports and series describing the perioperative management, complications and outcome of patients with WPW syndrome undergoing non-ablative procedures
| First author (year) | Syndrome | No of pts-gender/ age | Surgery/ procedure | Anaesthesia | Complications & Management (*) | Outcome / Remarks |
|---|---|---|---|---|---|---|
| Lustik15 (1999) | WPW† | 1F/34y | Uterus dilation / evacuation (17w) | RA SA (no further details) |
• Reported palpitations / chest pain • ECG: inferior Q waves *Cardiologic consultation |
• Uneventful course • Postop EPS/ RFCA |
| Le Manach16 (2006) | WPW† | 1M/67y | Abdominal aortic aneurysm repair | GA Premed: midazolam. IN & MNT: propofol, sufentanil, atracurium, N2O, morphine. |
• Post-op ECG changes mimicking inferior MI *Daily ECG follow-up, Troponin I measurements |
• Uncomplicated course • ECG returned to normal |
| Garg17 (2011) | WPW | 1M/32y | Urological surgery | Spinal: bupivacaine + fentanyl. Upper sensory level: T8 Other drugs: diazepam, midazolam |
Intermittent WPW - intraop rhythm changes (HR:70–90) *none |
• Uneventful course / pt haemodynamic stable • Vigilance for level of neuraxial block |
| Naço44 (2009) | WPW | 1F/17y | Thyroidectomy | GA IN: Midazolam, fentanyl, propofol, pancuronium MNT: halothane |
• SVT after pancuronium / tracheal intubation *Adenosine, esmolol |
• Uneventful course • Pancuronium may trigger SVT |
| Richmond45 (1988) | WPW | 1M/ 36w‡, 40w‡ | 1) IPPV for pneumonia 2) Pyloromyotomy |
1) Pancuronium for IPPV 2) GA with thiopental, vecuronium, isoflurane, N2O • Wound infiltration: bupivacaine |
1) Prolonged SVT episode (289 bpm) *Sync cardioversion 2) None |
Uneventful course |
| Schmitz46 (1997) | WPW | 1F/26y | Teeth surgical removal | • Premed: midazolam / Sedation: fentanyl, midazolam, N2O • Local anaesthesia (bupivacaine) |
• None / Sedation associated with ECG normalization | Uneventful course |
| Wakita47 (2007) | Intermittent WPW† | 1F/49y | Tooth extraction | IV sedation: propofol Local anaesthesia: lidocaine (±epinephrine) |
Repeated appearance of δ-waves | • Uneventful course • Epinephrine and autonomic imbalance implicated in δ-waves |
| Okada48 (1990) | WPW | 1M/29y | Maxillary cyst operation | GA (premed: atropine, hydroxyzine, pethilorfan) IN: thiopental, succinylcholine MNT: enflurane, N2O |
None | Uneventful course |
| Janes49 (1989) | WPW | 1F/35y | Laparoscopic sterilisation | GA (premed: temazepam) IN: etomidate, fentanyl, atracurium MNT: enflurane, N2O RV: glycopyrrolate/neostigmine |
Postop retrosternal discomfort + ECG changes: Glycopyrrolate suspected | • Uneventful course • Sympathetic stimulation should be avoided |
| Sinha50 (2010) | WPW/ Ebstein’s anomaly/ MVS | 1F/23y | Danielson’s repair & MVR | GA (premed: diazepam, morphine) IN: propofol, fentanyl, midazolam, vecuronium MNT: isoflurane |
• SVT (↓ BP) *Adenosine, amiodarone, IV fluids |
Pt discharged with persistent pre-excitation on ECG |
| Goldhill51 (1988) | WPW | 1M/46w‡ | 3 surgeries for VPS and hydroceles / 1 CT | GA (± premed with atropine) Thiopental, atracurium, isoflurane, N2O |
• SVTs *Vagal stimulation, propranolol or verapamil |
Uneventful course |
| Laloyaux52 (1998) | WPW/ Cantrell’s pentalogy | 1M/42w‡ & 48w‡ | 1) Inguinal hernia repair 2) Blalock-Taussig shunt |
1) GA: halothane / RA: Caudal with mepivacaine, bupivacaine 2) GA: sufentanil, pancuronium, lidocaine, diazepam |
• SVT preop / transient tachycardia intraop *no extra drugs (already on digoxin, amiodarone) |
• Uneventful recovery/ Infant died few weeks later due to unrelated reason |
| Kumar53 (1986) | WPW | 1M/30y | Lumbar laminectomy | GA (premed: papaveretum, hyoscine) IN: thiopental, succinylcholine MNT: isoflurane, N2O, fentanyl, vecuronium |
None | • Uneventful course • Isoflurane + fentanyl: safe choice • Vecuronium: safe choice |
| Kadoya54 (1999) | Intermittent WPW | 1M/67y | Laryngeal microsurgery | GA IN: propofol, fentanyl, vecuronium MNT: sevoflurane, N2O RV: Neostigmine without atropine |
• AF with narrow QRS after sevoflurane/N2O discontinuation *none • AF 110–180 bpm (wide QRS) with ↓ BP after neostigmine *Sync cardioversion |
• Extubation → ICU transfer → recovery uncomplicated • Avoidance of anti-cholinesterases |
| Şahin55 (2015) | WPW | 1M/51y | Inguinal hernia repair | GA (premed: midazolam) IN: tramadol, propofol, rocuronium MNT: sevoflurane 1 MAC, air RV: sugammadex 2 mg/kg |
↑ HR (108 bpm) after intubation *i.v. remifentanil |
• Uneventful recovery • Sugammadex: may be a safe choice |
| Nakamura56 (2009) | WPW/ Ebstein’s anomaly | n = 3 1M/34y 1M/5m 1F/5y |
Valvuloplasty/ AP ablation | GA with sevoflurane, fentanyl, midazolam | None | Successful procedures |
| Sengul57 (2016) | WPW | 1F/23y | CD | GA (parturient denied RA) IN: fentanyl, propofol, rocuronium MNT: sevoflurane, O2/air RV: sugammadex 2 mg/kg |
None | • Uneventful course • Sugammadex under NMT monitoring may be safe in WPW |
| Seki58 (1999) | WPW | 1F/29y | Uterus dilation & curettage (missed abortion) | GA Premed: midazolam IN & MNT: propofol, fentanyl |
WPW pattern on ECG/ Propofol caused ECG normalization / δ-wave returned after propofol discontinuation | • Postop ECG: WPW pattern • Propofol: possible favourable profile |
| Sato59 (2014) | WPW† | 1M/59y | Video-assisted thoracoscopic lobectomy | GA & TEA (catheter insertion) IN: propofol MNT: desflurane, remifentanil |
3 SVT episodes *Antiarrhythmics: no effect *Sync cardioversion |
• Uneventful course • Postop EPS revealed concealed WPW |
| Yamaguchi60 (1998) | WPW | 1M/62y | Microsurgery of larynx | GA Premed: atropine, hydroxyzine IN & MNT: propofol, fentanyl |
↑ BP after surgical laryngoscope inserted-stable thereafter *none |
Uneventful course |
| Kajikawa61 (2001) | WPW | 1M/57y | Thoracic surgery | GA & TEA IN: propofol, fentanyl MNT: propofol (+ TEA) |
Severe hypercapnia during one lung ventilation | Hypercarbia did not cause tachyarrhythmias |
| Takayama62 (2000) | WPW | 1M/55y | Minimally invasive direct CAB | GA IN: midazolam, fentanyl, vecuronium MNT: propofol, fentanyl, O2/air (+ diltiazem infusion) |
None | • Uneventful procedure • Propofol/fentanyl useful and safe • Intraop diltiazem may prevent paroxysmal SVT |
| Gupta63 (2013) | WPW | 1F/30y | Laparoscopic cholecystectomy | GA Premed: alprazolam, ranitidine IN: fentanyl, propofol MNT: isoflurane, propofol |
• Post-intubation: ?HR, ↑ BP, WPW pattern • Propofol caused ECG normalization |
• Uneventful course • Propofol: possilble favorable profile |
| Klepper64 (1981) | WPW | 1F/28y, pregnant | • Cardioversion (35w, 40w) • CD (40w) |
• GA with fentanyl, thiopental, succinylcholine, N2O • RA: EA for CD (+ oxytocin) |
• No complications associated with GA / EA | • Uneventful course |
| Sadowski65 (1979) | n = 13 11 WPW |
3½y-64y | • 7 bundle division • 4 non-ablative surgeries |
GA Thiopental, halothane or enflurane, N2O, morphine, pancuronium or d-tubocurarine ± diazepam |
• Arrhythmias in 2 cases after skin incision and during cardiac manipulation *Sync cardioversion |
• Thiopental 1–3 mg/kg: did not affect cardiac conduction • Pancuronium: may cause tachyarrhythmias |
| Hannington-Kiff66 (1968) | WPW† | 1F/16y | • Auditory meatus enlargement / tonsillectomy • Surgical pack change |
• GA (premed: hyoscine) IN: thiopental 4 mg/kg, succinylcholine MNT: halothane, N2O, tubocurarine RV: atropine/neostigmine |
• Soon after induction: T-wave inversion, ST depression in II, III, aVF *no specific measures |
• Constant WPW pattern • Family investigation: father with latent WPW • Hyoscine: better than atropine for premed due to less tachycardia |
| Campkin67 (1969) | WPW† | 1M/34y | Craniotomy & clipping of aneurysm | • GA with thiopental, succinylcholine, halothane, N2O (surgery cancelled) • GA Premed: promazine, atropine IN: thiopental, succinylcholine MNT: halothane, N2O, tubocurarine |
• Post-induction ECG changes: MI suspected *pt awakening, surgery postponed, investigation • Hypotension enhanced ECG changes *BP elevation: ECG changes resolved |
• Clinical course uneventful • ECG changes persisted for > 5 months |
| Van der Starre69 (1978) | WPW† | 1M/22y | Knee arthroscopy | GA Premed: atropine, promethazine IN: clemastine, propanidid, succinylcholine MNT: halothane, N2O |
Episodes of sinus tachycardia *Discontiuation of halothane / lidocaine i.v. / postop transfer to ICU |
Avoid drugs that produce tachycardia or negative inotropic effects |
| Suppan70 (1979) | WPW | 1F/45y | Laparoscopic ligation of the Fallopian tubes | GA IN: atropine, althesin, diazepam, succinylcholine, tubocurarine, pentazocine MNT: althesin, tubocurarine |
None | • Uneventful / no ECG changes • Althesin: a possible alternative to thiopental |
| Rahul71 (2006) | WPW | n = 2 1M/42y 1M/26y |
• Lower limb fracture • Nephrectomy |
1) RA: CSE SA: hyperbaric bupivacaine 0.5% + fentanyl EA: plain bupivacaine 0.375% infusion + fentanyl bolus 2) GA (premed: glycopyrrolate) IN: midazolam, fentanyl, propofol, vecuronium MNT: propofol, N2O, vecuronium RV: glycopyrrolate/neostigmine |
• In case 2 (GA): T-wave inversion in leads I-II-III without hemodynamic instability *No treatment |
• Uneventful recovery • ECG normalised (at 24 h postop) • Probably RA preferable to GA |
| Shiroyama76 (1994) | Intermittent WPW† | 1 pt / no further details | No further details | RA Spinal, upper sensory level: C6 |
WPW pattern on ECG | • ECG normalized in 3d • High spinal block may cause ↓ AV & ↑ AP conduction and unmask intermittent WPW |
| Lubarsky77 (1989) | WPW † | n = 2 1M/73y 1M/14y |
1) Transurethral resection of prostate 2) Circumcision |
1) RA Premed: pethidine, pentobarbital, cefazolin SA with tetracaine (i.v. diazepam, ephedrine, phenylephrine as needed) 2) GA Diazepam, isoflurane, N2O |
• Postop wide QRS complexes (T6 block, low Na+, hypothermia, nausea) *furosemide/warm saline • Wide QRS complexes after physostigmine for gagging *no treatment |
• ECG normalized • WPW unmasked due to ↑ vagal tone (nausea, hypothermia, spinal block, gagging, physostigmine) |
| Deviseti79 (2016) | WPW | 1F/20y | Evacuation of molar pregnancy | • RA: SA with hyperbaric bupivacaine 0.5% + fentanyl Level of sensory block: T8 • Other drugs: midazolam, fentanyl, oxytocin |
None | Postop transfer to HDU for monitoring |
| Brizgys80 (1984) | WPW | 1F/19y | VD | RA SA: morphine Pudendal nerve block (lidocaine) |
Transient sinus tachycardia (130 bpm) during delivery *Monitoring of vital signs |
• Uneventful course • Intrathecal opioids for labour analgesia do not induce sympathetic block: useful in WPW |
| Namshikar81 (2013) | WPW | n = 2 1F/30y 1F/28y |
Elective CDs | CSE SA: hyperbaric bupivacaine 0.5% (1.7–2 mL) Postop analgesia: epidural bupivacaine 0.1–0.125% ± fentanyl 50 μg Other drugs: diclofenac, oxytocin (20 IU infusion) |
None | • Uneventful course • CSE useful and safe |
| Ruiz-Castro82 (1996) | WPW/ MV prolapse | 1F/22y | CD | RA: EA | ↓ BP 45 min after block *Methoxamine |
No further incidents |
| Robinson83 (2000) | WPW/ FHPP | 1F/29y | Forceps assisted VD |
RA: EA with bupivacaine/epinephrine, fentanyl, morphine | None | • Uneventful course • Discharge on 2nd postnatal day |
| Misa84 (2007) | WPW/ Ebstein’s anomaly | 1F/25y | Forceps assisted VD |
RA: EA with bupivacaine, fentanyl, chloroprocaine, lidocaine | Mild ↓ BP after delivery *Phenylephrine |
• Uneventful course • Discharge after 48 h |
| Tachikawa85 (2008) | WPW/ Ebstein’s anomaly | Not available | Ankle joint fracture repair | RA: CSE (no further details) | None | Uneventful course |
| Sahu86 (2011) | WPW | 1F/45y | Abdominal hysterectomy | RA: CSE with bupivacaine, fentanyl Postop PCEA |
↓ BP after initial epidural bolus *Phenylephrine |
Postop ICU for 24 h monitoring |
| Palaria87 (2013) | WPW | 1F/30y | Emergency CD | RA (CSE)• SA with hyperbaric bupivacaine • Postop EA: bupivacaine • Other drugs: oxytocin |
None | Uneventful course |
| Kaur88 (2012) | WPW | 1F/30y | CD | RA (CSE)• SA: hyperbaric bupivacaine 0.5% (1.8 ml) - block up to T8 • EA: bupivacaine 0.5% - level T5 • Postop EA: bupivacaine 0.125% |
None | • Oxytocin was withheld • Postop transfer to ICU for 24 h observation |
| Kabade89 (2011) | WPW | 1F/48y | Abdominal hysterectomy | • RA: EA with bupivacaine, lidocaine • Other drugs: alprazolam, ranitidine, ondansetron, midazolam |
None | • Uneventful course • Epidural preferred for haemodynamic stability *Prepare defibrillator / antiarrhythmics |
| Shora90 (2007) | WPW | n = 2 1F/28y 1F/25y |
CDs | RA in both cases• SA: hyperbaric bupivacaine (12.5 mg) • Other drugs: oxytocin |
1. SVT with hypotension after oxytocin 5 IU *Vagal manoeuvres no effect, phenylephrine for hypotension, adenosine terminated SVT 2. None |
• Uneventful course • Adenosine - under fetal HR monitoring- is the first choice in parturients |
| Jacobson91 (1985) | WPW | 1M/17y | Eye surgery | GA (premed: diazepam) IN: thiopental, fentanyl, tubocurarine, lidocaine 100 mg, MNT: halothane, fentanyl, N2O RV: edrophonium |
2 SVT episodes with ↓ BP (at induction and postop) *O2, carotid sinus massage, verapamil, head down position, edrophonium, procainamide, sync cardioversion: no effect Phenylephrine: effective |
• Uneventful course • Possible triggering factors of SVT: ↓ BP & reflex ↑ HR (at induction), lidocaine, postop retching, MVP *Phenylephrine may be useful in terminating paroxysmal SVT |
| Van Zijl92 (2001) | WPW† | 1F/27y | Emergency CD | RA: SA with hyperbaric bupivacaine, fentanyl | SVT (220 bpm) with ?BP *Fluids, Valsalva maneuvre, carotid sinus massage: no effect Verapamil: effective |
• Pt transferred to ICU • EPS / RFCA in 2 m • Neonate died due to unrelated reason • Caution with SA |
| Okamoto93 (2003) | WPW | 1F/36y | CD | RA: EA with mepivacaine | 4 SVT episodes *Valsalva maneuvre, carotid massage: no effect Verapamil,dysopyramide: effective |
• Verapamil, dysopyramide: effective • Oxytocin, pain, anxiety, may trigger SVT |
| Bronheim95 (1992) | WPW | 1M/51y | Surgical ablation | GA (premed: morphine, scopolamine) IN: fentanyl, midazolam, pancuronium, metocurine. MNT: enflurane |
Paroxysmal SVT after pericardium manipulation *Adenosine: effective |
• Further procedure uneventful • Adenosine is effective in WPW syndrome |
| Jones96 (1984) | WPW | n = 3 (1WPW) 1F/72y |
Cholecystectomy | Propranolol before anaesthesia IN: thiopental, fentanyl, alcuronium MNT: enflurane, N2O RV: glycopyrrolate / neostigmine |
None | • Uneventful course • Prophylactic propranolol before laryngoscopy may be helpful |
| Wheeler98 (2002) | WPW† | 1M/72y | CABG | GA | Postop wide / narrow QRS tachy *Adenosine, amiodarone: no effect Sync cardioversion: effective, then sotalol |
• Hospitalized for 16 days • Tachy episodes after discharge • EPS / ablation 3 months later |
| Nishikawa99 (1993) | WPW† | 1M/50y | Transurethral resection of bladder tumor | RA• Premed: secobarbitone • SA: tetracaine • Obturator nerve block with lidocaine |
• Electrical stimulation for block triggered paroxysmal tachycardia *spontaneous resolution • 2 similar episodes without haemodynamic instability *midazolam |
• Uncomplicated course • Postop Holter suggested for possible concealed WPW |
| Chhabra100 (2003) | WPW† | 1M/15 | Modified radical mastoidectomy | GA IN: pethidine, thiopental, vecuronium MNT: halothane, N2O RV: glycopyrrolate / neostigmine |
WPW pattern, but haemodynamically stable *Switch to isoflurane, lidocaine i.v. (no effect) |
• Surgery continued and completed uneventfully • Normal SR after extubation / discharge after cardiac evaluation |
| Esenther101 (2015) | Intermittent WPW† | 1M/4y | Elective bronchoscopy | GA Sevoflurane, N2O |
Intermittent tachyarrhythmia haemodynamically stable *None |
• Uneventful course • ECG diagnosis of intermittent WPW |
| Braun103 (1996) | Intermittent WPW/ iso-rhythmic AV dissociation (after modified Fontan operation) |
1F/30y | CD | GA (RA not preferred because pt was receiving heparin SC) IN: etomidate, succinylcholine MNT: halothane, fentanyl, midazolam, N2O |
None | • Uneventful course (Main focus of paper on the management of post-Fontan parturients) |
AF: atrial fibrillation, AP: accessory pathway, AV: atrio-ventricular, BP: blood pressure, bpm: beats per minute, CA(B)G: coronary artery (bypass) graft, CD: caesarean delivery, CSE: combined spinal-epidural anaesthesia, CT: computerized tomography, EA: epidural anaesthesia/analgesia, ECG: electrocardiogram, EPS: electrophysiological study, F: female, FHPP: familial hypokalaemic periodic paralysis, GA: general anesthesia, HR: heart rate, HDU: high dependency unit, ICU: intensive care unit, IPPV: intermittent positive-pressure ventilation, IN: induction, M: male gender, m: months, MAC: minimum alveolar concentration, MI: myocardial infarction, MNT: maintenance, MVS: mitral valve stenosis, MVR: mitral valve repair, NMT: neuromuscular transmission monitoring, PC(E)A: patient controlled (epidural) analgesia, Premed: premedication, Preop: preoperatively, Postop: postoperatively, pt(s): patient(s), RA: regional anaesthesia, RFCA: radiofrequency catheter ablation, RV: reversal of neuromuscular blockade, SA: spinal anaesthesia, SC: subcutaneously, SR: sinus rhythm, SVT: supraventricular tachycardia, Sync cardioversion: synchronized electrical cardioversion, TEA: thoracic epidural anaesthesia/analgesia, †: undiagnosed, VD: vaginal delivery, VPS: ventriculo-peritoneal shunting, w‡: weeks (post-conceptual age), WPW: Wolff-Parkinson-White, y: years