Intraoperative Supra-Ventricular Tachycardia Revealing Intermittent Wolff-Parkinson-White Syndrome

Mehdi Oudrhiri Safiani^*, Nora Fernaoui, Ahlam Chaieri, El Mehdi El Awab, Rachid Moussaoui, Ahmed El Hijri, Abderrahim Azzouzzi

Surgical Resuscitation, Mohammed V University, Rabat, Morocco

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Abstract

Wolff-Parkinson-White Syndrome (WPW) is a congenital cardiac anomaly characterized by the presence of an accessory atrioventricular cardiac bundle called the Kent Bundle. Discovered by Wolf, Parkinson, and White, this condition can result in recurrent, sometimes fatal tachyarrhythmias. WPW is relatively rare, affecting approximately 0.1% to 0.3% of the general population. Its diagnosis relies on electrocardiography. Its management depends on the clinical presentation of each patient, varying in accordance with the severity of symptoms. It can range from vagal maneuvers and first-line anti-arrhythmic drugs to radiofrequency ablation in refractory cases. In this report, we present the case of a 40-year-old man undergoing surgery to remove a urachal cyst. During the intraoperative period, supra-ventricular tachycardia emerged, revealing a previously undiagnosed intermittent WPW syndrome.

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Introduction

Wolff-Parkinson-White (WPW) Syndrome is a congenital heart condition involving the presence of accessory conduction pathways, which can bypass the normal conduction system and create a short circuit between the atria and ventricles. The most recognized accessory pathway is the Bundle of Kent, which is atrioventricular and connects the atrium directly to the ventricle¹. Other less common accessory pathways include nodofascicular pathways and other variants, which differ in their anatomical location and insertion sites.

WPW is mostly asymptomatic and identified through electrocardiographic testing investigations². Nevertheless, Wolff-Parkinson-White syndrome can be symptomatic, presenting episodes of dyspnea, palpitations, or even syncope³.

It is a rare condition⁴, typically benign, yet it has the potential to result in serious arrhythmias³ during episodes of atrial fibrillation.

The interest of our work is to report the case of an intermittent WPW revealed by intraoperative supra-ventricular tachycardia.

Patient and Observation

A 40-year-old patient with no significant medical history, nor symptoms such as tachycardia, palpitation episodes, dyspnea, or syncope, is admitted to the urology department of our facility for the treatment of an infected urachal cyst discovered following a painful erythematous swelling of the umbilicus.

His pre-anesthetic evaluation finds an ASA I patient, OMS 0, conscious and well-oriented in time and space. Hemodynamic examination finds a NYHA I patient, with a functional capacity > 4 MET and an LEE score of 0. The patient has a blood pressure of 116/61 and a heart rate of 65. Cardiac auscultation reveals normal findings, and there are no signs of right heart failure (no lower limb edema, no jugular vein turgidity, no hepatojugular reflux) or signs of left heart failure (normal auscultation, no crackles, present and symmetrical peripheral pulses, and no signs of peripheral hypoperfusion).

Preoperative ECG shows regular sinus rhythm, axis in place, no conduction disorder, no repolarization disorder. (Figure 1)

Figure 1: Preoperative ECG

Respiratory examination and the upper airways examination, as well as the entire laboratory workup, returned unremarkable results.

The patient is admitted to the operating room at 8 am, placed in the dorsal decubitus position, monitored by non-invasive blood pressure, electrocardioscope, and pulse oximetry. An 18-gauge peripheral IV line was inserted into the left upper limb, and prophylactic antibiotics (Cefalotin 2g) were administered.

The patient was pre-oxygenated with a facial mask for 3 minutes with FiO2 at 1. Induction was done with 300 mcg of fentanyl, 200 mg of titrated propofol, and 50 mg of rocuronium.

The patient underwent successful orotracheal intubation, using a size 7.5 intubation tube, with clear visualization of the vocal cords (Cormack 1). Tube position was confirmed by auscultation and capnography. Anesthesia was maintained with sevoflurane (3%) and additional medications.

Eye protection was ensured for the patient. The patient's pressure points were checked to avoid any damage or discomfort due to prolonged positioning on the operating table. Anesthesia was maintained using sevoflurane at a concentration of 3% and drug reinjection.

The incision was made at 9:20 am to perform a resection of an infected urachal cyst by laparoscopy, followed by drain placement. The total duration of the intervention was 2 hours and 10 minutes.

An intra-anesthetic incident occurred with the onset of a cardiac arrhythmia: orthodromic tachycardia at 200 beats per minute without hemodynamic instability. (Figure 2)

Figure 2: Intraoperative ECG revealing orthodromic tachycardia on WPW Syndrome

Management steps:

• Deepening of anesthesia and temporary interruption of the surgical intervention.
• Interruption of insufflation to reduce the level of carbon dioxide in the blood.
• Performance of a Valsalva maneuver and carotid massage during the surgical intervention.
• Administration of beta-blockers.

The tachycardia resolved following the administration of beta-blockers. Surgery continued without further incident.

The postoperative ECG revealed:

• Shortening of the P-R interval
• Enlarged QRS
• The presence of a delta wave of pre-excitation

All of which favors a diagnosis of Wolff-Parkinson-White Syndrome. (Figure 3)

Figure 3: Postoperative ECG revealing Wolff-Parkinson-White Syndrome

Given that the previous ECG showed a normal appearance, we concluded the discovery of intermittent Wolff-Parkinson-White syndrome during the surgical intervention.

Discussion

Wolff-Parkinson-White Syndrome (WPW) is a congenital cardiac electrical anomaly characterized by the presence of an abnormal additional pathway between the atria and ventricles. This additional pathway, called the Kent bundle, allows premature electrical conduction, which can lead to cardiac rhythm disturbances, such as supraventricular tachycardia¹.

It is a relatively uncommon condition, affecting approximately 0.1% to 0.3% of the overall population⁴.

Pathophysiology

During embryonic development, additional myocardial tissues develop, creating abnormal interatrioventricular pathways⁵.

When electrical impulses from an atrium propagate through this bundle in the anterograde direction (from the atrium to the ventricle), the ventricular myocardium may be depolarized first. This explains the shortening of the P-R interval and the deformation of the ventriculogram, resulting from the fusion between initial atrioventricular activation and that passing through the nodo-hissian pathway. This early depolarization of a ventricle by an accessory bundle is called ventricular pre-excitation⁶.

Patients with WPW are therefore more likely to develop supraventricular arrhythmias, such as orthodromic or antidromic tachycardia, as well as atrial fibrillation, due to the presence of this accessory pathway.

Diagnosis

The diagnosis relies on the ECG⁷. The diagnosis of ventricular pre-excitation is established based on the following characteristics:

• Short PR intervals (<120 ms).
• Initial slurring of the QRS complex known as delta wave.
• Widening of the QRS complex (typically ≥120 ms in adults, or >90 ms in children) related to fusion.
• Secondary repolarization anomalies are frequent, slightly in appropriate discordance with the largest delta wave.

Tachycardias observed in WPW syndrome are mostly harmless. They may manifest in childhood but are generally symptomatic in adults, especially around the age of 40, with a higher prevalence in males than females. These tachycardias are paroxysmal, characterized by sudden onset and termination, and can cause palpitations, occasional chest discomfort, malaise, and rarely syncope⁸.

Three main types of WPW tachycardias:

• Atrioventricular reentrant tachycardias (AVRT)
• Orthodromic tachycardia (95%)
• Antidromic tachycardia (5%)

- Atrial fibrillation conducted with preexcitation (exceptional)⁹. (Figure 4)

Figure 4: Mechanisms of orthodromic and antidromic tachycardias

Specific Case: Intermittent Form

Pre-excitation can manifest in different forms:

• Patent (permanent preexcitation)
• Intermittent (occasional preexcitation)
• Concealed (exclusive retrograde conduction)

In the intermittent form¹⁰, ECG signs appear sporadically. as was the case with our patient.

This variability in electrocardiographic signs makes diagnosis challenging, often requiring electrophysiological examinations to confirm the presence of the abnormal accessory pathway.

Physiological factors, such as fluctuations in sympathetic and parasympathetic tone, as well as physical and emotional stress, can influence cardiac conduction and contribute to the intermittent manifestation of WPW signs. Thus, the operative context triggered the expression of WPW through orthodromic tachycardia, although it went unnoticed preoperatively.

Treatment

Therapeutic options for Wolff-Parkinson-White syndrome include managing acute symptoms with vagal maneuvers such as Valsalva maneuver and carotid massage, administration of antiarrhythmic drugs such as amantadine and beta-blockers, and the possibility of electrical cardioversion for episodes of tachycardias associated with hemodynamic instability¹¹.

Regarding long-term treatment, therapeutic abstention, pharmacological treatment aimed at controlling heart rate and preventing tachycardia episodes, and catheter or radiofrequency ablation considered for cases resistant to drug treatments are the main therapeutic options.

In our case, the patient benefited from vagal maneuvers followed by beta-blockers, which helped regress the tachycardia; then was referred postoperatively to the cardiology department for further management. In the cardiology department, the patient underwent Holter ECG monitoring, which confirmed the intermittent nature of his Wolff-Parkinson-White (WPW) syndrome.

Conclusion

In summary, the discovery of Wolff-Parkinson-White (WPW) syndrome during a surgical intervention highlights the crucial importance of monitoring and deep understanding of cardiac issues in surgical patients. The identification of intermittent ventricular preexcitation requires careful evaluation to assess the potential risks of serious arrhythmias and postoperative cardiac complications. Therapeutic options, including medical management and sometimes catheter ablation, should be considered to reduce the risk of recurrent arrhythmias and long-term complications. Close collaboration between cardiologists, surgeons, and the medical team is essential to ensure holistic and patient-centered care, thereby optimizing clinical outcomes and improving quality of life.

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