Brit. J. Anaesth. (1968), 40, 791 THE WOLFF-PARKINSON-WHITE SYNDROME AND GENERAL ANAESTHESIA BY J. G. HANNINGTON-KIFF SUMMARY The significance of the Wolff-Parkinson-White syndrome for the anaesthetist is illus- trated by a case report. There is a tendency to paroxysmal supraventricular tachycardia and there may be associated congenital cardiac abnormality. In the presence of a rapid heart rate, arising spontaneously or after atropine, the distinctive W-P-W electrocardio- graphic pattern usually disappears and only when the pulse rate slows will the W-P-W pattern reappear. Thus in the absence of a previous electrocardiogram the diagnosis of W-P-W syndrome cannot usually be made when a patient presents, in the anaesthetic room for instance, with a very rapid pulse rate. The electxocardiographic syndrome of short P-R interval and wide abnormal QRS complex was first described in 1930 by Wolff, Parkinson and White, who reported eleven cases. They drew at- tention to its occurrence in young people in good health apart from a tendency to paroxysmal tachycardia. They stressed that the electrocardio- gram could become normal spontaneously, fol- lowing exercise or administration of atropine. They concluded that vagal influences were largely responsible for the condition and that no serious heart disease was apparent. Following this defini- tion of the syndrome many similar cases were described by others and the related literature be- came extensive. The syndrome is commonly called after Wolff, Parkinson and White, but other names used are: accelerated conduction syndrome, ven- tricular pre-excitation syndrome, and syndrome of short P-R interval with bundle branch block. With more information to hand the syndrome could not be explained only in terms of vagal influences and it was thought that the condition was due to the presence of accessory conduction tissue between the atria and ventricles as des- cribed by Holzmann and Scherf (1932) and Wolferth and Wood (1933, 1941). Prinzmetal and his colleagues (1952) have suggested that the syndrome results from accelerated conduction through an irritable part of the atrioventricular node itself. Accessory conducting tissue, some- times called the Bundle of Kent, has been found at autopsy in some, but not all, cases of the W-P-W syndrome (Lev et al., 1961, 1963). Sup- port for the congenital nature of the syndrome is given by its familial incidence (Averill, 1956) and its association with other congenital cardiac lesions; for example Ebstein's anomaly of the tricuspid valve. The W-P-W syndrome is of particular interest to the anaesthetist because of the electrocardio- graphic and clinical changes which can occur suddenly and unexpectedly. Fear or premedica- tion with atropine can cause disproportionate tachycardia distressing to the patient and puzzling to die anaesthetist. Furthermore, the electro- cardiogram usually ceases to show the typical pattern of W-P-W syndrome and may either be normal or show S-T changes suggestive of cardiac infarction. On the other hand, pathological electrocardiographic changes masked by the W-P-W syndrome may be revealed for the first time. A case is here described which illustrates many of the points made in previous accounts of the W-P-W syndrome and serves to emphasize the variation in the electrocardiogram which can occur in relation to anaesthesia. CASE REPORT A fit girl, aged 16 years, was presented in July 1967 for surgical enlargement of an auditory meatus and tonsillectomy. Weight 51 kg; height 155 cm; BP 120/ 80 mm Hg; pulse rate 82 beats/min; sinus arrhythmia; not anaemic; no history of palpitations, fainting or shortness of breath. There were no chest deformities;
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