2026 FSA Podium and Poster Abstracts

Introduction: Wolff-Parkinson-White (WPW) pattern and syndrome are characterized by an accessory pathway (AP) connecting the atria and ventricles outside the atrioventricular node. This pathway may result in ventricular pre-excitation, with typical electrocardiographic findings of a shortened PR interval and widened QRS complex with a slurred upstroke. These findings are termed “WPW pattern” if asymptomatic or “WPW syndrome” if associated with a symptomatic arrhythmia.

Case Presentation: A 22-year-old male with acute cholecystitis presented for laparoscopic cholecystectomy. On preoperative assessment, the patient denied any medical history other than occasional alcohol/marijuana use. Physical exam and labs were unremarkable. In the OR, pre-induction vitals were unremarkable. ECG tracings of leads II and V5 showed normal sinus rhythm with ST-segment depressions up to ~3 mm and QRS complexes with a slurred upstroke. General anesthesia was induced with propofol and succinylcholine and maintained with sevoflurane. Shortly after intubation, the patient became tachycardic up to 144/min for ~30 seconds, which resolved with administration of fentanyl and deepening of anesthesia. At the conclusion of the case, sugammadex was administered, and the patient was extubated uneventfully. A postoperative 12-lead ECG demonstrated WPW pattern.

Discussion: WPW pattern occurs in up to 0.3% of the population and may present in the perioperative setting. Prior to elective surgery, patients with suspected WPW pattern/syndrome should be referred for consideration of an invasive electrophysiologic study (EPS), which can confirm the diagnosis, determine risk of acute arrhythmia (e.g., by measuring the AP’s refractory period), and/or ablate pathologic tissue. In patients for whom preoperative EPS is not feasible, higher risk of acute arrhythmia may be suggested by male sex, younger age, history of symptomatic arrhythmia, or persistent (rather than intermittent) WPW findings on ECG.

Intraoperatively, the goal is to maintain hemodynamic stability while avoiding agents that enhance AP conduction or suppress AV node conduction. Propofol, which is not known to affect AP conduction, and etomidate, which offers hemodynamic stability, are suitable induction agents; ketamine’s sympathomimetic effects make it less desirable. Isoflurane and desflurane may favorably prolong the AP refractory period, though sevoflurane and nitrous oxide also appear safe based on limited data. Neuromuscular blockers that increase histamine release (e.g., atracurium) or increase parasympathetic tone (e.g., succinylcholine in children) are unpreferred. Reversal with sugammadex is preferred over an anticholinesterase/antimuscarinic combination.

Finally, acute arrhythmias may present perioperatively. Orthodromic atrioventricular reentrant tachycardia (AVRT) is presumed in patients with WPW with a narrow-complex, regular tachycardia; if stable, patients can be treated with vagal maneuvers, AV node-blocking agents, or procainamide. Diagnostically unambiguous antidromic AVRT (a regular, wide-complex tachycardia) can be treated similarly; however, if diagnostic uncertainty exists, patients should be treated as having an undifferentiated wide-complex tachycardia, with procainamide as the first-line antiarrhythmic. Patients with stable, pre-excited atrial fibrillation should be treated with procainamide or ibutilide with avoidance of AV nodal blockade. All unstable tachyarrhythmias should be electrically cardioverted.

Conclusion: WPW pattern/syndrome may present in the perioperative setting. Anesthesiologists must understand the implications of these pathologies and adjust clinical management accordingly.