Anesthetic management for surgical repair of Ebstein′s anomaly along with coexistent Wolff-Parkinson-White syndrome in a patient with severe mitral stenosis

Abstract

Ebstein's anomaly (EA) is the most common cause of congenital tricuspid regurgitation. The associated anomalies commonly seen are atrial septal defect or patent foramen ovale and accessory conduction pathways. Its association with coexisting mitral stenosis (MS) has uncommonly been described. The hemodynamic consequences and anesthetic implications, of a combination of EA and rheumatic MS, have not so far been discussed in the literature. We report successful anesthetic management of a repair of EA and mitral valve replacement in a patient with coexisting Wolff-Parkinson-White (WPW) syndrome.

erioperative management of patients with pre-excitation syndromes

“…Conversely, Dobkowski and colleagues suggested that enflurane may trigger arrhythmias and should not be used in WPW syndrome [30]. In a more recent report, isoflurane was preferred among other volatiles due to its property to prolong the AP refractory period and decrease the likelihood of tachycardias [50]. Similarly, most investigators consider isoflurane as a safe choice for patients with WPW [45,[51][52][53].…”

“…Among intravenous anaesthetics, propofol does not affect the AP refractory period [22]. Induction or maintenance of anaesthesia with propofol combined with fentanyl has been associated with cardiovascular stability in WPW patients [44,50,54,55,[58][59][60][61][62][63]. Moreover, it was reported that delta waves disappeared after propofol administration and reappeared after its discontinuation [58].…”

“…Fentanyl at doses 30-50 μg/kg was found to exert no effect on the anterograde effective refractory period of the AP [34]. It is the most popular opioid, used in the majority of reported cases, and is described as very safe [44,49,50,53,54,56,58,60,[62][63][64]. Conversely, the atropine-like effect of pethidine renders it less appropriate for WPW patients [12].…”

“…The reversal of NMB may cause problems, since neostigmine can induce serious tachyarrhythmias by depressing the AV while facilitating AP conduction; Kadoya and collagues reported that 1mg of neostigmine converted a narrow complex AF to haemodynamically unstable wide complex tachycardia [54]. Additionally, the anticholinergic actions of atropine and glycopyrrolate are undesirable in WPW patients [49][50][51]. Especially atropine accelerates the conduction and shortens the anterograde and retrograde effective refractory period in the AP [72].…”

A patient of bad obstetric history with ebsteins anomaly: Perianesthetic concerns

“…[4] Tachyarrythmic sudden death is a threat regardless of the severity of Ebstein's anomaly. [5] There are three case reports in the literature which describes different anaesthetic techniques used for caesarean section in a patient with Ebstein's anomaly.…”