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  • Aberrant connection from the atria to the ventricles through an accessory pathway (AP)
  • Classic EKG pattern in sinus rhythm (Figure 17-1): short P–R interval (due to conduction over the faster AP) and a slurred upstroke of the QRS—“delta wave” (due to fusion of impulses that pass through AV node and those that pass via the AP)
  • Patients with Wolff–Parkinson–White (WPW) syndrome can present in sinus rhythm or with reentrant narrow complex tachycardias (orthodromic reciprocating tachycardia [ORT]), wide complex tachycardias (antidromic reciprocating tachycardia [ART]), and atrial fibrillation (AF)
  • AF with WPW pattern has classic EKG pattern (Figure 17-2) and can degenerate into VF

Figure 17-1. Classic WPW Pattern on EKG in Sinus Rhythm
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Slurring of the upstroke of the QRS. Reproduced from Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas of Emergency Medicine. 3rd ed. Figure 23-42A. Available at: Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

Figure 17-2. Atrial Fibrillation in a Patient with WPW
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Note wide, bizarre, and irregular QRS complexes. Reproduced from Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison’s Principles of Internal Medicine. 18th ed. Figure E30-21. Available at: Copyright © The McGraw-Hill Companies, Inc. All rights reserved.


  • Perform EKG: WPW is diagnosed by history and EKG findings
  • Consider referral to electrophysiologist for possible preoperative ablation


  • Management of paroxysmal tachycardia associated with WPW is similar to that of other SVTs. Treatment is required when there is clinical poor tolerance
  • Be cautious when administering anesthetics that cause an increase in sympathetic tone or the production of extrasystoles that may precipitate tachycardia:
    • Desflurane is sympathomimetic and can increase AV nodal conduction time, which may result in greater conduction via the AP and tachycardias
    • Atropine, glycopyrrolate, ketamine can resulting in PSVT or AF and should be avoided
    • Neostigmine slows AV nodal conduction and facilitates AP conduction. Therefore, it should be avoided
  • Patients who develop an atrial arrhythmia intraoperatively (AF or atrial flutter) and have underlying WPW should not be given nodal blockers (including adenosine, calcium channel blockers, beta-blockers, or digoxin) or carotid sinus massage. Nodal blockers slow AV nodal conduction and allow for greater conduction through the faster conducting AP. This promotes degeneration of AF to VF:
    • Cardioversion and/or sodium channel blockers (i.e., procainamide) are first-line therapy for patients with AF and WPW. Sodium channel blockers block the AP
    • However, patients who develop a narrow complex arrhythmia such as ORT can be given nodal blockers to slow the rate

Table Graphic Jump Location
Table 17-1 Drugs to Be Avoided in WPW

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