The significance of widely split P waves: a case report

BACKGROUND: P wave morphology on electrocardiogram is often overlooked but indicates abnormal cardiac conduction from various etiologies. Split P waves on electrocardiogram have been reported previously but not in a perioperative setting. CASE PRESENTATION: A 69-year-old Caucasian male patient with widely split P waves on his preoperative electrocardiogram was scheduled for a reimplantation right total hip replacement under a combined spinal–general anesthetic technique. The patient was evaluated prior to surgery by a cardiologist and the preoperative anesthesia clinic without any comment on the abnormal P wave morphology on electrocardiogram. The patient was cleared to proceed with anesthesia and surgery. Following induction of general anesthesia, his cardiac rhythm changed to a Mobitz type II pattern. The surgical procedure was cancelled, and a permanent cardiac pacemaker was inserted. CONCLUSIONS: Anesthesiologists should be aware that the presence of widely split P waves on electrocardiogram indicates the presence of atrial conduction abnormalities, likely from an ischemic or infiltrative process that can lead to more serious cardiac arrhythmias. P wave morphology should be observed and noted during the perioperative period for all patients.