From the Guidelines
Patients with frequent premature ventricular contractions (PVCs) in a bigeminy pattern should undergo comprehensive preoperative evaluation before surgery, including a 12-lead ECG, echocardiography, and possibly 24-hour Holter monitoring, as recommended by the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. This evaluation is necessary to assess the underlying cardiac structure and function, as frequent PVCs can indicate underlying cardiac disease and may increase the risk of more serious arrhythmias during the perioperative period.
- The evaluation should include:
- A 12-lead ECG to assess for any signs of ischemia or structural heart disease
- Echocardiography to assess ventricular function and rule out any structural heart disease
- 24-hour Holter monitoring to quantify PVC burden and assess for any other arrhythmias
- Laboratory tests should check electrolytes (particularly potassium and magnesium), thyroid function, and cardiac biomarkers to rule out any underlying conditions that may be contributing to the PVCs.
- If the patient has structural heart disease or PVCs comprise >10% of total heartbeats, cardiology consultation is recommended, as suggested by the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1.
- For symptomatic patients, beta-blockers like metoprolol (25-100 mg twice daily) may be initiated preoperatively, as they can help reduce the frequency and severity of PVCs.
- In cases of severe symptoms or ventricular dysfunction, antiarrhythmics such as amiodarone (loading dose 400-600 mg daily for 1 week, then 200 mg daily) might be considered under cardiologist guidance, as recommended by the 2015 ESC guidelines 1.
- During surgery, continuous cardiac monitoring is essential, and electrolyte levels should be maintained within normal ranges, as recommended by the international recommendations for electrocardiographic interpretation in athletes 1.
- The anesthesiologist should avoid medications that may exacerbate arrhythmias, and the patient should be closely monitored for any signs of cardiac instability during the perioperative period.
From the Research
Preoperative Evaluation of Frequent PVCs with Bigeminy Pattern
- Frequent premature ventricular contractions (PVCs) are associated with the presence or subsequent development of left ventricular dilatation and dysfunction 2.
- The bigeminy pattern, characterized by alternating premature and normal ventricular contractions, may be caused by premature ventricular complexes (PVCs) due to early afterdepolarizations in patients with prolonged ventricular repolarization 3.
- In patients with idiopathic frequent PVCs, medical therapy with Class I or III antiarrhythmic drugs (AADs) has been shown to be effective in reducing PVC burden, although the effectiveness of beta-blockers or calcium channel blockers is limited 4.
- The correlation of MRI premature ventricular contraction activation pattern in bigeminy with electrophysiology study-confirmed site of origin has been evaluated, and the results suggest that CMR ectopic beat contraction patterns analysis may provide a novel method for localizing PVC origin prior to ablation procedures 5.
- A narrative review of PVCs highlights the importance of evaluating and managing PVCs, which can be a sign of underlying cardiac disease and cause significantly impairing symptoms 6.
Key Considerations for Preoperative Evaluation
- Assessment for symptoms and associated cardiomyopathy is warranted in patients with high burden PVCs 2.
- Evaluation of the underlying cardiac rhythm and the coupling interval is important in understanding the mechanism of bigeminy 3.
- Medical therapy with AADs may be considered for symptomatic patients with idiopathic frequent PVCs 4.
- CMR ectopic beat contraction patterns analysis may be a useful tool for localizing PVC origin prior to ablation procedures 5.
- A comprehensive evaluation and management plan should be developed for patients with PVCs, taking into account the underlying etiology and epidemiology of the condition 6.