From the Guidelines
Based on the ECG findings of right bundle branch block, right axis deviation, and possible right ventricular hypertrophy, it is reasonable to consider additional cardiac evaluation before proceeding with umbilical hernia repair, as recommended by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. The ECG abnormalities may indicate underlying cardiac issues that could increase surgical risk.
- The 2014 ACC/AHA guideline suggests that preoperative resting 12-lead ECG is reasonable for patients with known coronary heart disease or other significant structural heart disease, except for low-risk surgery 1.
- However, for asymptomatic patients undergoing low-risk surgical procedures, routine preoperative resting 12-lead ECG is not useful, according to the guideline 1.
- Given the ECG findings, I recommend obtaining a cardiology consultation and possibly an echocardiogram to assess right ventricular function and pulmonary pressures, as the findings could represent normal variants or could indicate conditions like pulmonary hypertension or right heart strain that might affect anesthesia management.
- The anesthesiologist should be made aware of these findings regardless of further testing results.
- If cardiac evaluation shows no significant functional impairment, surgery can likely proceed with appropriate monitoring, as suggested by the guideline that for patients with elevated risk and excellent functional capacity, it is reasonable to forgo further exercise testing and proceed to surgery 1.
- However, if significant cardiac dysfunction is identified, the risk-benefit ratio of the procedure should be reassessed, and additional perioperative cardiac management may be necessary, considering the guideline's recommendation that routine preoperative evaluation of LV function is not recommended, but it may be reasonable for patients with dyspnea of unknown origin or HF with worsening dyspnea or other change in clinical status 1.
From the Research
Preoperative Clearance for Umbilical Hernia Repair
ECG Reading and Possible Right Ventricular Hypertrophy
- The patient's ECG reading shows a right bundle branch block (RBBB) and right axis, which may indicate possible right ventricular hypertrophy.
- According to 2, RBBB can have haemodynamic consequences in cardiac failure with associated asynchrony of the left ventricle or in certain cases of right ventricular dilatation encountered in congenital heart disease.
- However, the prognosis of RBBB in the absence of underlying cardiac disease is generally good, but it may be poor in other cases, particularly coronary artery disease 2.
Safety for Surgery
- There is no direct evidence from the provided studies that addresses the safety of surgery for a patient with RBBB and possible right ventricular hypertrophy.
- However, 3 and 4 discuss the importance of considering underlying cardiac disease when evaluating patients with RBBB and changing axis deviation.
- 5 suggests that RBBB ventricular tachycardia can originate from the right ventricle, which may be relevant to patients with possible right ventricular hypertrophy.
- Overall, the decision to proceed with surgery should be made on a case-by-case basis, taking into account the patient's overall health and any underlying cardiac conditions 6, 3, 4, 5, 2.