What are the appropriate next steps for a patient undergoing cataract surgery who develops new onset frequent premature ventricular contractions (PVCs) and is otherwise stable?

From the Guidelines

For a patient with new onset frequent premature ventricular contractions (PVCs) during cataract surgery who is otherwise stable, the appropriate next steps include continuing the procedure while closely monitoring the patient's vital signs, as isolated PVCs in an otherwise stable patient typically don't require specific treatment beyond monitoring and addressing underlying causes 1. The patient's vital signs should be closely monitored, and the surgeon should be informed about the arrhythmia to assess for potential causes such as hypoxia, electrolyte abnormalities, or pain.

• Check oxygen saturation and administer supplemental oxygen if needed.
• Consider obtaining a 12-lead ECG to better characterize the arrhythmia.
• If the PVCs are causing hemodynamic instability or increasing in frequency, consider administering IV lidocaine (1-1.5 mg/kg bolus, followed by 1-4 mg/min infusion) or IV beta-blockers like metoprolol (2.5-5 mg slow IV push) if there are no contraindications, as suggested by the 2009 ACCF/AHA focused update on perioperative beta blockade 1.
• Ensure adequate anesthesia and analgesia as pain can trigger arrhythmias.
• Check electrolytes, particularly potassium and magnesium levels, and correct if abnormal, as electrolyte imbalances can contribute to the development of PVCs, according to the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. The mechanism behind PVCs involves abnormal electrical impulses originating from the ventricles rather than the sinoatrial node, often triggered by surgical stress, electrolyte imbalances, or catecholamine surges during procedures.
• PVCs are common and increase in frequency with age, and their presence can be associated with increased cardiovascular risk and mortality, as noted in the 2017 AHA/ACC/HRS guideline 1.
• However, in the absence of other indications for monitoring in hospitalized patients, continued arrhythmia monitoring may be considered but is not required, as stated in the 2017 update to practice standards for electrocardiographic monitoring in hospital settings 1.

From the Research

Appropriate Next Steps for Cataract Surgery Patient with New Onset Frequent PVCs

• The patient's new onset frequent premature ventricular contractions (PVCs) should be evaluated to determine if they are symptomatic or at risk of tachycardia-induced cardiomyopathy 2
• If the patient is asymptomatic and has no underlying structural heart disease, the prognosis is generally excellent, and suppression of PVCs with antiarrhythmic medication is not indicated routinely 2
• However, if the patient is symptomatic, treatment options include antiarrhythmic drugs (AADs) such as metoprolol, propafenone, or verapamil, or radiofrequency ablation (RFCA) 3
• The choice of treatment depends on the patient's specific condition, and the efficacy and safety of AADs and RFCA should be carefully considered 3, 4
• Beta-blockers and calcium channel blockers may be effective in treating PVCs originating from the right ventricular outflow tract, while Class Ic AADs such as flecainide and propafenone may be effective in suppressing PVCs, but their usage is not recommended in patients with significant coronary artery disease 4
• RFCA may be an effective and safe treatment option for patients with frequent symptomatic PVCs, especially those who do not respond to AADs or have contraindications to AADs 3, 4

Considerations for Patient Selection and Treatment

• Patient selection criteria are vitally important in determining the appropriate treatment for PVC-induced cardiomyopathy, and AADs are indicated for polymorphic PVCs, epicardial PVCs, or when RFCA is contraindicated, not feasible, or failed 4
• The patient's underlying heart disease, symptoms, and response to treatment should be carefully evaluated to determine the best course of treatment 2, 3, 4
• The use of AADs and RFCA should be guided by the patient's specific condition and the available evidence, and treatment should be individualized to achieve the best possible outcome 3, 4