Can a patient with sinus rhythm, first-degree atrioventricular (AV) block, and frequent premature ventricular contractions (PVCs) be cleared for surgery?

Preoperative Clearance for Surgery with First-Degree AV Block and Frequent PVCs

Yes, a patient with sinus rhythm, first-degree AV block, and frequent PVCs can generally be cleared for surgery, as isolated first-degree AV block does not require pacemaker implantation or delay surgery, and frequent PVCs in the absence of hemodynamic compromise, ongoing ischemia, or significant left ventricular dysfunction do not necessitate preoperative intervention. 1

First-Degree AV Block Assessment

First-degree AV block alone is not an indication for pacemaker implantation and does not contraindicate surgery. 1

• First-degree AV block is defined as PR interval prolongation >200 ms and is generally benign 1
• Pacemaker implantation has little evidence for improving survival in isolated first-degree AV block 1
• The exception is marked first-degree AV block (PR >300 ms), which can occasionally cause symptoms even without higher-degree block, but this still does not typically delay surgery 1
• Patients with first-degree AV block and intraventricular conduction delays do not require temporary pacemaker implantation for surgery in the absence of syncope or more advanced AV block 1

Frequent PVCs Risk Stratification

Frequent PVCs require evaluation for underlying structural heart disease, but their presence alone does not preclude surgery. 1, 2

Key Assessment Points:

• Nearly half of high-risk patients undergoing noncardiac surgery have frequent PVCs or asymptomatic nonsustained ventricular tachycardia, yet these arrhythmias are NOT associated with increased nonfatal MI or cardiac death perioperatively 1
• Search for underlying causes: cardiopulmonary disease, ongoing myocardial ischemia/infarction, drug toxicity, or metabolic derangements 1
• PVCs with hemodynamic compromise, ongoing ischemia, or LV dysfunction require treatment, but simple or complex ventricular ectopy without these features typically does not 1

When PVCs Become Concerning:

• PVC burden >24% with short coupling intervals (<300 ms) suggests PVC-induced cardiomyopathy 1
• Frequent PVCs (>10 per hour) or NSVT in patients with structural heart disease contribute to increased mortality risk 1
• If PVCs are causing symptoms or contributing to reduced LVEF, consider medical therapy with beta-blockers or amiodarone 1

Perioperative Management Strategy

Prophylactic beta-blocker therapy should be strongly considered for patients with preoperative arrhythmias. 1

Specific Recommendations:

• Beta-blocker therapy reduces the incidence of perioperative arrhythmias 1
• Have a low threshold for instituting prophylactic beta-blockers in patients at increased risk of perioperative arrhythmias, including those with arrhythmias present during preoperative evaluation 1
• Continue chronic medications including rate-control agents through the perioperative period 1

Intraoperative Considerations:

• Be aware of potential interactions between electrocautery and cardiac electrical activity, though this primarily affects pacemakers/ICDs rather than native conduction 1
• Monitor for metabolic derangements and electrolyte abnormalities that can exacerbate arrhythmias 1

Common Pitfalls to Avoid

Do not delay surgery solely for isolated first-degree AV block or asymptomatic frequent PVCs. 1

• Avoid unnecessary pacemaker implantation: First-degree AV block and frequent PVCs are not indications for pacing 1
• Do not withhold beta-blockers perioperatively unless contraindicated, as they provide arrhythmia protection 1
• Ensure adequate evaluation for reversible causes (electrolytes, ischemia, medications) before surgery 1
• Document baseline rhythm and PVC burden for postoperative comparison 1

Surgical Clearance Decision Algorithm

1. Confirm isolated first-degree AV block (no higher-degree block, no syncope) → Proceed with surgery 1
2. Assess PVC characteristics:
   • No hemodynamic compromise? → Proceed 1
   • No ongoing ischemia? → Proceed 1
   • No significant LV dysfunction? → Proceed 1
3. Initiate/continue beta-blocker therapy perioperatively 1
4. Optimize electrolytes and correct reversible causes 1
5. Clear for surgery with appropriate perioperative monitoring 1