How should I evaluate and manage a patient with premature ventricular contractions undergoing anesthesia, including pre‑operative optimization, intra‑operative monitoring and treatment, and postoperative care?

Management of Premature Ventricular Contractions in the Perioperative Setting

Premature ventricular contractions do not require treatment or delay of surgery unless they cause hemodynamic compromise, occur with ongoing myocardial ischemia, or are associated with left ventricular dysfunction. 1

Preoperative Evaluation

Risk Assessment

• Asymptomatic PVCs, including complex ventricular ectopy and nonsustained ventricular tachycardia, are NOT associated with increased risk of nonfatal MI or cardiac death in the perioperative period. 1
• The presence of PVCs should trigger investigation for underlying causes: cardiopulmonary disease, ongoing myocardial ischemia or infarction, drug toxicity, electrolyte abnormalities (particularly hypokalemia and hypomagnesemia), or metabolic derangements. 1

When to Investigate Further

• Search for structural heart disease if not previously evaluated: Obtain echocardiography to assess left ventricular function and screen for coronary artery disease if the patient has risk factors. 1
• Check and correct electrolyte abnormalities, particularly potassium and magnesium levels. 1
• Assess thyroid function, as hyperthyroidism can trigger ventricular arrhythmias. 2, 3
• Evaluate for stimulant exposure (caffeine, medications, alcohol). 2, 3

When Surgery Can Proceed Without Delay

• Asymptomatic PVCs in the absence of structural heart disease do not require cardiac clearance or delay of surgery. 4
• Isolated PVCs, even with bigeminy or trigeminy patterns, without sustained ventricular tachycardia do not mandate treatment. 2
• PVC burden up to 10% is generally considered benign in structurally normal hearts. 2

When to Defer Surgery

• Sustained or symptomatic ventricular tachycardia causing hemodynamic compromise requires preoperative suppression with intravenous lidocaine, procainamide, or amiodarone, along with thorough investigation for underlying causes. 1
• Defer surgery if PVCs are associated with acute myocardial ischemia or infarction until stabilized. 1
• Consider deferring if PVCs occur with severe left ventricular dysfunction (LVEF <35%) until cardiology evaluation is complete. 1

Intraoperative Management

Monitoring

• Standard ECG monitoring is sufficient for patients with preoperative PVCs. 1
• No special invasive hemodynamic monitoring is required solely for the presence of PVCs. 1

Treatment Thresholds

• Unifocal or multifocal PVCs during surgery do not merit therapy unless they cause hemodynamic compromise or symptoms. 1
• Very frequent ventricular ectopy or prolonged runs of nonsustained ventricular tachycardia require antiarrhythmic therapy only if symptomatic or causing hemodynamic instability. 1

Pharmacologic Management During Surgery

• Intravenous beta-blockers are the most effective first-line agents for controlling symptomatic ventricular arrhythmias intraoperatively. 1
• Alternative agents include intravenous lidocaine, procainamide, or amiodarone for refractory cases. 1
• Electrical cardioversion should be used for sustained ventricular arrhythmias causing hemodynamic compromise. 1

Prophylactic Beta-Blocker Therapy

• Maintain a low threshold for prophylactic beta-blocker therapy in patients at increased risk of developing perioperative arrhythmias. 1
• Beta-blockers reduce the incidence of arrhythmias during the perioperative period and may reduce mortality and cardiovascular complications for up to 2 years postoperatively. 1, 3

Postoperative Management

Monitoring Strategy

• Continue standard cardiac monitoring in the immediate postoperative period. 1
• Patients who develop sustained or nonsustained ventricular tachycardia during the perioperative period should be referred to cardiology for evaluation of ventricular function and screening for coronary artery disease. 1

Treatment of Postoperative PVCs

• Unifocal or multifocal PVCs do not merit therapy postoperatively. 1
• Very frequent ventricular ectopy or prolonged runs of nonsustained ventricular tachycardia may require antiarrhythmic therapy if symptomatic or causing hemodynamic compromise. 1
• Ventricular arrhythmias may respond to intravenous beta-blockers, lidocaine, procainamide, or amiodarone. 1

Long-Term Considerations

• Patients with ischemic or nonischemic cardiomyopathy, particularly those with LVEF <35%, heart failure history, and nonsustained ventricular tachycardia in the perioperative period, may benefit from ICD therapy for primary prevention of sudden cardiac death—electrophysiology consultation is indicated. 1
• Address reversible causes: correct electrolyte deficiencies, optimize thyroid function, reduce caffeine/alcohol/stimulants, and evaluate for sleep-disordered breathing. 2, 3

Key Clinical Pitfalls to Avoid

• Do not delay surgery for asymptomatic PVCs in patients without structural heart disease—this represents unnecessary risk without benefit. 4
• Do not routinely suppress PVCs with antiarrhythmic drugs in the absence of symptoms or hemodynamic compromise—this approach is not supported by evidence and may introduce medication-related risks. 1
• Avoid acute preoperative potassium repletion in asymptomatic individuals, as this may be associated with greater risk than benefit. 1
• Remember that the presence of PVCs alone does not predict perioperative MI or cardiac death—focus on identifying underlying cardiac disease rather than treating the arrhythmia itself. 1