Management of PVCs in Emergency Surgery
Proceed immediately to the operating room without delay for preoperative cardiac testing or intervention. 1
Primary Recommendation
The ACC/AHA guidelines provide a Class I recommendation (Level of Evidence: C) that patients requiring emergency noncardiac surgery should proceed directly to the operating room and continue perioperative surveillance with postoperative risk stratification and risk factor management. 1 The presence of more than 5 PVCs on a single ECG does not constitute an "active cardiac condition" that would delay emergency surgery.
Rationale for Immediate Surgical Intervention
The finding of PVCs on preoperative ECG, even when frequent, does not meet the threshold for delaying emergency surgery unless accompanied by hemodynamically unstable ventricular tachycardia or other active cardiac conditions requiring immediate stabilization. 1
Emergency surgery by definition addresses life-threatening conditions where surgical delay poses greater mortality risk than proceeding with anesthesia in the presence of ventricular ectopy. 1
Perioperative Management Strategy
Intraoperative Monitoring
Continuous cardiac rate and rhythm monitoring with backup pacing and defibrillation equipment immediately available throughout the procedure. 1
Anesthesiologists should be aware that patients may be more sensitive to myocardial depressant and conduction effects of halogenated inhalational anesthetics. 2
Immediate Concerns to Address
Correct reversible causes before or during induction: Check and correct electrolyte abnormalities (hypokalemia, hypomagnesemia, hypercalcemia), assess for acute myocardial ischemia, evaluate for drug toxicity (particularly digitalis), and optimize volume status if dehydrated. 3
Avoid high adrenergic states: Minimize anxiety, pain, and catecholamine excess through appropriate anxiolysis and analgesia. 3
Pharmacologic Considerations
Beta-blockers are first-line if hemodynamically tolerated to reduce PVC frequency and prevent progression to more malignant arrhythmias during the stress of surgery. 1, 4
Amiodarone may be considered for recurrent hemodynamically relevant ventricular arrhythmias that develop intraoperatively, though prophylactic antiarrhythmic therapy is not indicated for isolated PVCs. 4, 2
Postoperative Management
Immediate Postoperative Period
Continue continuous cardiac monitoring with backup defibrillation equipment readily available. 1
Perform postoperative risk stratification including assessment of whether PVCs represent new-onset arrhythmia or pre-existing condition. 1
Subsequent Evaluation (After Surgical Recovery)
Once the patient has recovered from the acute surgical indication:
Obtain 24-hour Holter monitoring to quantify PVC burden as the absolute number of PVCs per day directly informs long-term risk and guides subsequent management. 4
Perform transthoracic echocardiography if PVC burden ≥24% or ≥2,000 PVCs per 24 hours to assess for structural heart disease or PVC-induced cardiomyopathy. 4
Consider cardiac MRI with contrast if PVC burden ≥2,000 per 24 hours, episodes of non-sustained ventricular tachycardia, or echocardiographic abnormalities to evaluate for cardiomyopathy, myocarditis, sarcoidosis, or arrhythmogenic right ventricular cardiomyopathy. 4
Critical Pitfalls to Avoid
Do not delay emergency surgery to perform cardiac stress testing or advanced imaging. The guidelines explicitly state that emergency surgery should proceed regardless of cardiac findings. 1
Do not assume PVCs are benign without quantifying burden postoperatively. PVC burden >10-15% can cause or worsen cardiomyopathy regardless of initial etiology. 3
Do not dismiss multifocal PVCs as insignificant. Multifocal PVCs indicate higher risk even without sustained ventricular tachycardia and are associated with increased cardiovascular events. 3