Electrocardiographic (ECG) monitoring assists with intraoperative patient surveillance during surgery by offering real-time insights into cardiac electrophysiology. During surgery, patients may experience varying degrees of physiological stress, electrolyte imbalances, anesthetic drug effects, and fluid shifts, all of which can lead to arrhythmias or cardiac ischemia. ECG monitoring allows anesthesiologists and surgeons to detect these potentially life-threatening events as early as possible, enabling them to intervene promptly and improve surgery outcomes.
ECG monitoring is especially important during high-risk surgeries, such as those involving the elderly, patients with known cardiovascular disease, and those undergoing cardiac or major non-cardiac surgery. The primary goal is to identify arrhythmias, ischemic changes, and conduction abnormalities early on. Advanced algorithms and monitoring technologies can now detect subtle changes like ST-segment depression or T-wave inversions, which may indicate myocardial ischemia before clinical symptoms appear (1).
Recent literature emphasizes that ECG monitoring plays a critical predictive role in postoperative cardiac complications. For example, studies of patients undergoing off-pump coronary artery bypass grafting (CABG) indicate that preoperative and intraoperative heart rate variability (HRV), a measure derived from ECG signals, is a strong predictor of postoperative atrial fibrillation (AF) (2). Since postoperative AF is associated with increased morbidity and length of hospital stay, the ability to predict and potentially mitigate these outcomes highlights the clinical utility of continuous ECG monitoring.
The use of ECGs is not limited to detecting arrhythmias—they also contribute to the broader risk stratification of patients. A user-friendly scoring system that integrates autonomic nervous system data and coronary physiology has been developed. This system incorporates ECG-derived metrics to classify patients with non-ST-elevation acute coronary syndrome into different risk categories (1). These systems have potential intraoperative applications, particularly for patients undergoing emergency or high-stress procedures.
ECG monitoring has also demonstrated its value in dental surgery settings, where hypertensive patients often undergo procedures under local anesthesia. A retrospective study found that ECG monitoring during tooth extraction procedures facilitated the early detection of hypertension-induced cardiac changes and arrhythmias, reinforcing the notion that even seemingly minor surgical interventions may benefit from cardiovascular monitoring in select populations (3).
Furthermore, new electrophysiological techniques and treatment modalities, such as pulsed field ablation (PFA), for persistent atrial fibrillation underscore the importance of precise ECG signal interpretation. While PFA is primarily a therapeutic modality, its success and safety during surgery depend heavily on accurate mapping and real-time ECG guidance (4). These findings highlight the growing sophistication of the ECG’s role in modern surgery, establishing it not only as a monitoring tool but also as a feedback mechanism for intraoperative therapeutic procedures.
Despite its clinical significance, ECG monitoring is not without limitations. Artifacts, especially in the operative field with electrocautery, can lead to false-positive signals. Interpretation requires training, and reliance on automated algorithms without expert validation may lead to oversight of significant changes. Nonetheless, as wearable and multi-lead technologies evolve, ECG’s intraoperative reliability and resolution are expected to improve further (5).
In summary, ECG monitoring remains a fundamental component of care during surgery, offering crucial insights into cardiac function and risk. Its application spans various surgical disciplines and patient populations, contributing significantly to safety, early detection of complications, and guiding real-time clinical decisions. As ECG technologies advance, their integration into surgical practice will likely become even more nuanced, paving the way for personalized and predictive perioperative care.
References
1. Yang X, Li Z, Liu X, et al. An Easy-to-Use Risk Stratification System for NSTE-ACS Patients Combining Autonomic Nervous System and Coronary Physiology. Int J Med Sci. 2025;22(10):2342-2353. Published 2025 Apr 28. doi:10.7150/ijms.111214
2. Kšela J, Kafol J, Avbelj V, Kališnik JM. Predictive Value of Heart Rate Variability for Postoperative Atrial Fibrillation in Off-Pump Coronary Artery Bypass Patients. Medicina (Kaunas). 2025;61(6):984. Published 2025 May 26. doi:10.3390/medicina61060984
3. Yang Y, Wang W, Ji Y, Xu X, Liu C, Li J. Risk analysis of tooth extraction in hypertensive patients under ECG monitoring: a single-center retrospective study. BMC Oral Health. 2025;25(1):904. Published 2025 Jun 3. doi:10.1186/s12903-025-06076-1
4. Reddy VY, Gerstenfeld EP, Schmidt B, et al. Pulsed Field Ablation for Persistent Atrial Fibrillation: 1-Year Results of ADVANTAGE AF. J Am Coll Cardiol. 2025;85(17):1664-1678. doi:10.1016/j.jacc.2025.03.515
5. Hartmeyer SL, Phillips NE, Jassil FC, et al. Multi-Wearable Approach for Monitoring Diurnal Light Exposure and Body Rhythms in Nightshift Workers. Acta Physiol (Oxf). 2025;241(7):e70069. doi:10.1111/apha.70069