Background: Acute coronary syndrome, coupled with severe mitral disease with a few hours of onset, is an anesthetic challenge. Perioperative handling, therapeutic choice and adequate monitoring are fundamental to maintain hemodynamic stability. The following case report describes a successful anesthetic approach in a patient with poor prognosis.
Case report: A 65 years old female, ASA VE, was admitted to the emergency OR for exploratory laparotomy for suspicion of mesenteric ischemia. Past history: type II Diabetes Mellitus, Hypertension and Obesity. Admitted to the Cardiology ICU in the past 48h for acute myocardial infarction. Transthoracic Ecocardiography: severely compromised left ventricular function (EF=22%) and severe mitral insufficiency with tendinous cord rupture. An intra-aortic ballon pump (IABP) was placed to maintain hemodynamic stability and she was scheduled for coronary bypass surgery and mitral valve replacement the next day. She had 2 episodes of atrial fibrillation with fast ventricular response that continued despite treatment. The IABP was removed 1 hour before surgery and heparin was suspended. After standard monitoring and placement of an arterial line, heart rate control was done with 3 boluses of labetalol 1mg. For the anesthetic induction we used midazolam 1mg, etomidate 0.2mg/kg, fentanyl 0.15 mg and rocuronium 1mg/kg. A central venous catheter was placed and 2 infusions were started: noradrenaline at 0.1 ug/kg/min to maintain adequate blood pressure and isosorbide dinitrate because of the coronary disease. Maintenance was done with sevoflurane, fentanyl and morphine. The patient stayed hemodinamically stable with no surgical or anesthetic events. Diagnosis was confirmed and a bowel resection and colostomy were made. She was transferred to the ICU under assisted ventilation and sedated with midazolam and morphine.
Discussion: The serious cardiac and surgical disease of this patient predicted a poor prognosis. Difficulties maintaining hemodynamic stability were expected after anesthetic induction and during the surgery. The choice of the anesthetic approach and drugs is not an easy one and this case report shows a successful handling of a critical situation.
References: Anesth Essays Res. 2013 Sep-Dec; 7(3): 399-401.
Learning points: Patients with severe cardiac conditions submitted to urgent procedures require a careful anesthetic management aiming for hemodynamic stability and outcome improvement.

Acute mesenteric ischemia in a patient with severe cardiac disease