Anesthetic Management of a Patient with Severe Multiple Valvular Heart Disease for Emergency Major Non-Cardiac Surgery: A Case Report
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Abstract
Valvular heart disease is a significant clinical factor associated with elevated perioperative cardiovascular risk. Current literature offers limited guidance on managing severe valvular heart disease in non-cardiac emergency surgeries. In this report, a 61-year-old male with sigmoid adenocarcinoma presents with hemodynamic instability due to partial gut obstruction, complicated by severe aortic and mitral stenoses from rheumatic heart disease. Echocardiography, electrocardiography, and blood tests were employed for preoperative planning. Emergency open abdominal surgery was done under combined regional and general anesthesia, employing techniques that maintained adequate preload and avoided heart rate extremes. Patient tolerated the procedure and the immediate postoperative course. In this case, anesthetic management incorporating effective fluid management, careful hemodynamic monitoring, and maintaining cardiac output is crucial in preventing acute cardiac decompensation.
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[2] Unger P, Pibarot P, Tribouilloy C, Lancellotti P, Maisano F, et al. Multiple and Mixed Valvular Heart Diseases. Circ Cardiovasc Imaging. 2018; 11(8):e007862.
[3] Zhuang S, Guo D, Yu D. A mini review of the pathogenesis of acute rheumatic fever and rheumatic heart disease. Front Cell Infect Microbiol. 2025; 15:1447149.
[4] Laudari S, Subramanyam G. A study of spectrum of rheumatic heart disease in a tertiary care hospital in Central Nepal. Int J Cardiol Heart Vasc. 2017; 15:26-30.
[5] Manjunath CN, Srinivas P, Ravindranath KS, Dhanalakshmi C. Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: a single center experience. Indian Heart J. 2014; 66(3):320-6.
[6] Basnet K, Bhattarai SR, Shah S, Joshi A, Sah SK, et al. Rheumatic Heart Disease among Patients with Valvular Heart Disease Admitted to the In-patient Department of a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc. 2022; 60(249):419-24.
[7] Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease. Lancet. 2012; 379(9819):953-64.
[8] Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021; 143(10):e784.
[9] Unger P, Lancellotti P, de Cannière D. The clinical challenge of concomitant aortic and mitral valve stenosis. Acta Cardiol. 2016; 71(1):3-6.
[10] Samarendra P, Mangione MP. Aortic stenosis and perioperative risk with noncardiac surgery. J Am Coll Cardiol. 2015; 65(3):295-302.
[11] Frogel J, Galusca D. Anesthetic considerations for patients with advanced valvular heart disease undergoing noncardiac surgery. Anesthesiol Clin. 2010; 28(1):67-85.
[12] Jackson P, Vigiola Cruz M. Intestinal Obstruction: Evaluation and Management. Am Fam Physician. 2018; 98(6):362-7.
[13] Thompson JP, Mahajan RP. Monitoring the monitors--beyond risk management. Br J Anaesth. 2006; 97(1):1-3.
[14] Høiseth LØ, Hoff IE, Hagen OA, Landsverk SA, Kirkebøen KA. Dynamic variables and fluid responsiveness in patients for aortic stenosis surgery. Acta Anaesthesiol Scand. 2014; 58(7):826-34.
[15] Ng JH, Leonard I. Managing multiple valvular disease in spine surgery: A case report. JCA Adv. 2025; 2(2):100097.
[16] Riaz S, Mir AW, Sidiq S, Gurcoo SA, Shah MA, et al. Perioperative serum lactate as a predictor of post-operative length of hospital stay and in-hospital mortality in patients undergoing major emergency abdominal surgeries. Asian J Med Sci. 2024; 15(5):16-21.
[17] Valk BI, Struys MMRF. Etomidate and its Analogs: A Review of Pharmacokinetics and Pharmacodynamics. Clin Pharmacokinet. 2021; 60(10):1253-69.
[18] Pillay L, Hardcastle T. Collective Review of the Status of Rapid Sequence Intubation Drugs of Choice in Trauma in Low- and Middle-Income Settings (Prehospital, Emergency Department and Operating Room Setting). World J Surg. 2017; 41(5):1184-92.
[19] Bovill JG. Intravenous anesthesia for the patient with left ventricular dysfunction. Semin Cardiothorac Vasc Anesth. 2006; 10(1):43-8.
[20] Xia Z, Kamra K, Dong J, Harp KA, Xiong Y, et al. Comparison of efficacy and safety of etomidate with other anesthesia induction drugs for patients undergoing cardiac surgery: A systematic review and meta-analysis of randomized controlled trials. Heliyon. 2024; 10(22):e38274.
[21] Stockham RJ, Stanley TH, Pace NL, King K, Groen F, et al. Induction of anesthesia with fentanyl or fentanyl plus etomidate in high-risk patients. J Cardiothorac Anesth. 1987; 1(1):19-23.
[22] Virmani S, Tempe DK, Datt V, Tomar AS, Banerjee A, et al. Effect of muscle relaxants on heart rate, arterial pressure, intubation conditions and onset of neuromuscular block in patients undergoing valve surgery. Ann Card Anaesth. 2006; 9(1):37-43.
[23] Schaefer MS, Hammer M, Santer P, Grabitz SD, Patrocinio M, et al. Succinylcholine and postoperative pulmonary complications: a retrospective cohort study using registry data from two hospital networks. Br J Anaesth. 2020; 125(4):629-36.
[24] Turan A, Mendoza ML, Gupta S, You J, Gottlieb A, et al. Consequences of succinylcholine administration to patients using statins. Anesthesiology. 2011; 115(1):28-35.
[25] Yang XL, Wang D, Zhang GY, Guo XL. Comparison of the myocardial protective effect of sevoflurane versus propofol in patients undergoing heart valve replacement surgery with cardiopulmonary bypass. BMC Anesthesiol. 2017; 17(1):37.
[26] Nimmo SM, Foo ITH, Paterson HM. Enhanced recovery after surgery: Pain management. J Surg Oncol. 2017; 116(5):583-91.
[27] Brown J, Morgan-Hughes NJ. Aortic stenosis and non-cardiac surgery. Contin Educ Anaesth Crit Care Pain. 2005; 5(1):1–4.
[28] Liu X, Song T, Chen X, Zhang J, Shan C, et al. Quadratus lumborum block versus transversus abdominis plane block for postoperative analgesia in patients undergoing abdominal surgeries: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol. 2020; 20(1):53.
[2] Unger P, Pibarot P, Tribouilloy C, Lancellotti P, Maisano F, et al. Multiple and Mixed Valvular Heart Diseases. Circ Cardiovasc Imaging. 2018; 11(8):e007862.
[3] Zhuang S, Guo D, Yu D. A mini review of the pathogenesis of acute rheumatic fever and rheumatic heart disease. Front Cell Infect Microbiol. 2025; 15:1447149.
[4] Laudari S, Subramanyam G. A study of spectrum of rheumatic heart disease in a tertiary care hospital in Central Nepal. Int J Cardiol Heart Vasc. 2017; 15:26-30.
[5] Manjunath CN, Srinivas P, Ravindranath KS, Dhanalakshmi C. Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: a single center experience. Indian Heart J. 2014; 66(3):320-6.
[6] Basnet K, Bhattarai SR, Shah S, Joshi A, Sah SK, et al. Rheumatic Heart Disease among Patients with Valvular Heart Disease Admitted to the In-patient Department of a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc. 2022; 60(249):419-24.
[7] Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease. Lancet. 2012; 379(9819):953-64.
[8] Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021; 143(10):e784.
[9] Unger P, Lancellotti P, de Cannière D. The clinical challenge of concomitant aortic and mitral valve stenosis. Acta Cardiol. 2016; 71(1):3-6.
[10] Samarendra P, Mangione MP. Aortic stenosis and perioperative risk with noncardiac surgery. J Am Coll Cardiol. 2015; 65(3):295-302.
[11] Frogel J, Galusca D. Anesthetic considerations for patients with advanced valvular heart disease undergoing noncardiac surgery. Anesthesiol Clin. 2010; 28(1):67-85.
[12] Jackson P, Vigiola Cruz M. Intestinal Obstruction: Evaluation and Management. Am Fam Physician. 2018; 98(6):362-7.
[13] Thompson JP, Mahajan RP. Monitoring the monitors--beyond risk management. Br J Anaesth. 2006; 97(1):1-3.
[14] Høiseth LØ, Hoff IE, Hagen OA, Landsverk SA, Kirkebøen KA. Dynamic variables and fluid responsiveness in patients for aortic stenosis surgery. Acta Anaesthesiol Scand. 2014; 58(7):826-34.
[15] Ng JH, Leonard I. Managing multiple valvular disease in spine surgery: A case report. JCA Adv. 2025; 2(2):100097.
[16] Riaz S, Mir AW, Sidiq S, Gurcoo SA, Shah MA, et al. Perioperative serum lactate as a predictor of post-operative length of hospital stay and in-hospital mortality in patients undergoing major emergency abdominal surgeries. Asian J Med Sci. 2024; 15(5):16-21.
[17] Valk BI, Struys MMRF. Etomidate and its Analogs: A Review of Pharmacokinetics and Pharmacodynamics. Clin Pharmacokinet. 2021; 60(10):1253-69.
[18] Pillay L, Hardcastle T. Collective Review of the Status of Rapid Sequence Intubation Drugs of Choice in Trauma in Low- and Middle-Income Settings (Prehospital, Emergency Department and Operating Room Setting). World J Surg. 2017; 41(5):1184-92.
[19] Bovill JG. Intravenous anesthesia for the patient with left ventricular dysfunction. Semin Cardiothorac Vasc Anesth. 2006; 10(1):43-8.
[20] Xia Z, Kamra K, Dong J, Harp KA, Xiong Y, et al. Comparison of efficacy and safety of etomidate with other anesthesia induction drugs for patients undergoing cardiac surgery: A systematic review and meta-analysis of randomized controlled trials. Heliyon. 2024; 10(22):e38274.
[21] Stockham RJ, Stanley TH, Pace NL, King K, Groen F, et al. Induction of anesthesia with fentanyl or fentanyl plus etomidate in high-risk patients. J Cardiothorac Anesth. 1987; 1(1):19-23.
[22] Virmani S, Tempe DK, Datt V, Tomar AS, Banerjee A, et al. Effect of muscle relaxants on heart rate, arterial pressure, intubation conditions and onset of neuromuscular block in patients undergoing valve surgery. Ann Card Anaesth. 2006; 9(1):37-43.
[23] Schaefer MS, Hammer M, Santer P, Grabitz SD, Patrocinio M, et al. Succinylcholine and postoperative pulmonary complications: a retrospective cohort study using registry data from two hospital networks. Br J Anaesth. 2020; 125(4):629-36.
[24] Turan A, Mendoza ML, Gupta S, You J, Gottlieb A, et al. Consequences of succinylcholine administration to patients using statins. Anesthesiology. 2011; 115(1):28-35.
[25] Yang XL, Wang D, Zhang GY, Guo XL. Comparison of the myocardial protective effect of sevoflurane versus propofol in patients undergoing heart valve replacement surgery with cardiopulmonary bypass. BMC Anesthesiol. 2017; 17(1):37.
[26] Nimmo SM, Foo ITH, Paterson HM. Enhanced recovery after surgery: Pain management. J Surg Oncol. 2017; 116(5):583-91.
[27] Brown J, Morgan-Hughes NJ. Aortic stenosis and non-cardiac surgery. Contin Educ Anaesth Crit Care Pain. 2005; 5(1):1–4.
[28] Liu X, Song T, Chen X, Zhang J, Shan C, et al. Quadratus lumborum block versus transversus abdominis plane block for postoperative analgesia in patients undergoing abdominal surgeries: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol. 2020; 20(1):53.
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| Section | Case Report(s) | |
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| Heart valve diseases Intestinal obstruction Laparotomy Anesthesia Case report | ||
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How to Cite
1.
Ona HM, Monteblanco C, Esguerra V. Anesthetic Management of a Patient with Severe Multiple Valvular Heart Disease for Emergency Major Non-Cardiac Surgery: A Case Report. Arch Anesth & Crit Care. 2026;.
