Successful anaesthetic management in a patient scheduled for open-heart surgery for the third time: A case report

Case description and management: This report presents the case of a 48-year-old man with severe mitral valve dysfunction and multiple comorbidities who underwent redo mitral valve replacement. A comprehensive anaesthetic management plan was tailored to the patient, incorporating invasive haemodynamic monitoring with a coordinated multidisciplinary strategy. Cardiopulmonary bypass was established using femorofemoral cannulation, ensuring haemodynamic stability during the procedure. Postoperative care involved vigilant monitoring of haemodynamic and respiratory complications. The patient experienced transient desaturation, which was effectively managed with targeted therapy. The patient was extubated on postoperative day three and discharged in stable condition.

Conclusion: This case highlights the critical importance of multidisciplinary planning, individualised anaesthetic strategies, and proactive postoperative management in high-risk reoperative cardiac surgery to achieve favourable outcome.

Reoperative cardiac surgery is associated with heightened morbidity due to the presence of adhesions, altered mediastinal anatomy, and changes in cardiac physiology [1]. Hemodynamic responses to induction, ventilation, and cardiopulmonary bypass can be unpredictable in patients undergoing repeat sternotomy [2]. Effective multidisciplinary collaboration is crucial to ensure patient safety and optimise perioperative outcomes in complex redo cardiac surgeries. This case report describes an effective anaesthetic method for a patient undergoing a third open-heart surgery.

Echocardiographic assessment identified major stenosis and regurgitation of the bioprosthetic mitral valve, with peak and mean pressure gradients measured at 20.4 mmHg and 14.2 mmHg, respectively. The left ventricular ejection fraction was 40%, while the right ventricular ejection fraction ranged between 35% and 40% (Figure 1a). Additionally, pulmonary artery pressure was found to be elevated. In light of the progressive symptoms and valve dysfunction, a surgical intervention was deemed necessary. Informed written consent was obtained from the patient and relatives after discussing the pros and cons of the third cardiac surgery.

The haemodynamic goals focus on maintaining adequate ventricular perfusion and preventing acute failure. Adrenaline and noradrenaline are essential inotropes that support the residual volume free wall and increase systemic vascular resistance [7]. Studies have shown that advanced haemodynamic monitoring supports the judicious use of inotropes [8, 9]. In our scenario, although advanced cardiac output monitoring was unavailable, careful titration guided by invasive arterial pressure and central venous pressure trends provided adequate haemodynamic assessment.

Transient postoperative desaturation underscores the need for vigilant pulmonary monitoring. Early detection and intervention prevented respiratory decline. Successful extubation demonstrates the effectiveness of proactive ventilatory strategies in reducing intensive care unit length of stay. We report here that a multidisciplinary team of cardiologist, anaesthesiologist and surgeon can safely manage anaesthetic procedure in a patient undergoing open heart surgery for the third time.