Perioperative Management of a High-Risk Cardiac Patient for Laparoscopic Anterior ResectionPatient Overview

A 78-year-old male, weighing 50 kg and 160 cm tall (BMI 19.5), with a history of prior percutaneous coronary intervention and moderate left ventricular dysfunction, was scheduled for a 4-hour laparoscopic anterior resection. His baseline vitals showed a heart rate of 62 beats per minute and blood pressure of 110/60 mmHg (MAP ~76 mmHg).

According to the 2014 ACC/AHA perioperative cardiovascular evaluation guideline, this patient represents a high cardiac risk profile due to prior ischemic heart disease and impaired left ventricular function (1).

Echocardiographic Assessment

Preoperative echocardiography revealed a left ventricular ejection fraction (LVEF) of 35% with fractional shortening of 17%, consistent with moderate systolic dysfunction. Chamber dimensions were mildly dilated (LVIDd 53 mm, LVIDs 37 mm), and regional wall motion abnormalities included akinesia of the interventricular septum, apex, and anterior wall, with hypokinesia of the inferior wall.

Diastolic assessment demonstrated an E/A ratio of 0.8 with a deceleration time of 148 ms, consistent with grade I diastolic dysfunction and impaired relaxation (2,3).

Valvular findings included trivial aortic regurgitation with calcification but no stenosis, mild mitral regurgitation with annular calcification, and trivial tricuspid regurgitation. Pulmonary pressures were normal with no evidence of pulmonary hypertension.

Physiological and Molecular Interpretation

Left ventricular systolic dysfunction reflected reduced contractility due to post-infarction remodeling, associated at the molecular level with reduced ATP availability, impaired SERCA2a activity, and upregulation of pro-inflammatory cytokines including TNF-α and IL-6 (4). Regional wall motion abnormalities correlated with myocardial scarring and hibernation, processes involving collagen deposition and matrix metalloproteinase activation. Diastolic dysfunction was attributed to delayed myocardial relaxation and increased fibrosis, mediated by transforming growth factor-β signaling and further reduction in SERCA2a activity. Valve calcification represented age-related osteogenic transformation of valve interstitial cells, involving transcriptional regulation via the Runx2 pathway (5,6).

Anesthetic Strategy

Premedication included glycopyrrolate 0.2 mg to prevent vagal bradycardia and midazolam 1 mg for anxiolysis with minimal cardiac depression. Fentanyl 200 mcg provided opioid analgesia without compromising contractility. Induction was achieved with propofol 40 mg in carefully titrated doses to minimize myocardial depression. Sevoflurane was used for maintenance, selected for its relative preservation of coronary perfusion.

For neuromuscular blockade, succinylcholine 50 mg was administered for rapid sequence induction due to aspiration risk, followed by atracurium 30 mg with infusion at 10 mg/hour to ensure predictable metabolism independent of hepatic or renal function. Dexmedetomidine at 20 mcg provided sedation, though vigilance was required for potential bradycardia and hypotension. Magnesium sulfate 1 g was given prophylactically for arrhythmia prevention. Morphine 3 mg intramuscularly and paracetamol 500 mg were included in a multimodal analgesic regimen, while dexamethasone 8 mg was administered for antiemetic prophylaxis.

This drug selection emphasized hemodynamic stability, minimal myocardial depression, and multimodal analgesia while balancing the risks of hypotension and respiratory depression (7,8).

Fluid and Perfusion Management

A restrictive fluid strategy was adopted to minimize the risk of heart failure. Intraoperatively, 1 L of crystalloid and 500 ml of Gelofusine were administered, maintaining adequate preload without excessive fluid loading. Urine output averaged 40 ml/hr (0.8 ml/kg/hr), indicating adequate renal perfusion. This approach aligned with evidence from the RELIEF trial and earlier studies showing that restrictive fluid therapy reduces postoperative complications in major abdominal surgery (9,10).

Surgical Considerations: Laparoscopy vs Open

Laparoscopic resection was favored over open surgery due to reduced postoperative pain and earlier recovery, though pneumoperitoneum introduced additional hemodynamic challenges. CO₂ insufflation reduced venous return and risked hypercapnia, which required close ventilation and hemodynamic monitoring. Trendelenburg positioning further compromised preload in the setting of diastolic dysfunction. Nevertheless, the laparoscopic approach reduced opioid requirements, particularly when combined with an erector spinae plane (ESP) block for regional analgesia (11,12).

Anticipated Complications and Vigilance

Several red-flag complications were identified:

• Myocardial ischemia: given the presence of regional wall motion abnormalities and LVEF of 35%. Preventive strategies included maintaining MAP above 65 mmHg and avoiding tachycardia.
• Heart failure: exacerbated by pneumoperitoneum, diastolic dysfunction, and Trendelenburg position. This was mitigated through strict fluid restriction and invasive monitoring.
• Hypotension: risk was elevated due to low cardiac reserve and dexmedetomidine administration, necessitating preparedness with vasopressors such as phenylephrine.
• Arrhythmias: CAD, myocardial scar, and electrolyte shifts predisposed to arrhythmias, with prophylactic magnesium administered.
• Respiratory depression: the patient’s advanced age and opioid use increased this risk, requiring close oxygen saturation monitoring and readiness with naloxone.
• Renal impairment: low cardiac output and advanced age posed risk, necessitating urine output and MAP monitoring to ensure renal perfusion.

These risks reflect evidence that elderly patients with ischemic cardiomyopathy are particularly vulnerable to perioperative cardiovascular events (13,14).

Conclusion

This elderly cardiac patient with prior PCI, moderate LV systolic dysfunction (LVEF 35%, FS 17%), and grade I diastolic dysfunction required a carefully tailored anesthetic plan. Echocardiographic findings guided risk stratification, while anesthetic agents were selected for minimal myocardial depression. A restrictive, goal-directed fluid approach ensured adequate perfusion without precipitating heart failure. The laparoscopic technique, complemented by regional analgesia, reduced opioid burden and supported early recovery. Continuous vigilance for myocardial ischemia, heart failure, hypotension, and arrhythmias was critical in ensuring a safe perioperative course.