Anesthetic Management of Intraoperative Hemodynamic Instability in Patient with Hypertrophic Obstructive Cardiomyopathy for Non-Cardiac Surgery: A Case Report

Hypertrophic Obstructive Cardiomyopathy (HOCM) presents formidable challenges in anesthetic management due to its high prevalence and complex pathophysiology, where hemodynamic stabilization is paramount. This case report details the successful intraoperative management of a 54-year-old female with HOCM who developed hemodynamic instability during spinal surgery concerning L4-L5, L5-S1 pedicle screw stabilization, decompression, and transforaminal interbody fusion in the prone position.Preoperatively, the patient exhibited dyspnea on exertion (DOE) grade 2 and an effort tolerance of less than 4 METS. A cardiology evaluation classified her as moderate to high risk for surgery. Due to limited resources, cardiac output monitoring and arterial line placement were not performed. The patient was advised to continue beta-blockers and discontinue angiotensin receptor blockers (ARBs) on the day of surgery. Intraoperative hypotension was managed with fluid boluses and phenylephrine aliquots (1:20, 1:100). Phenylephrine was chosen due to its reflex bradycardia effects, which were beneficial in this context. The patient's blood pressure ranged between 73/50 mmHg after turning prone and 108/61 mmHg during extubation, while the heart rate varied from 55 bpm post-induction to 102 bpm during extubation.The patient was relatively young, had no significant cardiac complaints, had a normal sinus rhythm, good ejection fraction, and no regional wall motion abnormalities or pulmonary arterial hypertension. However, factors such as a peak LVOT gradient of 103 mmHg at rest, systolic anterior motion (SAM) of the mitral valve, and grade 2 mitral regurgitation (MR) made this case challenging. Thus, this compelling case report highlights that with thorough preoperative evaluation, appropriate perioperative analgesia, and a well-coordinated multimodal approach involving cardiologists, anesthesiologists, and orthopedic surgeons, high-risk HOCM patients can be managed successfully even in resource-constrained environments.