Transesophageal Echocardiography-guided Anesthetic Management for Laparoscopic Cholecystectomy in a Patient with Left Ventricular Outflow Tract Obstruction: A Case Report

Background: Left ventricular outflow tract (LVOT) obstruction with systolic anterior motion (SAM) of the mitral valve poses significant perioperative risks during non-cardiac surgery. Transesophageal echocardiography (TEE) plays a critical role in real-time hemodynamic monitoring and management of such patients. Case Presentation: A 76-year-old female (54 kg) with suspected hypertrophic cardiomyopathy, diagnosed with LVOT obstruction (Vmax = 3.9 m/s, PG = 59 mm Hg) and SAM, underwent laparoscopic cholecystectomy under general anesthesia. TEE-guided management included: 1. Pre-induction fluid resuscitation (500 mL succinylated gelatin) to optimize preload. 2. Anesthetic induction with midazolam, sufentanil, cisatracurium, and propofol, combined with a continuous norepinephrine infusion (0.05 μg/kg/min) to maintain systemic vascular resistance without increasing contractility. 3. Intraoperative TEE monitoring of LVOT obstruction and SAM severity during reverse Trendelenburg positioning and CO₂ pneumoperitoneum (12 cm H₂O). Fluid therapy and vasopressor titration were adjusted based on TEE findings to maintain hemodynamic stability (BP 110–140/50–90 mm Hg, HR 60–80 bpm). 4. Postoperative pain control with oxycodone and tracheal lidocaine inhalation to prevent sympathetic surges during extubation. Conclusion: TEE-guided anesthesia management effectively mitigated the exacerbation of LVOT obstruction in this high-risk patient, highlighting its value in optimizing perioperative hemodynamics in cases of LVOT obstruction with SAM.