Slow-Onset Epidural Anesthesia for Cesarean Delivery in Severe Multivalvular Heart Disease and Atrial Fibrillation: The Role of Preoperative Optimization and Hemodynamic-Guided Management

Pregnancy places substantial stress on the cardiovascular system, and this effect is amplified in females with rheumatic valvular disease. We describe the anesthetic management of a 37-year-old multiparous patient with severe multivalvular disease (severe mitral stenosis, severe aortic insufficiency, and severe tricuspid regurgitation with stenosis) and atrial fibrillation, presenting with signs of congestive heart failure, who was submitted to an elective cesarean section at 37 weeks of gestation. Following admission, she received targeted medical optimization in a cardiac intensive care setting, including rate control and diuretic therapy, with subsequent clinical improvement. Anticoagulation with low-molecular-weight heparin was suspended 24 hours before surgery. Considering her fixed cardiac output and the potential harm of abrupt hemodynamic shifts during surgery, a slow-onset epidural anesthesia under invasive monitoring was performed. Incremental boluses of 0.75% ropivacaine, combined with early vasopressor support, allowed for an adequate sensory block, maintaining hemodynamic stability throughout surgery. Intraoperative tachyarrhythmia was managed through cautious fluid administration and pharmacological treatment. Oxytocin was carefully and slowly administered to prevent sudden reductions in systemic vascular resistance. Since resumption of therapeutic anticoagulation was planned due to high thromboembolic risk, the epidural catheter was removed at the end of the surgery. A multimodal analgesic strategy was adopted, including a single epidural morphine bolus and bilateral transversus abdominis plane blocks. Both maternal and neonatal outcomes were favorable. This case highlights the importance of meticulous preoperative optimization and planning, the safety of graded neuraxial anesthesia, and the need for multidisciplinary discussion when managing parturients with advanced multivalvular heart disease.