Bilateral risk-reducing mastectomy under awake regional anaesthesia with immediate prepectoral reconstruction using lightweight implants in a patient with severe cardiomyopathy: a case report

Risk-reducing mastectomy is an established preventive strategy for carriers of pathogenic germline mutations. In patients with severe cardiomyopathy, general anaesthesia may represent a prohibitive risk. Awake regional anaesthesia may offer a feasible alternative in selected high-risk patients. A 51-year-old woman with a pathogenic ATM mutation and severe hypertrophic cardiomyopathy (NYHA III-IV, ASA IV) underwent bilateral nipple-sparing risk-reducing mastectomy under awake thoracic regional anaesthesia using bilateral erector spinae plane and intertransverse process blocks with conscious sedation. Immediate prepectoral reconstruction with lightweight polyurethane-coated implants was performed. The procedure was completed without complications, recovery was uneventful, and the patient was discharged on postoperative day 1. Awake regional anaesthesia enabled maintenance of spontaneous ventilation and haemodynamic stability, while flap-preserving surgical technique and low-impact reconstruction supported uncomplicated recovery. Tailored perioperative strategies may allow safe completion of risk-reducing breast surgery in carefully selected patients otherwise considered unsuitable for conventional anaesthetic approaches.