Awake Bipolar Hemiarthroplasty Under Combined Posterior Lumbar Plexus and Subgluteal Sciatic Nerve Blocks in a Patient with True Severe Low- Flow Low-Gradient Aortic Stenosis and End-Stage Ischemic Cardiomyopathy: A Case Report

Background: Hip fracture surgery in patients with severe aortic stenosis and advanced heart failure presents a major anesthetic challenge. General anesthesia may cause myocardial depression and hemodynamic instability, while neuraxial anesthesia carries the risk of sympathectomy-induced hypotension. Peripheral nerve blocks may offer a safer alternative in selected high-risk patients. Case Presentation: A 74-year-old man with severe ischemic cardiomyopathy (ejection fraction 21%), true severe low-flow low-gradient aortic stenosis, moderate pulmonary hypertension, chronic atrial fibrillation with CRT-D, chronic kidney disease, and recent urosepsis required urgent bipolar hemiarthroplasty. After multidisciplinary optimization, surgery was performed under combined posterior lumbar plexus and subgluteal sciatic nerve blocks. The patient remained fully awake without sedation. Invasive monitoring was established, and a low-dose norepinephrine infusion (80-240 μg/h) maintained hemodynamic stability. The procedure lasted approximately four hours with blood loss <700 mL. Blood pressure remained stable around 100/60 mmHg and heart rate between 60-85 beats/min under CRT-D pacing. Conclusion: Combined posterior lumbar plexus and sciatic nerve blocks may provide a valuable anesthetic option for selected patients with severe low-flow low-gradient aortic stenosis and advanced heart failure undergoing urgent hip fracture surgery, allowing avoidance of both general anesthesia and neuraxial sympathectomy while preserving hemodynamic stability. Keywords: aortic valve stenosis, hemiarthroplasty, high risk surgical patients, hip fractures, ischemic cardiomyopathy, low flow low gradient aortic stenosis, lumbar plexus block, regional anesthesia, sciatic nerve block, systolic heart failure