Introduction

Aortic stenosis (AS) is the most common valvular heart disease in developed countries, and its prevalence increases with age 1, 2). Each year, over 300,000 patients aged 65 and older are hospitalized for proximal femur fractures, many of whom concurrently have AS 3). A normal aortic valve area ranges from 3–4 cm², whereas a valve area <1.0 cm² is classified as severe aortic stenosis (SAS). The main clinical manifestations of SAS include exertional angina, heart failure, presyncope, or syncope. Patients often experience exertional dyspnea due to elevated left ventricular filling pressures or an impaired ability to augment cardiac output during activity 4).

Severe aortic stenosis (SAS) in patients with left ventricular systolic dysfunction (LVEF <50%) significantly increases perioperative risk, as the fixed cardiac output can precipitate hemodynamic collapse 5, 6). These patients are also prone to hypotensive episodes and myocardial ischemia 7, 8), and pulmonary edema may occur due to fluid shifts 9, 10). Femur fractures in this population require urgent surgical fixation but present major anesthetic challenges. According to the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines 11), SAS is the greatest risk factor in non-cardiac surgery 12). Conversely, delaying surgery leaves patients bedridden, increasing the risk of physical and psychiatric complications associated with immobility. Our challenge was to select an anesthetic approach that provided adequate analgesia while maintaining stable hemodynamics in this high-risk patient.

Historically, neuraxial anesthesia has been considered contraindicated in patients with aortic stenosis (AS) due to its sympatholytic effects, which reduce vascular resistance and can decrease cardiac output and organ perfusion. Similarly, general anesthesia with intravenous or volatile agents may lead to arrhythmias, myocardial depression, and heart failure. In high-risk cardiac patients, general anesthesia is also associated with increased respiratory complications and higher 30-day mortality compared to neuraxial techniques 13).

Nevertheless, regional anesthesia offers potential advantages in this population, as it avoids myocardial depression from volatile agents 14, 15), minimizes blood pressure fluctuations 16), and reduces opioid requirements through its analgesic effect. Here, we present a case in which combined spinal anesthesia and a peripheral nerve block were used successfully in a patient with severe AS and reduced LVEF undergoing femur fracture repair.

Case presentation

A 79-year-old male patient was scheduled for elective orthopedic surgery. He had a known history of severe aortic stenosis (AS) and, according to his most recent echocardiography, demonstrated left ventricular systolic dysfunction with an LVEF of 30%, at least moderate mitral regurgitation (MR), severe low-flow, low-gradient AS with an aortic valve area (AVA) of 0.6 cm² by continuity equation, and up to moderate tricuspid regurgitation (TR) with a pulmonary artery pressure of 40 mmHg. He also had chronic atrial fibrillation. The patient sustained a right femur fracture from a fall on a flat surface and was scheduled for open reduction and internal fixation (ORIF).

The patient’s regular medications included losartan 25 mg, bisoprolol 2.5 mg, nitrocontin 2.6 mg, and rivaroxaban 2.5 mg twice daily. He also took aspirin 80 mg and furosemide 20 mg daily; aspirin was discontinued five days prior to surgery.

Radiological examination confirmed an intert-rochanteric fracture of the right femur (Figure 1). Preoperative laboratory studies revealed a hemoglobin level of 11.5 g/dL, platelet count of 168,000/mm³, prothrombin time of 20 seconds, activated partial thromboplastin time of 52 seconds, and an INR of 2. Renal function tests showed a BUN of 33 mg/dL and creatinine of 1.6 mg/dL. Electrolytes were within normal limits, with a serum sodium of 135 mEq/L and potassium of 4.5 mEq/L.

Intraoperative management

After an 8-hour NPO period, the patient was brought to the operating room. The planned anesthetic approach was multimodal analgesia using low-dose spinal anesthesia combined with a peripheral nerve block. Following informed consent, standard monitoring was initiated, including non-invasive blood pressure (NIBP), pulse oximetry (SpO₂), heart rate (HR), and electrocardiography (ECG). Baseline vital signs were: blood pressure 115/75 mmHg, HR 84 bpm, respiratory rate 14 breaths/min, and SpO₂ 96% on room air.

Figure 1. Before and after surgical repair of the intertrochanteric fracture.

After sterile preparation and draping of the groin, the lateral cutaneous and peripheral nerves of the right thigh were blocked under ultrasound guidance using 3 mL of 0.25% bupivacaine. Approximately 10 minutes later, the peripheral block took effect. The patient was then assisted to a sitting position, and following sterile preparation of the lower back, a low-dose spinal injection of 5 mg bupivacaine combined with 25 μg fentanyl was administered at the L4–L5 interspace. The patient was positioned in the right lateral decubitus position to maximize the unilateral effect of the spinal anesthetic. Once a T10 sensory blockade was achieved, surgery commenced with stable hemodynamics. Supplemental oxygen was administered at 4 L/min via face mask, and the patient was continuously monitored with ECG, NIBP, and pulse oximetry throughout the procedure.

The surgery lasted approximately two hours, during which adequate anesthesia was maintained without the need to convert to general anesthesia. Estimated blood loss was around 250 mL. The patient remained hemodynamically stable throughout the procedure, with no episodes of severe hypotension or bradycardia, and vasopressors such as phenylephrine were not required. No supplemental sedation was administered. Additionally, there were no signs of heart failure or respiratory compromise during the operation.

Intraoperatively, the patient’s blood pressure ranged from 100/65 to 110/70 mmHg, and heart rate remained between 80 and 86 bpm. Following surgery, he was transferred to the post-anesthesia care unit (PACU), where he continued to be closely monitored. In the PACU, his hemodynamics remained stable: BP 110–115/70 mmHg, HR 84 bpm, RR 12 breaths/min, and SpO₂ 99% on face mask, with effective pain control.

The patient was discharged three days postoperatively. At follow-up evaluations conducted one and three months after surgery, he was in good condition and had resumed his normal daily activities.

Discussion

The incidence of aortic valve stenosis (AS) due to degenerative calcification increases with age, and many elderly individuals may require non-cardiac surgery. According to current ACC and AHA guidelines, AS represents the most significant risk factor in non-cardiac surgical procedures 12).

The management of these patients is challenging due to both anesthetic and surgical stress. Severe aortic valve narrowing limits cardiac output, preventing it from increasing in response to heightened demands such as pain or hypotension 17). Additional factors, such as unexpected surgical bleeding, can further compromise hemodynamic stability. Hemodynamic instability may result in impaired coronary perfusion, myocardial injury, arrhythmias, ischemia, and even death 2).

When valvular repair surgery has not been performed and the patient requires non-cardiac surgery, selecting the optimal anesthetic plan is critical 14). General anesthetic agents often cause vasodilation and hypotension, while conventional neuraxial techniques can be hazardous due to sympathetic blockade and resultant systemic vasodilation. Conversely, drugs that increase heart rate and blood pressure should be minimized, as hypertension and tachycardia elevate myocardial oxygen consumption. In patients with severe aortic stenosis (SAS), who have impaired coronary perfusion and hypertrophied myocardium, this can readily precipitate myocardial ischemia. Effective pain management is therefore essential to prevent tachycardia. Additionally, general anesthesia in high-risk cardiac patients is associated with increased respiratory complications and higher 30-day mortality compared to neuraxial techniques 13).

Our patient was brought to the operating room for elective orthopedic surgery. He had known severe aortic stenosis (SAS) with systolic dysfunction, placing him at high risk for hemodynamic collapse. We elected to use a multimodal analgesic approach combining low-dose spinal anesthesia with a peripheral nerve block. The rationale was to achieve optimal analgesia and prevent tachycardia and hypertension from inadequate pain control, while minimizing drug exposure, reducing vasodilation, and maintaining stable hemodynamics.

The patient had discontinued aspirin five days prior to surgery; however, aspirin was not considered a contraindication to our neuraxial and regional anesthesia plan. For the peripheral nerve block, he received 3 mL of 0.25% bupivacaine to provide partial anesthesia of the surgical site and to ensure adequate analgesia when transitioning from supine to sitting for the spinal injection. This approach helped minimize the risk of tachycardia and exacerbation of heart failure. After administering low-dose spinal anesthesia, and to avoid excessive sympathectomy with potential bradycardia and hemodynamic compromise, the patient was positioned in the right lateral decubitus position to maximize the effect of the 5 mg bupivacaine on the surgical site while minimizing vasodilatory cardiova-scular effects.

Imré Van Herreweghe et al. reported that spinal anesthesia with ≤10 mg isobaric bupivacaine 0.5% without a peripheral nerve block in patients with moderate to severe AS resulted in systolic blood pressure <80 mmHg in 20% of patients and MAP <65 mmHg in 51%, requiring vasopressor intervention 18). Similarly, Errando et al. used 7.5 mg bupivacaine in elderly patients undergoing hip surgery; although none required rescue anesthesia, episodes of arterial hypotension were observed 20).

 Our multimodal analgesic approach appeared to be more effective compared to some previously reported cases. In our patient, surgery lasted approximately two hours, during which adequate analgesia was maintained without the need to convert to general anesthesia, and he remained pain-free throughout his stay in the PACU. In contrast, Zeynep Cagiran et al. reported using unilateral low-dose hyperbaric bupivacaine (6.5–7.5 mg) in geriatric patients with moderate to severe aortic stenosis. Although their surgeries were mostly completed within one hour, the initial analgesic effect dissipated rapidly, with 64.4% of patients requiring additional analgesia within the first postoperative hour 19).

The patient was an elderly man with severe aortic stenosis (SAS) who had previously declined aortic valve repair and subsequently presented with a femoral fracture. His surgical plan was open reduction and internal fixation (ORIF), which is routinely performed under spinal anesthesia (SA).

In this case, both general anesthesia (GA) and conventional SA posed significant life-threatening risks. Furthermore, delaying surgery would have resulted in immobility-related complications, including physical issues such as venous thromboembolism and pressure ulcers, as well as psychological consequences like depression and anxiety. To mitigate these risks, we employed a combination of peripheral nerve block and low-dose spinal anesthesia.

This approach prevented pain-induced tachycardia and excessive cardiac workload during position changes, maintained stable hemodynamics with minimal sympathectomy, and provided effective intraoperative analgesia without the need for vasopressor support.

Conclusion

By combining a peripheral nerve block with low-dose spinal anesthesia, a patient who might otherwise have been unable to tolerate surgery due to advanced age and severe aortic stenosis successfully underwent orthopedic repair and returned to normal daily activities without experiencing complications related to untreated fracture. This experience may help reassure anesthesiologists that carefully planned regional anesthesia can be safely administered in similar high-risk patients.

Recommendation

This protocol should be considered for patients with aortic stenosis undergoing urgent orthopedic surgery, particularly those with concomitant systolic dysfunction.

Data Availability Statement

Data sharing is not applicable to this article, as no datasets were generated or analyzed during the current study.

Funding Statement

No funding was received for this case report.

Ethics Approval Statement

The study was approved by the Ethics Committee of Babol University of Medical Sciences, Iran (IR.MUBABOL. HRI. REC. 1403.020).

Patient Consent Statement

Written informed consent was obtained from the patient for publication of this report in accordance with the journal’s patient consent policy.

Ethical Standards

This research was conducted in accordance with the principles of the 1975 Declaration of Helsinki, as revised in 2013 (http://ethics.iit.edu/ ecodes/ node/3931

Permission to Reproduce Material from Other Sources

All data supporting the results and findings of this study are included within the article.

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