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Background and Aims We present a case of a 57-year-old male with a femoral neck fracture staged for a total hip arthroplasty. Due to a Mustard operation for a transposition of the great vessels in his childhood, the patient is now heart insufficient NYHA IV with regular Levosimedanin infusions and waiting for a heart transplant. Furthermore, he has a situs inversus and is pacemaker dependent for sick sinus syndrome.

Methods Due to his medical condition, the anesthetic management of this patient required thoughtful planning and interdisciplinary consensus. Options such as spinal catheter or general anesthesia were discussed but rejected due to rescue back-up with ECMO/heart-lung machine and general anesthesia was considered too riskful. The surgical approach consisted in a total hip arthroplasty, regarding the patient´s condition uncemented, though. The anesthetic approach included preoperative optimization with Levosimedanin, preparation and standby for perioperative ECMO, spinal anesthesia and a femoral nerve block.

Results The operation went uneventfully, and the patient recovered well from the operation.

Conclusions Our case report shows that it is possible to provide good anesthetic management even in challenging patients by having a clear perioperative planning and an open dialogue with our orthopedic colleagues.