Background and Aims The patient with cardiac pathology is one of the greatest challenges in anesthesiology since they are often medicated with anticoagulants and anti-aggregants which leads to a higher risk of perioperative cardiovascular complications. In this case, we show the use of an epidural technique in order to maintain hemodynamic stability despite the patient‘s coagulation changes (INR>1.5).

Methods Data were collected from the patient‘s process.

Results A 59 years old man, diagnosed with a strangulated inguinal hernia, proposed for an emergent inguinal hernioplasty. He had arterial hypertension, ischemic dilated cardiomyopathy, heart failure treated with levosimendan, implantable defibrillator (ICD), severe pulmonary hypertension, history of stroke without sequelae and chronic kidney disease. Medicated with anti-aggregants and anticoagulants. Laboratory values: Hb 10,6g/dL; platelets 149×10⁹/L and INR 1,54. The echocardiogram showed a 20% left ventricular ejection fraction, severe mitral regurgitation, and moderate tricuspid regurgitation. An epidural block with slow induction was performed (0,75% ropivacaine fractional bolus), under standard monitoring and invasive blood pressure. A magnet was used to protect the ICD and the immediate availability of vasopressor drugs was ensured. The procedure took place without major complications with hemodynamic stability until recovery. Analgesia was guaranteed with epidural morphine.

Conclusions This case shows the importance of neuraxial anesthesia in patients with cardiovascular comorbidities. The use of an epidural technique allows maintenance of hemodynamic stability in a patient that does not have a good physiologic condition despite coagulation changes. For this reason, in this case, the benefits of a neuraxial technique outweigh its risks compared with a general anesthesia technique.