Anaesthetic Management of a Patient with Atrial Fibrillation and Post Double Valve Replacement Undergoing Elective Nephrectomy: A Case Report

The coexistence of Atrial Fibrillation (AF) and a bioprosthetic Double Valve Replacement (DVR) presents a significant perioperative challenge, especially in elderly patients undergoing non cardiac surgery. AF, when associated with a low Ejection Fraction (EF) and anticoagulation therapy, significantly increases the risk of thromboembolism, haemodynamic instability, and arrhythmias during surgery. The perioperative management of a 71-year-old man with persistent AF and prior bioprosthetic DVR, scheduled for left nephrectomy for a non functioning kidney. The case is unique due to the high cardiovascular risk profile, including New York Heart Association (NYHA) class II symptoms, EF of 35%, and chronic anticoagulation therapy. Preoperative evaluation included transthoracic echocardiography and risk stratification using the CHA2 DS2 -VASc score. Antiplatelet therapy was appropriately withheld, and bridging anticoagulation with low molecular weight heparin was administered. Intraoperatively, the patient developed sudden hypotension following lateral positioning, which was promptly managed with vasopressors. Later, the patient developed unstable AF with hypotension requiring synchronised cardioversion. An epidural catheter was placed for analgesia under strict coagulation monitoring, and the procedure was completed successfully with vigilant monitoring. Postoperatively, the patient was electively ventilated, anticoagulation was resumed safely, and sinus rhythm was maintained. He made an uneventful recovery and was discharged on postoperative day 9. This case emphasises the need for individualised anaesthetic strategies, guideline-based anticoagulation management, and interdisciplinary collaboration in high risk cardiac patients undergoing non cardiac surgery. It also highlights the successful perioperative handling of AF and valve prosthesis-related challenges using appropriate scoring systems, monitoring, and intervention protocols.