Anesthetic Management for Laparoscopic Cholecystectomy in an Elderly Patient With Torrential Tricuspid Regurgitation: A Case Report

Patients with severe tricuspid regurgitation are at risk of developing right heart failure due to excessive changes in right ventricular preload or increases in pulmonary vascular resistance, necessitating careful perioperative hemodynamic management.We report a case of anesthetic management for laparoscopic cholecystectomy in an elderly patient with torrential tricuspid regurgitation, using transesophageal echocardiography and peripheral venous pressure monitoring.The patient was a 79-year-old woman with a history of heart failure, atrial fibrillation, and myocardial infarction.Preoperative transthoracic echocardiography showed a maximum effective regurgitant orifice area of 0.85 cm² for tricuspid regurgitation.Right ventricular systolic function was preserved, and there was no clear echocardiographic evidence of pulmonary hypertension.General anesthesia was induced and maintained with remimazolam and remifentanil, and bilateral ultrasound-guided nerve blocks were performed.Transesophageal echocardiography performed after the induction of anesthesia demonstrated a vena contracta area of 1.56 cm² on three-dimensional color Doppler imaging, consistent with torrential tricuspid regurgitation.Intraoperatively, pneumoperitoneum pressure was gradually increased from a low level, and the patient was slowly transitioned to the head-up position.Ventilation was managed to avoid hypercapnia.Transesophageal echocardiography was used to quantitatively assess the severity of tricuspid regurgitation after the induction of anesthesia and to visually assess changes in tricuspid regurgitation before and after pneumoperitoneum and positional changes.Serial changes in peripheral venous pressure were used as an adjunctive indicator of right-sided filling pressure and systemic venous congestion.No visually apparent worsening of tricuspid regurgitation or sustained increase in peripheral venous pressure was observed following pneumoperitoneum or positional changes, and hemodynamics remained generally stable throughout the procedure.The surgery was completed without complications, and the patient was discharged on postoperative day 4.While performing laparoscopic surgery for a patient with torrential tricuspid regurgitation, combining the transesophageal echocardiographic assessment of tricuspid regurgitation with the serial monitoring of peripheral venous pressure provided an adjunctive means of evaluating changes in right-sided hemodynamics associated with pneumoperitoneum and positional changes.Because peripheral venous pressure is not an indicator of fluid responsiveness, it should not be interpreted in isolation but rather integrated with other hemodynamic parameters, including transesophageal echocardiographic findings and arterial blood pressure.