Overcoming the obstruction, anesthetic management of hypertrophic obstructive cardiomyopathy: The prudent paradox of less is more

Hypertrophic obstructive cardiomyopathy (HOCM) is a genetically mediated disease causing left ventricular outflow tract obstruction (LVOTO) predisposing the patient to systolic and diastolic dysfunction leading to arrhythmias and sudden cardiac deaths in the perioperative period. This case report describes the anesthetic management of a 76-year-old female posted for a semi-emergent three level lumbar canal decompression with severe HOCM with dynamic LVOTO with an initial resting gradient >70 mmHg, noninsulin-dependent diabetes mellitus, bronchial asthma, deep-vein thrombosis, and hypothyroidism as comorbidities. Preoperative evaluation of the risks, cardiac optimization, interdisciplinary shared decision making, preoperative invasive monitoring, preanesthetic placement of defibrillator pads, careful titration of anesthetic agents, with meticulous perioperative monitoring, and perioperative intensive care collaboration contributed to a successful outcome.