Tailoring Anesthesia for Cardiac Amyloidosis: A Case Report Highlighting Perioperative Challenges

Cardiac amyloidosis is a cause of restrictive cardiomyopathy, posing significant challenges in perioperative care. We report the case of an 85-year-old male with wild-type transthyretin amyloidosis (ATTRwt) undergoing urgent anterior cervical arthrodesis, following a traumatic cervical spine injury (C5-C6 fracture-dislocation and C2-C7 compressive hematoma). Preoperative evaluation revealed marked biventricular dysfunction (left ventricular ejection fraction 27%), atrial fibrillation, conduction abnormalities, and other comorbidities, including Parkinson's disease and chronic kidney disease. A tailored anesthetic approach was adopted, incorporating balanced general anesthesia, advanced hemodynamic monitoring, such as cardiac output assessment, and awake fiberoptic intubation to mitigate cardiovascular and airway risks. Anticoagulation was reversed with idarucizumab, and perioperative hemodynamic instability was managed with vasopressors and dynamic fluid responsiveness assessment. This case highlights the complexity of anesthetic management in amyloidosis, particularly with cardiac involvement, which requires careful anesthetic titration to minimize vasodilation and myocardial depression and avoidance of beta-blockers and calcium channel blockers. Furthermore, the authors highlight the perioperative hematologic, metabolic, and electrolyte disorders that may arise from disease and cardiac-target therapies such as tafamidis and sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors). We emphasize the importance of individualized planning, multidisciplinary coordination, and vigilant perioperative monitoring to optimize outcomes in this high-risk population.