[Anesthetic management of a patient complicated with restrictive cardiomyopathy for gastrectomy]

Restrictive cardiomyopathy is a rare condition characterized with endomyocardial fibrosis, which interferes diastolic ventricular filling. A 52-year-old man with a 38 year history of dyspnea on effort presented with advanced gastric cancer. Subtotal gastrectomy under general anesthesia was scheduled. Preoperative examination showed biventricular dysfunction, impaired liver function and chronic renal failure. General anesthesia was induced using fentanyl, pancuronium and isoflurane, and maintained with nitrous oxide/oxygen, isoflurane and fentanyl. Extensive invasive monitoring included arterial blood pressure, central venous pressure, pulmonary artery pressure and oxygen saturation of mixed venous blood as indices of left-sided pump function. Dopamine and nitroglycerin infusion was also started after the tracheal intubation. Although a transient improvement of cardiac function was noted after the removal of ascites 5 liter, restricted fluid administration induced desaturation of mixed venous blood and tachycardia. The start of low dose prostaglandin E1 markedly improved cardiac output without hypotension, while an increase of intravenous nitroglycerin did not prove to be beneficial. PGE1 was more selective in decreasing left ventricular afterload, while nitroglycerin produces greater decrease of preload.