Anaesthetic Management for Transurethral Resection of the Prostate in a Patient with Previously Undiagnosed Ebstein’s Anomaly.

Abstract

Improved survival among patients with congenital heart disease has resulted in a growing number of adults presenting for non-cardiac surgery. Ebstein’s anomaly is a rare congenital malformation of the tricuspid valve characterised by right ventricular dysfunction, susceptibility to arrhythmias, and intracardiac shunting, each of which poses distinct anaesthetic challenges. We report the perioperative management of an elderly patient with previously undiagnosed Ebstein’s anomaly undergoing transurethral resection of the prostate (TURP). A 70-year-old man with hypertension and chronic kidney disease was scheduled for elective TURP. Preoperative electrocardiography demonstrated right atrial enlargement and right bundle branch block, prompting further evaluation. Transthoracic echocardiography identified Ebstein’s anomaly with severe tricuspid regurgitation, an ostium secundum atrial septal defect with bidirectional shunting, severe pulmonary arterial hypertension, and borderline right ventricular dysfunction. Following multidisciplinary review, a decision was made to proceed with intrathecal ropivacaine under continuous invasive haemodynamic monitoring and appropriate precautions against paradoxical embolism.The patient’s cardiovascular stability was successfully managed with carefully titrated phenylephrine, allowing the surgery to proceed without any adverse events. An  elderly patient with previously undiagnosed Ebstein’s anomaly was managed successfully  through proper preoperative assessment, multidisciplinary planning, and vigilant intraoperative monitoring. Anaesthetic management in this case highlights that spinal anaesthesia is a viable strategy for TURP in carefully selected patients with complex right-heart physiology. This case also emphasises the importance of maintaining a broad differential diagnosis during preoperative evaluation, particularly in elderly patients in whom congenital cardiac pathology may be ignored in favour of more common acquired conditions.