An 80-year-old woman was scheduled to undergo a left maxillary sequestrectomy for medication-related osteonecrosis of the jaw (MRONJ). An aortic stenosis (AS) had been diagnosed when the patient was about 78 years old, and she had been under observation since then. She subsequently developed subjective symptoms of shortness of breath during exertion and was referred to the cardiology department of our hospital. A cardiac ultrasound revealed severe symptomatic AS. Because MRONJ can be a risk factor for infective endocarditis (IE), surgery for MRONJ was performed prior to transcatheter aortic valve implantation (TAVI).
Anesthesia was induced using remimazolam besilate and remifentanil hydrochloride under the continuous administration of noradrenaline, and the patient was managed using total intravenous anesthesia. A single dose of phenylephrine hydrochloride was also administered during the operation to manage her circulation. The patient’s hemodynamics were stable during the operation, and the scheduled surgery was completed. After extubation, the patient’s circulation and respiration both remained stable, and the patient was returned to the general ward and discharged on postoperative day 8. TAVI was performed 107 days after the surgery for MRONJ. For the perioperative management of patients with severe aortic stenosis, it is important to minimize cardiovascular responses during anesthesia induction, as there is a risk of coronary circulatory collapse and cardiac arrest arising from hypotension. In the presently reported case, the combination of remifentanil hydrochloride, which is unlikely to cause circulatory depression when administered alone, with remimazolam besilate, which is thought to have a smaller effect on circulatory depression, enabled severe hypotension to be avoided, allowing safe perioperative management.
