Dilated Cardiomyopathy (DCM)

Preserve contractility - Avoid myocardial depressants at induction; etomidate or a slow, titrated technique is kinder than a large propofol bolus. Have inotropes and vasopressors ready.

Rate, rhythm, and afterload - Maintain sinus rhythm and a controlled rate (the atrial kick matters), and use gentle afterload reduction - but never at the expense of coronary perfusion pressure, so avoid frank hypotension.

Volume - The failing ventricle tolerates neither hypovolemia nor fluid overload; aim for euvolemia and watch for pulmonary edema.

Devices - Many patients carry an ICD or CRT device; manage it perioperatively (magnet or reprogramming) and keep external defibrillation available.

Thromboembolism - Low ejection fraction and mural thrombus mean stroke and systemic embolism risk; patients may be anticoagulated - time neuraxial techniques around anticoagulation per current ASRA guidance.

Neuraxial - A carefully titrated neuraxial technique can reduce afterload favorably, but a single-shot spinal's abrupt sympathectomy is risky; support systemic vascular resistance throughout.

A dilated, poorly contractile ventricle with a reduced ejection fraction and little functional reserve. Causes are many - ischemic, idiopathic, familial, viral, alcoholic, tachycardia-mediated - but the shared physiology is systolic heart failure. Complications include arrhythmias, intraventricular (mural) thrombus with systemic thromboembolism, and sudden cardiac death. The anesthetic revolves around not tipping a heart with no reserve into decompensation.