Severe mitral stenosis (MS) during pregnancy represents a fixed cardiac output state and poses major anesthetic challenges during elective cesarean delivery (CD). Conventional single-shot spinal anesthesia may precipitate profound hypotension in these patients. We report two high-risk parturients with severe MS, classified as New York Heart Association (NYHA) class III, who underwent elective CD. Both patients were managed using low-dose segmental spinal anesthesia supplemented with ultrasound-guided erector spinae plane block (ESPB) and invasive hemodynamic monitoring. In both cases, the procedures were completed with stable intraoperative hemodynamics and effective postoperative analgesia, without cardiopulmonary complications. The combination of segmental spinal anesthesia with regional fascial plane blocks and invasive monitoring may represent a viable alternative anesthetic strategy for elective CD in carefully selected parturients with severe MS.

Mitral annular calcification (MAC) is a chronic degenerative process strongly associated with aging that predominantly affects the posterior mitral annulus. Its pathogenesis is linked to traditional cardiovascular risk factors that increase mechanical stress and inflammation, promoting pathological cellular differentiation within the annulus. MAC prevalence in the general population is approximately 8-15%, with 8% of affected patients developing clinically significant valvular disease, defined as mitral stenosis or moderate or greater mitral regurgitation. Patients with MAC are at higher risk of cardiovascular mortality and complications, including the development of atrial fibrillation, the development of conduction disorders, and often have signs of coronary or systemic atherosclerosis. Transthoracic echocardiogram remains the first-line imaging modality for the diagnosis of MAC, while cardiac-gated computed tomography is valuable for quantifying severity and progression while also guiding procedural planning. Though management is often conservative, in patients who have clinically significant valvular dysfunction, MAC can present a challenge when planning valvular interventions, and a multidisciplinary approach is often required.