{"id":"https://openalex.org/W7204702696","doi":"https://doi.org/10.63918/fhr.v3.n2.p76-85.2026","title":"A Little of Everything, Just In Time: Multimodal Opioid-Sparing Anesthesia for a Twin Pregnancy in Decompensated Heart Failure Caused by Severe Mitral Stenosis","display_name":"A Little of Everything, Just In Time: Multimodal Opioid-Sparing Anesthesia for a Twin Pregnancy in Decompensated Heart Failure Caused by Severe Mitral Stenosis","publication_year":2026,"publication_date":"2026-08-30","ids":{"openalex":"https://openalex.org/W7204702696","doi":"https://doi.org/10.63918/fhr.v3.n2.p76-85.2026"},"language":"en","primary_location":{"id":"doi:10.63918/fhr.v3.n2.p76-85.2026","doi":"https://doi.org/10.63918/fhr.v3.n2.p76-85.2026","is_oa":true,"landing_page_url":"https://doi.org/10.63918/fhr.v3.n2.p76-85.2026","pdf_url":"https://frontiersonhealthcare.org/index.php/id/article/download/123/83","source":{"id":"https://openalex.org/S5407045893","display_name":"Frontiers on Healthcare Research","issn_l":"3032-7725","issn":["3032-7725"],"is_oa":true,"is_in_doaj":true,"is_core":false,"listed_in":["doaj"],"host_organization":"https://openalex.org/I4405276615","host_organization_name":"Rumah Sakit Umum Pusat Dr. M. Djamil Padang","host_organization_lineage":["https://openalex.org/I4405276615"],"host_organization_lineage_names":[],"type":"journal"},"license":"cc-by","license_id":"https://openalex.org/licenses/cc-by","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Frontiers on Healthcare Research","raw_type":"journal-article"},"volume":null,"type":"article","is_traditional":true,"indexed_in":["crossref","doaj"],"open_access":{"is_oa":true,"oa_status":"diamond","oa_url":"https://frontiersonhealthcare.org/index.php/id/article/download/123/83","any_repository_has_fulltext":false},"authorships":[{"author_position":"first","author":{"id":"https://openalex.org/A5148703614","display_name":"Muhammad Imam Mulia Muhammad Imam","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I29617571","display_name":"University of Indonesia","ror":"https://ror.org/0116zj450","country_code":"ID","type":"education","lineage":["https://openalex.org/I29617571"]},{"id":"https://openalex.org/I4210155152","display_name":"Rumah Sakit Umum Pusat Nasional Dr. Cipto Mangunkusumo","ror":"https://ror.org/05am7x020","country_code":"ID","type":"healthcare","lineage":["https://openalex.org/I4210155152"]}],"countries":["ID"],"is_corresponding":false,"raw_author_name":"Muhammad Imam Mulia Muhammad Imam","raw_affiliation_strings":["Department of Anesthesiology and Intensive Therapy, Faculty of Medicine Universitas Indonesia \u2013 Dr. Cipto Mangunkusumo National General Hospital, Jakarta"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Department of Anesthesiology and Intensive Therapy, Faculty of Medicine Universitas Indonesia \u2013 Dr. Cipto Mangunkusumo National General Hospital, Jakarta","institution_ids":["https://openalex.org/I29617571","https://openalex.org/I4210155152"]}]},{"author_position":"last","author":{"id":"https://openalex.org/A5148702214","display_name":"Arief Cahyadi Arief","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I4210155152","display_name":"Rumah Sakit Umum Pusat Nasional Dr. Cipto Mangunkusumo","ror":"https://ror.org/05am7x020","country_code":"ID","type":"healthcare","lineage":["https://openalex.org/I4210155152"]}],"countries":["ID"],"is_corresponding":false,"raw_author_name":"Arief Cahyadi Arief","raw_affiliation_strings":["Department of Anesthesiology and Intensive Therapy, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Department of Anesthesiology and Intensive Therapy, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia","institution_ids":["https://openalex.org/I4210155152"]}]}],"institutions":[],"countries_distinct_count":1,"institutions_distinct_count":2,"corresponding_author_ids":[],"corresponding_institution_ids":[],"apc_list":null,"apc_paid":null,"fwci":0.0,"has_fulltext":true,"cited_by_count":0,"citation_normalized_percentile":{"value":0.6273208,"is_in_top_1_percent":false,"is_in_top_10_percent":false},"cited_by_percentile_year":null,"biblio":{"volume":"3","issue":"2","first_page":"76","last_page":"85"},"is_retracted":false,"is_paratext":false,"is_xpac":false,"primary_topic":{"id":"https://openalex.org/T12230","display_name":"Cardiovascular Issues in Pregnancy","score":0.9154999852180481,"subfield":{"id":"https://openalex.org/subfields/2705","display_name":"Cardiology and Cardiovascular Medicine"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},"topics":[{"id":"https://openalex.org/T12230","display_name":"Cardiovascular Issues in Pregnancy","score":0.9154999852180481,"subfield":{"id":"https://openalex.org/subfields/2705","display_name":"Cardiology and Cardiovascular Medicine"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T10189","display_name":"Anesthesia and Pain Management","score":0.03400000184774399,"subfield":{"id":"https://openalex.org/subfields/2703","display_name":"Anesthesiology and Pain Medicine"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T10436","display_name":"Anesthesia and Sedative Agents","score":0.021700000390410423,"subfield":{"id":"https://openalex.org/subfields/2703","display_name":"Anesthesiology and Pain Medicine"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}}],"keywords":[{"id":"https://openalex.org/keywords/mitral-stenosis","display_name":"mitral stenosis","score":0.9440000057220459},{"id":"https://openalex.org/keywords/rheumatic-heart-disease","display_name":"rheumatic heart disease","score":0.8939999938011169},{"id":"https://openalex.org/keywords/twin-pregnancy","display_name":"twin pregnancy","score":0.7459999918937683},{"id":"https://openalex.org/keywords/acute-decompensated-heart-failure","display_name":"acute decompensated heart failure","score":0.7910000085830688},{"id":"https://openalex.org/keywords/opioid-sparing-anesthesia","display_name":"opioid-sparing anesthesia","score":0.8429999947547913},{"id":"https://openalex.org/keywords/general-anesthesia","display_name":"general anesthesia","score":0.5989999771118164},{"id":"https://openalex.org/keywords/cesarean-section","display_name":"cesarean section","score":0.953000009059906},{"id":"https://openalex.org/keywords/dexmedetomidine","display_name":"dexmedetomidine","score":0.9039999842643738},{"id":"https://openalex.org/keywords/ketamine","display_name":"ketamine","score":0.9700000286102295},{"id":"https://openalex.org/keywords/propofol","display_name":"propofol","score":0.8370000123977661},{"id":"https://openalex.org/keywords/maternal-hemodynamic-stability","display_name":"maternal hemodynamic stability","score":0.746999979019165}],"concepts":[{"id":"https://openalex.org/C71924100","wikidata":"https://www.wikidata.org/wiki/Q11190","display_name":"Medicine","level":0,"score":0.9330000281333923},{"id":"https://openalex.org/C164705383","wikidata":"https://www.wikidata.org/wiki/Q10379","display_name":"Cardiology","level":1,"score":0.6050000190734863},{"id":"https://openalex.org/C2779161974","wikidata":"https://www.wikidata.org/wiki/Q815819","display_name":"Atrial fibrillation","level":2,"score":0.6003999710083008},{"id":"https://openalex.org/C2778198053","wikidata":"https://www.wikidata.org/wiki/Q181754","display_name":"Heart failure","level":2,"score":0.5667999982833862},{"id":"https://openalex.org/C2779234561","wikidata":"https://www.wikidata.org/wiki/Q11995","display_name":"Pregnancy","level":2,"score":0.5436000227928162},{"id":"https://openalex.org/C126322002","wikidata":"https://www.wikidata.org/wiki/Q11180","display_name":"Internal medicine","level":1,"score":0.5397999882698059},{"id":"https://openalex.org/C2780007028","wikidata":"https://www.wikidata.org/wiki/Q2343082","display_name":"Stenosis","level":2,"score":0.5022000074386597},{"id":"https://openalex.org/C2778721985","wikidata":"https://www.wikidata.org/wiki/Q1183680","display_name":"Decompensation","level":2,"score":0.5015000104904175},{"id":"https://openalex.org/C2779736815","wikidata":"https://www.wikidata.org/wiki/Q1130519","display_name":"valvular heart disease","level":2,"score":0.49729999899864197},{"id":"https://openalex.org/C2777707475","wikidata":"https://www.wikidata.org/wiki/Q422222","display_name":"Digoxin","level":3,"score":0.4961000084877014},{"id":"https://openalex.org/C42219234","wikidata":"https://www.wikidata.org/wiki/Q131130","display_name":"Anesthesia","level":1,"score":0.48910000920295715},{"id":"https://openalex.org/C2780074459","wikidata":"https://www.wikidata.org/wiki/Q389735","display_name":"Heart disease","level":2,"score":0.48739999532699585},{"id":"https://openalex.org/C178853913","wikidata":"https://www.wikidata.org/wiki/Q1642137","display_name":"Hemodynamics","level":2,"score":0.43849998712539673},{"id":"https://openalex.org/C2778881276","wikidata":"https://www.wikidata.org/wiki/Q552304","display_name":"Cardiopulmonary bypass","level":2,"score":0.4016000032424927},{"id":"https://openalex.org/C2780703314","wikidata":"https://www.wikidata.org/wiki/Q1140794","display_name":"Mitral valve stenosis","level":3,"score":0.36730000376701355},{"id":"https://openalex.org/C2779295919","wikidata":"https://www.wikidata.org/wiki/Q4677930","display_name":"Acute decompensated heart failure","level":3,"score":0.36550000309944153},{"id":"https://openalex.org/C2909479827","wikidata":"https://www.wikidata.org/wiki/Q2544879","display_name":"Tricuspid stenosis","level":3,"score":0.35679998993873596},{"id":"https://openalex.org/C2776371345","wikidata":"https://www.wikidata.org/wiki/Q5121708","display_name":"Circulatory collapse","level":2,"score":0.30640000104904175},{"id":"https://openalex.org/C2778094803","wikidata":"https://www.wikidata.org/wiki/Q410061","display_name":"Amiodarone","level":3,"score":0.2969000041484833},{"id":"https://openalex.org/C2994232697","wikidata":"https://www.wikidata.org/wiki/Q1115882","display_name":"Extracorporeal circulation","level":2,"score":0.2924000024795532},{"id":"https://openalex.org/C2778490853","wikidata":"https://www.wikidata.org/wiki/Q2938089","display_name":"Peripartum cardiomyopathy","level":4,"score":0.2809000015258789},{"id":"https://openalex.org/C3018745865","wikidata":"https://www.wikidata.org/wiki/Q749115","display_name":"Postpartum period","level":3,"score":0.2784000039100647},{"id":"https://openalex.org/C139940330","wikidata":"https://www.wikidata.org/wiki/Q596579","display_name":"Cardiac output","level":3,"score":0.27649998664855957},{"id":"https://openalex.org/C2778162923","wikidata":"https://www.wikidata.org/wiki/Q4990531","display_name":"Anesthetic","level":2,"score":0.2694999873638153},{"id":"https://openalex.org/C46973012","wikidata":"https://www.wikidata.org/wiki/Q28627","display_name":"Gestation","level":3,"score":0.2644999921321869},{"id":"https://openalex.org/C2779918671","wikidata":"https://www.wikidata.org/wiki/Q200656","display_name":"Diuretic","level":2,"score":0.25949999690055847},{"id":"https://openalex.org/C2909855057","wikidata":"https://www.wikidata.org/wiki/Q159979","display_name":"Twin Pregnancy","level":4,"score":0.2572000026702881},{"id":"https://openalex.org/C2777289489","wikidata":"https://www.wikidata.org/wiki/Q1729126","display_name":"Cardioversion","level":3,"score":0.25099998712539673},{"id":"https://openalex.org/C2780930700","wikidata":"https://www.wikidata.org/wiki/Q1128595","display_name":"Pulmonary hypertension","level":2,"score":0.25060001015663147},{"id":"https://openalex.org/C141071460","wikidata":"https://www.wikidata.org/wiki/Q40821","display_name":"Surgery","level":1,"score":0.2500999867916107}],"mesh":[],"locations_count":2,"locations":[{"id":"doi:10.63918/fhr.v3.n2.p76-85.2026","doi":"https://doi.org/10.63918/fhr.v3.n2.p76-85.2026","is_oa":true,"landing_page_url":"https://doi.org/10.63918/fhr.v3.n2.p76-85.2026","pdf_url":"https://frontiersonhealthcare.org/index.php/id/article/download/123/83","source":{"id":"https://openalex.org/S5407045893","display_name":"Frontiers on Healthcare Research","issn_l":"3032-7725","issn":["3032-7725"],"is_oa":true,"is_in_doaj":true,"is_core":false,"listed_in":["doaj"],"host_organization":"https://openalex.org/I4405276615","host_organization_name":"Rumah Sakit Umum Pusat Dr. M. Djamil Padang","host_organization_lineage":["https://openalex.org/I4405276615"],"host_organization_lineage_names":[],"type":"journal"},"license":"cc-by","license_id":"https://openalex.org/licenses/cc-by","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Frontiers on Healthcare Research","raw_type":"journal-article"},{"id":"pmh:oai:doaj.org/article:037b56fc785e4d3683d26227a483cdaf","doi":null,"is_oa":false,"landing_page_url":"https://doaj.org/article/037b56fc785e4d3683d26227a483cdaf","pdf_url":null,"source":{"id":"https://openalex.org/S4306401280","display_name":"DOAJ (DOAJ: Directory of Open Access Journals)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":null,"host_organization_name":null,"host_organization_lineage":[],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"submittedVersion","is_accepted":false,"is_published":false,"raw_source_name":"Frontiers on Healthcare Research, Vol 3, Iss 2, Pp 76-85 (2026)","raw_type":"article"}],"best_oa_location":{"id":"doi:10.63918/fhr.v3.n2.p76-85.2026","doi":"https://doi.org/10.63918/fhr.v3.n2.p76-85.2026","is_oa":true,"landing_page_url":"https://doi.org/10.63918/fhr.v3.n2.p76-85.2026","pdf_url":"https://frontiersonhealthcare.org/index.php/id/article/download/123/83","source":{"id":"https://openalex.org/S5407045893","display_name":"Frontiers on Healthcare Research","issn_l":"3032-7725","issn":["3032-7725"],"is_oa":true,"is_in_doaj":true,"is_core":false,"listed_in":["doaj"],"host_organization":"https://openalex.org/I4405276615","host_organization_name":"Rumah Sakit Umum Pusat Dr. M. Djamil Padang","host_organization_lineage":["https://openalex.org/I4405276615"],"host_organization_lineage_names":[],"type":"journal"},"license":"cc-by","license_id":"https://openalex.org/licenses/cc-by","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Frontiers on Healthcare Research","raw_type":"journal-article"},"sustainable_development_goals":[{"id":"https://metadata.un.org/sdg/3","score":1.0,"display_name":"Good health and well-being"}],"study_designs":[{"id":"https://openalex.org/study-designs/case-report","display_name":"Case Report"}],"awards":[],"funders":[],"has_content":{"pdf":true,"grobid_xml":true},"content_urls":{"pdf":"https://content.openalex.org/works/W7204702696.pdf","grobid_xml":"https://content.openalex.org/works/W7204702696.grobid-xml"},"referenced_works_count":0,"referenced_works":[],"related_works":["https://openalex.org/W7203890097","https://openalex.org/W2590896549","https://openalex.org/W7134228392","https://openalex.org/W2842347526","https://openalex.org/W4400743847","https://openalex.org/W7161179938","https://openalex.org/W3195904433","https://openalex.org/W7127575671","https://openalex.org/W2953742308","https://openalex.org/W4375865274"],"abstract_inverted_index":{"Background:":[0],"Rheumatic":[1],"heart":[2,10,129,134],"disease":[3,11,326],"remains":[4],"a":[5,58,63,74,112,140,174,285,310,315],"leading":[6],"cause":[7],"of":[8,14,31,36,126,289],"valvular":[9,325],"among":[12],"women":[13],"reproductive":[15],"age":[16],"in":[17,73,227,367],"low-":[18],"and":[19,43,62,83,145,183,208,240,270,275,317,327,364],"middle-income":[20],"countries.":[21],"Severe":[22,149],"mitral":[23,81,147,228],"stenosis":[24,82,229],"complicating":[25],"pregnancy":[26,76,114],"substantially":[27],"increases":[28],"the":[29,37,90,251],"risk":[30],"acute":[32,127],"cardiac":[33],"decompensation":[34],"because":[35,125],"hemodynamic":[38,187,242,362],"load":[39],"imposed":[40],"by":[41,78,204,255],"gestation,":[42],"anesthetic":[44,225],"management":[45],"becomes":[46],"considerably":[47],"more":[48],"complex":[49],"when":[50,258,329],"it":[51],"is":[52,314,337,346],"combined":[53,179],"with":[54,57,111,136,139,155,159,200,230,250,309,323],"atrial":[55,84,137],"fibrillation":[56,85,138],"rapid":[59,141],"ventricular":[60,142,195],"response":[61,143],"multifetal":[64],"pregnancy.":[65],"Reports":[66],"describing":[67],"general":[68],"anesthesia":[69,169,308],"for":[70,121,320],"cesarean":[71,123],"delivery":[72,124,283],"twin":[75,113],"complicated":[77],"both":[79,301,360],"severe":[80,146],"remain":[86],"scarce,":[87],"which":[88],"limits":[89],"guidance":[91],"available":[92],"to":[93,132,248,284],"clinicians":[94],"who":[95],"face":[96],"this":[97,368],"specific":[98],"combination.":[99],"Case":[100],"Presentation:":[101],"A":[102,263],"43-year-old":[103],"woman,":[104],"gravida":[105],"5":[106],"para":[107],"4":[108],"abortus":[109],"0,":[110],"at":[115,292],"32":[116],"weeks\u2019":[117],"gestation":[118],"was":[119,170,198,213,297],"referred":[120],"emergency":[122],"decompensated":[128],"failure":[130],"secondary":[131],"rheumatic":[133],"disease,":[135],"(AF-RVR)":[144],"stenosis.":[148],"dyspnea":[150],"that":[151,178,267,335,347],"improved":[152],"only":[153],"marginally":[154],"upright":[156],"positioning,":[157],"together":[158],"an":[160],"ongoing":[161],"therapeutic":[162],"heparin":[163],"infusion,":[164],"precluded":[165],"neuraxial":[166,256,330],"anesthesia.":[167],"General":[168,307],"therefore":[171],"planned":[172],"using":[173],"modified,":[175],"opioid-sparing":[176,265,312],"induction":[177],"low-dose":[180,350],"propofol,":[181],"ketamine,":[182],"dexmedetomidine":[184,269],"under":[185],"invasive":[186],"monitoring.":[188],"Two":[189],"live":[190],"infants":[191,302],"were":[192],"delivered;":[193],"postpartum":[194],"rate":[196],"control":[197],"achieved":[199],"intravenous":[201],"digoxin":[202],"followed":[203],"amiodarone,":[205],"alongside":[206],"vasopressor":[207],"diuretic":[209],"support.":[210],"The":[211,224,343],"patient":[212],"extubated":[214],"on":[215],"postoperative":[216],"day":[217],"1":[218],"without":[219],"further":[220],"cardiopulmonary":[221],"complications.":[222],"Discussion:":[223],"strategy":[226,313],"AF-RVR":[231],"must":[232],"be":[233],"directed":[234],"toward":[235],"avoiding":[236,355],"tachycardia,":[237],"preserving":[238],"preload,":[239],"maintaining":[241],"stability.":[243],"These":[244],"goals":[245],"are":[246,260,332],"difficult":[247],"reconcile":[249],"sympathetic":[252],"blockade":[253],"produced":[254],"techniques":[257,331],"these":[259],"otherwise":[261],"contraindicated.":[262],"multimodal,":[264],"approach":[266,319],"layered":[268],"ketamine":[271],"preserved":[272],"maternal":[273,361],"hemodynamics":[274],"respiratory":[276],"drive":[277],"while":[278],"limiting":[279],"opioid":[280],"exposure":[281],"before":[282],"single":[286],"low":[287],"dose":[288],"fentanyl":[290],"given":[291],"induction;":[293],"definitive":[294],"antiarrhythmic":[295],"therapy":[296],"deferred":[298],"until":[299],"after":[300],"had":[303],"been":[304],"born.":[305],"Conclusion:":[306],"multimodal":[311],"feasible":[316],"effective":[318],"high-risk":[321],"parturients":[322],"stenotic":[324],"arrhythmia":[328],"contraindicated,":[333],"provided":[334],"care":[336],"delivered":[338],"through":[339],"close":[340],"multidisciplinary":[341],"collaboration.":[342],"principal":[344],"lesson":[345],"sequencing":[348],"several":[349],"non-opioid":[351],"agents,":[352],"rather":[353],"than":[354],"opioids":[356],"altogether,":[357],"can":[358],"preserve":[359],"stability":[363],"fetal":[365],"well-being":[366],"setting.":[369]},"counts_by_year":[],"updated_date":"2026-11-02T09:45:03.842371","created_date":"2026-08-31T00:00:00"}