Clinical bottom line
Patients with amyloidosis undergoing surgery present unique anesthetic challenges due to multisystem involvement, particularly cardiac amyloidosis, which increases perioperative risk. Careful preoperative assessment, intraoperative hemodynamic monitoring, and tailored anesthetic techniques are essential to optimize outcomes. Current evidence, including recent case reports, highlights the importance of individualized management strategies focusing on cardiovascular stability and minimizing fluid overload. However, high-quality prospective data remain limited, and anesthesiologists should remain vigilant for complications related to amyloid infiltration of cardiac and other organ systems.
What the evidence shows
Amyloidosis is characterized by extracellular deposition of amyloid fibrils, often involving the heart, kidneys, and nervous system, which complicates anesthetic management. Cardiac amyloidosis, the most critical factor influencing perioperative risk, leads to restrictive cardiomyopathy, conduction abnormalities, and autonomic dysfunction. Kesimci et al. (2025) reported detailed anesthetic management of two patients with cardiac amyloidosis undergoing open cardiac surgery, emphasizing the need for invasive hemodynamic monitoring, cautious fluid administration, and avoidance of myocardial depressants to maintain cardiac output and prevent heart failure. Although focused on cardiac surgery, these principles are extrapolated to non-cardiac procedures given similar pathophysiology.
Preoperative evaluation should include echocardiography and electrocardiography to assess cardiac function and conduction system status. Intraoperative management benefits from arterial line placement and, when indicated, pulmonary artery catheterization or transesophageal echocardiography to guide fluid and vasoactive therapy. Li et al. (2023) in their review of patients with dilated cardiomyopathy undergoing noncardiac surgery underscore the importance of individualized anesthetic plans to maintain hemodynamic stability, a concept applicable to amyloidosis given overlapping cardiac dysfunction.
Autonomic neuropathy common in amyloidosis may cause labile blood pressure and heart rate responses, necessitating vigilant monitoring and readiness to treat hypotension or arrhythmias. Additionally, amyloid infiltration of the airway and soft tissues may complicate airway management, warranting preoperative airway assessment and preparation for difficult intubation.
Neurological outcomes after surgery in patients with amyloidosis have not been extensively studied; however, Danielson et al. (2021) demonstrated that biomarkers of neuronal injury and amyloidosis correlate with cognitive decline after major surgery, suggesting potential vulnerability in this population.
Caveats and uncertainty
The evidence base for anesthetic management in amyloidosis is largely limited to case reports and small series, with a paucity of prospective studies or randomized trials. Kesimci et al.’s (2025) two-case report provides valuable insights but cannot establish standardized protocols. The heterogeneity of amyloidosis subtypes and organ involvement further complicates generalization. Moreover, extrapolation from cardiac amyloidosis to systemic amyloidosis without cardiac involvement may not be appropriate.
There is limited data on the impact of various anesthetic agents on amyloid-affected tissues, and optimal fluid management strategies remain uncertain due to the risk of both volume overload and hypoperfusion. The role of advanced hemodynamic monitoring techniques in improving outcomes has not been definitively established. Additionally, the long-term cognitive and neurological effects of anesthesia in amyloidosis patients require further investigation.
How this may change practice
Anesthesiologists should incorporate a high index of suspicion for cardiac and autonomic involvement in patients with amyloidosis presenting for surgery. Preoperative multidisciplinary evaluation including cardiology is advisable. Invasive hemodynamic monitoring should be considered early to guide fluid and vasoactive therapy, with a focus on maintaining stable preload and avoiding myocardial depression.
Airway assessment should be thorough, with preparation for potential difficult intubation due to amyloid infiltration. Anesthetic plans should prioritize agents with minimal negative inotropic effects and allow rapid titration. Postoperative monitoring in an intensive care or high-dependency setting may be warranted for early detection of cardiac or neurological complications.
This evidence digest highlights the need for further research to develop evidence-based guidelines for anesthetic management in amyloidosis and to clarify the impact of anesthesia on long-term neurological outcomes in this vulnerable population.