Background: Anesthetic management for patients with significant cardiac disease is challenging and may be associated with high morbidity and mortality. Low-dose sequential combined spinal–epidural anesthesia [CSEA] is advantageous over single-shot spinal and epidural anesthesia as it provides rapid onset, efficacy, and minimal toxicity.  
Aim of the work: This study is planned to assess the safety of small-dose sequential CSEA in high-risk cardiac patients undergoing lower body surgeries and to estimate changes in hemodynamics, vasopressor use, surgeon satisfaction, and patient satisfaction.
Patients and Methods: Sixty adult cardiac patients [5 with pulmonary hypertension, systolic pulmonary artery pressure > 50 mmHg] and fifty-five with low systolic function [ejection fraction < 40%] planned for a lower body procedure were included in our study. The CSEA technique was done with patients receiving spinal anesthesia with 5 mg 0.5% hyperbaric bupivacaine plus 20 μg fentanyl, followed by an epidural top-up of 5 ml 0.25% isobaric bupivacaine. Hemodynamic parameters and block characteristics were recorded.
Results: There were no differences in the demographic data of the patients. No significant hemodynamic changes occurred during the procedure; hypotension happened in 5% of patients and bradycardia in less than 2% of patients. There were no arrhythmias or post-operative ECG changes, and postoperative troponin was negative. There was no postoperative nausea or vomiting.
Conclusion: We conclude that low-dose sequential CSEA is a secure and efficacious method for patients with significant cardiac disease scheduled for lower body procedures.