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Background and Aims High-risk cardiac patients undergoing vaginal hysterectomy pose significant anesthetic challenges due to the need for stable hemodynamics and avoidance of general anesthesia (GA)-related respiratory complications. Sequential spinal anesthesia using a combination of low-dose hyperbaric and isobaric bupivacaine offers a potential alternative by minimizing abrupt sympathetic blockade and preserving systemic vascular resistance (SVR).Methods We present a case series of five high-risk cardiac patients (including those with valvular lesions, reduced ejection fraction, and ischemic heart disease) scheduled for vaginal hysterectomy. All patients were deemed unfit for GA due to cardiopulmonary comorbidities. A sequential spinal technique was employed: initially, 5 mg of hyperbaric bupivacaine with 25 µg fentanyl was administered intrathecally, followed after 10–15 minutes by 5 mg of isobaric bupivacaine. Hemodynamic parameters were closely monitored, and vasopressors were used only if necessary.Results All five patients achieved adequate surgical anesthesia with this technique. No patient required conversion to GA. Hemodynamics remained stable in all cases, with minimal fluctuations in blood pressure and heart rate. None of the patients experienced significant hypotension or arrhythmias, and vasopressor support was not required. Postoperative recovery was uneventful, with no respiratory complications or delayed mobilization.Conclusions Sequential spinal anesthesia using a combination of low-dose hyperbaric and isobaric bupivacaine appears to be a safe and effective anesthetic approach in high-risk cardiac patients undergoing vaginal hysterectomy. This technique minimizes the risk of hemodynamic instability and avoids complications associated with GA. Further prospective studies are needed to validate these findings and refine the protocol.