A Sixty two year old female a known case of carcinoma of left breast T2 N1 M0 was admitted for mastectomy with axillary clearance. She was a known case of Rheumatic valvular heart disease who has been having chronic atrial fibrillation moderate severe mitral regurgitation, mild mitrial stenosis with mild to moderate pulmonary hypertension and mild tricuspid regurgitation. She has been on regular medication which included ionotrope, diuretic, class III antiarrhythmic agent and oral anticoagulant.