Low ejection fraction in the elderly presenting for anaesthesia could be very challenging to the anaesthetist on account of the heightened risk of perioperative complications. The combined risk of low ejection fraction and poor cardiac reserve may predispose to increase perioperative mortality. Complications in the perioperative period includes acute exacerbation of heart failure which can arise from pump failure or cardiac dyskinesia, and these could be debilitating in the elderly. Therefore, maintaining good systolic function and cardiac rhythm will ensure cardiovascular stability. We present the management of an 89year old man who had hypertensive heart disease with ejection fraction of 40% that successfully had dynamic hip replacement under combined spinal epidural (CSE) anaesthesia.