Cranioplasty is a surgical procedure that restores the normal anatomy following craniectomy. Restoring the skull bone ensures protection and normalizes the physiology as well as the cerebrospinal fluid dynamics. This surgical procedure usually requires administration of general anesthesia for retrieving the bone placed in the abdominal region and thereafter placing it in the cranium. We report the anesthetic management of a high-risk case who had severe mitral stenosis and was scheduled for cranioplasty. The anesthetic management of a patient with rheumatic heart disease, with severe mitral stenosis, posted for cranioplasty, is extremely challenging. The presence of cardiac pathology necessitates the need to balance patient's hemodynamics in accordance with the cardiac grid and tests the limits of the anesthesiologist's preparedness. We describe our experience of conduct of this case in regional anesthesia using scalp block on the defect site with an oblique transverse abdominis plane block for abdominal bone retrieval.