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The clinical application of ultra-fast track cardiac anesthesia in right-thoracoscopic minimally invasive cardiac surgery: a retrospective observational study

  • Shenjie Jiang
    Affiliations
    Rehabilitation Medicine Center, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang, China
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  • Lixin Wang
    Affiliations
    Jinzhou Medical University NO 40, Section 3, Songpo Road, Jinzhou City, Liaoning Province, China
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  • Haokang Teng
    Affiliations
    Jinzhou Medical University NO 40, Section 3, Songpo Road, Jinzhou City, Liaoning Province, China
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  • Xiaokan Lou
    Affiliations
    Rehabilitation Medicine Center, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang, China
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  • Hanwei Wei
    Affiliations
    Rehabilitation Medicine Center, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang, China
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  • Meijuan Yan
    Correspondence
    Correspondence Meijuan Yan M.D., Rehabilitation Medicine Center, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang, China, Phone number:13957116714
    Affiliations
    Rehabilitation Medicine Center, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang, China
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Open AccessPublished:January 12, 2023DOI:https://doi.org/10.1053/j.jvca.2023.01.010

      Abstract

      Objectives

      The purpose of this study was to investigate the effect of ultra-fast track cardiac anesthesia (UFTCA) on rapid postoperative recovery in patients undergoing right-thoracoscopic minimally invasive cardiac surgery.

      Design

      a retrospective observational study

      Setting

      a single large teaching hospital

      Participants

      A total of 153 patients who underwent right-thoracoscopic minimally invasive cardiac surgery between January 2021 and August 2021 were enrolled. Inclusion criteria were American Society of Anesthesiologists (ASA) grade I∼III, New York Heart Association (NYHA) cardiac function class I∼III, and age ≥ 18 years. Exclusion criteria were NYHA class IV, local anesthetic allergy, severe pulmonary hypertension (PASP> 70mmHg), age ≤ 18 years or ≥ 80 years old, emergency surgery, and patients with incomplete or missing data.

      Interventions

      Finally, a total of 122 patients were included and grouped by different anesthesia strategies. Sixty patients received SAPB-assisted ultra-fast track cardiac anesthesia (UFTCA group), while sixty-two patients received conventional general anesthesia (CGA group). The primary outcomes were length of hospital stay and postoperative ICU stay. Secondary outcomes were postoperative pain scores, opioids use, postoperative chest tube drainage, and complications.

      Measurements and Main Results

      The intraoperative dosages of sufentanil and remifentanil in the UFTCA group were significantly lower than those in the CGA group (66.25±1.03 µg vs 283.31±11.36 µg, P<0.001; and 1.94±0.38 mg vs 2.14±0.99 mg, P<0.001, respectively). The incidence of postoperative rescue analgesia in the UFTCA group was significantly lower than that in the CGA group {10 cases (16.67%) vs 30 cases (48.38%), P<0.001}. In the postoperative ICU, there were fewer patients with pain score NRS (numerical rating scale) ≥3 in the UFTCA group than that in the CGA group {10 cases (16.67%) vs 29 cases (46.78%), P<0.001}. The postoperative extubation time in the UFTCA group was shorter than that in the CGA group {0.3h (range 0.25∼0.4 h) vs 13.84 h (range 10.25∼18.36 h), P<0.001}. Length of ICU stay and hospital stay in the UFTCA group were shorter than those in the CGA group {27.73±16.54 h vs 61.69±32.48 h, P<0.001; and 8 (range 7∼9) days vs 9 (range 8∼12) days, P<0.001, respectively}. Compared with the CGA group, the patients in the UFTCA group had less chest tube drainage within 24 hours after surgery (197.67±13.05 ml vs 318.23±160.10 ml, P<0.001). There were no significant differences in in-hospital mortality, postoperative bleeding, or secondary surgery between the two groups. The incidence of postoperative nausea, vomiting, or atelectasis were comparable between the two groups.

      Conclusions

      SAPB-assisted ultra-fast track cardiac anesthesia can promote rapid postoperative recovery in patients with right-thoracoscopic minimally invasive cardiac surgery. This anesthesia regimen is clinically safe and feasible.

      Keywords

      Introduction

      With the advancement of surgical techniques, the improvement of cardiopulmonary bypass, and the application of minimally invasive thoracoscopy, the trauma of cardiovascular surgery has been greatly reduced, and postoperative recovery has been greatly improved 1, 2. Thoracoscopic right-side minimally invasive cardiac surgery has emerged as an alternative to conventional cardiac surgery and is increasingly accepted by patients based on favorable short- and long-term outcomes.
      The concept of enhanced recovery after cardiac surgery (ERACS) 3 was proposed on the basis of “fast-track” and “ultra-fast track” cardiac anesthesia, namely FTCA and UFTCA. The joint efforts of medical teams such as cardiac surgery, anesthesia, perfusion, and intensive care are the basis for promoting accelerated recovery of patients undergoing cardiovascular surgery 4, 5. FTCA refers to a patient's recovery from anesthesia and extubation with an appropriate anesthetic regimen within 6 hours post-surgery. UFTCA means that patients recover and are extubated within 1 hour, even immediately after surgery. The purpose of FTCA and UFTCA is to reduce ICU and hospital stay and associated complications, ultimately promoting recovery and reducing postoperative healthcare costs 6-8.
      Since January 2021, we have performed a serratus anterior plane block (SAPB) to assist UFTCA. We conducted this observational study under the assumption that ultra-fast track cardiac anesthesia in patients undergoing minimally invasive cardiovascular surgery would promote rapid postoperative recovery. Our primary endpoints were length of postoperative hospital stay and ICU stay, and secondary endpoints were postoperative pain scores, opioid use, postoperative chest tube drainage, and complications.

      Materials and Methods

      Patient Population

      The retrospective study enrolled 153 patients who underwent right-thoracoscopic minimally invasive cardiac surgery in our cardiac center from January 2021 to August 2021. The Institutional Review Board (IRB) of Zhejiang Provincial People's Hospital (IRB No.2021KY045; approval date: October 18th, 2021) approved this study. The IRB waived informed consent due to the retrospective nature of the analysis. Inclusion criteria were American Society of Anesthesiologists (ASA) class I∼III, New York Heart Association (NYHA) cardiac function class I∼III, and age ≥ 18 years. Exclusion criteria were NYHA class IV, local anesthetic allergy, severe pulmonary hypertension (PASP> 70mmHg), age ≤ 18 years or ≥ 80 years, emergency surgery, and patients with incomplete or missing data.

      General data

      Among the 153 patients, 31 patients were excluded, including 10 patients with NYHA class IV, 17 patients whose age did not meet the inclusion criteria, and 4 patients whose medical records were incomplete. Ultimately, 122 patients were eligible for analysis, with 27 underwent mitral valve replacement (MVR), 38 mitral valve repair (MVP), 26 aortic valve replacement (AVR), and 31 AVR and MVR. Of the 122 patients, 60 patients received SAPB-assisted ultra-fast track cardiac anesthesia (UFTCA group) and 62 received conventional general anesthesia (CGA group).

      Patients in the UFTCA group

      Ultrasound-guided SAPB: To improve patient comfort, serratus anterior plane block was performed after anesthesia induction, using a high-frequency ultrasound probe to locate the fourth rib in the right midaxillary line. Ropivacaine (20 ml, 0.375%) was injected into the deep surface of the serratus anterior muscle using the in-plane needle technique. Ultrasound-guided SAPBs were performed by the same anesthesiologist (Figure 1).
      Fig 1
      Fig 1Ultrasound-guided serratus anterior plane block: sonographic landmarks. Local anesthetic (LA); latissimus dorsi (LD); serratus anterior muscle (SA); serratus anterior plane block (SAPB).
      Fig 2
      Fig 2Study flowchart. UFTCA: ultra-fast track cardiac anesthesia,CGA: conventional general anesthesia
      Anesthesia induction:Anesthesia was induced with etomidate 0.2 mg/kg, propofol 0.5∼1.0 mg/kg, sufentanil 0.4∼0.5 µg/kg, and benzenesulfonate atracurium 0.15 mg/kg.
      Anesthesia was maintained with intravenous infusion of remifentanil 0.1∼0.5 µg/kg.min and propofol 100∼200 µg/kg.min. Benzenesulfonate atracurium 1.0∼2.0 µg/kg.min was intravenously infused. The routine dosage of sufentanil is 0.2∼0.5µg/kg before incision, 0.2∼0.3µg/kg at the beginning of CPB, 0.2∼0.3µg/kg after aortic clamping. The total amount of sufentanil during the operation was controlled at 1∼1.5µg/kg. The dosages of remifentanil and propofol were adjusted according to the degree of surgical stimulation to maintain the BIS value between 30 and 40 (the use of benzodiazepine sedatives was prohibited during anesthesia).
      Recovery from anesthesia: One hour before the end of the operation, the infusion of propofol was reduced according to the degree of surgical stimulation, and the infusion of benzenesulfonate atracurium was stopped. All intravenous anesthetics were discontinued 30 minutes before the end of surgery. If necessary, propofol 20∼30 mg was injected to keep the patient sedated until the end of surgery. The tracheal tube was extubated in patients who were awake immediately after surgery. When extubation was not possible within 30 minutes after surgery, the patient was transferred to the post-anesthesia care unit (PACU). If the tracheal tube could not be removed within 1 hour in the PACU, the ultra-fast track was abandoned, and the patient was transferred to ICU with the tracheal tube.
      Patients were extubated if the following criteria were met:① Hemodynamically stable, only small doses of vasoactive drugs are needed, such as dobutamine ≤5.0 μg/(kg.min) and norepinephrine ≤0.05 μg/(kg.min); hemoglobin ≥80g/L. ②PH value is maintained at 7.35∼7.45. ③ No active bleeding. ④ Restoration of consciousness, such as opening and closing eyes, sticking out tongue, and gripping and releasing hands as commanded. ⑤ Spontaneous breathing was smooth, tidal volume returned to normal, and airway defense reflexes recovered. ⑥ Pulse oxygen saturation≥ 95%.
      Neuromuscular blockade was reversed with neostigmine if needed

      Patients in the CGA group

      Anesthesia induction: Anesthesia was induced with etomidate 0.2 mg/kg, propofol 0.5∼1.0 mg/kg, sufentanil 0.4∼0.5 µg/kg, and benzenesulfonate atracurium 0.15 mg/kg. Anesthesia was maintained with intravenous infusion of remifentanil 0.1∼0.5 µg/kg.min, propofol 100∼200 µg/kg.min, and benzenesulfonate atracurium 1.0∼2.0 µg/kg.min. The conventional cardiac anesthesia is total intravenous anesthesia in our center including sufentanil of 0.5∼1µg/kg before incision, 0.5∼1µg/kg at the beginning of CPB, 0.5∼1µg/kg after aortic clamping and 0.5∼1µg/kg at the end of CPB. The total intraoperative amount of sufentanil was approximately 5µg/kg according to the length of operation. The dosages of remifentanil, propofol and sufentanil were adjusted according to the degree of surgical stimulation to maintain the BIS value between 30 and 40 (Benzodiazepine sedatives was prohibited during anesthesia). After the operation, the patient was immediately transferred to ICU for rehabilitation and extubation.
      All patients were connected to the intravenous analgesia pumps in ICU. If the intravenous analgesia pump reaches the limit dose of sufentanil, the Numeric Rating Scale (NRS) visual analog pain score was still ≥3 points, and the Critical Care Pain Observation Tool (CPOT) score was≥3 points, intravenous rescue analgesia was given (remifentanil 100 µg/ml intravenous micropump infusion 0.5∼1µg/kg/min). Patients were transferred to the general ward in stable condition. If the pain score in the general ward was≥3, tramadol 0.1 g was used for rescue analgesia.

      Surgical procedure

      Patient was placed in the supine position, and a transesophageal echocardiography (TEE) probe was inserted. As we reported previously 9, A 4 cm incision was made through the right thoracic fourth intercostal space and a rib spreader was placed. The pericardium was dissected and suspended before surgery.

      Data extraction and collation

      Clinical data were extracted from the electronic medical record system, including age, gender, BMI, comorbidities (such as hypertension, diabetes, atrial fibrillation, coronary heart disease, history of cerebral infarction), lung function, surgical method, aortic clamp time, cardiopulmonary bypass time, operation time, and anesthesia method.

      Outcome indicators

      Outcome indicators included the incidence of postoperative rescue analgesia, the incidence of CPOT (Critical care Pain Observation Tool) ≥3 or NRS ≥3 in ICU and general ward, postoperative mechanical ventilation time, length of ICU stay, and hospital stay, postoperative chest tube drainage within the first 24 hours, nausea and vomiting, atelectasis, in-hospital mortality, and incidence of postoperative bleeding and secondary surgery. In this observation, atelectasis was only a qualitative indicator based on the diagnostic report, and the severity was not graded.

      Statistical analysis

      The mean difference in postoperative hospital stay between the two groups was 2.5 days, and the common standard deviation of the two groups was 4 days. The difference test was adopted, with β=0.2 and α=0.05 (bilateral test), and the ratio of the two groups was set as 1:1. PASS 15 was used to calculate the sample size, with a minimum of 42 cases per group. Considering a 15% drop, a total of 122 patients were included in the study. SPSS 25 statistical software was used for analysis. Continuous variables with normal distribution were expressed as mean ± standard deviation (x±s), and skewed data was presented as median (interquartile range). Quantitative variables were compared using t-test, and categorical variables were compared using χ2 test or Fisher's exact test. A p-value <0.05 was considered statistically significant.

      Results

      All 60 patients in the UFTCA group successfully underwent ultra-fast track cardiac anesthesia as planned. There were no significant differences in demographic characteristics, operation time, CPB and aortic clamping, type of surgery, or intraoperative blood transfusion. The intraoperative doses of sufentanil and remifentanil in the UFTCA group were significantly lower than those in the CGA group (sufentanil, 66.25±1.03 µg vs 283.31±11.36 µg, P<0.001; remifentanil, 1.94±0.38 mg vs 2.14±0.99 mg, P<0.001, respectively) (Table 1).
      Table 1The basic demographic characteristics, operation related times, and incidence of intraoperative blood transfusion in the patient cohort.
      Overall (n=122)UFTCA group (n=60)CGA group(n=62)P value
      Age(y)

      Gender (male/female)

      Height (cm)

      Weight (kg)

      BMI (kg/m2)

      ASA

      NYHA

      Comorbidity

      Hypertension(n/%)

      Diabetes(n/%)

      Atrial fibrillation(n/%)

      Coronary heart disease(n/%)

      History of cerebral infarction(n/%)

      Type of surgery

      MVR(n/%)

      MVP(n/%)

      AVR(n/%)

      AVR and MVR(n/%)

      Operation (min)

      CPB time (min)

      Aortic clamp time (min)

      intraoperative blood transfusion
      56.76±12.21

      (65/57)

      162.95±8.63

      61.42±11.77

      23.12±3.35

      3(3-3)

      3(2-3)

      35(28.7)

      11(9.0)

      22(18.0)

      12(9.8)

      5(4.1)

      27 (22.13)

      35 (28.69)

      26 (21.31)

      31 (25.41)

      281.97±68.25

      139.39±28.55

      88.73±28.89

      22(18.03)
      57.68±12.55

      (31/29)

      163.05±8.17

      60.53±10.62

      22.66±2.88

      3(3-3)

      2(2-3)

      17(28.3)

      5(8.3)

      7(11.7)

      4(10.0)

      2(3.3)

      14 (23.33)

      18 (30.0)

      13 (21.67)

      15 (25.0)

      270.38±.7.941

      143.77±25.74

      93.13±24.68

      10(16.67)
      55.87±11.907

      (34/28)

      162.85±9.13

      62.29±12.81

      23.57±3.73

      3(3-3)

      2.5(2-3)

      18(29.0)

      6(9.7)

      15(24.2)

      6(9.7)

      3(4.8)

      13 (20.97)

      17 (27.42)

      13 (20.97)

      16 (25.81)

      293.63±78.16

      135.15±30.65

      84.47±32.07

      12(19.35)
      0.415

      0.726

      0.901

      0.413

      0.138

      0.368

      0.292

      0.932

      0.796

      0.072

      0.952

      1.000

      0.064

      0.141

      0.544

      0.699
      Continuous data were represented as mean standard deviation, categorical data by percentage (%), and ASA and NYHA by median (IQR).
      Abbr:
      ASA, American society of Aneshesiologists physical status classification system;BMI, Body mass index; NYHA, Classification of heart function of New York Heart Association; MVR, Mitral valve replacement; MVP, Mitral valve repair, AVR, Aortic valve replacement; CPB,Cardiopulmonary bypass; UFTCA, Ultrafast track cardiac surgery anesthesia assisted by serratus anterior plane block; CGA, Conventional general anesthesia;
      Statistically significant difference (P<0.05).
      The incidence of postoperative ICU rescue analgesia was 10 cases (16.67%) in UFTCA group while 30 cases (48.38%) in CGA group (P<0.001). The incidence of postoperative rescue analgesia in the general wards was 15 cases (25.0%) in UFTCA group and 12 cases (19.35%) in CGA group (P=0.453). There was no significant difference in postoperative rescue analgesia in the general ward (Table 2).
      Table 2Intraoperative amount of opioids and postoperative analgesia
      Overall (n=122)UFTCA group (n=60)CGA group(n=62)P value
      Sufentanil intraoperatively(ug)185.52±140.9767.0±8.55300.24±110.29<0.001
      significant difference.
      Semifentanil intraoperatively(mg)2.04±0.761.94±0.382.14±0.99<0.001
      significant difference.
      ICU rescue analgesia.(n/%)40(32.79)10(17.67)30(48.38)<0.001
      significant difference.
      ward rescue analgesia.(n/%)27(22.13)15(25.0)12(19.35)0.453
      The continuous data were expressed as the mean ± standard deviation, and categorical data were expressed as percentage (%).
      significant difference.
      Postoperative ICU NRS ≥3 was 10 cases (16.67%) in UFTCA group and 29 cases (46.78%) in CGA group (P<0.001). Ward NRS ≥3 in UFTCA group was 15 cases (25.0%) and 8 cases (12.90%) in CGA group (P=0.088) (Table 3). Postoperative ICU CPOT ≥3 was 29 cases (46.78%) in CGA group. Three patients in the CGA group switched to rescue analgesia due to side effects from the use of intravenous analgesic pump.
      Table 3Incidence of CPOT and NRS score3 in ICU and ward
      Overall (n=122)UFTCA group (n=60)CGA group(n=62)P value
      CPOT≥3 in ICU (n/%)29(23.78)29(46.78)
      NRS≥3 in ICU (n/%)39(31.97)10(16.67)29(46.78)<0.001
      NRS≥3 in Ward(n/%)23(18.85)15(25.0)8(12.90)0.088
      The categorical variables were expressed as percentages (%), CPOT: intensive care patient pain score, NRS: Numerical Rating Scale pain score.
      All patients in UFTCA group were extubated immediately, or within 1 hour after surgery (extubation time range from 0.25h to 0.4h), while patients in CGA group were extubated in ICU (extubation time range from 10.25h to 18.36h) (P<0.001). The postoperative ICU stay, hospital stay, and 24 h postoperative chest tube drainage were significantly lower in UFTCA group than those in CGA group (P<0.001), details see in Table 4.
      Table 4Postoperative recovery time and chest tube drainage
      Overall (n=122)UFTCA group (n=60)CGA group(n=62)P value
      Postoperative extubation time (h)6.64(0.30-13.94)0.3(0.25-0.4)13.84(10.25-18.36)<0.001
      Significant difference
      Length of stay in ICU(h)44.99±30.9227.73±16.5461.69±32.48<0.001
      Significant difference
      Length of stay in Hospital (d)8(7-10)8(7-9)9(8-12)<0.001
      Significant difference
      Chest tube drainage(ml)258.93±159.19197.67±130318.23±160.10<0.05
      Continuous data were represented as the mean ± standard deviation, and postoperative extubation time was represented as median (IQR).
      Significant difference
      There was no statistical difference in the incidence of postoperative complications, bleeding, secondary surgery, or in-hospital mortality between the two groups (Table 5).
      Table 5Summary of the postoperative complications.
      Overall (n=122)UFTCA group (n=60)CGA group(n=62)P value
      Nausea (n/%)13(10.66)5(8.33)8(12.90)0.560
      Vomiting (n/%)5(4.09)2(3.33)3(4.83)1.000
      Atelectasis(n/%)31(25.41)17(28.33)15(23.33)0.535
      In-hospital mortality(n/%)0 (0)0 (0)0 (0)
      Postoperative hemorrhage(n/%)1 (0.82)0 (0)1 (1.61)0.608
      Secondary surgery (n/%)1 (0.82)0 (0)1 (1.61)0.608
      The categorical variables were expressed as percentages (%)

      Discussion

      It is imperative to improve the quality of cardiovascular surgery and promote rapid postoperative recovery 10, which is a constant concern of cardiac surgeons and anesthesiologists. Since 2018, thoracoscopy-assisted right infra-axillary minimally invasive incision cardiac surgery has become a routine procedure in our cardiac center. A variety of procedures can be performed under this minimally invasive approach, including valve replacement or repair, repair of complex congenital heart disease, septal myectomy for hypertrophic obstructive cardiomyopathy 9. Given the growing interest in fast-track and ultra-fast track anesthesia for cardiac surgery, we innovatively performed UFTCA in some patients undergoing minimally invasive cardiac surgery. In this retrospective observation, we compared UFTCA with CGA and determined that UFTCA strategy is beneficial for better postoperative recovery.
      Patients in CGA group were administered with more sufentanil and remifentanil and were transferred to ICU for anesthesia recovery and extubation. Traditional cardiac anesthesia with high dose opioids had obvious analgesic effects, with mild myocardial injury and hemodynamic influence. It can significantly reduce the cardiovascular response to tracheal intubation and surgical stimulation without the release of histamine, which is called "stress-free anesthesia"11. That was the reason for our previously large amounts of sufentanil and remifentanil.
      The implementation of ERACS means that cardiac anesthesia needs to replace the previous application of high-dose opioids with a new perioperative multimodal analgesia technique, that is, reduced opioids or opioid-free 8 combined with balanced short-acting anesthetics. In our UFTCA strategy, total intravenous anesthesia combined with serratus anterior plane block (SAPB) was used, and the total intraoperative dose of sufentanil was controlled at 1∼1.5µg/kg.
      Ultrasound-guided right deep SAPB was used for UFTCA. Injection of local anesthetic between the fourth rib serratus and the surface of the rib (deep SAPB) effectively blocked pain conduction from the lateral cutaneous branch of the T2-6 intercostal nerve12. Thus, deep SAPB as an effective analgesic on the right chest wall 13, 14 reduced intraoperative opioids use, reduced postoperative pain scores, and the incidence of ICU rescue analgesia. SAPB is initially one of assistive techniques for UFTCA since January 2021 for right-thoracoscopic minimally invasive cardiac surgery in our center. Currently, SAPB combined with pectoralis I (PECS I) and pectoralis II (PECS II) block has been routinely applied in all patients undergoing right-thoracoscopic minimally invasive cardiac surgery in our center, regardless of UFTCA or not.
      Good perioperative analgesia management is the basis for successful UFTCA. Although the intraoperative opioids consumption in UFTCA group was lower than that in CGA group, the results suggested that the anesthesia regimen of SAPB-assisted UFTCA could achieve better postoperative analgesia. Fewer patients need rescue postoperative analgesia in ICU in UFTCA group. The incidence of NRS 3 in the postoperative ICU in UFTCA group was significantly lower than that in CGA group. However, a single injection of 0.375% ropivacaine 20 ml for SAPB did not provide prolonged analgesia. As the block effect subsided, there was no significant difference in analgesia between the two groups in the general ward (Table 2). Notably, the use of high-dose opioid analgesics resulted in delayed extubation, significantly prolongs postoperative mechanical ventilation, and hindered postoperative recovery 15, 16.
      Patients in UFTCA group had shorter extubation time and shorter ICU stay. Consistent with previous studies,our UFTCA also reduced the hospital stay 17, 18. Studies showed that extubation in the operating room for patients with congenital heart disease was safe and feasible19. Others proved that early extubation could reduce the dependence of patients on vasoactive drugs after surgery. It could also reduce postoperative fluid and blood product transfusion 20. Accelerating ICU discharge is pivotal for rapid postoperative recovery, speeding up ICU bed turnover, and alleviating the shortage of medical resources. The prolonged mechanical ventilation time in CGA group was partially related to the previous shortage of ICU physicians and the avoidance of extubation at night for safety reasons. UFTCA allowed patients to resume spontaneous ventilation as soon as possible after surgery, minimizing mechanical ventilation and length of stay in the ICU. This was what motivated us to conduct UFTCA.
      Another interesting finding was that patients in UFTCA group had less thoracic chest tube drainage within 24 hours after surgery. The specific mechanism is unclear. Less postoperative blood loss can lead to less postoperative blood transfusion, thereby reducing the incidence of transfusion-related complications 15. Although there was no statistically significant difference between the two groups, a subset of patients in both groups developed postoperative atelectasis, which deserves clinical attention.
      We did not observed difference of postoperative nausea or vomiting between the two groups, which is contrary to the findings of Park et al.21. That may owe to the routine use of dexamethasone 10 mg or methylprednisolone 5mg/kg during the operation, the use of anti-emetic drugs for all cardiac surgery patients in our center. Studies have shown that intraoperative glucocorticoids administration can prevent postoperative nausea and vomiting 22. One patient in CGA group underwent reoperation to stop active bleeding from the chest wall. There were no SAPB-related complications in the UFTCA group, such as local anesthetic toxicity, hematoma, or puncture site infection. All patients recovered and discharged. There was no significant difference between the two groups in-hospital mortality, postoperative hemorrhage and secondary surgery.
      We maintained excessive depth of anesthesia with BIS value between 30 and 40 with propofol continuous infusing in cardiac anesthesia before October 2021. Propofol infusing was discontinued until the end of suture in the group CGA, while discontinued earlier in the UFTCA group. But the dosage of propofol was not counted. Since October 2021, we changed the unnecessary excessive anesthesia depth to maintain BIS value between 40 and 60 in cardiac anesthesia.
      There are some limitations of the current study. This study was a retrospective observation, focusing on the occurrence of adverse events during hospitalization and did not follow up on long-term prognosis. Furthermore, the lack of randomization may bias the results. We are conducting further randomized studies focusing on long-term outcomes of UFTCA.

      Conclusions

      SAPB-assisted UFTCA promotes rapid postoperative recovery in patients with right-thoracoscopic minimally invasive cardiac surgery. This approach is safe and feasible in clinical practice.

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      Declaration of competing interest

      None of the authors has any conflict of interest