Combination of pectoralis nerve block II and serratus anterior plane blocks in minimally invasive cardiac surgery. Comment on Br J Anaesth 2023; 130: 786–94

Editor—We read with interest the recently published research article on the effectiveness of a combination of pectoralis nerve block II (PECS II) and serratus anterior plane block in robotically assisted minimally invasive cardiac surgery, 1 Alfirevic A. Marciniak D. Duncan A.E. et al. Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial. Br J Anaesth. 2023; 130: 786-794 Google Scholar and the correspondence article commenting on it. 2 Coppens S. Hoogma D. Rex S. Wolmarans M. Merjavy P. Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial. Comment on Br J Anaesth 2023; 130: 786–794. Br J Anaesth. 2023; 131: e49-e50 Google Scholar Coppens and colleagues 2 Coppens S. Hoogma D. Rex S. Wolmarans M. Merjavy P. Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial. Comment on Br J Anaesth 2023; 130: 786–794. Br J Anaesth. 2023; 131: e49-e50 Google Scholar state that the study by Alfirevic and colleagues 1 Alfirevic A. Marciniak D. Duncan A.E. et al. Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial. Br J Anaesth. 2023; 130: 786-794 Google Scholar compared serratus anterior plane and PECS blocks. However, it is potentially misleading as Alfirevic and colleagues 1 Alfirevic A. Marciniak D. Duncan A.E. et al. Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial. Br J Anaesth. 2023; 130: 786-794 Google Scholar used a combination of these blocks and did not compare them. Although Coppens and colleagues 2 Coppens S. Hoogma D. Rex S. Wolmarans M. Merjavy P. Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial. Comment on Br J Anaesth 2023; 130: 786–794. Br J Anaesth. 2023; 131: e49-e50 Google Scholar subsequently questioned the rationale of the combination of these blocks as they target the same nerves, they further stated that the addition of a block covering the ‘anterior ramus of the intercostal nerves’ would have potentially produced different results. We believe that they probably intended a parasternal block (i.e. pecto-intercostal fascial plane block or transversus thoracis muscle plane block) to cover the anterior cutaneous branches of the intercostal nerves. That would not have produced a significant change in the results, because parasternal blocks provide coverage for the medial aspect of the chest and are used for pain relief from a sternotomy incision that involves the anterior cutaneous branches, 3 Woodworth G.E. Ivie R.M.J. Nelson S.M. Walker C.M. Maniker R.B. Perioperative breast analgesia: a qualitative review of anatomy and regional techniques. Reg Anesth Pain Med. 2017; 42: 609-631 Google Scholar which is not the case in minimally invasive cardiac surgery using a mini-thoracotomy incision involving the lateral cutaneous branches of the intercostal nerves. Therefore, even regarding their third point involving an intercostal nerve block, 2 Coppens S. Hoogma D. Rex S. Wolmarans M. Merjavy P. Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial. Comment on Br J Anaesth 2023; 130: 786–794. Br J Anaesth. 2023; 131: e49-e50 Google Scholar which covers both anterior and lateral branches, the results would have been the same. Furthermore, intercostal nerve blocks need to be provided at multiple levels.