Left Subclavian Transcatheter Aortic Valve Replacement Under Combined Interscalene and Pectoralis Nerve Blocks: A Case Series

Abstract

The treatment for aortic stenosis is evolving rapidly with new developments in transcatheter aortic valve replacement (TAVR). While the procedure was initially performed under general anesthesia with invasive monitoring and transesophageal echocardiography, recent trends have shifted toward less invasive strategies. Transfemoral TAVRs are frequently performed under sedation; however, TAVRs using alternative access sites, such as the subclavian artery, are typically performed under general anesthesia. This case series describes 3 patients who underwent subclavian TAVR under combined pectoralis and interscalene blocks. All patients tolerated the procedure without complication, requiring no airway manipulation and minimal postoperative analgesia.

The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: a qualitative systematic review

“…There were 42 non‐randomised studies: 13 comparative cohort studies ; 19 case series ; and 10 case reports . Six of the cohort studies ; 14 of the case series ; and seven of the case reports were available only as abstracts or posters from conference proceedings.…”

“…Fourteen non‐randomised studies evaluated PECS blocks in a wide range of cardiothoracic applications, including: thoracotomy; sternotomy; transcatheter cardiac procedures; cardiac device placement; and thoracic trauma. These comprised: four comparative cohort studies ; seven case series ; and two case reports .…”

“…Although continuous serratus anterior plane block may be easier and safer to perform compared with continuous thoracic epidural analgesia or paravertebral blockade, more high‐quality studies are needed to determine if it provides equivalent analgesia in cardiothoracic surgery. The role of these blocks in minimally invasive cardiac procedures similarly warrants further exploration as their use may be associated with lower postoperative complication rates .…”

“…Two case series have described the successful implantation of internal cardiac defibrillators using a serratus anterior plane block without general anaesthesia [26,45] and a third case series described its efficacy in combination with general anaesthesia [50]. One retrospective cohort study [28]; three case series [33,44,46]; and one case report [56] have described using PECS 2 blocks, either in combination with general anaesthesia or as the sole anaesthetic modality, for transcatheter cardiac procedures or cardiac device implantation.…”

Ongoing Obstacles for Universal Use of Sedation for Transfemoral Transcatheter Aortic Valve Replacement

“…And of this list, nontransfemoral access often becomes the only absolute contraindication (although a regional/sedation approach has been described for subclavian access). 8 Other factors such as morbid obesity, low left ventricular ejection fraction, pulmonary hypertension, and severe pulmonary disease typically do not exclude the option of a sedation approach, but the decision is made rather on a case-by-case basis. As was shown by Marino and colleagues, there continues to be a trend of GA and TEE use in patients with higher STS scores.…”