A randomized comparison of erector spinae and paravertebral blocks for postoperative analgesia in minimally invasive mitral valve replacement surgery

• Author Details:   
• Adham Magdy Haggag ^*
• Esraa Muhammed Hasan
• Galal Adel Elkadi
• Mohamed Sidky Mahmoud Zaki
• Mona Ahmed Abdelmotaleb Ammar
• Islam Abdelaal Abdelmouty Taher

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Background and Aims: Optimizing postoperative analgesia is critical for enhancing recovery after cardiac surgery. The thoracic paravertebral plane block (PVPB) is a well-established regional technique, while the erector spinae plane block (ESPB) is a newer fascial plane block that may offer comparable or superior analgesia. This study aims to compare the opioid-sparing efficacy and recovery outcomes of ultrasound-guided ESPB versus PVPB in patients undergoing minimally invasive mitral valve replacement (MIMVR) within an Enhanced Recovery After Surgery (ERAS) protocol.

Materials and Methods: In this double-blind randomized controlled trial, 80 ASA III adults scheduled for MIMVR via right mini-thoracotomy were randomly assigned (1:1) to receive either ESPB or PVPB at the T5 level, with 20 mL of 0.25% bupivacaine. The primary outcome was total 24-hour postoperative morphine consumption. Secondary outcomes included intraoperative fentanyl use, time to first morphine request, pain scores, time to extubation and ambulation, ICU and hospital length of stay, and adverse events.

Results: The ESPB group required significantly less morphine over 24 hours (11.9 ± 1.3 mg vs 14.5 ± 1.2 mg; p < 0.001) and less intraoperative fentanyl (263.8 ± 17.3 µg vs 303.6 ± 20.2 µg; p < 0.001). Time to first morphine request was longer in the ESPB group (7.2 ± 1.1 hours vs 5.8 ± 1.3 hours; p < 0.001). Pain scores were lower in the ESPB group from the 4th to the 18th postoperative hour (p < 0.001). Extubation occurred earlier in the ESPB group (3.6 ± 0.9 hours vs 5.4 ± 0.8 hours; p < 0.001), and ambulation occurred sooner (7.4 ± 1.0 hours vs 9.1 ± 1.0 hours; p < 0.001). No adverse effects were reported.

Conclusions: Ultrasound-guided ESPB provides superior opioid-sparing analgesia and facilitates faster recovery compared to PVPB in patients undergoing minimally invasive mitral valve replacement, supporting its inclusion in ERAS cardiac protocols.