Congenital Cardiac Anesthesia Society
A Section of the the Society for Pediatric Anesthesia

{“questions”:{“47rhv”:{“id”:”47rhv”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Sana Ullah, MB ChB, FRCA – Children\u2019s Health, Dallas \r\n\r\nA 36-year-old male who recently emigrated to the United States from India presents with worsening dyspnea on exertion and palpitations. He reports a history of rheumatic fever as a child. A 12-lead ECG show atrial fibrillation with a HR of 110. Transthoracic echocardiogram demonstrates a large secundum atrial septal defect with left to right shunting and moderate right heart enlargement. What additional abnormality is MOST likely to be seen on the echocardiogram?”,”desc”:”EXPLANATION \r\nThe association of an atrial septal defect (ASD) with mitral stenosis (MS) is known as Lutembacher syndrome, named after the first publication in 1916 by a French physician. The ASD is usually congenital, but the MS is almost always due to a complication of rheumatic heart disease. Hence, this entity is more common in areas where rheumatic fever is endemic, such as sub-Saharan Africa and other under-developed countries. An iatrogenic form of Lutembacher syndrome is composed of a residual ASD created during trans-catheter balloon mitral valvuloplasty procedures for MS.\r\n\r\n\r\n \r\nThe natural history and hemodynamic sequelae of Lutembacher syndrome are determined by the size of the ASD, severity of MS, pulmonary vascular resistance, and compliance of the right ventricle. The magnitude of the left to right shunt across the typically large ASD is increased in the presence of severe MS resulting in volume overload of the right ventricle and pulmonary circulation. This will eventually result in right heart failure and pulmonary hypertension. In the presence of a restrictive ASD, the clinical course will be primarily determined by the severity of the MS. Atrial dilatation additionally predisposes patients to atrial fibrillation.\r\n\r\n\r\n\r\nDiagnosis is confirmed by transthoracic echocardiography (TTE) and confirms ASD size and severity of MS. Planimetry is usually preferred in assessing MS severity as doppler gradients across the valve will be significantly reduced due to shunting across the ASD.\r\n\r\n\r\n\r\nTreatment of Lutembacher syndrome in the current era is usually via trans-catheter techniques with balloon valvuloplasty of the mitral valve and device closure of the ASD. Surgical management is indicated for patients deemed unsuitable for trans-catheter procedure, such as inadequate rims around the ASD, left atrial thrombus, or concomitant severe mitral regurgitation.\r\n\r\n\r\n\r\nIn the patient described above, the most likely co-existing abnormality is MS due to the history of rheumatic heart disease. The mitral valve is the most common valve affected by rheumatic heart disease, initially causing mitral regurgitation that may progress to mitral stenosis. A significant ventricular septal defect is likely to result in pulmonary hypertension in a 36-year-old patient and reversal of shunting at level of the ASD. Therefore, answer B is incorrect. Partial anomalous pulmonary venous return is less likely in this patient with a history of rheumatic fever. Furthermore, PAPVR typially associated with sinus venosus ASDs rather than a secundum ASD. \r\n\r\n\r\n \r\nREFERENCES \r\n\r\nAminde LN, Dzudie A, Takah NF, Ngu KB, Sliwa K, Kengne AP. Current diagnostic and treatment strategies for Lutembacher syndrome: the pivotal role of echocardiography. Cardiovas Diag Ther <\/em>.2015; 5:122-132. doi: 10.3978\/j.issn.2223-3652.2015.03.07\r\n\r\n\r\nBashi VV, Ravikumar E, Jairaj PS, et al. Coexistent mitral valve disease with left-to-right shunt at the atrial level: clinical profile, hemodynamics, and surgical considerations in 67 consecutive patients. Am Heart J <\/em>.1987;114:1406-14. \r\n\r\n\r\nNagamani AC, Nagesh CM. Lutembacher Syndrome. In: Vijaylakshmi IB, Rao PS, ChughR, eds. A Comprehensive Approach to Congenital Heart Disease. <\/em> 2nd ed. New Dehli, India: Jaypee Brothers Medical Publishers; 2020:1036-1045.\r\n”,”hint”:””,”answers”:{“rbd2r”:{“id”:”rbd2r”,”image”:””,”imageId”:””,”title”:”A. Partial anomalous pulmonary venous return “},”c9xqe”:{“id”:”c9xqe”,”image”:””,”imageId”:””,”title”:”B. Ventricular septal defect”},”6vou8″:{“id”:”6vou8″,”image”:””,”imageId”:””,”title”:”C. Mitral stenosis”,”isCorrect”:”1″}}}}}

{“questions”:{“g8env”:{“id”:”g8env”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Sana Ullah, MB ChB, FRCA – Children\u2019s Health, Dallas \r\n\r\nA two-week-old male neonate is admitted to the cardiac intensive care unit for further evaluation of cyanosis. Physical exam reveals an imperforate anus and dysmorphic facial features including pre-auricular skin tags and vertical colobomas of both eyes. Chromosomal analysis demonstrates a duplication of the long arm of chromosome 22. What is the MOST likely congenital heart defect in this patient?”,”desc”:”EXPLANATION \r\nThe clinical features in this patient are consistent with cat-eye syndrome (CES), also known as Schmid-Fraccaro syndrome. This rare genetic disorder affects approximately 1 in 150,000 people and is caused by duplication or triplication of the long arm of chromosome 22. Although there is significant phenotypic variation, the syndrome usually consists of craniofacial anomalies including facial dysmorphism, ear tags, vertical colobomas leading to the appearance of cat\u2019s eyes, and imperforate anus. \r\n\r\n\r\nCongenital cardiac defects are found in approximately 50% of patients with CES. There are several small case series in the literature describing the association of total pulmonary venous connection (TAPVC) with CES. In an analysis of thirteen published cases in 1973 by Freedom and colleagues, congenital heart disease was present in five patients with TAPVC in three out of these five cases. Tetralogy of Fallot and interrupted aortic arch are examples of conotruncal defects that are commonly associated with DiGeorge syndrome resulting from a deletion of chromosome 22q.11.2. Interrupted aortic arch also does not present with cyanosis. Therefore, options A and C are incorrect.\r\n\r\n\r\nMany patients with CES will require anesthesia for non-cardiac or cardiac procedures during the neonatal period. Due to craniofacial abnormalities, these patients should be considered at risk for a difficult airway management. \r\n\r\n \r\n\r\nREFERENCES \r\nFreedom RM, Gerald PS. Congenital cardiac disease and the \u201ccat eye\u201d syndrome. Am J Dis Child <\/em>.1973; 126:16-18. \r\n\r\nGaspar N S, Rocha G, Grangeia A, et al. Cat-Eye Syndrome: A Report of Two Cases and Literature Review. Cureus<\/em>. 2022; 14(6): e26316. DOI 10.7759\/cureus.26316.\r\n\r\nWilliams JL, McDonald MT, Siefert BA, Deak KL, Rehder CW, Campbell MJ. An unusual association: Total anomalous pulmonary venous return and aortic arch obstruction in patients with cat eye syndrome. J Pediatr Genet <\/em>.2021;10:35\u201338. DOI https:\/\/doi.org\/ 10.1055\/s-0039-1701020. \r\n\r\nDevavaram P, Seefelder C, Lillehei CW. Anaesthetic management of cat eye syndrome (Letter). Pediatr Anesth <\/em>.2001 ; 11:746-748. DOI: 10.1046\/j.1460-9592.2001.0774c.x\r\n\r\n\r\n”,”hint”:””,”answers”:{“l3olo”:{“id”:”l3olo”,”image”:””,”imageId”:””,”title”:”A. Tetralogy of Fallot”},”79l7w”:{“id”:”79l7w”,”image”:””,”imageId”:””,”title”:”B. Total anomalous pulmonary venous connection”,”isCorrect”:”1″},”8dki7″:{“id”:”8dki7″,”image”:””,”imageId”:””,”title”:”C. Interrupted aortic arch”}}}}}

{“questions”:{“e334j”:{“id”:”e334j”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Meera Gangadharan MD, FASA, FAAP – Children\u2019s Memorial Hermann Hospital\/McGovern Medical School, Houston, TX \r\n\r\nA 15-month-old female with hypoplastic left heart syndrome, with borderline left heart structures, has been palliated with a bidirectional Glenn and is being considered for biventricular conversion. Her preoperative echocardiogram demonstrates severe endocardial fibroelastosis (EFE) of the left ventricle. What is the MOST likely long-term complication of EFE resection in this patient? “,”desc”:”EXPLANATION \r\nEndocardial fibroelastosis (EFE) is an abnormal thickening of the endocardium caused by an abnormal deposition of collagen by fibroblasts, resulting in systolic and diastolic myocardial dysfunction. Although primary EFE is associated with numerous diseases, in the context of congenital heart disease, it is usually caused by a reduction of blood flow through the cardiac chambers leading to significant systolic and diastolic dysfunction with restrictive physiology. \r\n\r\nDuring embryologic development, endocardial endothelial cells undergo transformation to mesenchymal cells which then form the endocardial cushions and valves. This endothelial-to-mesenchymal transition is altered by inflammation, hypoxia-ischemia, and mechanical flow disturbances, giving rise to the fibroblasts that form the fibrotic layer of EFE. Imbalances between transforming growth factor beta (TGF-\u03b2) and bone morphogenetic protein (BMP) signaling have been shown to contribute to the formation of EFE in mice. Exogenous supplementation with BMP has been shown to decrease EFE in this same mouse model (Xu et al). \r\nEFE has been described as an opaque porcelain-like layer which may be several millimeters thick (see illustration below). Although EFE can be diagnosed by echocardiogram with 95% sensitivity and 75% specificity, computed tomography (CT) scanning and magnetic resonance imaging (MRI) have also been used. MRI is particularly useful for measuring chamber volumes and flows. \r\n\r\n \r\nMacroscopic appearance of endocardial fibroelastosis. From: Luca AC, Lozneanu L, Miron IC, et al. Endocardial fibroelastosis and dilated cardiomyopathy – the past and future of the interface between histology and genetics. Rom J Morphol Embryol<\/em>. 2020;61(4):999-1005. doi:10.47162\/RJME.61.4.02. Used under Creative Commons License.\r\n\r\nThe severity of EFE on fetal echocardiograms can be used to predict prognosis after in-utero aortic balloon valvuloplasty for evolving hypoplastic left heart syndrome. The rate of change of left ventricular end-diastolic volume after the procedure was significantly greater in fetuses with mild EFE compared to those with severe EFE. Similarly, the severity of EFE can predict the likelihood that the child will be able to have biventricular repair as compared to a univentricular palliation postnatally after having undergone in-utero balloon aortic valvuloplasty. \r\nA significant proportion of patients within the spectrum of HLHS have borderline left heart structures in whom it may be possible to utilize a staged left ventricle recruitment strategy to eventually facilitate a biventricular repair. The underlying principle is to promote a flow and load-mediated growth of the left ventricle. These procedures include: (1) Interventions to relieve obstruction of the mitral and aortic valves; (2) resection of EFE to improve systolic and diastolic function; (3) restriction of the atrial communication to promote more flow into the LV; (4) adding accessory pulmonary blood flow. In a retrospective, single institution study of 34 patients undergoing a staged LV recruitment strategy, EFE resection was perfomed in the majority of patients at all three stages of palliation. There was a significant increase in left heart dimensions and ejection fraction. Thirteen of the 34 patients underwent successful biventricular repair with no mortality after a median follow-up of 2.9 years.\r\n\r\nAlthough conduction abnormalities can be seen with EFE resection, there have been no reports of heart block requiring permanent pacemaker insertion. In a 2009 retrospective study by Emani and colleagues of nine patients who had undergone EFE resection, three patients had evidence of right bundle branch block or hemifascicular block with mild prolongation of the QRS complex but none required pacemaker placement. In a separate study by Czosek and colleagues of 27 patients who had undergone EFE resection, 14 patients had varying degrees of QRS prolongation or fascicular blocks but no complete heart block requiring pacemaker placement.\r\n\r\nThere is a high rate of recurrence of EFE after resection. In a retrospective review by Diaz-Gil of 49 patients with a small LV who had undergone EFE resection, the risk of recurrence was 76% over a 10 year period.\r\n\r\n\r\n \r\nREFERENCES \r\nAldawsari, K.A., Alhuzaimi, A.N., Alotaibi, M.T. et al. Endocardial fibroelastosis in infants and young children: a state-of-the-art review. Heart Fail Rev <\/em>.(2023); 28:1023\u20131031. https:\/\/doi.org\/10.1007\/s10741-023-10319-0\r\n\r\nWeixler V, Marx GR, Hammer PE, Emani SM, Del Nido PJ, Friehs I. Flow disturbances and the development of endocardial fibroelastosis. J Thorac Cardiovasc Surg<\/em>. 2020;159(2):637-646. doi: 10.1016\/j.jtcvs.2019.08.101\r\n\r\nEmani SM, McElhinney DB, Tworetzsky W et al. Staged left ventricular recruitment after single-ventricle palliation in patients with borderline left-heart hypoplasia. J Am Coll Cardiol <\/em>. 2012. ;60:1966-74.\r\n\r\nEmani SM, Bacha EA, McElhinney DB et al. Primary left ventricular rehabilitation is effective is effective in maintaining two-ventricle physiology in the borderline left heart. J Thorac Cardiovasc Surg <\/em>. 2009;138:1276-82.\r\n\r\nDiaz-Gil D, Piekarski BL, Marx GR, Del Nido PJ, Emani S, Friehs I. Endocardial fibroelastosis recurrence: Comparing single ventricle palliation versus biventricular repair. Thorac Cardiovasc Surg <\/em>.2022. 70(S02): S67-S103. DOI: 10.1055\/s-0042-1742956\r\n\r\nCzosek RJ, Atallah J, Emani S, Hasan B, del Nido P, Berul CI. Electrical dyssynchrony and endocardial fibroelastosis resection in the rehabilitation of hypoplastic left cardiac syndrome. Cardiol Young<\/em>. 2010;20(5):516-521. doi:10.1017\/S1047951110000600\r\n\r\nHan RK, Gurofsky RC, Lee KJ, et al. Outcome and growth potential of left heart structures after neonatal intervention for aortic valve stenosis. J Am Coll Cardiol <\/em>.2007;50(25):2406-2414. doi:10.1016\/j.jacc.2007.07.082\r\n\r\nXu X, Friehs I, Zhong Hu T, et al. Endocardial fibroelastosis is caused by aberrant endothelial to mesenchymal transition. Circ Res <\/em>.2015;116(5):857-866. doi:10.1161\/CIRCRESAHA.116.305629\r\n\r\nMcElhinney DB, Vogel M, Benson CB, et al. Assessment of left ventricular endocardial fibroelastosis in fetuses with aortic stenosis and evolving hypoplastic left heart syndrome. Am J Cardiol <\/em>.2010;106(12):1792-1797. doi:10.1016\/j.amjcard.2010.08.02\r\n\r\n”,”hint”:””,”answers”:{“ysona”:{“id”:”ysona”,”image”:””,”imageId”:””,”title”:”A)\tReduced ejection fraction”},”tqplj”:{“id”:”tqplj”,”image”:””,”imageId”:””,”title”:”B)\tHeart block”},”cefjb”:{“id”:”cefjb”,”image”:””,”imageId”:””,”title”:”C)\tRecurrence of endocardial fibroelastosis\r\n\r\n”,”isCorrect”:”1″}}}}}

{“questions”:{“buizk”:{“id”:”buizk”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Sana Ullah, MB ChB, FRCA \u2013 Dallas, TX \r\n\r\nAn 8-month-old male infant is status post repair of a large perimembranous ventricular septal defect (VSD). After separation from cardiopulmonary bypass, the patient has the following vital signs: heart rate 130, blood pressure 80\/45, and pulse oximetry 99% with a fractional inspired oxygen (FiO_{2<\/sub>) of 0.25. The post-repair transesophageal echocardiogram (TEE) reveals a small residual VSD. In order to determine if the VSD is hemodynamically significant, the surgeon samples blood from the superior vena cava (SVC) and the main pulmonary artery (PA), resulting in oxygen saturations of 60% and 80% respectively. What is the Qp:Qs?”,”desc”:”EXPLANATION \r\nSmall residual ventricular septal defects (VSDs) are common after surgical repair and the decision to return to bypass is sometimes be difficult. The decision is based on TEE findings, direct pressure measurements in the right ventricle and PA, and a determination of the magnitude of the shunt by calculating the Qp:Qs ratio \u2013 where Qp is the pulmonary blood flow and the Qs is the systemic blood flow. The standard equation to calculate shunts in the cardiac catheterization laboratory is: \r\n\r\n\t\t\tQp:Qs = SaO2<\/sub> \u2013 SmvO2<\/sub> \/ SpvO2<\/sub> \u2013 SpaO2<\/sub> \r\n\r\nIn this equation, SaO2<\/sub> is the systemic arterial saturation, SmvO2<\/sub> represents the mixed venous saturation, SpvO2<\/sub> is pulmonary vein saturation, and SpaO2<\/sub> is the pulmonary artery saturation. In the absence of an intracardiac shunt, the mixed venous saturation is sampled from the main pulmonary artery. However, in patients with left to right intracardiac shunts, the superior vena cava saturation more accurately reflects a true mixed venous saturation. In patients without an underlying pulmonary pathology, the pulmonary vein saturation is assumed to be 100% and thus equal to the systemic arterial saturation. To avoid a confounding impact of dissolved oxygen, blood samples should be taken at a low FiO2<\/sub> of approximately 0.25-0.3. Therefore, in the operating room, the above equation can be simplified to: \r\n\t\t\t\r\n\t\t\tQp:Qs = SaO2 <\/sub> \u2013 SmvO2 <\/sub> \/ SaO2<\/sub> \u2013 SpaO2<\/sub>\r\n \r\n\r\n\r\nSubstituting the data from the stem into this equation results in a Qp:Qs of 2:1. A Qp:Qs of more than 1.5-2:1 should prompt a return to bypass and revision of the repair. Although most residual VSDs are not hemodynamically significant and are likely to close over time, some studies have shown defects larger than three millimeters in diameter should be addressed surgically, which requires another period of cardioplegic arrest. Interestingly, a recent publication in the Annals of Translational Medicine by Cao et al has reported successful repair of residual VSDs on cardiopulmonary bypass but after aortic unclamping and with a beating heart. They reported good outcomes with no apparent complications. This strategy may represent an unnecessary risk for air embolism to the cerebral and coronary circulation.\r\n\r\n\r\n \r\nREFERENCES \r\n1. Joffe DC, Shi MR, Welker CC. Understanding cardiac shunts. Pediatr Anesth<\/em>. 2018; 28:316-325. doi.org\/10\/1111\/pan.11347 \r\n2. Bibevski S, Ruzmetov M, Mendoza L et al. The destiny of postoperative residual ventricular septal defects after surgical repair in infants and children. World J Pediatr Congenit Heart Surg <\/em>.2020; 11: 438-443. \r\n3. Cao Z, Chai Y, Liu J et al. Revising ventricular septal defect residual shunts without aortic re-cross-clamping: a safe and effective surgical procedure. Ann Transl Med <\/em>. 2020; 8 (18):\r\n1134. doi: 10.21037\/atm-20-5041\r\n”,”hint”:””,”answers”:{“vfqn3”:{“id”:”vfqn3″,”image”:””,”imageId”:””,”title”:”A. 1 : 1″},”zayzn”:{“id”:”zayzn”,”image”:””,”imageId”:””,”title”:”B. 2 : 1″,”isCorrect”:”1″},”syza5″:{“id”:”syza5″,”image”:””,”imageId”:””,”title”:”C. 3 : 1″},”8ejws”:{“id”:”8ejws”,”image”:””,”imageId”:””,”title”:”D. Cannot be calculated with the given information”}}}}}}

{“questions”:{“mil6y”:{“id”:”mil6y”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Meera Gangadharan, MD, FASA, FAAP – University of Texas at Houston, McGovern Medical School, Children\u2019s Memorial Hermann Hospital \r\n\r\nA 5-year-old male with a history of Tetralogy of Fallot presents for revision of a right ventricle to pulmonary artery conduit. A multi-modal plan for post-operative pain control includes regional anesthesia. Which of the following regional techniques is MOST likely to provide the best post-operative analgesia in this patient? “,”desc”:”EXPLANATION \r\nEffective pain control after pediatric cardiac surgery is essential for enhanced recovery protocols. These protocols include early extubation, rapid mobilization, reduction in opioid use to minimize side effects, and shortened intensive care unit and hospital stay. Recent trends recommend multimodal approaches to pain management, including regional anesthetic techniques, to reduce systemic opioid use. Neuraxial techniques for pain control are not widely utilized in pediatric cardiac surgery due to the potential risk of bleeding from heparinization during cardiopulmonary bypass. However, there are several peripheral nerve blocks (musculofascial plane blocks), which are efficacious in a multimodal analgesic regimen after pediatric cardiac surgery.\r\n\r\nThe target of a peripheral nerve block for a median sternotomy or intercostal incision is the anterior\/ventral division of the spinal cord, which is the intercostal nerve. Intercostal nerves arise from the anterior rami of the thoracic spinal nerves and lie in between the innermost and internal intercostal muscles. Along its course from the spinal cord, the intercostal nerve branches into collateral and lateral cutaneous branches and finally terminates in the anterior cutaneous branch, which is distributed along the lateral and anterior chest wall. These branches provide sensory innervation to the skin, soft tissue, and muscle on the anterior aspect of the trunk, including the sternum. Thus, blocking the intercostal nerve at any reasonable site is the basis for a peripheral nerve block for cardiac surgery with a median sternotomy or intercostal incision. \r\n\r\nIntercostal muscles lie between the ribs. The pectoralis major muscle overlies the ribs. The intercostal muscles consist of three layers: the external, internal, and innermost intercostal muscles. The intercostal vessels are located on the lower margin of the ribs in the layer between the internal and innermost intercostal muscles. The transverse thoracic muscle lies below the innermost intercostal muscle and may be difficult to identify. The pleura lies below the intercostal muscles and can be identified as a mobile hyperechoic layer. \r\n\r\nThe intercostal nerves arising from the ventral rami of the first six thoracic spinal nerves, supply the sternum, ribs, and intercostal sites. Effective pain relief for a sternotomy or intercostal incision can be provided by blocking the intercostal nerves anywhere along their path (see illustration below). A bilateral parasternal block (PSB) can be performed by the surgeon under direct vision by injecting local anesthetic at a point that is 1.5 to 2 cm lateral to the sternum at the second to sixth intercostal spaces. The PSB has been shown to reduce opioid requirements in the first 24 hours and lower pain scores in pediatric patients after cardiac surgery. \r\n\t\r\n\r\n \r\n\r\nFig. Schema of access points to the intercostal nerve blocks for perioperative pain management for cardiac surgery. Blocking the intercostal nerve at any approachable site is the theory of peripheral nerve block for cardiac surgery with median sternotomy as well as intercostal approach. From: Yamamoto T, Schindler E. Regional anesthesia as part of enhanced recovery strategies in pediatric cardiac surgery. Curr Opin Anaesthesiol<\/em>. 2023;36(3):324-333. doi:10.1097\/ACO.0000000000001262. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\r\n\r\nA major disadvantage of the PSB is that multiple injections are required as the target intercostal nerves lie in the layer between the internal intercostal and innermost intercostal muscles, in the intercostal space. Two musculofascial plane blocks are alternative approaches to the parasternal block, which include the pectointercostal fascial block (PIFB) and transversus thoracic plane block (TTPB). Local anesthetic can thus spread along the fascial layers between muscles to cover multiple intercostal levels. Ultrasound guided PIFB and TTPB can be accomplished in the supine position. Local anesthetic is injected between the pectoralis major and the intercostal muscle layer in the PIFB. In the TTPB block, local anesthetic is injected between the innermost intercostal muscle and the transversus thoracic muscle. The PIFB has been reported to reduce opioid requirements and postoperative pain in the first 24 hours after surgery, as well as reducing the time to extubation and length of hospital stay. A retrospective study in pediatric patients demonstrated reduced intra and postoperative fentanyl use, postoperative pain scores and time to extubation. The PIFB and TTPB fascial block do not cover chest tube sites in the upper abdomen. Therefore, a rectus sheath block (RSB) is a useful adjunct to provide adequate analgesia after cardiac surgery. The efficacy of combining a RSB on the side ipsilateral to the chest tube and bilateral PIFBs has recently been described in pediatric patients after cardiac surgery in a retrospective, single center study. In this study, these interventions were associated with decreases in postoperative opioid use, pain scores and hospital length of stay. \r\n\r\nThe pectoral nerves blocks (PECS 1 and PECS 2) anesthetize the pectoral nerves, the third through sixth intercostal nerves, intercostobrachial nerve, and the long thoracic nerve. These blocks are performed by depositing local anesthetic between the pectoralis minor and major muscles (PECS 1) and between pectoralis minor and serratus anterior (PECS 2) muscles respectively. These blocks are more effective for surgical incisions that are further from the midline such as thoracotomy incisions and incisions for pacemaker implantations and breast surgery, but they are inadequate for a midline sternotomy incision. \r\n\r\nThe transversus abdominis plane block is inadequate for sternotomy and upper abdominal midline pain but is useful for procedures with lower abdominal incisions.\r\n\r\n\r\n\r\n \r\nREFERENCES \r\nYamamoto T, Schindler E. Regional anesthesia as part of enhanced recovery strategies in pediatric cardiac surgery. Curr Opin Anaesthesiol<\/em>. 2023;36(3):324-333. doi:10.1097\/ACO.0000000000001262\r\n\r\nRaj N. Regional anesthesia for sternotomy and bypass-Beyond the epidural. Paediatr Anaesth<\/em>. 2019;29(5):519-529. doi:10.1111\/pan.13626\r\n\r\nChaudhary V, Chauhan S, Choudhury M, et al. Parasternal intercostal block with ropivacaine for postoperative analgesia in pediatric patients undergoing cardiac surgery: a double-blind, randomized, controlled study. J Cardiothorac Vasc Anesth <\/em>.2012; 26:439\u2013442\r\n\r\nBloc S, Perot BP, Gibert H, et al. Efficacy of parasternal block to decrease intraoperative opioid use in coronary artery bypass surgery via sternotomy: a randomized controlled trial. Reg Anesth Pain Med<\/em>. 2021;46(8):671-678. doi:10.1136\/rapm-2020-102207\r\n\r\nFuller S, Kumar SR, Roy N, et al. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg <\/em>.2021;162(3):931-954. doi:10.1016\/j.jtcvs.2021.04.072\r\n\r\nTran DQ, Bravo D, Leurcharusmee P, Neal JM. Transversus Abdominis Plane Block: A Narrative Review. Anesthesiology<\/em>. 2019;131(5):1166-1190. doi:10.1097\/ALN.0000000000002842\r\n\r\nKumar AK, Chauhan S, Bhoi D, Kaushal B. Pectointercostal fascial block (PIFB) as a novel technique for postoperative pain management in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth <\/em>.2021; 35:116\u2013122.\r\n\r\nZhang Y, Gong H, Zhan B, Chen S. Effects of bilateral Pecto-intercostal Fascial Block for perioperative pain management in patients undergoing open cardiac surgery: a prospective randomized study. BMC Anesthesiol<\/em>. 2021; 21:175.\r\n\r\nEinhorn LM, Andrew BY, Nelsen DA, Ames WA. Analgesic effects of a novel combination of regional anesthesia after pediatric cardiac surgery: a retrospective cohort study. J Cardiothorac Vasc Anesth<\/em>. 2022; 36:4054\u20134061.\r\n\r\nCakmak M, Isik O. Transversus thoracic muscle plane block for analgesia after pediatric cardiac surgery. J Cardiothorac Vasc Anesth<\/em>. 2021; 35:130\u2013136\r\n”,”hint”:””,”answers”:{“7gwtw”:{“id”:”7gwtw”,”image”:””,”imageId”:””,”title”:”A.\tPECS 1 and PECS 2 blocks”},”cs781″:{“id”:”cs781″,”image”:””,”imageId”:””,”title”:”B.\tPectointercostal fascial block and rectus sheath block”,”isCorrect”:”1″},”8j2ni”:{“id”:”8j2ni”,”image”:””,”imageId”:””,”title”:”C.\tTransversus abdominis plane block”}}}}}