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. 2023 Feb 6;28(3):e13050. doi: 10.1111/anec.13050

Efficacy and safety of Extrapleural block in patients with coronary artery disease after thoracoscopic surgery

Tianfang Qu 1,✉, Tian Han 1, Wenqu Yang 2, Zhihui Wei 1, Huizhen He 1, Xin Yuan 3
PMCID: PMC10196090  PMID: 36745525

Abstract

Objective

This study aimed to investigate the efficacy and safety of extrapleural block (EPB) application in patients with coronary artery disease after thoracoscopic surgery.

Methods

Patients with typical symptoms of angina and myocardial ischemia who underwent thoracoscopic surgery at our institution between December 2018 and December 2020 were screened for eligibility and they received paravertebral blocking (PVB), EPB, and patient‐controlled intravenous analgesia (PCIA). Visual analog scale (VAS) scores were used to assess the analgesic effect and safety outcomes included heart rate, incidence of postoperative rescue analgesics, cardiac complications, and adverse reactions such as nausea and vomiting.

Results

In total, 76 patients (age: 66.5 [61.3, 71] years; male: 63.2%) were eligible, including the PVB group (n = 22), EPB group (n = 25), and PVIA group (n = 29) with comparable baseline characteristics. There was a significantly higher proportion of patients with a VAS score of 1 in the EPB group compared with the other groups at 4 h (88.0% vs. 10.3% for PCIA and 45.5% for PVB; p < .001) and 6 h after the surgery (32.0% vs. 3.4% for PCIA and 13.6% for PVB; p = .012). The preoperative heart rate in the EPB group (81 [71, 94] beats/min) was slightly higher than those in the PVB (76 [70, 85] beats/min) and PCIA groups (76 [69, 84 beats/min]) but without significant difference (p = .193). There was no significant difference in the incidence of rescue analgesia, adverse events, and cardiac complications among the three groups (p = .296, .808, and .669, respectively.)

Conclusion

Compared with PVB and PCIA, the EPB could more effectively relieve acute pain after thoracoscopic surgery in patients with coronary artery disease and offer comparable safety benefits in the management of postoperative heart rate, adverse events, and cardiac complications.

Keywords: coronary artery disease, extrapleural block, thoracoscopy, postoperative analgesia

A total of 76 patients with coronary artery disease were included to investigate the clinical benefit of extrapleural block after thoracoscopic surgery. Compared with other techniques, the extrapleural block could more effectively relieve acute pain and offer comparable postoperative heart rate, adverse events, and cardiac complications.

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1. INTRODUCTION

In patients with coronary artery disease having thoracoscopic surgery, the risk of perioperative cardiovascular problems varies from 1% to 5%, which is a moderate to high risk (Glance et al., 2012). Patients may have sympathetic excitement, a rise in heart rate, and an increase in blood pressure owing to a physical stress reaction brought on by surgical trauma and immediate postoperative pain. Hypoxemia, a precursor to perioperative cardiac problems, may result from discomfort that prevents deep breathing and coughing. Patients may have myocardial ischemia concurrently without experiencing normal chest discomfort (Liu et al., 2020). A key predictor of the severity of coronary heart disease is the resting heart rate, and an elevated heart rate may exacerbate the degree and extent of cell necrosis in acute myocardial damage (Wang et al., 2019). Therefore, typical postoperative monitoring includes recording patients' resting heart rates and visual analog scale (VAS) ratings. For patients with coronary artery disease to recover quickly, it is crucial to evaluate analgesic effects and improve post‐thoracoscopic analgesia.

Paravertebral blocking (PVB), patient‐controlled intravenous analgesia (PCIA), and epidural blocks are now the most frequently utilized analgesic techniques after thoracoscopic surgery. The analgesia of PCIA is also insufficient (Tang & Huang, 2014), while the analgesic effect of PVB is comparable to that of the thoracic epidural block, with fewer side effects and a better quality of postoperative recovery (Kingma et al., 2020). The puncture is challenging and prone to failure, which frequently results in pneumothorax (D'Ercole et al., 2018). Extrapleural block (EPB) and intercostal nerve blocks have been presented as analgesic modalities with analgesic efficacy and high safety and operability (Macrae, 2008); among them, EPB has been incorporated as a routine method at Karolinska University Hospital in Sweden (Larsson et al., 2018). The analgesic effect of EPB after thoracoscopic surgery in patients with coronary heart disease and the impact on postoperative cardiovascular problems, however, are yet poorly documented.

For this reason, the present study aimed to compare the effectiveness and safety of EPB compared to PVB and PCIA in patients who had coronary artery disease and underwent thoracoscopic surgery, which provides insights into the optimal analgesia strategy in the management of postoperative thoracotomy pain.

2. METHODS

2.1. Study and population

This is a retrospective, single‐center study screening consecutive patients with coronary heart disease who underwent thoracoscopic surgery and received different analgesic strategies including EPB, PVB, and PCIA at our hospital between December 2018 and December 2020. Patients with stable angina and evidence of myocardial ischemia confirmed by preoperative electrocardiogram manifestations (ST‐T abnormalities or QT interval abnormalities) were eligible for this study. All patients had a clinical assessment of cardiac function greater than four metabolic equivalents (METs) and had no episodes of angina and/or precordial discomfort in the 3 months before the procedure. Patients would be excluded if they: (1) failed to remove the tracheal tube on a postoperative day requiring continued sedation; (2) had a previous history of allergy to local anesthetics; (3) had long‐term opioid use; and (4) chronic pain. The protocol was approved by the local institutional review board and the requirement of informed consents was waived due to the retrospective design of this study.

2.2. Analgesic strategies

Following admission, the patients received regular oxygen therapy, an intravenous line was set up, the ECG, heart rate, and fingertip oxygen saturation were checked, and invasive arterial pressure monitoring via a radial artery puncture was done. On the afflicted side, patients in the PVB group had an ultrasound‐guided PVB using either a single point at T5 or a two‐point block at T5 and T6. In each instance, 30 ml of 0.5% ropivacaine hydrochloride were injected all at once. An effective barrier was thought to have been achieved via the drug's diffusion in the paravertebral space as detected by ultrasonography. Using a single injection of 30 ml of 0.5% ropivacaine hydrochloride, patients in the EPB group underwent a thoracoscopic direct view percutaneous EPB at the paravertebral space one rib below the incision following surgery. The block was deemed successful when the medication was diffused at the extrapleural level under the thoracoscope. Through a percutaneous puncture, the local anesthetic was administered into the extrapleural area. The medication solution could be observed diffusing outside of the pleura during the thoracoscopy. To ensure that the drug diffusion range could adequately cover the surgical damage, the puncture site was chosen near the entry of the thoracoscopy in the area around the rib cage. All patients were fitted with an intravenous analgesic pump after surgery, which delivered sufentanil at a concentration of 2 ug/kg diluted to 100 ml, at a background infusion rate of 2 ml/h, with a self‐controlled dosage of 0.5 ml, and with a lock time of 15 min. The patient received 5–10 mg of injectable morphine as rescue analgesia when his pain score reached 3.

2.3. Clinical indicators

Baseline characteristics of included patients were collected, including cardiovascular risk factors, previous history of stroke and revascularization, and cardiac function manifested by the New York Heart Association (NYHA) classification and American Society of Anesthesiologists (ASA) physical status classification (Caraballo et al., 2019; Irlbeck et al., 2017). The primary outcome was the VAS scores at 2, 4, and 6 h after the surgery, indicating the effectiveness of analgesic strategies. The safety outcomes were heart rate, incidence of postoperative rescue analgesics, cardiac complications, and adverse reactions. The heart rate was analyzed for preoperative timepoint (after 5–10 min of admission), 2, 4, and 6 h after the surgery. The cardiac complications were defined as chest discomfort, chest tightness or symptoms similar to previous angina pectoris, or significant ST segment depression on ECG. Patients were treated with nitroglycerin or intravenous nitrates if they had cardiac complications. Adverse reactions were referred to nausea and vomiting after the analgesic strategy was administered. All clinical data were collected from the electronic medical records at our institution and this process was performed by two independent investigators, which was supervised by another senior investigator.

2.4. Statistical analysis

All statistical analysis was performed using the SPSS software (version 25.0, IBM. Corp., Silicon Valley, CA, USA). Histograms and Q‐Q plots were used to examine whether continuous data followed a normal distribution. Continuous variables were expressed as mean ± standard deviation or median (interquartile range) as appropriate, and were compared among the three groups using the one‐way analysis of variance (ANOVA) and Kruskal‐Wallis H test, respectively. Categorical variables were expressed as counts (percentages) and compared using the chi‐square test or Fisher's exact test as appropriate. A two‐tailed p value of <.05 was considered statistically significant.

3. RESULTS

3.1. Baseline characteristics of included patients

In total, 76 patients (age: 66.5 [61.3, 71] years; male: 63.2%) were eligible for the analysis, including the PVB group (n = 22), EPB group (n = 25), and PVIA group (n = 29). The EPB group had comparable age (68 [64, 71] years vs. 63 [57, 71] years for PVB vs. 67 [62, 72] years for PVIA; p = .319) and male proportion (60.0% vs. 68.2% for PVB vs. 62.1% for PVIA) compared with the PVB and PVIA groups. Moreover, there was no significant difference in the distribution of body mass index, cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidemia, and smoking), previous history of revascularization and stroke, atrial fibrillation, and cardiac function (NYHA and ASA classification) among the three groups (p > .05 for all). The baseline characteristics of included patients are detailed in Table 1.

TABLE 1.

Baseline characteristics of the included population

Variables PVB group (n = 22) EPB group (n = 25) PCIA group (n = 29) p‐value
Age, years 63 (57, 71) 68 (64, 71) 67 (62, 72) .319
Male 15 (68.2) 15 (60.0) 18 (62.1) .835
BMI, kg/m2 26.5 (21.9, 29.1) 26.6 (24.1, 28.0) 24.9 (22.0, 27.9) .554
Hypertension 13 (59.1) 18 (72.0) 18 (62.1) .616
Diabetes mellitus 5 (22.7) 5 (20.0) 5 (17.2) .935
Dyslipidemia 1 (4.5) 2 (8.0) 1 (3.4) .826
Smoking 14 (63.6) 14 (56.0) 17 (58.6) .865
Previous revascularization 5 (22.7) 4 (16.0) 4 (13.8) .691
Prior stroke 4 (18.2) 3 (12.0) 4 (13.8) .846
Atrial fibrillation 3 (13.6) 1 (4.0) 1 (3.4) .431
NYHA classification .570
II 19 (86.4) 24 (96.0) 27 (93.1)
III 3 (13.6) 1 (4.0) 2 (6.9)
ASA classification .639
II 17 (77.3) 22 (88.0) 24 (82.8)
III 5 (22.7) 3 (12.0) 5 (17.2)
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Note: Data were expressed as median (interquartile range) or n (%).

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; EPB, extrapleural block; NYHA, New York Heart Association; PCIA, patient‐controlled intravenous analgesia; PVB, paravertebral blocking.

3.2. Postoperative VAS scores

The comparison of postoperative VAS scores among the three groups is shown in Table 2. When regarded as a categorical variable, there was significant differences in the postoperative VAS scores among the three groups for 2 h, 4 h, and 6 h after the surgery (p = .003, <.001, and .012, respectively). Two hours after the surgery, the EPB group was more likely to have a VAS score of 1 than the PCIA group (96.0% vs. 72.4%) but similar to the PVB group (96.0% vs. 100%). There was a significantly higher proportion of patients with a VAS score of 1 in the EPB group compared with the other groups at 4 h (88.0% vs. 10.3% for PCIA and 45.5% for PVB; p < .001) and 6 h after the surgery (32.0% vs. 3.4% for PCIA and 13.6% for PVB; p = .012). When regarded as a numerical variable, there was a time‐dependent upward pattern for the postoperative VAS scores in the EPB group (2‐hour: 1 [1, 1] vs. 4 h: 1 [1, 1] vs. 6 h: 2 [1, 2]; p < .001).

TABLE 2.

Comparison of heart rate, pain scores, and complications among three groups

Variables PVB group (n = 22) EPB group (n = 25) PCIA group (n = 29) p‐value
Postoperative 2 h VAS .003
1 score 22 (100.0) 24 (96.0) 21 (72.4)
2 scores 0 (0.0) 1 (4.0) 8 (27.6)
Postoperative 4 h VAS <.001
1 score 10 (45.5) 22 (88.0) 3 (10.3)
2 scores 12 (54.5) 3 (12.0) 26 (89.7)
Postoperative 6 h VAS .012
1 score 3 (13.6) 8 (32.0) 1 (3.4)
2 scores 17 (77.3) 16 (64.0) 20 (69.0)
3 scores 2 (9.1) 1 (4.0) 8 (27.6)
Preoperative HR, beats/min 76 (70, 85) 81 (71, 94) 76 (69, 84) .193
Postoperative 2 h HR, beats/min 78 (73, 85) 77 (72, 85) 79 (72, 87) .833
Postoperative 4 h HR, beats/min 83 (75, 88) 80 (74, 86) 83 (77, 87) .599
Postoperative 6 h HR, beats/min 86 (78, 88) 83 (76, 85) 86 (78, 89) .153
Rescue analgesia 3 (13.6) 2 (8.0) 7 (24.1) .296
Nausea and vomiting 2 (9.1) 2 (8.0) 4 (13.8) .808
Adverse cardiac events 2 (9.1) 2 (8.0) 5 (17.2) .669
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Note: Data are presented as median (interquartile range) or n (%).

Abbreviations: EPB, extrapleural block; HR, heart rate; PCIA, patient‐controlled intravenous analgesia; PVB, paravertebral blocking; VAS, visual analog scale.

3.3. Preoperative and postoperative heart rate

The preoperative and postoperative heart rates at different timepoints are shown in Table 2. The preoperative heart rate in the EPB group (81 [71, 94] beats/min) was slightly higher than those in the PVB (76 [70, 85] beats/min) and PCIA groups (76 [69, 84 beats/min]) but without significant difference (p = .193). Compared with the baseline heart rates, the postoperative heart rates in the EPB group significantly decreased (p < .001); the pairwise comparisons showed that the postoperative heart rates at 2 h and 6 h were significantly lower than those before the surgery (corrected p < .001 for both) while the difference between postoperative 4‐hour heart rates and baseline heart rates almost reached the statistical threshold (corrected p = .055). There was also a time‐dependent downward tendency for the heart rates in the EPB group (corrected p < .001 for 2 h vs. 4 h; = 0.001 for 4 h vs. 6 h). However, no significant difference was observed in the heart rates at 2, 4, and 6 h after the surgery (p = .833, 0.599, and 0.153, respectively) among the three groups.

3.4. Rescue analgesia and postoperative complications

The comparison of rescue analgesia and postoperative complications is shown in Table 2. There was a tendency that the EPB group had a less incidence of postoperative rescue analgesia than the PVB group (8.0% vs. 13.6%) and the PVIA group (8.0% vs. 24.1%) but the difference did not reach the statistical significance (p = .296). No significant difference was observed in the incidence of postoperative nausea and vomiting among the three groups (8.0% for EPB vs. 9.1% for PVB vs. 13.8% for PVIA; p = .808). The incidence of postoperative adverse cardiac events in the PCIA group was comparable to that in the PVB group and EPB group (8.0% for EPB vs. 9.1% for PVB vs. 17.2% for PVIA; p = .669).

4. DISCUSSION

The present study compared the postoperative analgesic effect of EPB under thoracoscope with other analgesic methods including PVB and PCIA in patients with coronary artery disease. The main findings can be summarized as follows: (1) the EPB group was more likely to have a less VAS score than those in the PCIA group and the PVB group; (2) there was a time‐dependent upward pattern for the postoperative VAS scores in the EPB group; (3) there was a time‐dependent downward tendency for the heart rates in the EPB group but no significant difference was observed in the postoperative heart rates among the three groups; (4) the incidences of postoperative rescue analgesia, adverse reactions, and cardiac complications were comparable among the three groups. This study demonstrated that the EPB had better efficacy and comparable safety than the PCIA and PVB strategies in patients with coronary artery disease after receiving thoracoscopic surgery, indicating the promising value of this analgesic method for this population.

Pain during thoracoscopic surgery is a major contributor to postoperative pulmonary function alterations because it results from tissue injury to the ribs, chest muscles, and peripheral nerves (Bolotin et al., 2000). After non‐cardiac surgery, patients with coronary artery disease are more likely to develop lung infections, which may quickly result in hypoxemia and tissue hypoxia (Marchetti‐Filho et al., 2014; Zhang et al., 2020). Increased cardiac oxygen consumption was a result of the stress response brought on by trauma and pain; this imbalance between myocardial oxygen supply and demand is a characteristic etiology of cardiovascular disease. According to studies (Basalay et al., 2020), there is little chance of increasing oxygen supply while treating patients with myocardial damage, but there are a number of ways to reduce myocardial oxygen demand, one of which is decreasing heart rate. A slower heart rate may quickly recover ischemic cardiomyocyte activity, while an accelerated heart rate is to blame for aggravating myocardial damage in patients (Luca et al., 2015).

The PVB is a local anesthetic injection into the interfascia that blocks the receptor tissue that produces pain after chest surgery by acting as both a local infiltration anesthesia and an intercostal nerve block. In this trial, patients in the PVB group had good analgesia because their heart rates were stable for the first 6 h after surgery and were similar to preoperative levels. The rise in VAS ratings and the patients' increased heart rates were approximately timed. The EPB with intravenous analgesia did not increase postoperative myocardial oxygen consumption in patients with coronary artery disease, according to the analysis of the data from the three groups. The incidence of hypotension and hematoma was found to be about 3% in previous studies, the incidence of epidural or intrathecal spread could be up to 1%, the incidence of catheter misplacement into vessels would be as high as 6.7%, and its safety may limit its use in future surgical clinics (Naja & Lönnqvist, 2001). However, no higher incidence of cardiac complications and adverse events was found in the PVB group than in the EPB group in this study.

The greater analgesic impact of a single injection for 6 h postoperatively demonstrated that EPB tended to decrease the requirement for postoperative rescue analgesia while reducing the intensity of pain in the early postoperative period (6 h). According to the research by Chen et al. (Chen et al., 2020), its effectiveness was the same as PVB. Patients in the EPB group saw less variation in calm state VAS ratings and had smoother heart rates at all postoperative periods, which is expected to shield the patient's cardiovascular system against typical problems. Continuous extrapleural catheter block was shown to have analgesic efficacy in a retrospective investigation (Larsson et al., 2018), but more research is needed to determine its safety. According to Costache (Costache et al., 2017), EPB may be used as an analgesic during thoracoscopic surgery since it can be operated on more precisely and safely with the use of viewing equipment. In the investigation of video‐controlled EPB in thoracoscopic surgery, Xiao et al. (Xiao et al., 2013) came to the conclusion that the effect was identical to an epidural block. It was safer and more precise, which is in line with the findings of the current trial, showing that a post‐thoracoscopic epidural block for patients with coronary artery disease guided by another imaging technology decreased patient discomfort and led to fewer problems.

The idea of quick rehabilitation surgery necessitates that surgical clinics have standardized procedures for managing analgesics that are effective, minimally intrusive, and beneficial to rehabilitation. Non‐invasive procedure‐associated problems were noted in this study's data collection, which may be due to the use of thoracoscopic support and ultrasound guidance. In addition, Chen et al. (Chen et al., 2020) found that the probability of myofascial space puncture is significantly reduced with an ultrasound‐guided transverse process‐pleural midpoint block compared to a lumbar paravertebral nerve block. Thoracoscopy offers a clear vision during surgery, lessens organ damage as compared to executing without a visualization aid, optimizes the integrity of the chest wall, lessens procedure‐related discomfort, lowers the risk of complications, and encourages the patient's early discharge (Andrews & Paul, 2016).

There are several limitations in this study. First, a single‐center, retrospective design with a relatively small sample size might result in potential selection bias. Therefore, subsequent multicenter, randomized clinical trials are warranted to elucidate the analgesic effect of EPB strategy in the treatment of postoperative pain. Second, the long‐term efficacy and safety of EPB treatment are still underdetermined due to lack of follow‐up data. Lastly, the indicators are susceptible from subjective factors although we collected the data using the blind method.

5. CONCLUSION

Compared with PVB and PCIA, intraoperative thoracoscopic EPB is more effective in reducing postoperative pain and offers a similar benefit in the management of heart rates, adverse events, and cardiac complications after video‐assisted thoracoscopic surgery in patients with coronary artery disease.

AUTHOR CONTRIBUTIONS

(I) Conception and design: Qu TF. (II) Administrative support: Han T. (III) Provision of study materials or patients: Yang WQ and Wei ZH. (IV) Collection and assembly of data: He HZ and Yuan X. (V) Data analysis and interpretation: Yuan X. (VI) Manuscript writing: All authors. (VII) Final approval of manuscript: All authors.

FUNDING INFORMATION

This research did not receive any funding support.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no competing interests.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of Baoding No.2 central hospital. Written informed consent was obtained from all participants. Ethics board approval number: 2021No.34.

CONSENT FOR PUBLICATION

The manuscript is not submitted for publication or consideration elsewhere.

ACKNOWLEDGMENTS

Not applicable.

Qu, T. , Han, T. , Yang, W. , Wei, Z. , He, H. , & Yuan, X. (2023). Efficacy and safety of Extrapleural block in patients with coronary artery disease after thoracoscopic surgery. Annals of Noninvasive Electrocardiology, 28, e13050. 10.1111/anec.13050

DATA AVAILABILITY STATEMENT

All data generated or analyzed during this study are included in this published article

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

All data generated or analyzed during this study are included in this published article

Articles from Annals of Noninvasive Electrocardiology are provided here courtesy of International Society for Holter and Noninvasive Electrocardiology, Inc. and Wiley Periodicals, Inc.

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