Effectiveness of wound infusion of 0.2% ropivacaine by patient control analgesia pump after minithoracotomy aortic valve replacement: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Local anesthetic wound infusion has become an invaluable technique in multimodal analgesia. The effectiveness of wound infusion of 0.2% ropivacaine delivered by patient controlled analgesia (PCA) pump has not been evaluated in minimally invasive cardiac surgery. We tested the hypothesis that 0.2% ropivacaine wound infusion by PCA pump reduces the cumulative dose of opioid needed in the first 48 h after minithoracothomy aortic valve replacement (AVR). METHODS: In this prospective, randomized, double-blind, placebo-controlled study, 70 adult patients (31 female and 39 male) were analyzed. Patients were randomized to receive 0.2% ropivacaine or 0.9% saline wound infusion by PCA pump for 48 h postoperatively. PCA pump was programmed at 5 ml h- 1 continuously and 5 ml of bolus with 60 min lockout. Pain levels were assessed and recorded hourly by Numeric Rating Scale (NRS). If NRS score was higher than three the patient was administered 3 mg of opioid piritramide repeated and titrated as needed until pain relief was achieved. The primary outcome was the cumulative dose of the opioid piritramide in the first 48 h after surgery. Secondary outcomes were frequency of NRS scores higher than three, patient's satisfaction with pain relief, hospital length of stay, side effects related to the local anesthetic and complications related to the wound catheter. RESULTS: The cumulative dose of the opioid piritramide in the first 48 h after minithoracotomy AVR was significantly lower (p < 0.001) in the ropivacaine (R) group median 3 mg (IQR 6 mg) vs. 9 mg (IQR 9 mg). The number of episodes of pain where NRS score was greater than three median 2 (IQR 2), vs 3 (IQR 3), (p = 0.002) in the first 48 h after surgery were significantly lower in the ropivacaine group, compared to control. Patient satisfaction with pain relief in our study was high. There were no wound infections and no side-effects from the local anesthetic. CONCLUSIONS: Wound infusion of local anesthetic by PCA pump significantly reduced opioid dose needed and improves pain control postoperatively. We have also shown that it is a feasible method of analgesia and it should be considered in the multimodal pain control strategy following minimally invasive cardiac surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT03079830 , date of registration: March 15, 2017. Retrospecitvely registered.

Fluoroless catheter ablation of accessory pathways in adult and pediatric patients: a single centre experience.

Catheter radio-frequency ablation (RFA) and cryo-ablation (CRA) procedures are an effective and safe treatment options for adult and pediatric patients with accessory pathway (AP) mediated tachycardias. Non-fluoroscopic techniques during catheter ablation (CA) procedures reduce potentially harmful effects of radiation. Our aim was to investigate the efficacy and safety of completely fluoroless RFA and CRA procedures in pediatric and adult patients with APs. Consecutive patients with AP-related tachycardia and high risk asymptomatic ventricular pre-excitation were assessed in retrospective analysis. Three-dimensional (3D) electro-anatomical mapping (EAM) and intra-cardiac echocardiography (ICE) were used as principal imaging modalities. Fluoroscopy was not used during any stage of the procedures. Among 116 included patients (22.76 ± 16.1 years, 68 patients < 19 years), 60 had left-sided APs, 16 right-sided APs and 40 septal APs. Altogether, 96 had RFA and 20 CRA procedures. The acute success rates (ASR) of RFA and CRA were 97.9% and 95%, respectively (p = 0.43), with recurrence rates (RR) of 8.33% and 40%, respectively (p < 0.0001). The outcome difference was principally driven by lower RR with RFA in septal APs (9.1% vs. 38.9%, p = 0.025). Pediatric patients with APs (12.21 ± 3.76 years) had similar procedural parameters and outcomes compared to adult patients. There were no procedure-related complications. In adult and pediatric patients with AP-related tachycardias, both CRA and RFA can be effectively and safely performed without the use of fluoroscopy. In addition, RFA resulted in better outcomes compared to CRA.