Quality of Early Recovery after Ultrasound-guided Serratus Plane Block for Transapical Transcatheter Aortic Valve Implantation Surgery under General Anesthesia：a single-center randomized controlled trial

Quality of Early Recovery after Ultrasound-guided Serratus Plane Block for Transapical Transcatheter Aortic Valve Implantation Surgery under General Anesthesia：a single-center randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Quality of Early Recovery after Ultrasound-guided Serratus Plane Block for Transapical Transcatheter Aortic Valve Implantation Surgery under General Anesthesia：a single-center randomized controlled trial Cheng Xiao, Sheng Jing, Guiying Yang, Fang Chen, Ming Yang, Lei Cao, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7828277/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Nov, 2025 Read the published version in BMC Anesthesiology → Version 1 posted 14 You are reading this latest preprint version Abstract Background Regional anesthesia techniques, including the serratus anterior plane block (SAPB), reduce postoperative pain after minimally invasive cardiac surgery. However, the evidence regarding its impact on transapical transcatheter aortic valve replacement (TA-TAVR) is limited, and data specifically exploring its effectiveness on patient-centric outcomes are lacking. Methods We conducted a single-center randomized controlled trial comparing the efficacy of ultrasound-guided SAPB with ropivacaine 0.5% (40 ml) with no block for patients undergoing TA-TAVR. The primary outcome was 24-hour Quality of Recovery-40 (QoR-40) score. Secondary outcomes included QoR-40 at 48 h, pain scores, opioid consumption, and complications. Results A total of 66 participants were included in the analysis. The median QoR-40 [IQR] at 24 h was higher in SAPB group (n = 32) compared with the no block group (n = 34): 180.5 (171.25–183) VS 172 (165.25–179), p = 0.006. At 48 h, scores were 185.5 (182–189) vs 183.5 (178.5–187), p = 0.048. Although these differences were statistically significant, they did not reach the minimum clinically important difference (MCID) of 6.3. Early postoperative analgesia was superior in the SAPB group, with lower resting/coughing NRS scores at 6 and 12 hours (median difference 1, P < 0.001). However, there were no intergroup differences in opioid consumption or the need for rescue analgesia. Conclusions As part of multimodal analgesia for TA-TAVR, SAPB improved early postoperative analgesia but did not enhance the multidimensional quality of early recovery, as measured by the QoR-40 score. Further studies are warranted. Trial registration ChiCTR2300068584. Registered 24 February 2023. https://www.chictr.org.cn/bin/project/edit?pid=184719 quality of recovery serratus anterior plane block transapical transcatheter aortic valve replacement Figures Figure 1 Figure 2 Background China’s rapidly aging population has fueled an annual rise in degenerative aortic valve diseases, for which transcatheter aortic valve replacement (TAVR) has emerged as a transformative therapy since 2002[ 1 ]. TAVR eliminates the need for median sternotomy, cardiopulmonary bypass, cardiac arrest, and reperfusion, reducing surgical trauma and significantly lowering patient risk. Over time, it has transformed from a high- risk, challenging procedure into a simple and effective treatment[ 2 , 3 ]. When peripheral vascular anatomy is unfavorable, transapical transcatheter aortic valve replacement (TA-TAVR) provides a critical alternative. This approach circumvents diseased vasculature entirely and, owing to the shorter access-to-target distance, enables superior catheter and prosthesis control[ 4 ]. Compared with traditional surgery, the minimally invasive technique is associated with less trauma and faster recovery. However, it still requires rib spreading, which leads to postoperative pain—an important issue that requires attention and resolution in enhanced recovery after surgery (ERAS). Ultrasound-guided regional analgesia has revolutionized perioperative care, however, its integration into cardiac surgery lags behind its use in other specialties. The serratus anterior plane block (SAPB), targeting T2-T9 intercostal nerves lateral branches, provides effective anterior-lateral chest wall analgesia[ 5 , 6 ]. Compared with neuraxial techniques, SAPB is associated with fewer complications— a crucial advantage for anticoagulated cardiac patients. SAPB has been widely applied in thoracic, breast, and rib fracture surgeries[ 7 , 8 ]. Numerous studies have demonstrated that SAPB not only alleviates pain but also decrease opioid consumption, and mitigate related side effects. This is particularly important for elderly patients and those with severe systemic comorbidities. Despite documented benefits of serratus anterior plane block (SAPB) in minimally invasive cardiac surgery, its application remains underexplored[ 9 ]. Some studies have reported successful cases of TA-TAVR performed under SAPB, suggesting that SAPB improves postoperative pain control after minimally invasive sternotomy[ 10 , 11 ]. However, no randomized trials have evaluated its impact on multidimensional recovery quality following TA-TAVR, representing a critical knowledge gap. Recovery quality is a key concept in perioperative management, with substantial prognostic and economic implications. However, the application of validated recovery quality instruments, such as the Quality of Recovery-40 (QoR-40) scale, to evaluate the holistic impact of regional anesthesia techniques within minimally invasive cardiac interventions remains limited. With the growing emphasis on regional blocks in minimally invasive cardiac surgery and the integration of ERAS protocols to improve recovery quality as a key surgical outcome, establishing a direct link between ultrasound-guided SAPB and recovery quality following TA-TAVR is essential. To address this knowledge gap, we conducted a prospective RCT testing whether ultrasound-guided SAPB enhances patient-perceived recovery quality after TA-TAVR. Our primary outcome measure was the 24-hour global QoR-40 score. Secondary outcomes comprised 48-hour QoR-40, postoperative pain scores, and opioid consumption. Methods Study design and participants This single-center, double-blind, randomized controlled trial was approved by the medical ethics committee of Second Affiliated Hospital of Army Medical University, PLA (reference number 2022-452-01). Patient enrolment started on February 28, 2023 and written informed consent was obtained from participants prior to enrollment. The trial was registered with the China Clinical Trial Register (ChiCTR2300068584) on 24 February, 2023, before the recruitment of the first patient. This study adheres to CONSORT guidelines (Supplementary 1). We include adult patients aged 55–80 years undergoing TA-TAVR under general anesthesia. Exclusion criteria included allergies to local anesthetics (Las), a history of mental illness or psychotropic drug use, severe coagulation abnormalities, long-term use of analgesics or sedatives, history of drug, alcohol, or opioid abuse, recent acute pain or chronic pain, postoperative mechanical ventilation ≥ 24 hours, or refusal to participate in the study. Participants retained the right to withdraw from the study at any time, either at their own discretion or if the researchers deemed their continued participation inappropriate. A total of 70 eligible patients were enrolled and randomly allocated 1:1 to the ultrasound-guided SAPB group or control group using a computer-generated block randomization sequence (fixed block size of 4). This design ensured balanced group allocation throughout the recruitment period. Randomization was performed by independent personnel not involved in the study. Group allocation was concealed in sealed, opaque envelopes to ensure blinding. To ensure that the anesthesiologist performing regional block in a double-blind manner was different from the one managing the patient during the operation. Neither the intraoperative anesthesiologist nor the postoperative outcome evaluator was aware of the group allocation. Intraoperative Management Patients were prepared according to cardiopulmonary bypass protocols, and standard monitoring were established. Radial arterial and right internal jugular venous catheters were placed under local anesthesia and mild sedation (midazolam and sufentanil with local infiltration), respectively. General anesthesia was induced using midazolam, etomidate, rocuronium and sufentanil. Ultrasound-guided regional block was performed after endotracheal intubation. Anesthesia was maintained with propofol, remifentanil and sevoflurane, titrated to achieve bispectral index (BIS) of 40–60. After the skin closure was completed, patient-controlled intravenous analgesia (PCIA) was initiated as part of a multimodal analgesia regimen. Patients were then transferred to the cardiac surgery intensive care unit for standardized monitoring and management. The PCIA regimen consisted of sufentanil (2.5 µg kg − 1 , maximum dose 200 ug), dexmedetomidine (3 ug kg − 1 , maximum dose 200 ug) and tropisetron (5 mg). The PCIA pump was programmed to deliver a 2mL bolus with a 15-minute lockout interval and a basal infusion of 4 mL/h. Patients were thoroughly educated on the use of the PCIA pump. Rescue analgesia included oral paracetamol and tramadol hydrochloride tablets (one tablet, p.o.) for pain with a numerical rating scale(NRS)>4 at rest, and intravenous hydromorphone (1 mg) for severe pain (NRS > 7). Ultrasound Guided Serratus Anterior Plane Block Ultrasound-guided SAPB was performed after the induction of general anesthesia. Patients were positioned supine with the upper limb abducted. A linear ultrasound transducer was placed in the 5th intercostal space along the left axillary line. The probe was adjusted to visualize anatomical structures, including the latissimus dorsi, pectoralis major, pectoralis minor and serratus anterior muscles. A 22-G nerve block needle was advanced into the superficial serratus plane using an in-plane technique. Aspiration was performed to ensure the absence of blood or air before injection. Subsequently, 2 ml of a local anesthetic mixture (0.4% ropivacaine combined with 10 mg of dexamethasone) was injected slowly. The spread of the anesthetic mixture between the fascia layers was monitored via ultrasound, appearing as a hypoechoic area. Additional anesthetic mixture was slowly administered. The control group did not receive any injection. Study outcomes The primary outcome was the 40-item quality of recovery scale (QoR-40) score at 24 h after TA-TAVR. The QoR-40 is a widely used, patient-centered global outcome measure of postoperative recovery, with demonstrated validity, reliability, and responsiveness. This scale comprises questions on pain, physical comfort, physical independence, psychological state, and emotional state[ 12 , 13 ]. The total score ranges from 0 to 200, with higher scores indicating better recovery. Secondary outcomes included: (1) QoR-40 score at 48 h postoperatively. (2) NRS pain scores at rest and during coughing at 6 h, 12 h, 24 h, and 48 h postoperatively. (3) PCIA-related parameters, including the total and effective compression counts, opioid consumption and the need for rescue analgesia at 24h and 48h. (4) Incidence of nausea, vomiting and delirium at 48 h post-surgery. (5) patient satisfaction scores (range from 0 to 5, where 0 indicates “very dissatisfied” and 5 indicates “very satisfied”). All assessments were standardized to fixed postoperative intervals calculated from completion of surgery (skin closure). Sample size Our primary outcome was QoR-40 score at 24 h after surgery. The established minimum clinically important difference (MCID) in QoR-40 is 6.3[ 14 ]. We considered a difference in the mean QoR-40 scores between groups of 9 to be clinically meaningful, which is greater than the minimum clinically important difference (MCID) of 6.3[ 15 ]. Its standard deviation (SD) after cardiac surgery is typically 9–26. we chose a SD of 12 to best reflect our study population. To achieve a power of 80% to detect this difference at a two-side α level of 0.05, a total of 58 participants would be required. We enrolled 35 participants per group to account for loss to follow-up, withdrawal, or significant missing data. Statistical analysis The Kolmogorov–Smirnov test was used to assess the normality of data distribution. Normality distributed continuous variables were expressed as mean ± standard deviation and analyzed using an independent samples t -test. Non-normally distributed date was analyzed using the Mann-Whitney U test, with results presented as median and interquartile range. Categorical variables were described as frequencies (%) and analyzed using the χ 2 test or Fisher’s exact test, as appropriate. The primary outcome was the global QoR-40 score at 24 hours, analyzed at a two-sided alpha level of 0.05. Comparisons of the five QoR-40 subscales were conducted as exploratory analyses to aid interpretation of the primary outcome and were not adjusted for multiple comparisons, to minimize the risk of Type II errors for these hypothesis-generating measures. A P -value < 0.05 was considered statistically significant for the primary outcome. SPSS software version 26 (IBM, New York, USA) was used to conduct statistical analyses. Results Between February 2023 to November 2024, a total of 70 patients who underwent TA-TAVR surgery in our department were recruited. Three patients were excluded from the experimental group: two due to unplanned conversion to open-chest surgery, and one due to unplanned mechanical ventilation for ≥ 24 hours. In the control group, one patient was excluded due to early discharge. These exclusions were mandated by protocol safety criteria and unrelated to group allocation. Ultimately, 32 patients in the experimental group and 34 patients in the no block group were included in the final analysis (Fig. 1 ). Baseline characteristics were comparable between the two groups (Table 1 ). Table 1 Baseline characteristics of subjects. Date presented as mean (standard deviation) or n (%), as appropriate. SAPB (n = 32) No block (n = 34) Age (yr) 69.97 (5.71) 70.53 (4.70) Female, n (%) 11(34.38) 7(20.59) Height (cm) 158.95 (9.29) 161.63 (7.37) Weight (kg) 61.59 (11.31) 59.95 (10.95) BMI (kg m − 2 ) 24.33 (3.91) 22.86 (3.25) Surgical duration (min) 85.50 (80.00-107.00) 94.00 (81.00-111.50) Preoperative QoR-40 scores 196.50 (193.00- 198.00) 197.00 (194.00- 198.00) BMI, body mass index; QoR-40, 40-item quality of recovery scale Primary outcome data The primary outcome, QoR-40 at 24 h after surgery, is summarized in Table 2 . The SAPB group exhibited a higher median (25–75%) total QoR-40 score of 180.5 (171.25–183) VS 172 (165.25–179) in the no block group ( P = 0.006). The median difference between the two groups was 5 (95% CI, 2–9), which was statistically significant ( p < 0.05). An exploratory analysis of the QoR-40 subscales at 24 h showed a statistically significant between-group difference in the pain dimension (SAPB group: 33 [30.25-34] VS control group: 31 [28.5–33]; P = 0.013). However, the total score difference was below the minimal clinically important difference (MDIC) of 6.3 for QoR-40 score, which has been previously identified as indicative of a meaningful clinical improvement in recovery quality after surgery and anesthesia[ 14 ]. Thus, while statistically significant, the observed difference lacks clinical significance (∆ < 6.3). Table 2 Overall QoR-40 score and scores in different domains at 24 h and 48 h. Data shown are median (25–75% range). SAPB (n = 32) No block (n = 34) Median difference(95% CI) P -value Primary outcome QoR-40 at 24 h 180.5 (171.25 ~ 183) 172 (165.25 ~ 179) 5 (2 ~ 9) 0.006* Emotional status 44 (41.25 ~ 45) 43 (40 ~ 44) 1 (0 ~ 2) 0.106 Physical comfort 55 (51.25 ~ 56) 53 (49 ~ 55.25) 2 (0 ~ 3) 0.068 Psychological support 35 (35 ~ 35) 35 (35 ~ 35) 0 (0 ~ 0) 0.675 Physical independence 13 (12 ~ 14) 13 (12 ~ 13) 0 (0 ~ 1) 0.108 Pain 33 (30.25 ~ 34) 31 (28.5 ~ 33) 2 (0 ~ 3) 0.013* Continuous secondary outcomes QoR-40 at 48 h 185.5 (182 ~ 189) 183.5 (178.5 ~ 187) 3 (0 ~ 5) 0.048* Emotional status 45 (44 ~ 45) 44 (42 ~ 45) 1 (0 ~ 1) 0.004* Physical comfort 57 (55 ~ 59) 56 (54 ~ 58) 1 (-1 ~ 2) 0.269 Psychological support 35 (35 ~ 35) 35 (35 ~ 35) 0 (0 ~ 0) 0.088 Physical independence 16 (15 ~ 17) 15 (14 ~ 16) 1 (0 ~ 2) 0.023* Pain 34 (32.25 ~ 35) 34 (32 ~ 35) 0 (-1 ~ 1) 0.626 SAPB, serratus anterior plane block; QoR-40, 40-item quality of recovery scale * Statistically significant Secondary outcome date Similarly, the total QoR-40 score at 48 h was marginally higher in the SAPB group (185.5[182–189] vs 183.5[178.5–187]), but this difference was not a clinically meaningful. Exploratory analysis of the subscales at 48 h revealed significantly higher scores in the SAPB group for the emotional state and physical independence dimensions (Table 2 ). These dimensional analyses should be interpreted as exploratory due to uncorrected multiple comparisons. Figure 2 illustrates the Boxplots and violin plots for QoR-40 scores at 24 h and 48 h. At 6 h and 12 h after surgery, NRS pain scores at rest and during coughing were significantly lower in the SAPB group (difference in medians − 1, 95% CI, -1 to 0, P < 0 .001; difference in medians − 1, 95% CI, -2 to -1, P < 0.001; difference in medians − 1, 95% CI, -1 to 0, P < 0 .001; difference in medians − 1, 95% CI, -1 to 0, P = 0 .002 ;). The NRS pain scores were comparable between the groups at 24 h and 48 h after surgery. No significant differences were observed in the number of effective compressions and the total number of compressions in PCIA, the dosage of sufentanil in PCIA, the rate of rescue analgesia 48 h after surgery, or the incidence of adverse reactions such as nausea and vomiting. furthermore, no adverse events, such as infection, hematoma, delirium or local anesthetic toxicity, occurred in either group. The use of SAPB was associated with higher patient satisfaction (Table 3 ). Table 3 Secondary outcomes. These include VAR scores for pain at rest and during coughing at 6 h, 12 h, 24 h, 48 h, PCIA-related parameters, rescue analgesia, adverse reactions and patient satisfaction scores. All values shown are mean (SD), median (25–75%) or n (%) as appropriate. SAPB (n = 32) No block (n = 34) Median difference(95% CI) P -value Pain NRS score at rest At 6 h 1 (0 ~ 1) 2 (1 ~ 2) -1 (-1 ~ 0) < 0.001* At 12 h 1 (1 ~ 1) 2 (1 ~ 2) -1 (-1 ~ 0) < 0.001* At 24 h 1 (1 ~ 2) 1 (1 ~ 2) 0 (-1 ~ 0) 0.299 At 48 h 1 (1 ~ 1) 1 (1 ~ 1) 0 (0 ~ 0) 0.051 Pain NRS score during coughing At 6 h 3 (2 ~ 4) 5 (3.75 ~ 5) -1 (-2~-1) < 0.001* At 12 h 3.5 (3 ~ 4) 4.5 (3.75 ~ 5) -1(-1 ~ 0) 0.002* At 24 h 4 (3 ~ 4) 4 (4 ~ 5) 0 (-1 ~ 0) 0.223 At 48 h 4 (3 ~ 4) 4 (3 ~ 4.25) 0 (-1 ~ 0) 0.059 PCIA Number of total compressions at 24 h 4.5 (1 ~ 7.75) 4 (2 ~ 7.25) 0 (-2 ~ 1) 0.604 Number of effective compressions at 24 h 4 (1 ~ 6.75) 4 (2 ~ 6.25) 0 (-2 ~ 1) 0.551 Total number of compressions at 48 h 5 (1 ~ 17.25) 8 (3.75 ~ 15.25) -1 (-4 ~ 2) 0.373 Number of effective compressions at 48 h 4 (1 ~ 13) 6.5 (3.75 ~ 14.25) -2 (-4 ~ 1) 0.192 Dosage of sufentanil at 24 h 52.48 ± 10.47 52.32 ± 7.88 0.16 (-4.45 ~ 4.77) 0.945 Dosage of sufentanil at 48 h 105.23 ± 21.10 104.06 ± 17.05 1.16 (-8.25 ~ 10.57) 0.806 rescue analgesia, n (%) 6 (19) 11 (32) 0.207 Adverse reactions nausea/vomiting, n (%) 9 (28) 8 (23.5) 0.67 Patient satisfaction 5 (4 ~ 5) 4 (4 ~ 5) 0 (0 ~ 1) 0.024* SAPB, serratus anterior plane block; NRS, numerical rating scale; PCIA, patient-controlled intravenous analgesia * Statistically significant Discussion Consistent with the growing emphasis on postoperative recovery quality beyond traditional metrics such as opioid consumption and pain scores, our study assessed the impact of ultrasound-guided single-injection serratus anterior plane block (SAPB) as part of a multimodal analgesia regimen on recovery outcomes following TA-TAVR. While the primary outcome—the QoR-40 score at 24 hours—showed a statistically significant improvement (median difference: 5, P = 0.006), the clinical relevance of this change remains marginal, as it fell below the predefined MCID of 6.3 points. It is noteworthy, however, that the exploratory analysis indicated that the observed improvement in the global score was largely driven by a significant reduction in the pain dimension. This aligns with the finding that SAPB provided significant early pain relief, as evidenced by lower NRS scores at rest and during coughing at 6 and 12 hours postoperatively ( P < 0.001). However, this analgesic benefit did not translate into a reduction in cumulative opioid consumption or the need for rescue analgesia, indicating that the analgesic efficacy of a single-injection SAPB may be insufficient to independently influence short-term recovery quality in TA-TAVR patients Although numerous studies have reported that ultrasound-guided SAPB effectively enhances recovery quality following various surgeries, especially in video-assisted thoracic surgery [ 7 , 8 , 16 ], our findings demonstrated that although a single-injection SAPB is safe and technically straightforward, its transient analgesic effect may not fully address the prolonged recovery needs for TA-TAVR patients[ 9 ]. This is supported by the lack of sustained improvement in the QoR-40 pain dimension beyond 24 h. Thus, while SAPB has been used in TA-TAVR, evidence for clinically significant benefits and patient-centered results remains inconclusive. Ongoing research focus is exploring whether continuous block of catheter or supplementary secondary blocks at specific intervals could enhance clinical outcome[ 17 – 19 ]. Additionally, while the single-center design and modest sample size were appropriate for this pilot investigation, they confer limited statistical power and reduced precision in effect estimates—increasing the risk of Type II errors and potentially obscuring clinically meaningful recovery differences. Finally, the generalizability of ΜCID thresholds across diverse surgical populations may also be inconsistent[ 15 , 20 , 21 ]. TA-TAVR patients are typically older, with higher frailty indices and multiple comorbidities, which may attenuate their responsiveness to recovery metrics. Cha EDK et al. identified advanced age as a significant predictor for failing to achieve MCID in minimally invasive lumbar decompression[ 22 ]. In this vulnerable cohort, the statistically significant 5-point improvement in global QoR-40 — while below the predefined 6.3-point MCID threshold — may still confer value, where modest gains could translate into disproportionate clinical benefits. In addition, our findings showed that SAPB specifically improved the pain dimension of QoR-40 at 24 h, and the SAPB group exhibited superior emotional state and physical independence at 48 h. These dimensional outcomes should be interpreted as exploratory given uncorrected multiple comparisons and limited subgroup power. Nevertheless, these results may suggest that traditional MCID thresholds underestimate the clinical benefits of regional analgesia in vulnerable populations. The significant reduction in resting and during coughing NRS scores at 6 h and 12 h postoperatively (median difference: 1, P < 0.001) demonstrates that SAPB effectively alleviates acute incisional pain from the anterolateral thoracotomy required for transapical access. This aligns with numerous studies confirming the efficacy of single-injection block for early postoperative analgesia in cardiac surgery[ 23 – 25 ]. However, the nature of a single-injection of local anesthetic limits the ability to sustain long-term pain control. Our results did not demonstrate a reduction in opioid consumption associated with SAPB, as evidenced by multidimensional analgesic metrics: comparable resting/coughing pain scores, equivalent patient-controlled sufentanil requirements and similar rescue analgesia incidence. This convergence of findings indicates that SAPB in TA-TAVR primarily enhances early pain experience. This phenomenon also been observed in video-assisted thoracic surgery (VATS) by Do-Hyeong[ 8 ], where SAPB reduced pain scores and opioid use at 6 hours but failed to show significant differences at 24 hours. Similarly, Jackson recently reported that adding single-injection SAPB to a multimodal analgesia plan did not reduce 24 h or 48 h intravenous morphine equivalents compared to the control group undergoing thoracoscopic lung resection[ 26 ]. In our cohort, the multimodal analgesia protocol incorporating PCIA maintained a median resting NRS score ≤ 3 in the control group at 24 hours, which may have obscured subtle between-group differences in opioid demand. Besides, this early analgesic effect is clinically pivotal, as optimal pain control facilitates deep breathing, coughing, and early mobilization, which can reduce postoperative pulmonary complications, a cornerstone of ERAS. Patient satisfaction scores were significantly higher in the SAPB group. This likely reflects that pain relief remains a pivotal factor in patient-perceived care quality. Furthermore, the absence of SAPB-related complications (e.g., hematoma, local anesthetic toxicity) in our fully heparinized cohort reinforces its safety profile. Notably, no instances of block failure or technical difficulties were documented during ultrasound-guided procedures performed by experienced anesthesiologists. This supports the feasibility of SAPB as a component of multimodal analgesia for TA-TAVR patients. Limitations Out study has several limitations. First, the single-center design and relatively small size may limit statistical power for detecting smaller treatment effects. Post hoc analysis showed that 75.4% of the power detected the observed QoR-40 difference, which might increase the risk of Type II error for detecting smaller effects, particularly for secondary endpoints or differences approaching the MCID threshold. Future larger studies are needed to confirm these findings and explore subgroup effects. Nevertheless, the statistically robust primary outcome (p = 0.006) and clinically relevant confidence interval provide meaningful evidence of treatment benefit, suggest that these findings, despite their statistical limitations, can still inform clinical practice while awaiting larger confirmatory studies. Second, the absence of sensory testing (due to general anesthesia) introduced a potential unblinding risk. However, all blocks were performed under ultrasound guidance by experienced anesthesiologists, minimizing technical failure rates. Third, although all postoperative assessments were standardized to fixed intervals from skin closure, we acknowledge that patients receiving PCIA prior to full emergence from anesthesia could theoretically exhibit altered pain perception or compromised QoR-40 validity. However, all patients had achieved full alertness by the 6-hour assessment timepoint. Furthermore, supplementary analysis revealed comparable sufentanil consumption between groups during the initial 6-hour period, suggesting that pre-extubation analgesic administration did not systematically bias our pain or QoR-40 measurements. Finally, we administered dexamethasone as an adjuvant to prolong the duration of SAPB. However, its systemic effects may partially mask or amplify the true impact of SAPB on QoR-40 scores. Literature reports indicate that dexamethasone can independently improve QoR-40 domains, including emotional state, physical comfort, and pain[ 27 ]. Future studies should employ a three-arm randomized controlled trial design to assess recovery following continuous catheter SAPB combined with biomarker/inflammatory panel-guided inflammatory profiling, objectively quantifying both the SAPB-specific effect and the systemic anti-inflammatory potency of dexamethasone. Additionally, the high doses of opioids used in the perioperative period may have attenuated the observed opioid-sparing effects of the regional block. Future trials employing lower opioid doses or opioid-free anesthesia regimens may better elucidate the opioid-sparing potential of these techniques within multimodal analgesia. Conclusion The inclusion of serratus anterior plane block (SAPB) in the multimodal analgesia regimen for TA-TAVR patients led to statistically significant improvements in early postoperative recovery quality (24 h QoR-40 score) and effectively reduced acute pain during the first 6 h and 12 h postoperatively. However, it did not achieve the predefined MCID threshold (6.3 points) and lacked opioid-sparing effects, which highlight its effect on the early recovery in TA-TAVR may be limited. It also reminds us that individual regional group, such as SAPB, may not always provide the comprehensive benefits across all recovery-related outcomes. Nevertheless, within established enhanced recovery pathways, SAPB remains a valuable component, with its safety profile—demonstrated by the absence of complications in fully heparinized patients—reinforcing its role as part of multimodal analgesia strategies for TA-TAVR, though it should not be viewed as a standalone solution. Abbreviations TAVR Transcatheter aortic valve replacement TA-TAVR Transapical transcatheter aortic valve replacement ERAS Enhanced recovery after surgery SAPB Serratus anterior plane block Las local anesthetics BIS Bchieve bispectral index PCIA Patient-controlled intravenous analgesia QoR-40 40-item quality of recovery scale NRS Numerical rating scale MCID Minimum clinically significant difference SD Standard deviation VATS Video-assisted thoracic surgery Declarations Human Ethics and consent to participate declarations This study involves human participants and was approved by the medical ethics committee of Second Affiliated Hospital of Army Medical University, PLA (reference number 2022-452-01). Participants gave informed consent to participate in the study before taking part. The study was registered with the Chinese Registry of Clinical Trials (http://www.chictr.org.cn) (ChiCTR2300068584, 24/02/2023) and conducted in accordance with the Helsinki Declaration of 1975. Consent for publication Not applicable. Availability of data and materials Data will be available upon request from the corresponding author. Competing interests The authors declare no competing interests. Funding This work was supported by the National Nature Science Foundation of China (Project No.82171265). Authors' contributions Cheng Xiao helped conceived and designed the study, analyzed the data and wrote the draft; Sheng Jing helped searched the literature, performed the anesthesia block, analyzed the data and revised the manuscript; GuiYing Yang helped conceived and designed the study, interpretated the data; Fang Chen helped with data acquisition and date interpretation; Ming Yang supplemented key intellectual content; Lei Cao helped manage clinical record forms and revised the manuscript; YuTing Tan helped with patient enrollment and data analysis; GuoYun Lin helped to manage the clinical recording forms; Hong Li designed experiments and revised the manuscript. All the authors approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. HL is the guarantor. Acknowledgements We are very grateful to our cardiovascular surgeon colleagues (Z Jian, ZZ Feng, MW Li) for their kind cooperation in facilitating this trial. References Cribier A, Eltchaninoff H, Bash A, Borenstein N, Tron C, Bauer F, Derumeaux G, Anselme F, Laborde F, Leon MB. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation 2002, 106(24):3006–8. Vahanian A, Alfieri OR, Al-Attar N, Antunes MJ, Bax J, Cormier B, Cribier A, De Jaegere P, Fournial G, Kappetein AP, et al. Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2008;34(1):1–8. Barbanti M, Webb JG, Gilard M, Capodanno D, Tamburino C. EuroIntervention : Transcatheter aortic valve implantation in 2017: state of the art. 2017, 13(AA):AA11–21. Alfieri O, Sala A, Buzzatti N. Comparing traditional aortic valve surgery and transapical approach to transcatheter aortic valve implant. Eur Heart J Supplements. 2020;22(SupplementE):E7–12. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68(11):1107–13. Mayes J, Davison E, Panahi P, Patten D, Eljelani F, Womack J, Varma M. An anatomical evaluation of the serratus anterior plane block. Anaesth 2016, 71(9):1064–9. Yao Y, Li J, Hu H, Xu T, Chen Y. Ultrasound-guided serratus plane block enhances pain relief and quality of recovery after breast cancer surgery: A randomised controlled trial. Eur J Anaesthesiol. 2019;36(6):436–41. Kim DH, Oh YJ, Lee JG, Ha D, Chang YJ, Kwak HJ. Efficacy of Ultrasound-Guided Serratus Plane Block on Postoperative Quality of Recovery and Analgesia After Video-Assisted Thoracic Surgery: A Randomized, Triple-Blind, Placebo-Controlled Study. Anesth Analg. 2018;126(4):1353–61. Berthoud V, Ellouze O, Nguyen M, Konstantinou M, Aho S, Malapert G, Girard C, Guinot PG, Bouchot O, Bouhemad B. Serratus anterior plane block for minimal invasive heart surgery. BMC Anesthesiol. 2018;18(1):144. Peng L, Ding M, Wei W. Ultrasound-guided serratus anterior plane block for transapical transcatheter aortic valve implantation. J Cardiothorac Surg. 2023;18(1):4. Berthoud V, Ellouze O, Bievre T, Konstantinou M, Jazayeri S, Bouchot O, Girard C, Bouhemad B. Serratus Anterior Plane Block for Apical TAVR in an Awake Patient. J Cardiothorac Vasc Anesth 2018, 32(5):2275–7. Myles PS, Weitkamp B, Jones K, Melick J, Hensen S. Validity and reliability of a postoperative quality of recovery score: the QoR-40. Br J Anaesth. 2000;84(1):11–5. Chan MT, Lo CC, Lok CK, Chan TW, Choi KC, Gin T. Psychometric testing of the Chinese quality of recovery score. Anesth Analg. 2008;107(4):1189–95. Myles PS, Myles DB, Galagher W, Chew C, MacDonald N, Dennis A. Minimal Clinically Important Difference for Three Quality of Recovery Scales. Anesthesiology. 2016;125(1):39–45. Wessels E, Perrie H, Scribante J, Jooma Z. Quality of recovery in the perioperative setting: A narrative review. J Clin Anesth. 2022;78:110685. Fu Y, Fu H, Wei W, Liu H, Wen Z, Lv X, Lu Y. Effect of bilateral low serratus anterior plane block on quality of recovery after trans-subxiphoid robotic thymectomy: Results of a randomized placebo-controlled trial. Int J Med Sci. 2024;21(7):1241–9. Omindo WW, Ping W, Qiu R, Zheng S, Sun Q, Qian Y, Zhang R, Zhang N, Zhou B. Efficacy of ultrasound-guided second serratus anterior plane block on postoperative quality of recovery and analgesia after video-assisted thoracic surgery: a randomized, triple-blind, placebo-controlled study. J Thorac Dis. 2024;16(7):4195–207. Eochagain AN, Moorthy A, Shaker J, Abdelaatti A, O'Driscoll L, Lynch R, Hassett A, Buggy DJ. Programmed intermittent bolus versus continuous infusion for catheter-based erector spinae plane block on quality of recovery in thoracoscopic surgery: a single-centre randomised controlled trial. Br J Anaesth. 2024;133(4):874–81. Moorthy A, Ni Eochagain A, Dempsey E, Wall V, Marsh H, Murphy T, Fitzmaurice GJ, Naughton RA, Buggy DJ. Postoperative recovery with continuous erector spinae plane block or video-assisted paravertebral block after minimally invasive thoracic surgery: a prospective, randomised controlled trial. Br J Anaesth. 2023;130(1):e137–47. Riddle DL, Dumenci L. Limitations of Minimal Clinically Important Difference Estimates and Potential Alternatives. J Bone Joint Surg Am. 2024;106(10):931–7. Myles PS. Measuring quality of recovery in perioperative clinical trials. Curr Opin Anaesthesiol. 2018;31(4):396–401. Cha EDK, Lynch CP, Geoghegan CE, Jadczak CN, Mohan S, Singh K. Risk Factors for Failing to Reach a Minimal Clinically Important Difference Following Minimally Invasive Lumbar Decompression. Int J Spine Surg. 2022;16(1):51–61. Torre DE, Pirri C, Contristano M, Behr AU, De Caro R, Stecco C. Ultrasound-Guided PECS II + Serratus Plane Fascial Blocks Are Associated with Reduced Opioid Consumption and Lengths of Stay for Minimally Invasive Cardiac Surgery: An Observational Retrospective Study. Life (Basel) 2022, 12(6). Gautam S, Pande S, Agarwal A, Agarwal SK, Rastogi A, Shamshery C, Singh A. Evaluation of Serratus Anterior Plane Block for Pain Relief in Patients Undergoing MIDCAB Surgery. Innovations (Phila). 2020;15(2):148–54. Jack JM, McLellan E, Versyck B, Englesakis MF, Chin KJ. The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: a qualitative systematic review. Anaesthesia. 2020;75(10):1372–85. Jackson JC, Tan KS, Pedoto A, Park BJ, Rusch VW, Jones DR, Zhang H, Desiderio D, Fischer GW, Amar D. Effects of Serratus Anterior Plane Block on Early Recovery from Thoracoscopic Lung Resection: A Randomized, Blinded, Placebo-controlled Trial. Anesthesiology 2024, 141(6):1065–74. Murphy GS, Sherwani SS, Szokol JW, Avram MJ, Greenberg SB, Patel KM, Wade LD, Vaughn J, Gray J. Small-dose dexamethasone improves quality of recovery scores after elective cardiac surgery: a randomized, double-blind, placebo-controlled study. J Cardiothorac Vasc Anesth. 2011;25(6):950–60. Additional Declarations No competing interests reported. Supplementary Files CONSORT2010checklist.doc Cite Share Download PDF Status: Published Journal Publication published 24 Nov, 2025 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Accepted 19 Nov, 2025 Reviews received at journal 14 Nov, 2025 Reviews received at journal 05 Nov, 2025 Reviewers agreed at journal 05 Nov, 2025 Reviewers agreed at journal 05 Nov, 2025 Reviews received at journal 03 Nov, 2025 Reviews received at journal 02 Nov, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers invited by journal 30 Oct, 2025 Editor assigned by journal 25 Oct, 2025 Editor invited by journal 24 Oct, 2025 Submission checks completed at journal 22 Oct, 2025 First submitted to journal 21 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:20:27","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":117011,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7828277/v1/20ecfcb5dbd9fb2d712c03f3.html"},{"id":95566887,"identity":"c170261e-161a-47eb-9697-6358988ae452","added_by":"auto","created_at":"2025-11-10 16:20:27","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73518,"visible":true,"origin":"","legend":"\u003cp\u003eConsolidated Standards of Reporting Trials (CONSORT) flowchart. SAPB, serratus anterior plane block; TA-TAVR, Transapical transcatheter aortic valve replacement.\u003c/p\u003e","description":"","filename":"groupimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7828277/v1/529dc6f81587a26e98bd843a.jpeg"},{"id":95655381,"identity":"c5788d17-c389-45ca-a9e0-26b0e9f4760c","added_by":"auto","created_at":"2025-11-11 16:15:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":130221,"visible":true,"origin":"","legend":"\u003cp\u003eQoR-40 total by group and postoperative day. Boxplots display the median and 25% and 75% inter-quartile range. Violin plots show the QoR-15 distribution. QoR-40, 40-item quality of recovery scale; SAPB, serratus anterior plane block.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7828277/v1/54a25fdc9292a53430c13a4e.png"},{"id":97178311,"identity":"e69b1c33-0d10-4070-a439-30d08d638eaa","added_by":"auto","created_at":"2025-12-01 16:07:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1108334,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7828277/v1/1648accb-65d1-46cc-93f7-42ef8c677d56.pdf"},{"id":95566893,"identity":"7a8af727-2bb1-4c07-83f0-0926a5746c7b","added_by":"auto","created_at":"2025-11-10 16:20:27","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":208896,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2010checklist.doc","url":"https://assets-eu.researchsquare.com/files/rs-7828277/v1/504fdf19c8d989391c51f65d.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Quality of Early Recovery after Ultrasound-guided Serratus Plane Block for Transapical Transcatheter Aortic Valve Implantation Surgery under General Anesthesia：a single-center randomized controlled trial","fulltext":[{"header":"Background","content":"\u003cp\u003eChina\u0026rsquo;s rapidly aging population has fueled an annual rise in degenerative aortic valve diseases, for which transcatheter aortic valve replacement (TAVR) has emerged as a transformative therapy since 2002[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. TAVR eliminates the need for median sternotomy, cardiopulmonary bypass, cardiac arrest, and reperfusion, reducing surgical trauma and significantly lowering patient risk. Over time, it has transformed from a high- risk, challenging procedure into a simple and effective treatment[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhen peripheral vascular anatomy is unfavorable, transapical transcatheter aortic valve replacement (TA-TAVR) provides a critical alternative. This approach circumvents diseased vasculature entirely and, owing to the shorter access-to-target distance, enables superior catheter and prosthesis control[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Compared with traditional surgery, the minimally invasive technique is associated with less trauma and faster recovery. However, it still requires rib spreading, which leads to postoperative pain\u0026mdash;an important issue that requires attention and resolution in enhanced recovery after surgery (ERAS).\u003c/p\u003e\u003cp\u003eUltrasound-guided regional analgesia has revolutionized perioperative care, however, its integration into cardiac surgery lags behind its use in other specialties. The serratus anterior plane block (SAPB), targeting T2-T9 intercostal nerves lateral branches, provides effective anterior-lateral chest wall analgesia[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Compared with neuraxial techniques, SAPB is associated with fewer complications\u0026mdash; a crucial advantage for anticoagulated cardiac patients. SAPB has been widely applied in thoracic, breast, and rib fracture surgeries[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Numerous studies have demonstrated that SAPB not only alleviates pain but also decrease opioid consumption, and mitigate related side effects. This is particularly important for elderly patients and those with severe systemic comorbidities.\u003c/p\u003e\u003cp\u003eDespite documented benefits of serratus anterior plane block (SAPB) in minimally invasive cardiac surgery, its application remains underexplored[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Some studies have reported successful cases of TA-TAVR performed under SAPB, suggesting that SAPB improves postoperative pain control after minimally invasive sternotomy[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, no randomized trials have evaluated its impact on multidimensional recovery quality following TA-TAVR, representing a critical knowledge gap.\u003c/p\u003e\u003cp\u003eRecovery quality is a key concept in perioperative management, with substantial prognostic and economic implications. However, the application of validated recovery quality instruments, such as the Quality of Recovery-40 (QoR-40) scale, to evaluate the holistic impact of regional anesthesia techniques within minimally invasive cardiac interventions remains limited. With the growing emphasis on regional blocks in minimally invasive cardiac surgery and the integration of ERAS protocols to improve recovery quality as a key surgical outcome, establishing a direct link between ultrasound-guided SAPB and recovery quality following TA-TAVR is essential. To address this knowledge gap, we conducted a prospective RCT testing whether ultrasound-guided SAPB enhances patient-perceived recovery quality after TA-TAVR. Our primary outcome measure was the 24-hour global QoR-40 score. Secondary outcomes comprised 48-hour QoR-40, postoperative pain scores, and opioid consumption.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and participants\u003c/h2\u003e\u003cp\u003e This single-center, double-blind, randomized controlled trial was approved by the medical ethics committee of Second Affiliated Hospital of Army Medical University, PLA (reference number 2022-452-01). Patient enrolment started on February 28, 2023 and written informed consent was obtained from participants prior to enrollment. The trial was registered with the China Clinical Trial Register (ChiCTR2300068584) on 24 February, 2023, before the recruitment of the first patient. This study adheres to CONSORT guidelines (Supplementary 1).\u003c/p\u003e\u003cp\u003eWe include adult patients aged 55\u0026ndash;80 years undergoing TA-TAVR under general anesthesia. Exclusion criteria included allergies to local anesthetics (Las), a history of mental illness or psychotropic drug use, severe coagulation abnormalities, long-term use of analgesics or sedatives, history of drug, alcohol, or opioid abuse, recent acute pain or chronic pain, postoperative mechanical ventilation\u0026thinsp;\u0026ge;\u0026thinsp;24 hours, or refusal to participate in the study. Participants retained the right to withdraw from the study at any time, either at their own discretion or if the researchers deemed their continued participation inappropriate.\u003c/p\u003e\u003cp\u003e A total of 70 eligible patients were enrolled and randomly allocated 1:1 to the ultrasound-guided SAPB group or control group using a computer-generated block randomization sequence (fixed block size of 4). This design ensured balanced group allocation throughout the recruitment period. Randomization was performed by independent personnel not involved in the study. Group allocation was concealed in sealed, opaque envelopes to ensure blinding. To ensure that the anesthesiologist performing regional block in a double-blind manner was different from the one managing the patient during the operation. Neither the intraoperative anesthesiologist nor the postoperative outcome evaluator was aware of the group allocation.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eIntraoperative Management\u003c/h3\u003e\n\u003cp\u003ePatients were prepared according to cardiopulmonary bypass protocols, and standard monitoring were established. Radial arterial and right internal jugular venous catheters were placed under local anesthesia and mild sedation (midazolam and sufentanil with local infiltration), respectively. General anesthesia was induced using midazolam, etomidate, rocuronium and sufentanil. Ultrasound-guided regional block was performed after endotracheal intubation. Anesthesia was maintained with propofol, remifentanil and sevoflurane, titrated to achieve bispectral index (BIS) of 40\u0026ndash;60.\u003c/p\u003e\u003cp\u003eAfter the skin closure was completed, patient-controlled intravenous analgesia (PCIA) was initiated as part of a multimodal analgesia regimen. Patients were then transferred to the cardiac surgery intensive care unit for standardized monitoring and management. The PCIA regimen consisted of sufentanil (2.5 \u0026micro;g kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, maximum dose 200 ug), dexmedetomidine (3 ug kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, maximum dose 200 ug) and tropisetron (5 mg). The PCIA pump was programmed to deliver a 2mL bolus with a 15-minute lockout interval and a basal infusion of 4 mL/h. Patients were thoroughly educated on the use of the PCIA pump. Rescue analgesia included oral paracetamol and tramadol hydrochloride tablets (one tablet, p.o.) for pain with a numerical rating scale(NRS)\u0026gt;4 at rest, and intravenous hydromorphone (1 mg) for severe pain (NRS\u0026thinsp;\u0026gt;\u0026thinsp;7).\u003c/p\u003e\n\u003ch3\u003eUltrasound Guided Serratus Anterior Plane Block\u003c/h3\u003e\n\u003cp\u003eUltrasound-guided SAPB was performed after the induction of general anesthesia. Patients were positioned supine with the upper limb abducted. A linear ultrasound transducer was placed in the 5th intercostal space along the left axillary line. The probe was adjusted to visualize anatomical structures, including the latissimus dorsi, pectoralis major, pectoralis minor and serratus anterior muscles. A 22-G nerve block needle was advanced into the superficial serratus plane using an in-plane technique. Aspiration was performed to ensure the absence of blood or air before injection. Subsequently, 2 ml of a local anesthetic mixture (0.4% ropivacaine combined with 10 mg of dexamethasone) was injected slowly. The spread of the anesthetic mixture between the fascia layers was monitored via ultrasound, appearing as a hypoechoic area. Additional anesthetic mixture was slowly administered. The control group did not receive any injection.\u003c/p\u003e\n\u003ch3\u003eStudy outcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was the 40-item quality of recovery scale (QoR-40) score at 24 h after TA-TAVR. The QoR-40 is a widely used, patient-centered global outcome measure of postoperative recovery, with demonstrated validity, reliability, and responsiveness. This scale comprises questions on pain, physical comfort, physical independence, psychological state, and emotional state[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The total score ranges from 0 to 200, with higher scores indicating better recovery.\u003c/p\u003e\u003cp\u003eSecondary outcomes included: (1) QoR-40 score at 48 h postoperatively. (2) NRS pain scores at rest and during coughing at 6 h, 12 h, 24 h, and 48 h postoperatively. (3) PCIA-related parameters, including the total and effective compression counts, opioid consumption and the need for rescue analgesia at 24h and 48h. (4) Incidence of nausea, vomiting and delirium at 48 h post-surgery. (5) patient satisfaction scores (range from 0 to 5, where 0 indicates \u0026ldquo;very dissatisfied\u0026rdquo; and 5 indicates \u0026ldquo;very satisfied\u0026rdquo;).\u003c/p\u003e\u003cp\u003eAll assessments were standardized to fixed postoperative intervals calculated from completion of surgery (skin closure).\u003c/p\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003eOur primary outcome was QoR-40 score at 24 h after surgery. The established minimum clinically important difference (MCID) in QoR-40 is 6.3[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. We considered a difference in the mean QoR-40 scores between groups of 9 to be clinically meaningful, which is greater than the minimum clinically important difference (MCID) of 6.3[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Its standard deviation (SD) after cardiac surgery is typically 9\u0026ndash;26. we chose a SD of 12 to best reflect our study population. To achieve a power of 80% to detect this difference at a two-side α level of 0.05, a total of 58 participants would be required. We enrolled 35 participants per group to account for loss to follow-up, withdrawal, or significant missing data.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe Kolmogorov\u0026ndash;Smirnov test was used to assess the normality of data distribution. Normality distributed continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and analyzed using an independent samples \u003cem\u003et\u003c/em\u003e-test. Non-normally distributed date was analyzed using the Mann-Whitney U test, with results presented as median and interquartile range. Categorical variables were described as frequencies (%) and analyzed using the χ\u003csup\u003e2\u003c/sup\u003e test or Fisher\u0026rsquo;s exact test, as appropriate. The primary outcome was the global QoR-40 score at 24 hours, analyzed at a two-sided alpha level of 0.05. Comparisons of the five QoR-40 subscales were conducted as exploratory analyses to aid interpretation of the primary outcome and were not adjusted for multiple comparisons, to minimize the risk of Type II errors for these hypothesis-generating measures. A \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for the primary outcome. SPSS software version 26 (IBM, New York, USA) was used to conduct statistical analyses.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween February 2023 to November 2024, a total of 70 patients who underwent TA-TAVR surgery in our department were recruited. Three patients were excluded from the experimental group: two due to unplanned conversion to open-chest surgery, and one due to unplanned mechanical ventilation for \u0026ge;\u0026thinsp;24 hours. In the control group, one patient was excluded due to early discharge. These exclusions were mandated by protocol safety criteria and unrelated to group allocation. Ultimately, 32 patients in the experimental group and 34 patients in the no block group were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Baseline characteristics were comparable between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of subjects. Date presented as mean (standard deviation) or n (%), as appropriate.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSAPB (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo block (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (yr)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69.97 (5.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70.53 (4.70)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11(34.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7(20.59)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e158.95 (9.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e161.63 (7.37)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61.59 (11.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.95 (10.95)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg m\u003csup\u003e\u0026minus;\u0026thinsp;2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e24.33 (3.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22.86 (3.25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical duration (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e85.50 (80.00-107.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e94.00 (81.00-111.50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative QoR-40 scores\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e196.50 (193.00- 198.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e197.00 (194.00- 198.00)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eBMI, body mass index; QoR-40, 40-item quality of recovery scale\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003ePrimary outcome data\u003c/h3\u003e\n\u003cp\u003eThe primary outcome, QoR-40 at 24 h after surgery, is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The SAPB group exhibited a higher median (25\u0026ndash;75%) total QoR-40 score of 180.5 (171.25\u0026ndash;183) VS 172 (165.25\u0026ndash;179) in the no block group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006). The median difference between the two groups was 5 (95% CI, 2\u0026ndash;9), which was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). An exploratory analysis of the QoR-40 subscales at 24 h showed a statistically significant between-group difference in the pain dimension (SAPB group: 33 [30.25-34] VS control group: 31 [28.5\u0026ndash;33]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013). However, the total score difference was below the minimal clinically important difference (MDIC) of 6.3 for QoR-40 score, which has been previously identified as indicative of a meaningful clinical improvement in recovery quality after surgery and anesthesia[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Thus, while statistically significant, the observed difference lacks clinical significance (∆ \u0026lt; 6.3).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOverall QoR-40 score and scores in different domains at 24 h and 48 h. Data shown are median (25\u0026ndash;75% range).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSAPB (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo block (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedian difference(95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary outcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQoR-40 at 24 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e180.5 (171.25\u0026thinsp;~\u0026thinsp;183)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e172 (165.25\u0026thinsp;~\u0026thinsp;179)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (2\u0026thinsp;~\u0026thinsp;9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.006*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44 (41.25\u0026thinsp;~\u0026thinsp;45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (40\u0026thinsp;~\u0026thinsp;44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (0\u0026thinsp;~\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.106\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical comfort\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55 (51.25\u0026thinsp;~\u0026thinsp;56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (49\u0026thinsp;~\u0026thinsp;55.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (0\u0026thinsp;~\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.068\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35 (35\u0026thinsp;~\u0026thinsp;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (35\u0026thinsp;~\u0026thinsp;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0\u0026thinsp;~\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.675\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical independence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (12\u0026thinsp;~\u0026thinsp;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (12\u0026thinsp;~\u0026thinsp;13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.108\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (30.25\u0026thinsp;~\u0026thinsp;34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (28.5\u0026thinsp;~\u0026thinsp;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (0\u0026thinsp;~\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.013*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eContinuous secondary outcomes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQoR-40 at 48 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e185.5 (182\u0026thinsp;~\u0026thinsp;189)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e183.5 (178.5\u0026thinsp;~\u0026thinsp;187)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (0\u0026thinsp;~\u0026thinsp;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.048*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 (44\u0026thinsp;~\u0026thinsp;45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (42\u0026thinsp;~\u0026thinsp;45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (0\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.004*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical comfort\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57 (55\u0026thinsp;~\u0026thinsp;59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56 (54\u0026thinsp;~\u0026thinsp;58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (-1\u0026thinsp;~\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.269\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35 (35\u0026thinsp;~\u0026thinsp;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (35\u0026thinsp;~\u0026thinsp;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0\u0026thinsp;~\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.088\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical independence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (15\u0026thinsp;~\u0026thinsp;17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (14\u0026thinsp;~\u0026thinsp;16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (0\u0026thinsp;~\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.023*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (32.25\u0026thinsp;~\u0026thinsp;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (32\u0026thinsp;~\u0026thinsp;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (-1\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.626\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eSAPB, serratus anterior plane block; QoR-40, 40-item quality of recovery scale\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Statistically significant\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSecondary outcome date\u003c/h2\u003e\u003cp\u003eSimilarly, the total QoR-40 score at 48 h was marginally higher in the SAPB group (185.5[182\u0026ndash;189] vs 183.5[178.5\u0026ndash;187]), but this difference was not a clinically meaningful. Exploratory analysis of the subscales at 48 h revealed significantly higher scores in the SAPB group for the emotional state and physical independence dimensions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These dimensional analyses should be interpreted as exploratory due to uncorrected multiple comparisons. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the Boxplots and violin plots for QoR-40 scores at 24 h and 48 h.\u003c/p\u003e\u003cp\u003eAt 6 h and 12 h after surgery, NRS pain scores at rest and during coughing were significantly lower in the SAPB group (difference in medians \u0026minus;\u0026thinsp;1, 95% CI, -1 to\u003c/p\u003e\u003cp\u003e0, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0 .001; difference in medians \u0026minus;\u0026thinsp;1, 95% CI, -2 to -1, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; difference in medians \u0026minus;\u0026thinsp;1, 95% CI, -1 to 0, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0 .001; difference in medians \u0026minus;\u0026thinsp;1, 95% CI, -1 to\u003c/p\u003e\u003cp\u003e0, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0 .002 ;). The NRS pain scores were comparable between the groups at 24 h and 48 h after surgery. No significant differences were observed in the number of effective compressions and the total number of compressions in PCIA, the dosage of sufentanil in PCIA, the rate of rescue analgesia 48 h after surgery, or the incidence of adverse reactions such as nausea and vomiting. furthermore, no adverse events, such as infection, hematoma, delirium or local anesthetic toxicity, occurred in either group. The use of SAPB was associated with higher patient satisfaction (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSecondary outcomes. These include VAR scores for pain at rest and during coughing at 6 h, 12 h, 24 h, 48 h, PCIA-related parameters, rescue analgesia, adverse reactions and patient satisfaction scores. All values shown are mean (SD), median (25\u0026ndash;75%) or n (%) as appropriate.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSAPB (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo block (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedian difference(95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain NRS score at rest\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 6 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (1\u0026thinsp;~\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1 (-1\u0026thinsp;~\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 12 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (1\u0026thinsp;~\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1 (-1\u0026thinsp;~\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 24 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1\u0026thinsp;~\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1\u0026thinsp;~\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (-1\u0026thinsp;~\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.299\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 48 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0\u0026thinsp;~\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePain NRS score during coughing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 6 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (2\u0026thinsp;~\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (3.75\u0026thinsp;~\u0026thinsp;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1 (-2~-1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 12 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.5 (3\u0026thinsp;~\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.5 (3.75\u0026thinsp;~\u0026thinsp;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1(-1\u0026thinsp;~\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.002*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 24 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (3\u0026thinsp;~\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (4\u0026thinsp;~\u0026thinsp;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (-1\u0026thinsp;~\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.223\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 48 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (3\u0026thinsp;~\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (3\u0026thinsp;~\u0026thinsp;4.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (-1\u0026thinsp;~\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePCIA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of total compressions at 24 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.5 (1\u0026thinsp;~\u0026thinsp;7.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2\u0026thinsp;~\u0026thinsp;7.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (-2\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.604\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of effective compressions at 24 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (1\u0026thinsp;~\u0026thinsp;6.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2\u0026thinsp;~\u0026thinsp;6.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (-2\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.551\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal number of compressions at 48 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (1\u0026thinsp;~\u0026thinsp;17.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (3.75\u0026thinsp;~\u0026thinsp;15.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1 (-4\u0026thinsp;~\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.373\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of effective compressions at 48 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (1\u0026thinsp;~\u0026thinsp;13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.5 (3.75\u0026thinsp;~\u0026thinsp;14.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-2 (-4\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.192\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDosage of sufentanil at 24 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52.48\u0026thinsp;\u0026plusmn;\u0026thinsp;10.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52.32\u0026thinsp;\u0026plusmn;\u0026thinsp;7.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.16 (-4.45\u0026thinsp;~\u0026thinsp;4.77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.945\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDosage of sufentanil at 48 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105.23\u0026thinsp;\u0026plusmn;\u0026thinsp;21.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104.06\u0026thinsp;\u0026plusmn;\u0026thinsp;17.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.16 (-8.25\u0026thinsp;~\u0026thinsp;10.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.806\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003erescue analgesia, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.207\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdverse reactions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enausea/vomiting, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient satisfaction\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (4\u0026thinsp;~\u0026thinsp;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (4\u0026thinsp;~\u0026thinsp;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.024*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eSAPB, serratus anterior plane block; NRS, numerical rating scale; PCIA, patient-controlled intravenous analgesia\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Statistically significant\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eConsistent with the growing emphasis on postoperative recovery quality beyond traditional metrics such as opioid consumption and pain scores, our study assessed the impact of ultrasound-guided single-injection serratus anterior plane block (SAPB) as part of a multimodal analgesia regimen on recovery outcomes following TA-TAVR. While the primary outcome\u0026mdash;the QoR-40 score at 24 hours\u0026mdash;showed a statistically significant improvement (median difference: 5, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006), the clinical relevance of this change remains marginal, as it fell below the predefined MCID of 6.3 points. It is noteworthy, however, that the exploratory analysis indicated that the observed improvement in the global score was largely driven by a significant reduction in the pain dimension. This aligns with the finding that SAPB provided significant early pain relief, as evidenced by lower NRS scores at rest and during coughing at 6 and 12 hours postoperatively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, this analgesic benefit did not translate into a reduction in cumulative opioid consumption or the need for rescue analgesia, indicating that the analgesic efficacy of a single-injection SAPB may be insufficient to independently influence short-term recovery quality in TA-TAVR patients\u003c/p\u003e\u003cp\u003eAlthough numerous studies have reported that ultrasound-guided SAPB effectively enhances recovery quality following various surgeries, especially in video-assisted thoracic surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], our findings demonstrated that although a single-injection SAPB is safe and technically straightforward, its transient analgesic effect may not fully address the prolonged recovery needs for TA-TAVR patients[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This is supported by the lack of sustained improvement in the QoR-40 pain dimension beyond 24 h. Thus, while SAPB has been used in TA-TAVR, evidence for clinically significant benefits and patient-centered results remains inconclusive. Ongoing research focus is exploring whether continuous block of catheter or supplementary secondary blocks at specific intervals could enhance clinical outcome[\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Additionally, while the single-center design and modest sample size were appropriate for this pilot investigation, they confer limited statistical power and reduced precision in effect estimates\u0026mdash;increasing the risk of Type II errors and potentially obscuring clinically meaningful recovery differences. Finally, the generalizability of ΜCID thresholds across diverse surgical populations may also be inconsistent[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. TA-TAVR patients are typically older, with higher frailty indices and multiple comorbidities, which may attenuate their responsiveness to recovery metrics. Cha EDK et al. identified advanced age as a significant predictor for failing to achieve MCID in minimally invasive lumbar decompression[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In this vulnerable cohort, the statistically significant 5-point improvement in global QoR-40 \u0026mdash; while below the predefined 6.3-point MCID threshold \u0026mdash; may still confer value, where modest gains could translate into disproportionate clinical benefits. In addition, our findings showed that SAPB specifically improved the pain dimension of QoR-40 at 24 h, and the SAPB group exhibited superior emotional state and physical independence at 48 h.\u003c/p\u003e\u003cp\u003eThese dimensional outcomes should be interpreted as exploratory given uncorrected multiple comparisons and limited subgroup power. Nevertheless, these results may suggest that traditional MCID thresholds underestimate the clinical benefits of regional analgesia in vulnerable populations.\u003c/p\u003e\u003cp\u003eThe significant reduction in resting and during coughing NRS scores at 6 h and 12 h postoperatively (median difference: 1, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) demonstrates that SAPB effectively alleviates acute incisional pain from the anterolateral thoracotomy required for transapical access. This aligns with numerous studies confirming the efficacy of single-injection block for early postoperative analgesia in cardiac surgery[\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, the nature of a single-injection of local anesthetic limits the ability to sustain long-term pain control. Our results did not demonstrate a reduction in opioid consumption associated with SAPB, as evidenced by multidimensional analgesic metrics: comparable resting/coughing pain scores, equivalent patient-controlled sufentanil requirements and similar rescue analgesia incidence. This convergence of findings indicates that SAPB in TA-TAVR primarily enhances early pain experience. This phenomenon also been observed in video-assisted thoracic surgery (VATS) by Do-Hyeong[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], where SAPB reduced pain scores and opioid use at 6 hours but failed to show significant differences at 24 hours. Similarly, Jackson recently reported that adding single-injection SAPB to a multimodal analgesia plan did not reduce 24 h or 48 h intravenous morphine equivalents compared to the control group undergoing thoracoscopic lung resection[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our cohort, the multimodal analgesia protocol incorporating PCIA maintained a median resting NRS score\u0026thinsp;\u0026le;\u0026thinsp;3 in the control group at 24 hours, which may have obscured subtle between-group differences in opioid demand. Besides, this early analgesic effect is clinically pivotal, as optimal pain control facilitates deep breathing, coughing, and early mobilization, which can reduce postoperative pulmonary complications, a cornerstone of ERAS. Patient satisfaction scores were significantly higher in the SAPB group. This likely reflects that pain relief remains a pivotal factor in patient-perceived care quality. Furthermore, the absence of SAPB-related complications (e.g., hematoma, local anesthetic toxicity) in our fully heparinized cohort reinforces its safety profile. Notably, no instances of block failure or technical difficulties were documented during ultrasound-guided procedures performed by experienced anesthesiologists. This supports the feasibility of SAPB as a component of multimodal analgesia for TA-TAVR patients.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eOut study has several limitations. First, the single-center design and relatively small size may limit statistical power for detecting smaller treatment effects. Post hoc analysis showed that 75.4% of the power detected the observed QoR-40 difference, which might increase the risk of Type II error for detecting smaller effects, particularly for secondary endpoints or differences approaching the MCID threshold. Future larger studies are needed to confirm these findings and explore subgroup effects. Nevertheless, the statistically robust primary outcome (p\u0026thinsp;=\u0026thinsp;0.006) and clinically relevant confidence interval provide meaningful evidence of treatment benefit, suggest that these findings, despite their statistical limitations, can still inform clinical practice while awaiting larger confirmatory studies. Second, the absence of sensory testing (due to general anesthesia) introduced a potential unblinding risk. However, all blocks were performed under ultrasound guidance by experienced anesthesiologists, minimizing technical failure rates. Third, although all postoperative assessments were standardized to fixed intervals from skin closure, we acknowledge that patients receiving PCIA prior to full emergence from anesthesia could theoretically exhibit altered pain perception or compromised QoR-40 validity. However, all patients had achieved full alertness by the 6-hour assessment timepoint. Furthermore, supplementary analysis revealed comparable sufentanil consumption between groups during the initial 6-hour period, suggesting that pre-extubation analgesic administration did not systematically bias our pain or QoR-40 measurements.\u003c/p\u003e\u003cp\u003eFinally, we administered dexamethasone as an adjuvant to prolong the duration of SAPB. However, its systemic effects may partially mask or amplify the true impact of SAPB on QoR-40 scores. Literature reports indicate that dexamethasone can independently improve QoR-40 domains, including emotional state, physical comfort, and pain[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Future studies should employ a three-arm randomized controlled trial design to assess recovery following continuous catheter SAPB combined with biomarker/inflammatory panel-guided inflammatory profiling, objectively quantifying both the SAPB-specific effect and the systemic anti-inflammatory potency of dexamethasone. Additionally, the high doses of opioids used in the perioperative period may have attenuated the observed opioid-sparing effects of the regional block. Future trials employing lower opioid doses or opioid-free anesthesia regimens may better elucidate the opioid-sparing potential of these techniques within multimodal analgesia.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe inclusion of serratus anterior plane block (SAPB) in the multimodal analgesia regimen for TA-TAVR patients led to statistically significant improvements in early postoperative recovery quality (24 h QoR-40 score) and effectively reduced acute pain during the first 6 h and 12 h postoperatively. However, it did not achieve the predefined MCID threshold (6.3 points) and lacked opioid-sparing effects, which highlight its effect on the early recovery in TA-TAVR may be limited. It also reminds us that individual regional group, such as SAPB, may not always provide the comprehensive benefits across all recovery-related outcomes. Nevertheless, within established enhanced recovery pathways, SAPB remains a valuable component, with its safety profile\u0026mdash;demonstrated by the absence of complications in fully heparinized patients\u0026mdash;reinforcing its role as part of multimodal analgesia strategies for TA-TAVR, though it should not be viewed as a standalone solution.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTAVR Transcatheter aortic valve replacement\u003c/p\u003e\u003cp\u003eTA-TAVR Transapical transcatheter aortic valve replacement\u003c/p\u003e\u003cp\u003eERAS Enhanced recovery after surgery\u003c/p\u003e\u003cp\u003eSAPB Serratus anterior plane block\u003c/p\u003e\u003cp\u003eLas local anesthetics\u003c/p\u003e\u003cp\u003eBIS Bchieve bispectral index\u003c/p\u003e\u003cp\u003ePCIA Patient-controlled intravenous analgesia\u003c/p\u003e\u003cp\u003eQoR-40 40-item quality of recovery scale\u003c/p\u003e\u003cp\u003eNRS Numerical rating scale\u003c/p\u003e\u003cp\u003eMCID Minimum clinically significant difference\u003c/p\u003e\u003cp\u003eSD Standard deviation\u003c/p\u003e\u003cp\u003eVATS Video-assisted thoracic surgery\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and consent to participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study involves human participants and was approved by the medical ethics committee of Second Affiliated Hospital of Army Medical University, PLA (reference number 2022-452-01). Participants gave informed consent to participate in the study before taking part. The study was registered with the Chinese Registry of Clinical Trials (http://www.chictr.org.cn) (ChiCTR2300068584, 24/02/2023) and conducted in accordance with the Helsinki Declaration of 1975.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Nature Science Foundation of China (Project No.82171265).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCheng Xiao helped conceived and designed the study, analyzed the data and wrote the draft; Sheng Jing helped searched the literature, performed the anesthesia block, analyzed the data and revised the manuscript; GuiYing Yang helped conceived and designed the study, interpretated the data; Fang Chen helped with data acquisition and date interpretation; Ming Yang supplemented key intellectual content; Lei Cao helped manage clinical record forms and revised the manuscript; YuTing Tan helped with patient enrollment and data analysis; GuoYun Lin helped to manage the clinical recording forms; Hong Li\u0026nbsp;designed experiments and revised the manuscript. All the authors approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. HL is the guarantor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are very grateful to our cardiovascular surgeon colleagues (Z Jian, ZZ Feng, MW Li) for their kind cooperation in facilitating this trial.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCribier A, Eltchaninoff H, Bash A, Borenstein N, Tron C, Bauer F, Derumeaux G, Anselme F, Laborde F, Leon MB. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation 2002, 106(24):3006\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVahanian A, Alfieri OR, Al-Attar N, Antunes MJ, Bax J, Cormier B, Cribier A, De Jaegere P, Fournial G, Kappetein AP, et al. Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2008;34(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarbanti M, Webb JG, Gilard M, Capodanno D, Tamburino C. EuroIntervention : Transcatheter aortic valve implantation in 2017: state of the art. 2017, 13(AA):AA11\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlfieri O, Sala A, Buzzatti N. Comparing traditional aortic valve surgery and transapical approach to transcatheter aortic valve implant. Eur Heart J Supplements. 2020;22(SupplementE):E7\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68(11):1107\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMayes J, Davison E, Panahi P, Patten D, Eljelani F, Womack J, Varma M. An anatomical evaluation of the serratus anterior plane block. Anaesth 2016, 71(9):1064\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYao Y, Li J, Hu H, Xu T, Chen Y. Ultrasound-guided serratus plane block enhances pain relief and quality of recovery after breast cancer surgery: A randomised controlled trial. Eur J Anaesthesiol. 2019;36(6):436\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim DH, Oh YJ, Lee JG, Ha D, Chang YJ, Kwak HJ. Efficacy of Ultrasound-Guided Serratus Plane Block on Postoperative Quality of Recovery and Analgesia After Video-Assisted Thoracic Surgery: A Randomized, Triple-Blind, Placebo-Controlled Study. Anesth Analg. 2018;126(4):1353\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerthoud V, Ellouze O, Nguyen M, Konstantinou M, Aho S, Malapert G, Girard C, Guinot PG, Bouchot O, Bouhemad B. Serratus anterior plane block for minimal invasive heart surgery. BMC Anesthesiol. 2018;18(1):144.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeng L, Ding M, Wei W. Ultrasound-guided serratus anterior plane block for transapical transcatheter aortic valve implantation. J Cardiothorac Surg. 2023;18(1):4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerthoud V, Ellouze O, Bievre T, Konstantinou M, Jazayeri S, Bouchot O, Girard C, Bouhemad B. Serratus Anterior Plane Block for Apical TAVR in an Awake Patient. J Cardiothorac Vasc Anesth 2018, 32(5):2275\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMyles PS, Weitkamp B, Jones K, Melick J, Hensen S. Validity and reliability of a postoperative quality of recovery score: the QoR-40. Br J Anaesth. 2000;84(1):11\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChan MT, Lo CC, Lok CK, Chan TW, Choi KC, Gin T. Psychometric testing of the Chinese quality of recovery score. Anesth Analg. 2008;107(4):1189\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMyles PS, Myles DB, Galagher W, Chew C, MacDonald N, Dennis A. Minimal Clinically Important Difference for Three Quality of Recovery Scales. Anesthesiology. 2016;125(1):39\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWessels E, Perrie H, Scribante J, Jooma Z. Quality of recovery in the perioperative setting: A narrative review. J Clin Anesth. 2022;78:110685.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFu Y, Fu H, Wei W, Liu H, Wen Z, Lv X, Lu Y. Effect of bilateral low serratus anterior plane block on quality of recovery after trans-subxiphoid robotic thymectomy: Results of a randomized placebo-controlled trial. Int J Med Sci. 2024;21(7):1241\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOmindo WW, Ping W, Qiu R, Zheng S, Sun Q, Qian Y, Zhang R, Zhang N, Zhou B. Efficacy of ultrasound-guided second serratus anterior plane block on postoperative quality of recovery and analgesia after video-assisted thoracic surgery: a randomized, triple-blind, placebo-controlled study. J Thorac Dis. 2024;16(7):4195\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEochagain AN, Moorthy A, Shaker J, Abdelaatti A, O'Driscoll L, Lynch R, Hassett A, Buggy DJ. Programmed intermittent bolus versus continuous infusion for catheter-based erector spinae plane block on quality of recovery in thoracoscopic surgery: a single-centre randomised controlled trial. Br J Anaesth. 2024;133(4):874\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoorthy A, Ni Eochagain A, Dempsey E, Wall V, Marsh H, Murphy T, Fitzmaurice GJ, Naughton RA, Buggy DJ. Postoperative recovery with continuous erector spinae plane block or video-assisted paravertebral block after minimally invasive thoracic surgery: a prospective, randomised controlled trial. Br J Anaesth. 2023;130(1):e137\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRiddle DL, Dumenci L. Limitations of Minimal Clinically Important Difference Estimates and Potential Alternatives. J Bone Joint Surg Am. 2024;106(10):931\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMyles PS. Measuring quality of recovery in perioperative clinical trials. Curr Opin Anaesthesiol. 2018;31(4):396\u0026ndash;401.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCha EDK, Lynch CP, Geoghegan CE, Jadczak CN, Mohan S, Singh K. Risk Factors for Failing to Reach a Minimal Clinically Important Difference Following Minimally Invasive Lumbar Decompression. Int J Spine Surg. 2022;16(1):51\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTorre DE, Pirri C, Contristano M, Behr AU, De Caro R, Stecco C. Ultrasound-Guided PECS II\u0026thinsp;+\u0026thinsp;Serratus Plane Fascial Blocks Are Associated with Reduced Opioid Consumption and Lengths of Stay for Minimally Invasive Cardiac Surgery: An Observational Retrospective Study. Life (Basel) 2022, 12(6).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGautam S, Pande S, Agarwal A, Agarwal SK, Rastogi A, Shamshery C, Singh A. Evaluation of Serratus Anterior Plane Block for Pain Relief in Patients Undergoing MIDCAB Surgery. Innovations (Phila). 2020;15(2):148\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJack JM, McLellan E, Versyck B, Englesakis MF, Chin KJ. The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: a qualitative systematic review. Anaesthesia. 2020;75(10):1372\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJackson JC, Tan KS, Pedoto A, Park BJ, Rusch VW, Jones DR, Zhang H, Desiderio D, Fischer GW, Amar D. Effects of Serratus Anterior Plane Block on Early Recovery from Thoracoscopic Lung Resection: A Randomized, Blinded, Placebo-controlled Trial. Anesthesiology 2024, 141(6):1065\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurphy GS, Sherwani SS, Szokol JW, Avram MJ, Greenberg SB, Patel KM, Wade LD, Vaughn J, Gray J. Small-dose dexamethasone improves quality of recovery scores after elective cardiac surgery: a randomized, double-blind, placebo-controlled study. J Cardiothorac Vasc Anesth. 2011;25(6):950\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"quality of recovery, serratus anterior plane block, transapical transcatheter aortic valve replacement","lastPublishedDoi":"10.21203/rs.3.rs-7828277/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7828277/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e Regional anesthesia techniques, including the serratus anterior plane block (SAPB), reduce postoperative pain after minimally invasive cardiac surgery. However, the evidence regarding its impact on transapical transcatheter aortic valve replacement (TA-TAVR) is limited, and data specifically exploring its effectiveness on patient-centric outcomes are lacking.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e We conducted a single-center randomized controlled trial comparing the efficacy of ultrasound-guided SAPB with ropivacaine 0.5% (40 ml) with no block for patients undergoing TA-TAVR. The primary outcome was 24-hour Quality of Recovery-40 (QoR-40) score. Secondary outcomes included QoR-40 at 48 h, pain scores, opioid consumption, and complications.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e A total of 66 participants were included in the analysis. The median QoR-40 [IQR] at 24 h was higher in SAPB group (n\u0026thinsp;=\u0026thinsp;32) compared with the no block group (n\u0026thinsp;=\u0026thinsp;34): 180.5 (171.25\u0026ndash;183) VS 172 (165.25\u0026ndash;179), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006. At 48 h, scores were 185.5 (182\u0026ndash;189) vs 183.5 (178.5\u0026ndash;187), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.048. Although these differences were statistically significant, they did not reach the minimum clinically important difference (MCID) of 6.3. Early postoperative analgesia was superior in the SAPB group, with lower resting/coughing NRS scores at 6 and 12 hours (median difference 1, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, there were no intergroup differences in opioid consumption or the need for rescue analgesia.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e As part of multimodal analgesia for TA-TAVR, SAPB improved early postoperative analgesia but did not enhance the multidimensional quality of early recovery, as measured by the QoR-40 score. Further studies are warranted.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration\u003c/b\u003e ChiCTR2300068584. Registered 24 February 2023.\u003c/p\u003e\u003cp\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.chictr.org.cn/bin/project/edit?pid=184719\u003c/span\u003e\u003cspan address=\"https://www.chictr.org.cn/bin/project/edit?pid=184719\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e","manuscriptTitle":"Quality of Early Recovery after Ultrasound-guided Serratus Plane Block for Transapical Transcatheter Aortic Valve Implantation Surgery under General Anesthesia：a single-center randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 16:20:22","doi":"10.21203/rs.3.rs-7828277/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-11-19T17:22:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-14T10:45:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-05T19:57:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311678264626658281336715393460852029623","date":"2025-11-05T19:51:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78881592293282245511378541328800991945","date":"2025-11-05T17:21:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-03T12:58:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-02T09:46:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212414732093253329816779765309576075488","date":"2025-10-30T08:38:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216881967914867188710763022787424735936","date":"2025-10-30T08:32:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-30T08:24:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-25T13:27:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-24T12:42:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-22T11:17:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2025-10-22T02:48:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e7df12d1-a3f7-426c-9386-01ee38f825f0","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:00:48+00:00","versionOfRecord":{"articleIdentity":"rs-7828277","link":"https://doi.org/10.1186/s12871-025-03528-7","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2025-11-24 15:57:21","publishedOnDateReadable":"November 24th, 2025"},"versionCreatedAt":"2025-11-10 16:20:22","video":"","vorDoi":"10.1186/s12871-025-03528-7","vorDoiUrl":"https://doi.org/10.1186/s12871-025-03528-7","workflowStages":[]},"version":"v1","identity":"rs-7828277","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7828277","identity":"rs-7828277","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}