Liposomal bupivacaine versus ropivacaine thoracic paravertebral block for thoracoscopic atrial septal defect repair: analgesic efficacy and cardiac biomarker outcomes in a single-center, assessor-blinded, randomized trial.

Abstract

Background: Thoracoscopic atrial septal defect (ASD) repair, although minimally invasive, can cause substantial postoperative pain. Thoracic paravertebral block (TPVB) provides effective chest wall analgesia, and liposomal bupivacaine (LB), a long-acting local anesthetic with sustained release, may prolong analgesic duration. We investigated whether ultrasound-guided TPVB using long-acting LB improves postoperative analgesia without compromising cardiovascular safety compared with ropivacaine (RP).

Methods: This randomized, assessor-blinded trial enrolled 94 patients undergoing thoracoscopic ASD repair, who were randomly assigned (1:1) to receive ultrasound-guided TPVB with either LB or RP. Eligibility criteria included age 18-55 years, American Society of Anesthesiologists (ASA) II-III, New York Heart Association (NYHA) II-III, and ejection fraction (EF) >50%. Randomization was computer-generated with sealed envelopes. Safety monitoring included continuous electrocardiography (ECG) for arrhythmias, with Clavien-Dindo grading and Naranjo causality assessment. The primary endpoint was the numerical rating scale (NRS, 0-10) pain score during coughing at 24 h postoperatively. Secondary outcomes included NRS scores at other time points, 72-h opioid consumption (morphine milligram equivalents, MME), time to first rescue analgesia, extended analgesia outcomes [postoperative days 4-7 (POD4-POD7)], perioperative hemodynamics, postoperative recovery, cardiac/inflammatory biomarker trajectories, and adverse events (with postoperative arrhythmias analyzed separately).

Results: Baseline demographic, clinical, and intraoperative variables were well-balanced between groups (all P>0.05). Compared with RP, LB was associated with lower NRS pain scores at rest and during coughing from extubation through 72 h (all P<0.05), including the primary endpoint at 24 h. LB significantly reduced 72-h opioid consumption [median interquartile range (IQR) 7.5 (0, 42) mg vs. 45 (30, 67.5) mg; P<0.001] and increased the proportion of patients requiring no rescue analgesia within 72 h (72.4% vs. 27.6%; P=0.003). Time to first rescue analgesia was numerically longer with LB (20.5 h vs. 12.0 h; P=0.10), and opioid-sparing effects persisted on POD4-POD7 (both P<0.001). Mechanical ventilation duration was shorter in the LB group [5 (3, 6) h vs. 6 (4, 7.5) h; P=0.03]. Cardiac and inflammatory biomarker trajectories did not differ between groups. Non-arrhythmic adverse events were comparable, and postoperative arrhythmia incidence within 30 days was similar between groups (13.3% vs. 15.6%).

Conclusions: In adults undergoing thoracoscopic ASD repair, LB-based TPVB provides superior early analgesia with sustained opioid sparing and shorter mechanical ventilation duration, without signals of increased cardiovascular risk, including postoperative arrhythmias. These findings support considering LB-TPVB as part of multimodal analgesia for thoracoscopic ASD repair, pending confirmation in larger multicenter studies.

Trial registration: ChiCTR2500112278, retrospectively registered at the Chinese Clinical Trial Registry on November 12, 2025.