To the Editor:
Weread with great interest the article “Transverse thoracic muscle plane
block: tricks and tips to accomplish the block” by Murata et al.1 We would like to contribute by sharing our thoughts and experience.

The transverse thoracic muscle plane block (TTMPB) was first described by Ueshima et al,2 as an adjunct to the Pecs (pectoral nerves block) II for breast surgery and as an analgesic block for median sternotomy. Alternatives to and modifications of the Pecs I are available in literature as well. In 2005, McDonald et al3 described a parasternal infiltration proven to be effective for pain reduction after median sternotomy. In 2014, de la Torre et al4 described the ultrasound-guided “pectointercostal fascial block” as a useful tech nique for rib cage pain relief, difficult weaning improvement in critically ill patients, and also for pain relief in breast surgery. In the work of de la Torre et al, the injection takes place 2 cm lateral to the sternum, between the pectoralis major and the external intercostal muscles. In 2016, Hansen et al5 reported the “Ultrasound guided parasternal Pecs block” as a support for Pecs I, Pecs II, and serratus anterior plane block in breast surgery when the parasternal area is involved. Hansen and colleagues per formed the block by injecting the local anes thetic between the pectoralis major muscle and the sternum, approximately 3 cm below the jugular notch. Similarly, Raza et al6 reported a case of a successfully man aged sternal fracture pain with a bilateral “subpectoral interfascial plane” catheter.

Reading these articles, it seems that the superficial subpectoral techniques are as effective as the TTMPBfor the analgesia of the anterior surface of the thorax for breast surgery, cardiac surgery, and sternal fractures. Different names were given to these blocks, but they all target the anterior
branches of the intercostal nerves. A differ ence is that the TTMPB is performed deeper than the Pecs, with a potential risk of vessel and pleural puncture, as stated by the authors themselves.

In our department, we perform this block as described by de la Torre et al, un der ultrasound guidance in the interfascial plane between the pectoralis major and in tercostal muscles in selected cases of cardio thoracic surgery, when median sternotomy occurs. We simply call it parasternal Pecs. The block is performed right after induction of general anesthesia, before the central venous catheter (CVC) placement. Since we started using this block, we noticed a reduced opioid consumption both intraoperatively and postoperatively as well as better he modynamic stability during incision and sternotomy. Regarding the postoperative period, a subxiphoid local anesthetic infiltration may also be needed for drainage pain relief. In our opinion, patients undergoing off pump coronary artery bypass graft surgery may benefit from this block, for intraoperative and postoperative pain management and
weaning from mechanical ventilation.

In conclusion, the superficial approach of the same block gives results comparable to the TTMPB with fewer morbidity risks; it may be suggested as an alternative ap proach to the paravertebral block or the Pecs I when anesthesia to the medial sur face of the anterior hemithorax needs to be achieved.

Romualdo Del Buono, MD
Fabio Costa, MD
Felice Eugenio Agrò, MD

Unit of Anesthesia
Intensive Care and Pain Management
Department of Medicine
Università Campus Bio-Medico di Roma
Rome, Italy

The authors declare no conflict of interest.

1. Murata H, Hida K, Hara T. Transverse thoracic
muscle plane block: tricks and tips to accomplish
the block. RegAnesthPainMed. 2016;41:411–412.
2. Ueshima H, Hara E, Marui T, Otake H. The
ultrasound-guided transversus thoracic muscle
plane block is effective for the median
sternotomy. JClinAnesth. 2016;29:83.
3. McDonald SB, Jacobsohn E, Kopacz DJ, et al.
Parasternal block and local anesthetic infiltration
with levobupivacaine after cardiac surgery with
desflurane: the effect on postoperative pain,
pulmonary function, and tracheal extubation
times. Anesth Analg. 2005;100:25–32.
4. de la Torre PA, García PD, Alvarez SL, Miguel
FJ, Pérez MF. Anovelultrasound-guidedblock: a
promising alternative for breast analgesia.
Aesthet Surg J. 2014;34:198–200.
5. HansenCK,DamM,PoulsonTD,LönnqvistPA,
Bendsten TF, Børglum J. Ultrasound-guided
parasternal Pecs block: a new and useful
supplement to Pecs I and serratus anterior plane
blocks. Anaesthesia Cases. 2016 Available at:
http://www.anaesthesiacases.org/case-reports/
2016-0007. Accessed May 18, 2016.
6. Raza I, Narayanan M, Venkataraju A, Ciocarlan
A. Bilateral subpectoral interfascial plane
catheters for analgesia for sternal fractures: a case
report. Reg Anesth Pain Med. 2016;41:607–609.