To the Editor:

There is a growing interest in minimally invasive and transcatheter mitral surgery to treat degenerative mitral disease. One such technique entails the use of sternal sparing mini-thoracotomy and transcatheter beating heart targeted NeoChord resuspension under echo guidance (NeoChord DS1000, St. Louis Park, MN).1, 2 However, the procedure does require a mini-thoracotomy, which can result in significant postoperative pain.³ As such, we performed serratus anterior plane block (SAPB) as part of a multimodal pain management strategy in 3 consecutive patients undergoing minimally invasive NeoChord mitral valve repair. All 3 patients (ages 61, 57, and 62 years) were deemed high-risk for conventional mitral valve repair owing to comorbid conditions. After endotracheal intubation, the SAPB was performed on the left side under ultrasound guidance (SonoSite S-Nerve ultrasound system fitted with a L38 × 10-5 MHz transducer, SonoSite, Inc, Bothell, WA). The ultrasound probe was placed in a sagittal plane at the midaxillary T3-4 level. The probe was moved medially until the latissimus dorsi and serratus anterior muscle planes were identified overlying the fourth and fifth ribs. Using an in-plane technique with a 22-gauge, 50-mm SonoPlex Stim needle (Pajunk Medical Systems, Tucker, GA), 30 mL of 0.25% bupivacaine was deposited between the latissimus dorsi and serratus anterior muscle plane from a caudal to cranial direction (Fig 1, A).⁴ Surgical access to the left ventricular apex was achieved with an incision (4-5 cm) in the fifth intercostal space just lateral to the midclavicular line, which corresponds to the T5-T6 dermatomes (Fig 1, B). After full heparinization, apical ventriculotomy was created, and the NeoChord system was deployed.