The researchers are working to improve recovery after heart surgery by reducing reliance on opioids. Newer regional anesthesia techniques can provide strong pain relief with fewer risks, but the choice of method depends on each patient's condition, medications, and surgical plan

Optimal anesthesia in cardiac surgery requires careful management to avoid sympathetic stimulation, with analgesia being central to patient safety and recovery. Traditionally, high-dose opioids were used, but this approach delays extubation, conflicting with fast-track protocols that emphasize early extubation. Consequently, opioid-free analgesia has gained importance, employing regional techniques such as neuraxial, paravertebral, and fascial plane blocks.

Thoracic epidural analgesia (TEA) offers effective pain control and reduces perioperative cardiovascular and respiratory complications. However, its use in anticoagulated patients raises concern for epidural hematoma. Alternatives like paravertebral and fascial plane blocks provide comparable analgesia with lower risk. The erector spinae plane block (ESPB) reduces analgesic requirements, though deep blocks still pose bleeding risks.

Superficial plane blocks are therefore clinically valuable. The parasternal intercostal block-targeting anterior cutaneous branches of intercostal nerves-has emerged as a safe option for patients undergoing median sternotomy while on anticoagulant or antiplatelet therapy. Additionally, bilateral rectus sheath block can reduce chest tube insertion pain after cardiac surgery.

Inclusion Criteria:

• Both sexes,
• ASA III-IV patients
• body mass index between 20- 35 kg/m2
• adult patients above 18 years old will be included in the study

Exclusion Criteria:

• Patients with global hypokinesia
• ejection fraction < 40%
• low platelet count
• coagulation impairment
• deformity in the vertebral column
• severe renal and hepatic impairment
• any known allergy to the drugs used