Awake Surgery

General anesthesia is actually considered the main procedure adopted for cardiac surgery both with on-pump and off-pump techniques. With the advent and improvement of locoregional anesthesia in the era of Enhanced Recovery After Surgery protocols, general anesthesia could be safely associated with the ultrasound chest wall block to reduce both the adverse effects related to the opioid administration and the time intubation aiming at the early extubation and early pulmonary rehabilitation. Despite the potential use of high thoracic epidural anesthesia and paravertebral block both for the standard and awake cardiac surgery, there is still an ongoing discussion about the bleeding risk and neurological injury associated with these procedures. On this basis, the use of ultrasound chest wall blocks could be considered the new wave of the tsunami born with Rafael Blanco in 2011 and fully entering the cardiac surgery field. To date, the most performed chest wall blocks in awake and spontaneous breathing cardiac surgery patients are represented by the parasternal block to manage sternal dehiscence and sternal wound debridement; serratus anterior plane, pectoserratus plane, and interpectoral plane blocks for rib fractures; chest tube insertion for pneumothorax; pacemaker and subcutaneous implantable cardioverter defibrillator implantation; and transcatheter aortic valve implantation. Locoregional anesthesia could be applied on the basis of the personal expertise also evaluating the risks and the benefits for cardiac patients, and more studies are needed to validate their routinary use.