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Background and Aims Adults with congenital heart disease (ACHD) undergoing cardiac surgery are increasingly common and present unique anesthetic challenges due to complex cardiac physiology and high perioperative risk. While regional anesthesia reduces time to extubation and hospital length of stay (LOS) in pediatric congenital heart surgery (1), similar literature in ACHD is limited. This case series details individualized regional anesthesia as part of multimodal analgesia to optimize outcomes in this unique population.Methods Three ACHD underwent subrectus epicardial pacemaker insertion or generator exchange. Patient 1 underwent generator exchange with extension of midline sternotomy from midsternum to subxiphoid. They received left T5–9 intercostal nerve blocks and right parasternal intercostal fascial block (PIFB). Patient 2 underwent epicardial pacemaker insertion, attempted via subxiphoid sternotomy then converted to full sternotomy. They received bilateral T6–7 and left T8–9 paravertebral blocks (PVB) and additional bilateral PIFB after incision extension. Patient 3 had a staged procedure: firstly, a redo sternotomy with temporary epicardial pacemaker pacing leads and received bilateral multi-orifice PIFB catheters. Subsequently, Patient 3 had a left thoracotomy for pacemaker insertion and sternotomy VAC dressing closure and received left T3–7 intercostal nerve cryoneurolysis.Results All patients were extubated by 0–4 hours post-op and reported almost no surgical incisional pain in the first day. Analgesia was superior to previous surgeries with similar incisions, and opioid consumption in the first 24 hours was minimal. LOS varied from 2 to 20 days for reasons outside of pain management. In all cases, pain was more prominent at the chest tube insertion site than the surgical incision.Conclusions Regional anesthesia was effective in managing postoperative pain in ACHD undergoing epicardial pacemaker procedures. Despite major surgical incisions, patients were extubated quickly and required minimal opioids in the first 24 hours. Further research is needed to assess the broader benefits of these techniques in the growing ACHD population.