Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management

Abstract

Diaphragmatic paralysis (DP) after cardiac surgery is an important complication especially in infants. We analyzed the incidence, clinical course, surgical management and follow up of the patients with DP, retrospectively. Between 1996 and 2005, 3,071 patients underwent cardiac surgery. Total number of patients with DP was 152 (4.9%). Out of 152 patients, 42 were surgically treated with transthoracic diaphragm plication (1.3%). The overall incidence of diaphragm paralysis was higher in correction of tetralogy of Fallot (31.5%), Blaloc-Taussig (B-T) shunt (11.1%) and VSD closure with pulmonary artery patch plasty (11.1). The incidence of DP which require plication was higher in B-T shunt (23.8%) arterial switch (19%) and correction of tetralogy of Fallot (11.9%). Mean and median age at the time of surgery were 17.8 +/- 3.6 and 6 months, respectively. Median time from cardiac surgery to surgical plication was 12 days. Indications for plication were repeated reintubations (n = 22), failure to wean from ventilator (n = 12), recurrent lung infections (n = 5) and persistent respiratory distress (n = 3). Mortality rate was 19.1%. Being under 1 year of age, pneumonia and plication 10 days after mechanical ventilation were associated with higher incidence mortality (P < 0.05). Phrenic nerve injury is a serious complication of cardiac surgery. It is more common after some special procedures. Spontaneous recovery is very rare. Being under 1 year of age, plication after 10 days from the surgery and pneumonia are major risk factors for mortality even in plicated patients. Transthoracic plication is helpful if performed early.

Diagnosis of Abnormal Diaphragm Motion after Cardiothoracic Surgery: Ultrasound Performed by a Cardiac Intensivist vs. Fluoroscopy

“…Prevalence of diaphragmatic paralysis after cardiothoracic surgery in children varies from 0.3% to 12.8%. Retrospective studies report prevalence that varies from 0.3% to 5.7%, whereas prospective studies report a slightly higher prevalence, from 1.6% to 12.8% 5,9 . In our study, the use of our clinical criteria gave us a pretest probability of 31%, which represents a good clinical screening tool defining the target population in which to apply the diagnostic test.…”

Diaphragmatic palsy after cardiac surgical procedures in patients with congenital heart

“…The incidence is particularly high after the bidirectional Glenn or Fontan operation, systemic to pulmonary artery shunts particularly the classic or modified Blalock-Taussig (BT) shunt, ventricular septal defect closure, surgery for tetralogy of Fallot, and arterial switch operation. Akay[6] reported a high incidence of DP following correction of tetralogy of Fallot (31.5%), BT shunt (11.1%), and VSD closure with pulmonary artery patch plasty (11.1%). The incidence of DP requiring diaphragmatic plication was higher following BT shunt (23.8%), arterial switch operation (19%), and correction of tetralogy of Fallot (11.9%).…”

“…The incidence of DP requiring diaphragmatic plication was higher following BT shunt (23.8%), arterial switch operation (19%), and correction of tetralogy of Fallot (11.9%). [6] Joho-areola et al . [7] also reported a higher incidence of DP after arterial switch operation (10.8%), Fontan procedure (17.6%), and BT Shunt (12.8%).…”

Efficacy of intra-operative unilateral diaphragm plication for patients undergoing unilateral phrenicotomy during extended surgery

“…A diaphragm paralysis due to phrenicotomy causes decreases in tidal volume and in dynamic lung compliance, and an increase in the work of breathing due to paradoxical movements of the paralysed diaphragm [5][6][7], which may lead to increases in postoperative morbidity and motility. Diaphragm plication is an acceptable treatment for paediatric patients with life-threatening unilateral diaphragm paralysis [8][9][10], while benefits have also been reported in adult patients with chronic unilateral diaphragm paralysis [1,11]. The purpose of diaphragm plication is to reduce the paradoxical movement by stiffening the diaphragm, leading to more efficient ventilation.…”