Impact of prior diaphragm plication on subsequent stages of single ventricle palliation

Pulmonary blood flow in children with univentricular heart and unilateral diaphragmatic paralysis

“…Nevertheless, the current results combined with those of Hsia et al [ 18 ] suggest that normalisation of the Glenn/Fontan circulation is not restored after diaphragmatic plication. On the other hand, Kumar et al [ 27 ] showed that there was no difference in postoperative outcome between patients with diaphragm plication and those with intact diaphragm. Based on these findings, larger studies are needed to investigate the effect of diaphragmatic plication on haemodynamics in Glenn and Fontan circulation.…”

Commentary: The challenge of postoperative diaphragmatic paralysis in patients with functionally univentricular circulation: A data-driven strategy

“…These suboptimal features of splanchnic circulation in Fontan patients who have experienced diaphragm paralysis and undergone plication are similar to those noted in some patients with failing Fontan circulation. Long-term follow-up of patients such as those in the study by Kumar and colleagues 1 plication of a paralyzed hemidiaphragm are at a higherthan-usual risk for protein-losing enteropathy or other modes of eventual Fontan failure, despite having enjoyed an uncomplicated early postoperative recovery. Notwithstanding the potential for recovery of function of a paralyzed hemidiaphragm, as well as the important observations of Kumar and colleagues 1 regarding the potential benefit of prior plication in terms of mitigation of shortterm post-Fontan morbidities, it is a fact that the best strategy regarding phrenic nerve injury and diaphragm paralysis is to avoid it completely.…”

“…The hospital course during subsequent stages of palliation for plicated patients is no different than that of matched controls." 1 Importantly, the authors comment that no prospective studies exist to help guide the management of postoperative diaphragmatic paralysis in functionally univentricular patients. Because the total cavopulmonary connection is a passive low-pressure system that is sensitive to PVR, anything that increases PVR, such as elevated diaphragm causing decreased lung volume, can adversely impact short-term and long-term physiology.…”

Is simultaneous diaphragmatic plication at Fontan completion beneficial?

“…We did, however, find an article by Kumar et al, in 2020, that describes performing a diaphragm plication at the time of BDG in 30 patients with suspected phrenic palsy, out of a total of 1146 patients undergoing the final Fontan palliation. [ 4 ] The authors used the propensity scoring method to compare each of these 30 patients to those who did not undergo concomitant diaphragmatic plication. Interestingly, when these patients underwent subsequent Fontan completion at a mean follow-up period of 3 years, no differences in duration or amount of pleural effusion were noted between those undergoing versus those not undergoing concomitant diaphragmatic plication at the time of the initial BDG on even suspicion of minor diaphragmatic dysfunction.…”