Incidence and aetiology of a raised hemidiaphragm after cardiopulmonary bypass.

Abstract

A raised hemidiaphragm has been reported as an uncommon complication of cardiopulmonary bypass, possibly resulting from cold injury to the phrenic nerve. At Papworth Hospital myocardial protection during cardiac arrest relies in part on irrigation of the pericardial cavity with large volumes of Hartmann's solution at 40C. Retrospective review of the chest radiographs of 100 consecutive patients undergoing cardiopulmonary bypass showed that 31 had a raised left hemidiaphragm soon after operation. The only significant correlation was with aortic cross clamp time (p < 0.03). A prospective study of 36 consecutive patients undergoing cardiopulmonary bypass was then undertaken with diaphragmatic screening and chest radiography. Preoperative screening gave normal results in all patients. In the early postoperative period 16 (44%) had left diaphragmatic weakness or paralysis, two (5.5%) right sided weakness, and two (5.5%) bilateral weakness. Repeat screening of these patients showed resolution in all but four cases (80%) at six months and in all but two (90%) at one year. The greater number of left sided lesions than of right (8:1) is probably due to the fact that the cold jet of irrigating fluid is directed towards the left phrenic nerve. These findings have implications with regard to the optimum temperature of the irrigant fluid for myocardial protection during cardiopulmonary bypass.A raised hemidiaphragm complicating cardiopulmonary bypass has been previously reported.' The incidence is variable and the aetiology remains uncertain but has been attributed to cold injury of the left phrenic nerve.' 2 Gastric distension, left lower lobe atelectasis, pulmonary trauma,2 stretch trauma,6 and association with dissection of the left internal mammary artery-have also been proposed.We recently noted that a raised left hemidiaphragm on postoperative chest radiographs of patients undergoing open heart operations was relatively common in our unit. These investigations were undertaken to define the incidence, duration, and possible aetiology of this complication. Patients and methodsA retrospective review of the previous 100 consecutive patients undergoing operations with cardiopulmonary bypass during 1982 was undertaken. Their Address for reprint requests: Mr SR Large, Surgical Unit, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE.Accepted 10 January 1985 mean age was 54 years (range 11-77) and 27 were women. The immediate preoperative, early postoperative (8-10 days), and late postoperative (6 months) posteroanterior chest radiographs were studied. The highest point of the left hemidiaphragm was compared with that of the right. If the point on the left was at the same horizontal level or higher than that on the right it was described as raised. An estimate of the incidence of raised left hemidiaphragm soon after operation and its subsequent resolution by six months was made.To investigate the aetiology of this complication the early postoperative incidence was compared in different groups of patients with rega...

Diaphragm plication following phrenic nerve injury: a comparison of paediatric and adult patients

“…14 The incidence of unilateral phrenic nerve paralysis following paediatric heart surgery has been reported in different series to vary from 0.46% to 4.6%, with the highest incidence after a Blalock-Taussig shunt. 15 In all age groups DP has been reported with increasing frequency after open heart surgery [16][17][18][19][20][21] and is mainly related to topical cooling. 22 In adults DP has also been reported after external trauma 23 or as a result of tumour growth.…”

Phrenic Nerve Injury After Atrial Fibrillation Catheter Ablation

“…Protective measures during cardiac surgery has led to significant decline in the incidence of PNI from 30%-55% [2] during the early 1980s to 10% in the last few years [3]. …”

Bilateral diaphragm paralysis after cardiac surgery with topical hypothermia.

“…The diaphragm paralysis Unit, Churchill Hospital, has been attributed to cold injury of the Oxford OX3 7LJ. phrenic nerve as a result of the topical iced or Accepted 14 January 1991 slush saline used for myocardial protection, [1][2][3] …”