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Simsek B, Ozyuksel A, Saygi M, Bilal MS. Plication for diaphragm paralysis after paediatric cardiac surgery: a single-centre experience. Cardiol Young 2023; 33:2087-2093. [PMID: 36876638 DOI: 10.1017/s1047951123000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVE Diaphragm paralysis is a well-known complication following surgery for CHDs, which increases morbidity, mortality, and length of hospital stay as well as costs. Herein, we present our experience with diaphragm plication following paralysis of the phrenic nerve encountered after paediatric cardiac surgery. METHODS This study retrospectively reviewed the medical records of 23 diaphragm plications in 20 patients who underwent paediatric cardiac surgery between January 2012 and January 2022. The patients were carefully selected based on aetiology and a combination of clinical manifestation and chest imaging characteristics including chest X-ray, ultrasonography, and fluoroscopy. RESULTS Twenty-three successful plications were performed in 20 patients (15 males and 5 females) out of a total of 1938 operations performed in our centre. Mean age and body weight were 18.2 ± 17.1 months and 8.3 ± 3.7 kg, respectively. The period between the cardiac surgery and diaphragmatic plication was 18.7 ± 15.1 days. The highest incidence of diaphragm paralysis was encountered in systemic to pulmonary artery shunt patients with 7 out of 152 patients (4.6%). Any mortality was not encountered during a mean follow-up period of 4.3 ± 2.6 years. CONCLUSIONS Early results of plication of the diaphragm following phrenic nerve palsy in symptomatic patients who underwent paediatric cardiac surgery are encouraging. Evaluation of the diaphragmatic function should be a routine part of post-operative echocardiography. Diaphragm paralysis may be a consequence of dissection, contusion, stretching, and thermal injury both in terms of hypothermia and hyperthermia.
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Affiliation(s)
- Baran Simsek
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
| | - Arda Ozyuksel
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
- Department of Cardiovascular Surgery, Biruni University, Istanbul, Turkey
| | - Murat Saygi
- Department of Pediatric Cardiology, Medicana International Hospital, Istanbul, Turkey
| | - Mehmet Salih Bilal
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
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Kratz T, Ruff R, Bernhardt M, Katzer D, Herberg U, Asfour B, Breuer J, Oetzmann von Sochaczewski C, Bierbach B. A porcine model of postoperative hemi-diaphragmatic paresis to evaluate a unilateral diaphragmatic pacemaker. Sci Rep 2023; 13:12628. [PMID: 37537216 PMCID: PMC10400610 DOI: 10.1038/s41598-023-39468-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
Unilateral phrenic nerve damage is a dreaded complication in congenital heart surgery. It has deleterious effects in neonates and children with uni-ventricular circulation. Diaphragmatic palsy, caused by phrenic nerve damage, impairs respiratory function, especially in new-borns, because their respiration depends on diaphragmatic contractions. Furthermore, Fontan patients with passive pulmonary perfusion are seriously affected by phrenic nerve injury, because diaphragmatic contraction augments pulmonary blood flow. Diaphragmatic plication is currently employed to ameliorate the negative effects of diaphragmatic palsy on pulmonary perfusion and respiratory mechanics. This procedure attenuates pulmonary compression by the abdominal contents. However, there is no contraction of the plicated diaphragm and consequently no contribution to the pulmonary blood flow. Hence, we developed a porcine model of unilateral diaphragmatic palsy in order to evaluate a diaphragmatic pacemaker. Our illustrated step-by-step description of the model generation enables others to replicate and use our model for future studies. Thereby, it might contribute to investigation and advancement of potential improvements for these patients.
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Affiliation(s)
- Tobias Kratz
- Department of Paediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Roman Ruff
- Fraunhofer IBMT, Institute for Biomedical Engineering, Sulzbach, Germany
| | - Marit Bernhardt
- Institute of Pathology, University Hospital Bonn, Bonn, Germany
| | - David Katzer
- Department of Paediatrics, University Hospital Bonn, Bonn, Germany
| | - Ulrike Herberg
- Department of Paediatric Cardiology, University Hospital Bonn, Bonn, Germany
- Department of Paediatric Cardiology, University Hospital Aachen, Aachen, Germany
| | - Boulos Asfour
- Department of Paediatric Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Johannes Breuer
- Department of Paediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Benjamin Bierbach
- Department of Paediatric Cardiac Surgery, University Hospital Bonn, Bonn, Germany
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Denamur S, Chenouard A, Lefort B, Baron O, Neville P, Baruteau A, Joram N, Chantreuil J, Bourgoin P. Outcome analysis of a conservative approach to diaphragmatic paralysis following congenital cardiac surgery in neonates and infants: a bicentric retrospective study. Interact Cardiovasc Thorac Surg 2021; 33:597-604. [PMID: 34000037 DOI: 10.1093/icvts/ivab123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Diaphragmatic paralysis following congenital cardiac surgery is associated with significant morbidity and mortality. Spontaneous recovery of diaphragmatic function has been described, contrasting with centres providing early diaphragmatic plication. We aimed to describe the outcomes of a conservative approach, as well as to identify factors associated with a failure of the strategy. METHODS This is a retrospective study of patients admitted after cardiac surgery and suffering unilateral diaphragmatic paralysis within 2 French Paediatric Cardiac Surgery Centers. The conservative approach, defined by the prolonged use of ventilation until successful weaning from respiratory support, was the primary strategy adopted in both centres. In case of unsuccessful evolution, a diaphragmatic plication was scheduled. Total ventilation time included invasive and non-invasive ventilation. Diaphragm asymmetry was defined by the number of posterior rib segments counted between the 2 hemi-diaphragms on the chest X-ray after cardiac surgery. RESULTS Fifty-one neonates and infants were included in the analysis. Patients' median age was 12.0 days at cardiac surgery (5.0-82.0), and median weight was 3.5 kg (2.8-4.9). The conservative approach was successful for 32/51 patients (63%), whereas 19/51 patients (37%) needed diaphragm plication. There was no difference in patients' characteristics between groups. Respiratory support prolonged for 21 days or more and diaphragm asymmetry more than 2 rib segments were independently associated with the failure of the conservative strategy [odds ratio (OR) 6.9 (1.29-37.3); P = 0.024 and OR 6.0 (1.4-24.7); P = 0.013, respectively]. CONCLUSIONS The conservative approach was successful for 63% of the patients. We identified risk factors associated with the strategy's failure.
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Affiliation(s)
- Sophie Denamur
- Department of Pediatrics, Pediatric Pneumology, University Hospital, Tours, France
| | - Alexis Chenouard
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Bruno Lefort
- Department of Pediatric Cardiology, University Hospital, Tours, France
| | - Olivier Baron
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Paul Neville
- Department of Congenital Cardiac Surgery, University Hospital, Tours, France
| | - Alban Baruteau
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Nicolas Joram
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Julie Chantreuil
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital, Tours, France
| | - Pierre Bourgoin
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France.,Department of Anesthesiology, University Hospital, Nantes, France
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Abstract
Cardiac critical care has become an increasingly complex subspecialty, involving multiple subspecialists to support patients with congenital heart disease. This requires understanding of their physiology and the impact of medical interventions. The purpose of this article is to provide a concise review of the current strategies utilized by cardiac intensivists to optimize outcomes for this vulnerable patient population, with the goal of broadening the knowledge of other members of the multi-disciplinary team.
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Parmar D, Panchal J, Parmar N, Garg P, Mishra A, Surti J, Patel K. Early diagnosis of diaphragm palsy after pediatric cardiac surgery and outcome after diaphragm plication - A single-center experience. Ann Pediatr Cardiol 2021; 14:178-186. [PMID: 34103857 PMCID: PMC8174623 DOI: 10.4103/apc.apc_171_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/17/2020] [Accepted: 11/27/2020] [Indexed: 11/24/2022] Open
Abstract
Objective : The aims of our prospective observational study were to evaluate the (1) reliability of clinical signs in the early detection of diaphragm palsy (DP); (2) reliability of ultrasonography using echo machine as a bedside tool for the diagnosis of DP; and (3) does early diaphragm plication result in the improved outcome? We also sought to determine the incidence and predominant risk factors for DP and diaphragm plication at our center. Materials and Methods : This prospective observational study included patients with suspected DP from January 2015 to December 2018. Patients with suspected DP were initially evaluated by bedside ultrasonography using echo machine and confirmed by fluoroscopy. Diaphragm plication was considered for patients having respiratory distress, difficult weaning, or failed extubation attempt without any obvious cardiac or pulmonary etiology. Patients were followed for 3 months after discharge to assess diaphragm function. Results: A total of 87 patients were suspected of DP based on clinical signs. DP was diagnosed in 61 patients on fluoroscopy. The median time from index operation to diagnosis was 10 (1–59) days. Diaphragm plication was done among 52 patients and not done in nine patients. Bedside ultrasonography using echo machine was 96.7% sensitive and 96.15% specific in diagnosing DP. Early plication (<14 days) significantly reduced the need for nasal continuous positive airway pressure (65% vs. 96%, P = 0.02), duration of mechanical ventilation (12 vs. 25 days, P = 0.018), intensive care unit (ICU) stay (25 days vs. 39 days, P = 0.019), and hospital stay (30 days vs. 46 days, P = 0.036). Conclusion : Hoover's sign and raised hemidiaphragm on chest X-ray are the most specific clinical signs to suspect unilateral DP. Bedside ultrasonography using an echo machine is a good diagnostic investigation comparable to fluoroscopy. Early plication facilitates weaning from the ventilator and thereby decreases the ICU stay and hospital stay.
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Affiliation(s)
- Divyakant Parmar
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jigar Panchal
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Neha Parmar
- Department of Physiotherapy, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Pankaj Garg
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Amit Mishra
- Department of Pediatric Cardiac Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jigar Surti
- Department Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Kartik Patel
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
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Fraser CD, Ravekes W, Thibault D, Scully B, Chiswell K, Giuliano K, Hill KD, Jacobs JP, Jacobs ML, Kutty S, Vricella L, Hibino N. Diaphragm Paralysis After Pediatric Cardiac Surgery: An STS Congenital Heart Surgery Database Study. Ann Thorac Surg 2020; 112:139-146. [PMID: 32763270 DOI: 10.1016/j.athoracsur.2020.05.175] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/08/2020] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Previous single-center studies of diaphragm paralysis (DP) after pediatric cardiac surgery report incidence of 0.3% to 12.8% and associate DP with respiratory complications, prolonged ventilation and length of stay, and mortality. To better define incidence and associations between DP and various procedures and outcomes, we performed a multicenter study. METHODS The Society of Thoracic Surgeons Congenital Heart Surgery Database was queried to identify children who experienced DP after cardiac surgery (2010-2018; 126 centers). Baseline characteristics and postoperative outcomes were compared between patients with and without DP as well as between patients who underwent plication and those who did not. Associations between center volume and center rates of DP and use of plication were also explored. RESULTS A total of 2214 of 191,463 (1.2%) patients experienced DP. Postoperative DP portended worse outcomes, including mortality (5.6% vs 3.5%; P < .001), major morbidity (37.2% vs 10.7%; P < .001), tracheostomy (7.1% vs 0.9%; P < .001), prolonged mechanical ventilation (38.0% vs 7.8%; P < .001), and 30-day readmission (22.0% vs 10.6%; P < .001). A total of 1105 of 2214 (49.9%) patients with DP underwent plication. Patients who underwent plication were younger, were smaller, had more risk factors, and underwent more complex surgeries. Plication rates varied widely across centers. There was no correlation between center volume and center risk-adjusted rates of DP (r = .05, P = .5), nor frequency of plication (r = .08, P = .4). CONCLUSIONS DP complicating pediatric heart surgery is rare but portends significantly worse outcomes. One-half of patients underwent plication. Center-level risk-adjusted rates of DP and plication are not associated with case volume. Significant variability in plication practices suggests a target for quality improvement.
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Affiliation(s)
- Charles D Fraser
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
| | - William Ravekes
- Division of Pediatric Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Brandi Scully
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Katherine Giuliano
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, University of Florida Congenital Heart Center, Gainesville, Florida
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Shelby Kutty
- Division of Pediatric Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Luca Vricella
- Division of Pediatric Cardiac Surgery, University of Chicago, Chicago, Illinois
| | - Narutoshi Hibino
- Division of Pediatric Cardiac Surgery, University of Chicago, Chicago, Illinois
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Kane L. Commentary: Brains over brawn: Do strong diaphragm muscles matter? J Thorac Cardiovasc Surg 2020; 160:1299-1300. [PMID: 32747119 DOI: 10.1016/j.jtcvs.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Lauren Kane
- Department of Surgery, University of Central Florida, Orlando, Fla.
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Kumar SR, Bainiwal J, Cleveland JD, Pike N, Wells WJ, Starnes VA. Impact of prior diaphragm plication on subsequent stages of single ventricle palliation. J Thorac Cardiovasc Surg 2020; 160:1291-1296.e1. [PMID: 32713630 DOI: 10.1016/j.jtcvs.2020.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 06/11/2020] [Accepted: 06/13/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Phrenic nerve injury is a known cause of morbidity after single ventricle palliation. Previous studies have shown that hemidiaphragm plication improves short-term outcomes. The effect of plication on the outcomes of subsequent stages of single ventricle palliation is unknown. METHODS From 1997 to 2015, 1146 patients underwent surgical management of single ventricle physiology at our institution. We reviewed the records of 30 patients who had undergone diaphragm plication for phrenic nerve injury before Fontan completion. Each patient was compared with 2 propensity-matched controls identified from patients who underwent the Glenn or Fontan procedure during the same period without diaphragm plication. Propensity matching was achieved for each test subject using the nearest neighbor algorithm. Data are presented as the median and quartiles or numbers and percentages. RESULTS The cohort included 18 boys (60%). Of the 30 patients, 19 (63%) had undergone plication after first-stage palliation. Of these, 13 have undergone completion Fontan, 5 were awaiting Fontan at the last follow-up, and 1 had died. An additional 11 patients had undergone plication after Glenn and proceeded to Fontan completion. Thus, 24 patients with diaphragm plication have undergone Fontan completion. No difference was found in pulmonary pressure or resistance between the plicated patients and their propensity-matched controls. Both groups had comparable chest tube output and hospital lengths of stay. Equal proportions of patients in both groups required pulmonary vasodilator therapy and/or supplemental oxygen at hospital discharge. CONCLUSIONS Prior diaphragm plication does not adversely affect Fontan completion in children with single ventricle physiology. The hospital course during subsequent stages of palliation for plicated patients was no different than that of matched controls.
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Affiliation(s)
- S Ram Kumar
- Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Surgery, University of Southern California, Los Angeles, Calif; Department of Pediatrics, University of Southern California, Los Angeles, Calif.
| | - Jassimran Bainiwal
- Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Surgery, University of Southern California, Los Angeles, Calif
| | - John D Cleveland
- Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Nancy Pike
- Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Winfield J Wells
- Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Vaughn A Starnes
- Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Surgery, University of Southern California, Los Angeles, Calif
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Unilateral diaphragmatic paralysis associated with surgical mitral valve repair in dogs. J Vet Cardiol 2020; 29:33-39. [PMID: 32408112 DOI: 10.1016/j.jvc.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 02/25/2020] [Accepted: 03/04/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Unilateral diaphragmatic paralysis (UDP) due to phrenic nerve injury is a potential complication of thoracic surgery. This study evaluated the prevalence of UDP associated with surgical mitral valve repair (MVR) and its effect on surgical outcomes in dogs. ANIMALS, MATERIALS AND METHODS Two hundred ninety-four dogs that underwent MVR were included in the study. A retrospective review of medical records was performed for dogs surviving surgery. Diagnosis of UDP was based on preoperative and postoperative thoracic dorsoventral radiographs. RESULTS A total of 284 dogs survived until the day after surgery. The prevalence of UDP on the day after surgery, on the day of discharge, and after the first postoperative month was 30%, 24%, and 9%, respectively. One case of UDP was observed at 3 months after surgery. Unilateral diaphragmatic paralysis was exhibited by nine of the 21 patients that died in the hospital. The proportion of patients with UDP was higher in dogs that died of respiratory failure than in dogs that died of other causes (p = 0.002). Most dogs whose deaths were suspected to have been related to respiratory failure also had pre-existing respiratory diseases. The occurrence of UDP did not relate to the lengths of stay in the intensive care unit or the hospital. CONCLUSIONS Our findings suggest that UDP is a common complication in dogs after MVR and that the prevalence of UDP decreases with time after surgery. Unilateral diaphragmatic paralysis is a risk factor for postoperative death, especially in patients with pre-existing respiratory disease.
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Thoracic versus abdominal approach to correct diaphragmatic eventration in children. J Pediatr Surg 2020; 55:245-248. [PMID: 31761454 DOI: 10.1016/j.jpedsurg.2019.10.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/26/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Plication of diaphragm (DP) for eventration (DE) can be done using thoracic or abdominal approaches. The purpose of our study was to compare outcomes between these approaches based on our experience and on systematic literature review. METHODS Retrospective records of children <16 years who underwent DP (single-center, 2004-2018) were recorded and analyzed. Systematic review and meta-analysis of related studies was undertaken. Data are reported as median (range). RESULTS Eighty-nine cases were identified in thoracic (Congenital = 5, Acquired = 84) and 13 (Congenital = 10, Acquired = 3) in abdominal group aged 5.88 (0.36-184.44) and 10.0 (0.12-181.8) months. Improvement in diaphragm level post-DP was significantly higher in abdominal [2(0-4)] than chest [1.5(0-5)] group (p = 0.04). On Cox regression analysis, there was a non-significant trend to a longer time to extubation in the chest group (Hazard ratio (HR) = 0.539[0.208-1.395], p = 0.203). Patients operated transthoracically left intensive care unit after a significantly longer time (HR = 0.339[0.119-0.966], p = 0.043). Patients operated transabdominally tended to be fed later, although this was not significant (HR = 1.801[0.762-4.253], p = 0.043). On Kaplan-Meier analysis, there was a non-significant trend to a lower rate of recurrence in the abdominal group (HR = 0.3196[0.061-1.675], p = 0.1876). In the meta-analysis including three published studies as well as our data (total n = 181, Thoracic = 139, Abdominal = 42), no difference was found in the incidence of recurrence amongst the 2 groups (RD = -0.04, 95%CI = -0.25, 0.18, p = 0.74). CONCLUSION This is one of the largest reports on outcomes of children undergoing DP for DE. There is no significant difference in recurrence rate, even though all recurrences in our series (15.7%) were in the acquired cases operated using a thoracic approach. TYPE OF STUDY Treatment Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
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Ultrasonographic postoperative evaluation of diaphragm function of patients with congenital heart defects. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:70-75. [PMID: 32175145 DOI: 10.5606/tgkdc.dergisi.2020.18458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/23/2019] [Indexed: 11/21/2022]
Abstract
Background This study aims to investigate the role of ultrasonography in the postoperative evaluation of diaphragm function in patients with congenital heart defect. Methods This prospective study included a total of 360 patients (176 males, 184 females; mean age 2 years; range, 1 month to 8 years) who underwent congenital heart surgery and 44 patients (22 males, 22 females; mean age 1 years; range, 1 month to 4 years) who underwent diaphragm ultrasonography between September 2018 and March 2019. Ultrasonography was performed for the patients who had difficulty in weaning from mechanical ventilation or who were thought to have diaphragm dysfunction due to pathological findings on postoperative chest X-rays. The findings were interpreted as normal, paresis, or paralysis. Results Diaphragm dysfunction was demonstrated in 23 patients (6.3%), paralysis in 11 patients (3%), and paresis in 12 patients (3.3%). A median sternotomy was performed in 21 patients (91%), and seven of them (30%) were redo cases. Five patients (21%) had single ventricle physiology. Six patients (1.6%) needed an intervention due to diaphragm dysfunction. The interventional procedures were diaphragm plication in three patients (0.8%) and tracheotomy in three patients (0.8%). Three of these patients had a single ventricle and three had biventricular physiology. The median time after surgery for these procedures was 36 days. One patient (0.2%) died in the intensive care unit. The mean length of stay in the intensive care unit and hospital was 36±12 and 48±21 days, respectively. Conclusion Diaphragm dysfunction should be kept in mind in patients undergoing congenital heart surgery and in those who need prolonged intubation during the postoperative period. Ultrasonography is a non-invasive diagnostic tool which can be used to identify diaphragm dysfunction and the best course of management of this clinical condition.
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Komori M, Hoashi T, Shimada M, Kitano M, Ohuchi H, Kurosaki K, Ichikawa H. Impact of Phrenic Nerve Palsy on Late Fontan Circulation. Ann Thorac Surg 2019; 109:1897-1902. [PMID: 31733188 DOI: 10.1016/j.athoracsur.2019.09.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although adverse effects of phrenic nerve palsy (PNP) on early Fontan circulation have been reported, detailed late impact remains unclear. METHODS Of 218 patients undergoing extracardiac total cavopulmonary connection between 1995 and 2008, 160 who all underwent cardiac catheter examination, spirometry, and exercise capacity testing 10 years after the operation were enrolled. The cohort was divided into 2 groups: with (N = 21) or without PNP (control group, N = 139). The patients with PNP were further divided into the recovered PNP group (n = 10) and the persistent PNP group (n = 11). All but 2 patients who developed PNP (90.9%) underwent diaphragmatic plication. There was no difference in hemodynamic indices at pre-Fontan evaluation among the three groups. RESULTS Ten years after the Fontan procedure, the averaged forced vital capacity was 81% ± 18% of predicted in the control group, 86% ± 17% in the recovered PNP group, and 56% ± 12% in the persistent PNP group (P < .001). Peak oxygen consumption was linearly correlated to the forced vital capacity (r = 0.222, P = .009). There was no significant difference in the peak oxygen consumption between groups. Significant veno-venous collaterals into the diaphragm from lower body to pulmonary vein(s) or atria more frequently developed in patients who underwent diaphragmatic plication compared with those who did not (P < .001). CONCLUSIONS Persistent PNP resulted in reduced forced vital capacity; however, its influence on exercise intolerance could not be identified. Diaphragmatic plication should be reserved for patients who experience clinically significant respiratory or hemodynamic sequelae of PNP.
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Affiliation(s)
- Motoki Komori
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan.
| | - Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Masataka Kitano
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
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Edmiston TL, Elrick MJ, Kovler ML, Jelin EB, Onders RP, Sadowsky CL. Early use of an implantable diaphragm pacing stimulator for a child with severe acute flaccid myelitis-a case report. Spinal Cord Ser Cases 2019; 5:67. [PMID: 31632725 PMCID: PMC6786381 DOI: 10.1038/s41394-019-0207-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction Acute Flaccid Myelitis (AFM) is a recently recognized, polio-like illness of children that can be functionally devastating. Severe cases can lead to ventilatory failure. Incomplete phrenic nerve injuries in other populations has been shown to respond to diaphragmatic stimulation. We therefore proposed an early assessment for incomplete denervation by laparoscopic direct stimulation of the diaphragm and placement of a diaphragmatic pacing system to enhance diaphragm function. Case presentation A 3 year-old girl presented with AFM with clinically and electrodiagnostically severe involvement of all four limbs and muscles of respiration. Direct stimulation of the diaphragm demonstrated contraction and a diaphragmatic stimulator was placed at 3 weeks post presentation. The patient was immediately able to tolerate short bouts of reduced ventilation settings. Electromyography via the pacing wires demonstrated intact motor units consistent with partial denervation/reinnervation in the left hemidiaphragm, and no motor units in the right hemidiaphragm. At three months, she tolerated 6 h of pacing on pressure support setting. At 5 months she demonstrated larger tidal volumes with active pacing than without. Discussion In our experience, AFM patients who require chronic ventilator support are rarely able to be weaned. Despite clinical and surface electrodiagnostic evidence of complete phrenic nerve involvement, the patient's diaphragm responded to direct stimulation. The patient preferred pacing over non-pacing times and showed improved ventilatory ability with pacing as opposed to without, though remains ventilator-dependent. These findings support augmentation of diaphragm function and possible enhanced recovery of spontaneous function.
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Affiliation(s)
- Travis L. Edmiston
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Mathew J. Elrick
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Mark L. Kovler
- Department of Pediatric Surgery, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Eric B. Jelin
- Department of Pediatric Surgery, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Raymond P. Onders
- Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | - Cristina L. Sadowsky
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD USA
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Al-Ebrahim KE, Elassal AA, Eldib OS, Abdalla AHA, Allam ARA, Al-Ebrahim EK, Abdelmohsen GA, Dohain AM, Al-Radi OO. Diaphragmatic palsy after cardiac surgery in adult and pediatric patients. Asian Cardiovasc Thorac Ann 2019; 27:481-485. [DOI: 10.1177/0218492319859806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Important differences in the mechanism of respiration between adults and children warrant distinction in the management of diaphragmatic paralysis as a complication of cardiac surgery. We describe the management and outcomes of this complication in both groups. Methods We retrospectively analyzed 16 patients (5 adults and 11 children) with diaphragmatic paralysis after cardiac surgery performed between 2008 and 2018. Clinical examination, chest radiography, and confirmation with fluoroscopy in selected cases were our modalities of diagnosis. All adults were managed conservatively, whereas plication was performed in all children. Results The incidence of diaphragmatic paralysis was 0.98% in pediatric patients and 0.43% in adults. The mean age was 2.33 ± 2.59 years in children and 53.2 ± 17.99 years in adults. All adults were symptomatic. All children showed difficulty in weaning from mechanical ventilation after cardiac surgery. The period of mechanical ventilation before plication was 2–6 days (median 4 days). Death occurred as a result of low cardiac output in a 10-year-old boy, and due to respiratory failure in a 30-year-old woman. Children were successfully weaned from mechanical ventilation after diaphragmatic plication. The median time to extubation after plication was 2.5 days (range 1–13 days). The median period of recovery in adults was 52 days (range 32–85 days). All survivors had acceptable outcomes at 6 months to one year. Conclusion Conservative management in adults and early plication in children are viable treatment options for diaphragmatic palsy after cardiac surgery, with acceptable outcomes.
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Affiliation(s)
| | | | - Osama Saber Eldib
- Cardiac Surgery Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | | | | | | | | | | | - Osman Osama Al-Radi
- Cardiac Surgery Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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15
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Burkhart HM, Thompson JL, Schwartz RM. C3, C4, and C5 Keeps the Diaphragm Alive… and Reduces Morbidity and Hospital Costs. Semin Thorac Cardiovasc Surg 2018; 30:325-326. [PMID: 29935229 DOI: 10.1053/j.semtcvs.2018.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Harold M Burkhart
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | - Jess L Thompson
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Randall M Schwartz
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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16
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Abstract
AIM To develop examination algorithm and to determine the indications for various options for surgical treatment. MATERIAL AND METHODS It is presented analysis of surgical treatment of 25 patients with unilateral diaphragm relaxation for the period from 1963 to 2016. There were 15 men and 10 women aged from 39 to 65 years. Diagnosis included predominantly radiological methods. All patients were operated openly through thoracotomy. Procedure consisted of creation of new diaphragmatic cupola at the usual level with two flaps of diaphragm and prosthesis between them. In 12 (48%) patients who were operated before 1990 xenopericardial patch was used. Further, synthetic materials (Teflon, polypropylene) were preferred. RESULTS Postoperative morbidity and mortality was 20% (n=6) and 4% (n=1) respectively. Long-term results were followed-up within terms from 8 months to 12 years. Recurrent relaxation was absent. Most of patients had improved dyspnea, increased vital capacity and FEV1 in long-term period. Certain and general values of SF-36 life quality questionnaire were high in long-term postoperative period and similar to those in general population.
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Affiliation(s)
- V D Parshin
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Burdenko Clinic of Faculty Surgery, Moscow, Russia
| | - M A Khetagurov
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Burdenko Clinic of Faculty Surgery, Moscow, Russia
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17
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Greene CL, Mainwaring RD, Sidell D, Yarlagadda VV, Patrick WL, Hanley FL. Impact of Phrenic Nerve Palsy and Need for Diaphragm Plication Following Surgery for Pulmonary Atresia With Ventricular Septal Defect and Major Aortopulmonary Collaterals. Semin Thorac Cardiovasc Surg 2018; 30:318-324. [PMID: 29545034 DOI: 10.1053/j.semtcvs.2018.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/11/2022]
Abstract
Injury to the phrenic nerves may occur during surgery for pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (PA-VSD and MAPCAs). These patients may develop respiratory failure and require diaphragm plication. The purpose of this study was to evaluate the impact of phrenic nerve palsy on recovery following surgery for PA-VSD and MAPCAs. Between 2007 and 2016, approximately 500 patients underwent surgery for PA-VSD and MAPCAs at our institution. Twenty-four patients (4.8%) subsequently had evidence of new phrenic nerve palsy. Sixteen patients were undergoing their first surgical procedure, whereas 8 were undergoing reoperations. All 24 patients underwent diaphragm plication. A cohort of matched controls was identified based on identical diagnosis and procedures but did not sustain a phrenic nerve palsy. Eighteen of the 24 patients (75%) had clinical improvement following diaphragm plication as evidenced by the ability to undergo successful extubation (5 ± 2 days), transition out of the intensive care unit (32 ± 16 days), and discharge from the hospital (42 ± 19 days). In contrast, there were 6 patients (25%) who did not demonstrate a temporal improvement following diaphragm plication, as evidenced by intervals of 61 ± 38, 106 ± 45, and 108 ± 46 days, respectively (P < 0.05 for all 3 comparisons). The 6 patients who failed to improve following diaphragm plication had a significantly greater number of comorbidities compared to the 18 patients who demonstrated improvement (2.2 vs 0.6 per patient, P < 0.05). When compared with the control group, patients who improved following diaphragm plication spent an additional 22 days and patients who failed to improve an additional 90 days in the hospital. The data demonstrate a bifurcation of clinical outcome in patients undergoing diaphragm plication following surgery for PA-VSD and MAPCAs. This bifurcation appears to be linked to the presence or absence of other comorbidities.
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Affiliation(s)
- Christina L Greene
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, California
| | - Richard D Mainwaring
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, California.
| | - Douglas Sidell
- Division of Pediatric Otorhinolaryngology, Lucile Packard Children's Hospital/Stanford University, Stanford, California
| | - Vamsi V Yarlagadda
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital/Stanford University, Stanford, California
| | - William L Patrick
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, California
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, California
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18
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Olmscheid J, Molero H, Gershan W, Demirel N. Bilateral diaphragmatic paresis following pediatric liver transplantation. SAGE Open Med Case Rep 2017; 5:2050313X17719214. [PMID: 28781878 PMCID: PMC5521332 DOI: 10.1177/2050313x17719214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 06/02/2017] [Indexed: 12/04/2022] Open
Abstract
Background: Although diaphragm paresis or paralysis is fairly common following cardiac procedures; it is a less common complication following liver transplantation. Unilateral diaphragm paresis, usually right sided, has been described following liver transplantation in adults and has been rarely described in children. Purpose: Diaphragmatic injury following LT is often unrecognized and is typically unilateral, involving the right hemidiaphragm. Bilateral diaphragm dysfunction following liver transplantation in children is a rare complication. Methods: This is a case report of bilateral diaphragm paresis in a young child following a repeat liver transplantation. Conclusion: Bilateral diaphragm paresis following liver transplantation in children is rare and spontaneous resolution is possible. A conservative approach with noninvasive ventilation as a first line treatment to allow the diaphragm to regain function should be considered.
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Affiliation(s)
- Jillian Olmscheid
- Midwestern University, Glendale, AZ, USA.,Arizona College of Osteopathic Medicine, Glendale, AZ, USA
| | - Helena Molero
- Division of Pediatric Pulmonology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - William Gershan
- Division of Pediatric Pulmonology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Nadir Demirel
- Division of Pediatric Pulmonology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
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19
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Floh AA, Zafurallah I, MacDonald C, Honjo O, Fan CPS, Laussen PC. The advantage of early plication in children diagnosed with diaphragm paresis. J Thorac Cardiovasc Surg 2017; 154:1715-1721.e4. [PMID: 28712584 DOI: 10.1016/j.jtcvs.2017.05.109] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/25/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND In this single-center study, we sought to determine the frequency of phrenic nerve injury leading to diaphragm paresis (DP) in children following open cardiac surgery over the last 10 years, and to identify possible variables that predict the need for plication and associated clinical outcomes. METHODS Patients diagnosed with DP were identified from departmental databases and a review of clinical diaphragm ultrasound images. A cohort was analyzed for predictors of diaphragm plication and associations with clinical outcomes. Cumulative proportion graphs modeled the association between plication and length of stay. RESULTS DP was diagnosed in 161 of 6448 patients (2.5%) seen between January 2002 and December 2012. All diagnoses but 1 were confirmed by ultrasound. Plication of the diaphragm was performed in 30 patients (19%); compared with patients who did not undergo plication, these patients were younger (median age, 10 days vs 138 days; P < .001), more likely to have undergone deep hypothermic circulatory arrest (47% vs 18%; P = .005), had a longer duration of positive pressure ventilation (median, 15 days vs 7 days; P < .001), and had longer lengths of stay in both the intensive care unit (median, 23 days vs 8 days; P < .0001) and the hospital (median, 37 days vs 15 days; P < .0001). Early plication was associated with reduction in all intervals of care. CONCLUSIONS Early plication should be considered for patients with diaphragm paresis requiring prolonged respiratory support after cardiac bypass surgery. Longer follow-up evaluation is required to better define the long-term implications of plication.
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Affiliation(s)
- Alejandro A Floh
- Department of Critical Care Medicine and Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Intikhab Zafurallah
- Paediatric Intensive Care and KIDS Retrieval Service, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Cathy MacDonald
- Department of Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery and Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chun-Po S Fan
- Cardiovascular Data Management Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter C Laussen
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
Diaphragmatic paralysis following phrenic nerve injury is a major complication following congenital cardiac surgery. In contrast to unilateral paralysis, patients with bilateral diaphragmatic paralysis present a higher risk group, require different management methods, and have poorer prognosis. We retrospectively analysed seven patients who had bilateral diaphragmatic paralysis following congenital heart surgery during the period from July, 2006 to July, 2014. Considerations were given to the time to diagnosis of diaphragm paralysis, total ventilator days, interval after plication, and lengths of ICU and hospital stays. The incidence of bilateral diaphragmatic paralysis was 0.68% with a median age of 2 months (0.6-12 months). There was one neonate and six infants with a median weight of 4 kg (3-7 kg); five patients underwent unilateral plication of the paradoxical diaphragm following recovery of the other side, whereas the remaining two patients who did not demonstrate a paradoxical movement were successfully weaned from the ventilator following recovery of function in one of the diaphragms. The median ventilation time for the whole group was 48 days (20-90 days). The median length of ICU stay was 46 days (24-110 days), and the median length of hospital stay was 50 days (30-116 days). None of the patients required tracheostomy for respiratory support and there were no mortalities, although all the patients except one developed ventilator-associated pneumonia. The outcome of different management options for bilateral diaphragmatic paralysis following surgery for CHD is discussed.
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21
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Cao GQ, Tang ST, Aubdoollah TH, Yang L, Li S, Lei HY, Zhang X, Li K, Wang XX, Xiang XC. Laparoscopic Diaphragmatic Hemiplication in Children with Acquired Diaphragmatic Eventration After Congenital Heart Surgery. J Laparoendosc Adv Surg Tech A 2015; 25:852-7. [PMID: 26312945 DOI: 10.1089/lap.2014.0675] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To report our technique and experiences in the laparoscopic diaphragmatic hemiplication (LDHP) in children with acquired diaphragmatic eventration after congenital heart surgery. SUBJECTS AND METHODS Between October 2007 to December 2013, 3498 children with congenital heart disease underwent cardiac surgery in our hospital, and 40 (1.14%) of them had unilateral diaphragmatic elevation on postoperative chest X-ray (mean elevation, 2.5 ± 0.26 intercostal spaces [ICS]) and were diagnosed as having diaphragmatic eventration due to diaphragmatic hemiparesis as a result of phrenic nerve injury. These 40 patients were followed up, and 22 of them recovered after conservative treatment; the other 18 needed surgical intervention. We conducted a retrospective study relating to surgical indications, surgical technique, complications, and outcomes. RESULTS There were 24 boys and 16 girls with a mean age of 10.0 ± 4.5 months old (range, 2 months-4 years). Twenty-two patients did not require surgical intervention. Eighteen patients underwent LDHP (12 cases left-sided and 6 cases right-sided); 2 of them had emergency LDHP with a history of ventilator dependency after cardiac surgery, and 16 of them had planned LDHP with a history of recurrent pneumonia and dyspnea. The operative time was 60 ± 7.9 minutes (range, 45-105 minutes), with minimal blood loss (3 ± 1.5 mL [range, 1-9 mL]), no intra- or postoperative complications, and postoperative hospital stay of 7 ± 1.3 days (range, 5-10 days). The diaphragmatic drop was 2.4 ± 0.2 (range, 2-4 ICS) without recurrence, and the follow-up time for all 40 patients was 14.8 ± 1.6 months (range, 11-36 months). CONCLUSIONS Our study further shows that LDHP is feasible and effective in selected patients after congenital heart surgery. Our technique is convenient and provides excellent clinical and radiological results.
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Affiliation(s)
- Guo-qing Cao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Shao-tao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Tajammool Hussein Aubdoollah
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Li Yang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Hai-yan Lei
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Xi Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Kang Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Xin-xing Wang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Xian-cai Xiang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
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Fujishiro J, Ishimaru T, Sugiyama M, Arai M, Suzuki K, Kawashima H, Iwanaka T. Minimally invasive surgery for diaphragmatic diseases in neonates and infants. Surg Today 2015; 46:757-63. [PMID: 27246508 DOI: 10.1007/s00595-015-1222-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
Owing to recent advances in minimally invasive surgery (MIS), laparoscopic and thoracoscopic surgery have been gradually introduced for use in neonates and infants. This review focuses on two popular MIS procedures for diaphragmatic diseases in neonates and infants: congenital diaphragmatic hernia (CHD) repair and plication for diaphragmatic eventration. While several advantages of MIS are proposed for CDH repair in neonates, there are also some concerns, namely intraoperative hypercapnia and acidosis and a higher recurrence rate than open techniques. Thus, neonates with severe CDH, along with an unstable circulatory and respiratory status, may be unsuitable for MIS repair, and the use of selection criteria is, therefore, important in these patients. It is generally believed that a learning curve is associated with the higher recurrence rate. Contrary to CDH repair, no major disadvantages associated with the use of MIS for diaphragmatic eventration have been reported in the literature, other than technical difficulty. Thus, if technically feasible, all pediatric patients with diaphragmatic eventration requiring surgical treatment are potential candidates for MIS. Due to a shortage of studies on this procedure, the potential advantages of MIS compared to open techniques for diaphragmatic eventration, such as early recovery and more rapid extubation, need to be confirmed by further studies.
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Affiliation(s)
- Jun Fujishiro
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Tetsuya Ishimaru
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masahiko Sugiyama
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Mari Arai
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Suzuki
- Division of Surgery, Saitama Children's Medical Center, Magome 2100, Iwatsuki-ku, Saitama, Saitama, 339-8551, Japan
| | - Hiroshi Kawashima
- Division of Surgery, Saitama Children's Medical Center, Magome 2100, Iwatsuki-ku, Saitama, Saitama, 339-8551, Japan
| | - Tadashi Iwanaka
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan.,Saitama Children's Medical Center, Magome 2100, Iwatsuki-ku, Saitama, Saitama, 339-8551, Japan
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Rombolá CA, Genovés Crespo M, Tárraga López PJ, García Jiménez MD, Honguero Martínez AF, León Atance P, Rodríguez Ortega CR, Triviño Ramírez A, Rodríguez Montes JA. Is video-assisted thoracoscopic diaphragmatic plication a widespread technique for diaphragmatic hernia in adults? Review of the literature and results of a national survey. Cir Esp 2014; 92:453-62. [PMID: 24602484 DOI: 10.1016/j.ciresp.2013.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 12/04/2013] [Accepted: 12/05/2013] [Indexed: 02/01/2023]
Abstract
Diaphragmatic plication is the most accepted treatment for symptomatic diaphragmatic hernia in adults. The fact that this pathology is infrequent and this procedure not been widespread means that this is an exceptional technique in our field. To estimate its use in the literature, we carried out a review in English and Spanish, to which we added our series. We found only six series that contribute 59 video-assisted mini-thoractomy for diaphragmatic plications in adults, and none in Spanish. Our series will be the second largest with 18 cases. Finally, we conducted a survey in all the Spanish Thoracic Surgery units in Spain: none reported more than 10 cases operated by thoracoscopy in the last 8 years (except our series) and most continue employing thoracotomy as the main approach. We believe that many patients with symptomatic diaphragmatic hernia could benefit from the use of such techniques.
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Affiliation(s)
- Carlos A Rombolá
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España.
| | - Marta Genovés Crespo
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | | | | | | | - Pablo León Atance
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | | | - Ana Triviño Ramírez
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
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Smith BM, Ezeokoli NJ, Kipps AK, Azakie A, Meadows JJ. Course, Predictors of Diaphragm Recovery After Phrenic Nerve Injury During Pediatric Cardiac Surgery. Ann Thorac Surg 2013; 96:938-42. [DOI: 10.1016/j.athoracsur.2013.05.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 05/07/2013] [Accepted: 05/17/2013] [Indexed: 11/30/2022]
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25
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Georgiev S, Konstantinov G, Latcheva A, Mitev P, Mitev I, Lazarov S. Phrenic nerve injury after paediatric heart surgery: is aggressive plication of the diaphragm beneficial? Eur J Cardiothorac Surg 2013; 44:808-12. [DOI: 10.1093/ejcts/ezt110] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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26
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Tsakiridis K, Visouli AN, Zarogoulidis P, Machairiotis N, Christofis C, Stylianaki A, Katsikogiannis N, Mpakas A, Courcoutsakis N, Zarogoulidis K. Early hemi-diaphragmatic plication through a video assisted mini-thoracotomy in postcardiotomy phrenic nerve paresis. J Thorac Dis 2013; 4 Suppl 1:56-68. [PMID: 23304442 DOI: 10.3978/j.issn.2072-1439.2012.s007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 11/26/2012] [Indexed: 11/14/2022]
Abstract
New symptom onset of respiratory distress without other cause, and new hemi-diaphragmatic elevation on chest radiography postcardiotomy, are usually adequate for the diagnosis of phrenic nerve paresis. The symptom severity varies (asymptomatic state to severe respiratory failure) depending on the degree of the lesion (paresis vs. paralysis), the laterality (unilateral or bilateral), the age, and the co-morbidity (respiratory, cardiac disease, morbid obesity, etc). Surgical treatment (hemi-diaphragmatic plication) is indicated only in the presence of symptoms. The established surgical treatment is plication of the affected hemidiaphragm which is generally considered safe and effective. Several techniques and approaches are employed for diaphragmatic plication (thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery). The timing of surgery depends on the severity and the progression of symptoms. In infants and young children with postcardiotomy phrenic nerve paresis the clinical status is usually severe (failure to wean from mechanical ventilation), and early plication is indicated. Adults with postcardiotomy phrenic nerve paresis usually suffer from chronic dyspnoea, and, in the absence of respiratory distress, conservative treatment is recommended for 6 months -2 years, since improvement is often observed. Nevertheless, earlier surgical treatment may be indicated in non-resolving respiratory failure. We present early (25(th) day postcardiotomy) right hemi-diaphragm plication, through a video assisted mini-thoracotomy in a high risk patient with postcardiotomy phrenic nerve paresis and respiratory distress. Early surgery with minimal surgical trauma, short operative time, minimal blood loss and postoperative pain, led to fast rehabilitation and avoidance of prolonged hospitalization complications. The relevant literature is discussed.
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Affiliation(s)
- Kosmas Tsakiridis
- Cardiothoracic Department, St Luke's Hospital, Panorama, Thessaloniki, Greece
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27
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Tantawy AEE, Imam S, Shawky H, Salah T. Diaphragmatic Nerve Palsy After Cardiac Surgery in Children in Egypt. World J Pediatr Congenit Heart Surg 2013; 4:19-23. [DOI: 10.1177/2150135112454444] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Diaphragmatic paralysis (DP) due to phrenic nerve injury is a complication which occurs in association with congenital cardiac surgery and may be a life-threatening event in infants and young children. Information about this complication is still scarce from the developing countries. Methods: Retrospective study evaluated the incidence of DP among 414 patients who underwent congenital cardiac surgery in Abo Elriesh Children’s Specialized Hospital, Cairo University, Egypt, in the duration from April 2009 to December 2011. Results: Incidence of DP was 3.6% (15 of 414 cases). Median age of affected patients was 10 months (ranged from 1 month to 13 years). Diagnosis of DP was observed after ventricular septal defect repair (3.9%), Glenn anastomosis (8.6%), Tetralogy of Fallot repair (4.3%), Senning operation (10%), arterial switch operation (3.2%), Fontan procedure (33%), coarctation of the aorta repair (7%), and pulmonary artery banding (6.4%). Diaphragmatic plication was performed in 4 of 15 cases. Patients with DP had significantly prolonged mechanical ventilation duration as compared to unaffected patients (median 120, range 48-600 vs 4, range 0-48 hours, P < .000). They also had a higher incidence of nosocomial pneumonia in 8 of 15 (53%) cases, longer duration of intensive care unit stay (median 15, range 4-62 days, P < .006), and significant mortality in 7 of 15 (46%; P < .004). Mortality among patients who underwent diaphragm plication was 1 of 4 (25%). Conclusion: Diaphragmatic paralysis is a relatively rare complication of congenital cardiac surgery in children. Its occurrence is associated with increased morbidity and mortality. A high index of clinical suspicion, utilization of bedside diagnostic tools, and a policy of early plication for certain patients may lead to improved outcomes.
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Affiliation(s)
| | - Soha Imam
- Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Hisham Shawky
- Department of Thoracic and Cardiovascular Surgery, Cairo University, Cairo, Egypt
| | - Tarek Salah
- Department of Thoracic and Cardiovascular Surgery, Cairo University, Cairo, Egypt
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Sanchez de Toledo J, Munoz R, Landsittel D, Shiderly D, Yoshida M, Komarlu R, Wearden P, Morell VO, Chrysostomou C. Diagnosis of Abnormal Diaphragm Motion after Cardiothoracic Surgery: Ultrasound Performed by a Cardiac Intensivist vs. Fluoroscopy. CONGENIT HEART DIS 2010; 5:565-72. [DOI: 10.1111/j.1747-0803.2010.00431.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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29
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Gazit AZ, Huddleston CB, Checchia PA, Fehr J, Pezzella AT. Care of the pediatric cardiac surgery patient--part 2. Curr Probl Surg 2010; 47:261-376. [PMID: 20207257 DOI: 10.1067/j.cpsurg.2009.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Avihu Z Gazit
- Pediatric Critical Care Medicine and Cardiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
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Goussard P, Gie RP, Kling S, Andronikou S, Janson JT, Roussouw GJ. Phrenic nerve palsy in children associated with confirmed intrathoracic tuberculosis: diagnosis and clinical course. Pediatr Pulmonol 2009; 44:345-50. [PMID: 19283762 DOI: 10.1002/ppul.21007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In this descriptive retrospective cases series of eight cases phrenic nerve palsy in children caused by tuberculosis lymph gland infiltration of the phrenic nerve. The lymph gland enlargement was in all cases caused by culture confirmed Mycobacterium tuberculosis. The phrenic nerve palsy was on the left side in all eight cases with the presenting feature a raised diaphragm on chest radiography that was accompanied by consolidation of the left upper lobe (88%) The diagnosis of phrenic nerve palsy was confirmed by fluoroscopy of the chest. On computer tomography the outstanding features were left sided hilar and paratracheal lymph gland enlargement with displacement of the mediastinum to the right. Mediastinal displacement lead to anterior displacement of the descending aorta, which further compressed the left main bronchus. Two children had accompanying respiratory failure requiring assisted ventilation and in two additional cases the airway compression was so severe that glandular enucleation of the enlarged glands was indicated. Of the eight children five remained symptomatic after completion of TB treatment to which steroids were added for the initial month. Diaphragmatic plication was indicated in all five cases. On clinical follow-up two children had repeated respiratory tract infections secondary to underlying lung damage while the other six remained asymptomatic.
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Affiliation(s)
- P Goussard
- Faculty of Health Sciences, Department of Paediatrics, Stellenbosch University, Tygerberg Childrens' Hospital, Tygerberg, South Africa.
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