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Yongue C, Geraci TC, Chang SH. Management of Diaphragm Paralysis and Eventration. Thorac Surg Clin 2024; 34:179-187. [PMID: 38705666 DOI: 10.1016/j.thorsurg.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
An elevated diaphragm may be due to eventration or paralysis. Diaphragm elevation is often asymptomatic and found incidentally on imaging. Fluoroscopic testing can be used to differentiate eventration (no paradoxic motion) from paralysis (paradoxic motion). Regardless of etiology, a diaphragm plication is indicated in all symptomatic patients with an elevated diaphragm. Plication can be approached either from a thoracic or abdominal approach, though most thoracic surgeons perform minimally invasive thoracoscopic plication. The goal of plication is to improve lung volumes and decrease paradoxic elevation of the hemidiaphragm. Diaphragm plication is safe, has excellent outcomes, and is associated with symptom improvement.
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Affiliation(s)
- Camille Yongue
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, New York University Langone Health, 530 First Avenue, Suite 9V, New York, NY 10016, USA
| | - Travis C Geraci
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, New York University Langone Health, 530 First Avenue, Suite 9V, New York, NY 10016, USA
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, New York University Langone Health, 530 First Avenue, Suite 9V, New York, NY 10016, USA.
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Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med 2015; 43:1477-97. [PMID: 25962078 DOI: 10.1097/ccm.0000000000001059] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient. DATA SOURCE AND SYNTHESIS Narrative review of relevant English-language peer-reviewed medical literature. CONCLUSIONS Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.
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3
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Phrenic Nerve Injury During Cardiac Surgery: Mechanisms, Management and Prevention. Heart Lung Circ 2013; 22:895-902. [DOI: 10.1016/j.hlc.2013.06.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 06/26/2013] [Accepted: 06/27/2013] [Indexed: 11/17/2022]
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Prognosis of phrenic nerve injury following thoracic interventions: Four new cases and a review. Clin Neurol Neurosurg 2012; 114:199-204. [DOI: 10.1016/j.clineuro.2011.12.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Revised: 11/20/2011] [Accepted: 12/11/2011] [Indexed: 11/19/2022]
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Moreno AM, Castro RRT, Sorares PPS, Sant' Anna M, Cravo SLD, Nóbrega ACL. Longitudinal evaluation the pulmonary function of the pre and postoperative periods in the coronary artery bypass graft surgery of patients treated with a physiotherapy protocol. J Cardiothorac Surg 2011; 6:62. [PMID: 21524298 PMCID: PMC3096897 DOI: 10.1186/1749-8090-6-62] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 04/27/2011] [Indexed: 12/27/2022] Open
Abstract
Background The treatment of coronary artery disease (CAD) seeks to reduce or prevent its complications and decrease morbidity and mortality. For certain subgroups of patients, coronary artery bypass graft surgery (CABG) may accomplish these goals. The objective of this study was to assess the pulmonary function in the CABG postoperative period of patients treated with a physiotherapy protocol. Methods Forty-two volunteers with an average age of 63 ± 2 years were included and separated into three groups: healthy volunteers (n = 09), patients with CAD (n = 9) and patients who underwent CABG (n = 20). Patients from the CABG group received preoperative and postoperative evaluations on days 3, 6, 15 and 30. Patients from the CAD group had evaluations on days 1 and 30 of the study, and the healthy volunteers were evaluated on day 1. Pulmonary function was evaluated by measuring forced vital capacity (FVC), maximum expiratory pressure (MEP) and Maximum inspiratory pressure (MIP). Results After CABG, there was a significant decrease in pulmonary function (p < 0.05), which was the worst on postoperative day 3 and returned to the preoperative baseline on postoperative day 30. Conclusion Pulmonary function decreased after CABG. Pulmonary function was the worst on postoperative day 3 and began to improve on postoperative day 15. Pulmonary function returned to the preoperative baseline on postoperative day 30.
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Affiliation(s)
- Adalgiza M Moreno
- Post-Graduate Program in Cardiovascular Sciences, Fluminense Federal University, Niteroi, RJ, Brazil
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A Prospective Study of Temporal Course of Phrenic Nerve Palsy in Children After Cardiac Surgery. J Clin Neurophysiol 2011; 28:222-6. [DOI: 10.1097/wnp.0b013e3182121601] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Ross Russell RI. C 3, 4 and 5, keep the diaphragm alive. Intensive Care Med 2006; 32:1109-11. [PMID: 16741695 DOI: 10.1007/s00134-006-0209-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Accepted: 04/26/2006] [Indexed: 11/26/2022]
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Barner KC, Landau ME, Campbell WW. A review of perioperative nerve injury to the upper extremities. J Clin Neuromuscul Dis 2003; 4:117-123. [PMID: 19078702 DOI: 10.1097/00131402-200303000-00004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Perioperative nerve injuries can be a complication of surgical procedures and accounts for approximately 16% of all anesthesia-related claims in the United States. Whereas ulnar neuropathy at the elbow is the most common, other nerve injuries of the upper extremity and the phrenic nerve are not rare occurrences. A number of possible etiologies have been proposed to explain perioperative nerve injury to include stretch, compression, ischemia, and metabolic derangement. There appears to be additional factors making some patients more prone to nerve injury than others, for example, the sex of the patient and pre-existing disease. Also, in some cases there is a discrepancy between the timing of the surgery and the injury manifestations that can be the result of delayed recognition or an insult in the postoperative setting.
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Affiliation(s)
- Kristen C Barner
- From the Department of Neurology, Walter Reed Army Medical Center, Washington, DC
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Abstract
Phrenic nerve injury following cardiac surgery is variable in its incidence depending on the diligence with which it is sought. Definitive studies have shown this complication to be related to cold-induced injury during myocardial protection strategies and possibly to mechanical injury during internal mammary artery harvesting. The consequences are also variable and depend to a large extent on the underlying condition of the patient, particularly with regard to pulmonary function. The response of the patient may range from an asymptomatic radiographic abnormality to severe pulmonary dysfunction requiring prolonged mechanical ventilation and other associated morbidities and even mortality. Two cases are presented to demonstrate the variability in clinical responses to diaphragmatic dysfunction secondary to phrenic nerve injury from cardiac surgery. In addition, treatment strategies are reviewed including early tracheostomy and diaphragmatic plication, which appear to be the most effective options for patients who are compromised by phrenic injuries.
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Affiliation(s)
- H F Tripp
- Department of Cardiothoracic Surgery, Wilford Hall USAF Medical Center/MKSC 59th Medical Wing (AETC), Lackland Air Force Base, Texas 78236-5300, USA
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Nikas DJ, Ramadan FM, Elefteriades JA. Topical hypothermia: ineffective and deleterious as adjunct to cardioplegia for myocardial protection. Ann Thorac Surg 1998; 65:28-31. [PMID: 9456090 DOI: 10.1016/s0003-4975(97)01261-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Topical hypothermia, an early method developed for myocardial protection by virtue of its reduction of cardiac metabolic rate, is not without sequelae such as phrenic nerve paralysis and pulmonary complications. METHODS The hospital records of 505 nonrandomized consecutive patients undergoing coronary artery bypass grafting between 1991 and 1995 at the University of South Alabama were reviewed to evaluate the effectiveness of topical hypothermia and its relationship to pulmonary complications. Group A included 191 patients between 1991 and 1992 who received systemic hypothermia and topical hypothermia with iced slush in addition to cold blood cardioplegia. Group B included 314 patients between 1993 and 1995 who received systemic hypothermia and intermittent cold blood cardioplegia without iced slush. RESULTS Myocardial temperature mapping did not reveal any difference between the two groups. Postoperative cardiac morbidity, manifested as intraaortic balloon use, low cardiac output, inotrope use, and perioperative myocardial infarction, was decreased in group B, but the difference failed to achieve statistical significance. Mortality (group A, 3.14%; group B, 3.82%) and rates of significant morbidity such as sternal infection, stroke, reoperation for bleeding, renal failure, and prolonged ventilation were comparable between the two groups. However, there was a statistically significant difference in the incidence of diaphragmatic paralysis between group A and group B. Group A had a 25% incidence of diaphragmatic paralysis on the first postoperative day, 18% on the 15th postoperative day, and 8% at 6 months, as opposed to group B, which had incidences of 2% on the first postoperative day, 1% on the 15th postoperative day, and 1% at 6 months (p < 0.001). Also, there was a significant difference in incidence of pleural effusions (60% versus 25%) and rate of thoracentesis (25% versus 8%) between groups A and B (p < 0.0001). CONCLUSIONS We conclude that topical hypothermia did not offer any additional cardioprotective benefit above systemic hypothermia and cold blood cardioplegia alone in coronary bypass patients, but significantly increased the incidence of diaphragmatic paralysis and associated pulmonary complications.
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Affiliation(s)
- D J Nikas
- Section of Cardiothoracic Surgery, University of South Alabama, Mobile, USA
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Cohen AJ, Katz MG, Katz R, Mayerfeld D, Hauptman E, Schachner A. Phrenic nerve injury after coronary artery grafting: is it always benign? Ann Thorac Surg 1997; 64:148-53. [PMID: 9236351 DOI: 10.1016/s0003-4975(97)00288-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the effect of phrenic nerve injury (PNI) occurring during coronary artery bypass grafting in patients with major chronic obstructive pulmonary disease (COPD). METHODS Over a 42-month period, 1,303 patients underwent primary coronary artery bypass grafting. Sixty-seven (5.14%) had major COPD, and 29 (43.3%) of these 67 sustained PNI (group I). These patients were matched for age and ejection fraction with 29 CABG patients with COPD but without PNI (group II), 29 patients without COPD but with PNI (group III), and 29 patients with neither COPD nor PNI (group IV). The groups were compared on the basis of preoperative and operative factors and immediate and midterm morbidity and mortality. RESULTS There were no significant differences between the groups with respect to hypertension, diabetes, ejection fraction, number of grafts, internal mammary artery use, cardiopulmonary bypass time, and ischemic time. Postoperatively, group I had a longer total hospitalization (group I, 11.7 days; group II, 7.8 days; group III, 7.8 days; and group IV, 6 days; p = 0.0001) and stay in the intensive care unit (I, 3.6 days; II, 2.2 days; III, 2.1 days; and IV, 1.2 days; p = 0.0023). More patients in group I required reintubation (I, 37.9%; II, 3.4%; III, 6.9%; and IV, 0%; p < 0.0001). Mean follow-up was 32.8 months (range, 7 to 48 months). Group I had more hospital readmissions (I, 78; II, 50; III, 61; and IV, 28; p < 0.007) and lower cumulative survival (I, 60.6%; II, 93%; III, 96.8%; and IV, 100%; p < 0.0015) compared with the other groups. CONCLUSIONS In patients with COPD, PNI during coronary artery bypass grafting has a major negative impact on immediate and midterm results.
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Affiliation(s)
- A J Cohen
- Department of Cardiovascular Surgery, Edith Wolfson Medical Center, Holon, Israel
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Thomas JA, Cusimano RJ, Hoffstein V. Is atelectasis following aortocoronary bypass related to temperature? Chest 1997; 111:1290-4. [PMID: 9149585 DOI: 10.1378/chest.111.5.1290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To determine the frequency of acute postoperative atelectasis in patients undergoing aortocoronary bypass with either normothermic (warm) or hypothermic (cold) technique. DESIGN Prospective, randomized study comparing two groups. SETTING University-affiliated hospital. PATIENTS Three hundred thirty-one patients (166 cold and 165 warm) undergoing isolated aortocoronary bypass. MEASUREMENTS Chest radiographs were obtained preoperatively, on the day of surgery, and subsequently as clinically indicated until discharge from the hospital. Radiologist (blinded to the patient allocation into warm or cold group) scored the atelectasis from 0 to 3 based on its severity. Regression analysis was used to determine if there was any difference in the atelectasis scores between the two groups. RESULTS Mean daily postoperative atelectasis scores were not different between the cold and warm groups. The number of patients requiring chest radiographs was similar in both groups. The percent of patients with abnormal chest radiographs was similar in both groups. CONCLUSION The temperature of cardioplegia has no effect on the development of atelectasis following aortocoronary bypass, and therefore temperature-related cold injury is not a major cause of atelectasis following this type of surgery.
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Affiliation(s)
- J A Thomas
- Division of Cardiovascular Surgery, Toronto Hospital, Ontario, Canada
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Mazzoni M, Solinas C, Sisillo E, Bortone F, Susini G. Intraoperative phrenic nerve monitoring in cardiac surgery. Chest 1996; 109:1455-60. [PMID: 8769493 DOI: 10.1378/chest.109.6.1455] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Left hemidiaphragmatic paralysis due to phrenic nerve lesion is a frequent complication of hypothermic cardiopulmonary bypass. Although this is believed to be caused by cold injury to the phrenic nerve, its exact cause is still not clear. STUDY OBJECTIVE To assess feasibility, safety, and usefulness of intraoperative phrenic nerve function monitoring. SETTING Elective cardiac surgery in a university hospital. PATIENTS Consenting patients scheduled for myocardial revascularization surgery with the use of the left internal mammary artery. DESIGN Intraoperative monitoring of compound diaphragmatic action potentials (CDAPs) through transcutaneous stimulation of phrenic nerves. INTERVENTIONS Patients were divided in two groups. Group 1 received intracoronary cold St. Thomas's solution as the only cardioplegic method. Group 2 received topical cardiac cooling with ice-cold solutions in addition to intracoronary cardioplegia. RESULTS In all group 1 patients, function of phrenic nerves was maintained throughout the surgical procedure. Group 2: in two patients, bilateral, and in one patient, left phrenic nerve conduction was abolished after submersion of the heart in ice-cold solution. In two of them, the action potential of the left hemidiaphragm was absent by the end of surgery. In one, nerve conduction recovered with rewarming of the patient. DISCUSSION Intraoperative monitoring of CDAP was safe and easily obtained in the intraoperative setting. It allowed us to observe changes in phrenic nerve conduction occurring during surgery and as a result of cold cardioplegia. Cryogenic lesion of phrenic nerve might explain our findings. However, nerve ischemia cannot be ruled out and it may worsen axonal damage or delay its recovery. COMMENT This monitoring method allowed us to predict postoperative diaphragmatic dysfunction. Also, surgeons can be warned of the damaging effects of excessive cooling of the pericardium and surrounding structures; thus, preventive measures can be taken.
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Affiliation(s)
- M Mazzoni
- Department of Anesthesia and Intensive Care Unit, IRCCS Centro Cardiologico Fondazione Italo Monzino, Milano, Italy
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Maccherini M, Davoli G, Sani G, Rossi P, Giani S, Lisi G, Mazzesi G, Toscano M. Warm heart surgery eliminates diaphragmatic paralysis. J Card Surg 1995; 10:257-61. [PMID: 7626876 DOI: 10.1111/j.1540-8191.1995.tb00606.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Since January 1992, we adopted a new method of myocardial protection: warm blood cardioplegia with continuous ante-retrograde combined delivery during normothermic cardiopulmonary bypass, (CPB) instead of cold blood intermittent cardioplegia plus topical ice slush in hypothermic CPB. We have compared postoperative chest X-rays of 50 patients who underwent elective coronary artery bypass with normothermic CPB to postoperative chest X-rays, of 50 patients operated upon with hypothermia. In the cold group transitory diaphragmatic paralysis, as well as pleural effusions and thoracentesis related to the hypothermia, and topical cooling, were statistically increased over that of warm group. The data suggest that topical cooling with slush ice is responsible for phrenic nerve injury and that warm heart surgery has no associated incidence of diaphragmatic injury.
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Affiliation(s)
- M Maccherini
- Istituto di Chirurgia Toracica e Cardiovascolare, Università Degli Studi di Siena, Siena, Italy
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Takahashi T, Nakano S, Shimazaki Y, Kaneko M, Nakahara K, Miyata M, Kamiike W, Matsuda H. Concomitant coronary bypass grafting and curative surgery for cancer. Surg Today 1995; 25:131-5. [PMID: 7772915 DOI: 10.1007/bf00311084] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The surgical management of patients with concomitant critical coronary artery disease (CAD) and surgically resectable cancer is controversial. We evaluated 19 patients who underwent concomitant coronary artery bypass grafting (CABG) and curative operation for cancer of the stomach in 9 patients, the colon in 4, the lung in 4, and the breast in 2. Each cancer operation was performed under stable hemodynamics without any serious bleeding tendency, immediately after CABG with an average of 2.5 +/- 0.8 grafts. There were no operative deaths and no incidences of perioperative myocardial infarction. Postoperative complications developed in three of the patients with lung cancer: respiratory dysfunction caused by phrenic nerve paralysis in two and mediastinitis in one. During the mean follow-up period of 33 +/- 23 months, 5 patients died of recurrent cancer or non-cardiac disease; however, all 19 patients remained free from any postoperative cardiac events and their quality of life apparently improved. This experience suggests that such simultaneous correction would be safe and beneficial in carefully selected patients who have surgically correctable CAD and potentially curable cancer.
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Affiliation(s)
- T Takahashi
- First Department of Surgery, Osaka University Medical School, Japan
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Yamazaki K, Kato H, Tsujimoto S, Kitamura R. Diabetes mellitus, internal thoracic artery grafting, and risk of an elevated hemidiaphragm after coronary artery bypass surgery. J Cardiothorac Vasc Anesth 1994; 8:437-40. [PMID: 7948801 DOI: 10.1016/1053-0770(94)90284-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The elevated hemidiaphragm after coronary artery bypass grafting (CABG) that occurs in some patients is associated with internal thoracic artery (ITA) grafting as well as with the use of topical cardiac hypothermia. An increased incidence of elevated hemidiaphragm after CABG surgery in diabetic patients was observed. To determine the incidence and risk factors of elevated hemidiaphragm after CABG surgery and the relationship to preoperative diabetes, 200 consecutive patients undergoing CABG were studied; 29 (14.5%) had hemidiaphragm elevation postoperatively (25 on the left, 1 on the right, 3 bilateral). In the remaining 171 there was no hemidiaphragm elevation. Factors analyzed were age, gender, preoperative diabetes, duration of cardiopulmonary bypass (CPB) and aortic cross-clamping, minimum esophageal temperature during CPB, and use of the ITA graft. Univariate analysis showed a significant association between elevated hemidiaphragm and diabetes (P < 0.05), left ITA grafting (P < 0.01), and age (P < 0.05). Right ITA was not used for any patient. Multivariate analysis ruled out age, whereas preoperative diabetes and the use of the ITA remained the independent factors associated with elevated hemidiaphragm (odds ratio, 3.41; 95% confidence interval 1.41 to 8.18, and 2.86; 1.01 to 8.06, respectively). The relative risk of an elevated hemidiaphragm was 9.75 in diabetic patients with the ITA graft, as compared with nondiabetic patients without this graft. All 3 patients with bilateral diaphragm paralysis and a patient with a right hemidiaphragm elevation were diabetic. In conclusion, both diabetes and use of the ITA graft appear to be important risk factors for the development of elevated hemidiaphragm following CABG.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K Yamazaki
- Department of Anesthesiology, Kobe City General Hospital, Japan
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Raffa H, Kayali MT, al-Ibrahim K, Mimish L. Fatal bilateral phrenic nerve injury following hypothermic open heart surgery. Chest 1994; 105:1268-9. [PMID: 8162765 DOI: 10.1378/chest.105.4.1268] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
A 30-year-old woman underwent mitral valvotomy for severe mitral stenosis. Extracorporeal circulation by means of cardiopulmonary bypass and systemic hypothermia, in addition to local topical hypothermia using iced saline solution and slushed ice, was used. Fatal bilateral phrenic nerve paralysis with inability to wean her from the ventilator occurred. This report is presented to illustrate the pathophysiology, pathology, and means of possible prevention of such a potentially highly fatal injury following hypothermic open heart surgery.
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Affiliation(s)
- H Raffa
- Department of Cardiac Surgery, King Fahd Heart Center, Jeddah, Saudi Arabia
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Diehl JL, Lofaso F, Deleuze P, Similowski T, Lemaire F, Brochard L. Clinically relevant diaphragmatic dysfunction after cardiac operations. J Thorac Cardiovasc Surg 1994. [DOI: 10.1016/s0022-5223(94)70094-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Daily PO. Invited letter concerning: Myocardial temperature management during aortic clamping for cardiac surgery: protection, preoccupation, and perspective (J Thorac Cardiovasc Surg 1991;102:895-903). J Thorac Cardiovasc Surg 1993. [DOI: 10.1016/s0022-5223(19)33720-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Jameson N, Bates JD. Protecting the phrenic nerve during open heart surgery. AORN J 1993; 58:325-8. [PMID: 8368817 DOI: 10.1016/s0001-2092(07)65236-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Saadeh PB, Crisafulli CF, Sosner J, Wolf E. Needle electromyography of the diaphragm: a new technique. Muscle Nerve 1993; 16:15-20. [PMID: 8423828 DOI: 10.1002/mus.880160105] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Electrodiagnostic evaluation of diaphragmatic function has consisted of phrenic nerve stimulation and surface or esophageal recordings of the electrical activity of the diaphragm. Needle electromyography of the diaphragm has rarely been reported because of the perceived danger of this procedure. We describe a new technique for needle electromyography of the diaphragm. An EMG electrode is placed in the costal insertion of the diaphragm under the 8th, 9th, or 10th rib cartilage, distant from the major vessels, pleura, lungs, and abdominal viscera. Diaphragmatic denervation was found in 42 of 81 patients using this method. There were no complications related to the procedure. Needle electromyography of the diaphragm provides important information in the diagnosis and management of respiratory dysfunction.
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Affiliation(s)
- P B Saadeh
- Department of Physical Medicine and Rehabilitation, St. Vincent's Hospital and Medical Center, New York, New York 10011
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Fedullo AJ, Lerner RM, Gibson J, Shayne DS. Sonographic measurement of diaphragmatic motion after coronary artery bypass surgery. Chest 1992; 102:1683-6. [PMID: 1359958 DOI: 10.1378/chest.102.6.1683] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Forty-eight patients were prospectively evaluated following coronary artery bypass grafting (CABG) in order to determine values for diaphragmatic mobility by sonography, to compare diaphragmatic motion to chest x-ray findings, to relate diaphragmatic motion to pulmonary function tests, and to determine whether use of the left internal mammary artery (LIMA), aortic cross-clamp time, or other clinical variables were predictive of diaphragmatic dysfunction. Mean left diaphragmatic motion was 2.8 +/- 1.1 cm (range, 1.0 to 5.7 cm), mean right diaphragmatic motion was 3.9 +/- 1.1 cm (range, 1.8 to 6.4 cm), and ratio of left to right motion was 0.74 +/- 0.27 (range, 0.19 to 1.4). Forty-one patients had normally positioned diaphragms on the chest x-ray film; four of these had poor mobility by ultrasonography (< 1.6 cm). Of the seven elevated left hemidiaphragms on chest x-ray films, three had an excursion of 1.6 cm or more by ultrasonography. The mean FVC for all patients was 59 +/- 13 percent of predicted. There was no relationship between diaphragmatic mobility and FVC or negative inspiratory pressure. The diaphragmatic motion in 36 patients having LIMA grafting was similar to those without (2.7 +/- 1.2 cm [n = 36] vs 2.8 +/- 0.8 cm [n = 12], respectively). Aortic cross-clamp time and respiratory symptoms also did not correlate with diaphragmatic mobility. Sonography can be used in the evaluation of diaphragmatic motion after CABG and may be more accurate in detecting a poorly mobile diaphragm than is the chest x-ray film.
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Affiliation(s)
- A J Fedullo
- Department of Medicine, University of Rochester, Rochester General Hospital, NY 14621
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26
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DeLisser HM, Grippi MA. Phrenic Nerve Injury Following Cardiac Surgery, with Emphasis on the Role of Topical Hypothermia. J Intensive Care Med 1991. [DOI: 10.1177/088506669100600605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Phrenic nerve dysfunction that develops after cardiac surgery has generally been attributed to the topical hypothermia used for myocardial preservation and protection. Although studies relying on postoperative radiographic findings to establish the diagnosis reveal an incidence as high as 73%, investigations employing electrophysiological assessment indicate a 10% incidence. Most patients who sustain phrenic injury during cardiac surgery do not suffer major respiratory morbidity; those who do generally recover. In addition to the role of topical hypothermia as a major etiological factor, physical trauma or compromise of the vascular supply to the phrenic nerve and diaphragm may also be important factors. Although a number of measures have been advocated to lower the incidence of the problem, none have been evaluated in a prospective, randomized study using electrophysiological techniques. This review focuses on the incidence, underlying mechanisms, and clinical and electrophysiological recognition of phrenic nerve dysfunction following cardiac surgery.
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Affiliation(s)
- Horace M. DeLisser
- Pulmonary and Critical Care Section and the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael A. Grippi
- Pulmonary and Critical Care Section and the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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27
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Bonchek LI. Cooling jacket modifications. Ann Thorac Surg 1991; 52:345. [PMID: 1750897 DOI: 10.1016/0003-4975(91)91377-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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28
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O'Brien JW, Johnson SH, VanSteyn SJ, Craig DM, Sharpe RE, Mauney MC, Smith PK. Effects of internal mammary artery dissection on phrenic nerve perfusion and function. Ann Thorac Surg 1991; 52:182-8. [PMID: 1863137 DOI: 10.1016/0003-4975(91)91334-r] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The effects of left internal mammary artery (LIMA) dissection and distal division on phrenic nerve perfusion and function were examined in an adult swine model. Phrenic nerve perfusion was determined by left atrial injection of radioactively labeled microspheres. Phrenic nerve function was determined by measuring nerve and diaphragm potentials evoked by bilateral phrenic nerve stimulation. In the first group of animals (n = 9), the LIMA was dissected with ligation of all its branches. Left phrenic nerve perfusion and function decreased after LIMA dissection in every animal studied, whereas only minimal changes were observed on the right. Sixty minutes after LIMA dissection, left phrenic nerve mean perfusion decreased 71%. Left phrenic nerve and left diaphragm mean action potential amplitudes decreased 54% and 80%, respectively. In the second group of animals (n = 4), the LIMA dissection was performed without division of the pericardiacophrenic artery, a small proximal branch of the internal mammary artery that supplies the phrenic nerve. Sixty minutes after LIMA dissection, left phrenic nerve perfusion had decreased by 21% from control values, with a corresponding decrease in left phrenic nerve and diaphragm mean action potential amplitudes of 19% and 23%, respectively. These results indicate that LIMA dissection with division of all its branches in this model is associated with a significant impairment in left phrenic nerve perfusion and function and suggests a causal relationship. These results may also explain the apparent increased phrenic nerve cold sensitivity and increased incidence of phrenic nerve dysfunction associated with LIMA grafting.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J W O'Brien
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710
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29
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Montero Martínez M, Verea Hernando H, Fontán Bueso J. Parálisis diafragmática bilateral como complicación de cirugía cardíaca con utilización de hipotermia local. Arch Bronconeumol 1991. [DOI: 10.1016/s0300-2896(15)31487-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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30
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Torres A, Rodrigo C. Alteración de la función diafragmática en la cirugía abdominal, cardíaca y torácica. Arch Bronconeumol 1991. [DOI: 10.1016/s0300-2896(15)31479-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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31
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Mok Q, Ross-Russell R, Mulvey D, Green M, Shinebourne EA. Phrenic nerve injury in infants and children undergoing cardiac surgery. Heart 1991; 65:287-92. [PMID: 2039675 PMCID: PMC1024633 DOI: 10.1136/hrt.65.5.287] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Fifty infants and 50 children less than 15 years undergoing palliative or corrective cardiac surgery in the Brompton Hospital between March and October 1988 had direct percutaneous stimulation of the phrenic nerve before and after operation. Ten patients, six under 1 year of age and four over, developed unilateral phrenic nerve injury. In those aged less than 1 year recovery after operation was prolonged because their diaphragmatic palsy made it difficult to wean them from the ventilator. Older children had symptoms but their rate of recovery did not seem to be affected by the phrenic nerve injury. Phrenic nerve damage was no more frequent after a lateral thoracotomy than after a median sternotomy. There was no significant association with the type of operation performed, the experience of the surgeon, the use of bypass or topical ice, the duration of bypass, circulatory arrest or aortic cross clamping, or the age of the patient at the time of operation. In patients who had cardiopulmonary bypass the risk of injury was significantly higher in those who had undergone previous operation. The 10% frequency of phrenic nerve injury determined in this prospective study was higher than that seen in earlier retrospective reports. Direct percutaneous stimulation of the phrenic nerve can be used at the bedside in infants and children to facilitate early and accurate diagnosis of phrenic nerve palsy, and the results may influence early management.
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Affiliation(s)
- Q Mok
- Department of Paediatric Cardiology, Royal Brompton National Heart and Lung Hospital, London
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32
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Efthimiou J, Butler J, Benson MK, Westaby S. Bilateral diaphragm paralysis after cardiac surgery with topical hypothermia. Thorax 1991; 46:351-4. [PMID: 2068692 PMCID: PMC463134 DOI: 10.1136/thx.46.5.351] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Bilateral diaphragm paralysis is a rare but important complication of open heart surgery. Two cases were found among 360 prospectively studied patients undergoing open heart surgery during one year. Both patients had insulin dependent diabetes with peripheral neuropathy and this may have contributed to their diaphragm paralysis. The patients were studied postoperatively for one year with measurements of lung function, nocturnal oximetry, diaphragmatic function, and phrenic nerve conduction. Treatment with intermittent positive airway pressure ventilation by nasal mask was effective in both patients. After nine months one patient had recovered completely with normal phrenic nerve conduction and diaphragmatic function; the other continues most of his normal daytime activities, but still requires nasal positive airway pressure ventilation for six hours at night.
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Affiliation(s)
- J Efthimiou
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford
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33
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Daily PO, Kinney TB. Optimizing myocardial hypothermia: II. Cooling jacket modifications and clinical results. Ann Thorac Surg 1991; 51:284-9. [PMID: 1989545 DOI: 10.1016/0003-4975(91)90801-v] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
After induction of myocardial hypothermia by cold cardioplegic solution, myocardial rewarming occurs at 0.5 degrees to 1.0 degrees C/min. In addition to preventing myocardial rewarming from systemic and pulmonary venous return, continuous cooling of the myocardial surface must be provided. Modifications of a previously reported cooling jacket are described. These modifications include decreased width and thickness of the metal skeleton for easier application and increased malleability, respectively. Also, the double-row flow channel markedly minimizes obstruction of flow secondary to kinking and allows inlet and outlet lines to attach at adjacent points of the jacket thus minimizing obstruction of the operative field. The effectiveness of the jacket in 36 patients undergoing valve replacement and 19 patients having pulmonary thromboendarterectomy was evaluated by measurement of myocardial temperatures at multiple sites throughout aortic cross-clamping. Temperatures at all sites were maintained at 12 degrees C or less. Temperatures measured in phrenic nerve pedicles ranged from 25 degrees to 27 degrees C. During cooling, heat removal by the jacket was 330 calories/min. During maintenance of myocardial hypothermia, heat flow was 190 calories/min. Modifications of a cooling jacket facilitate usability and an array of sizes enhances applicability.
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34
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Wilcox PG, Paré PD, Pardy RL. Recovery after unilateral phrenic injury associated with coronary artery revascularization. Chest 1990; 98:661-6. [PMID: 2394143 DOI: 10.1378/chest.98.3.661] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Hemidiaphragmatic paralysis occurs in some patients following CAB surgery, possibly related to an intraoperative stretch or cold-induced phrenic injury. To determine the time and extent of recovery of phrenic nerve function, we studied five patients with left phrenic paresis or paralysis after CAB. The FVC, FEV1, Pmax and PEmax pressures, latency of conduction and amplitude of CDAP with phrenic nerve stimulation, and diaphragmatic excursion during fluoroscopy were measured for 12 months after CAB. Left phrenic paralysis was substantiated in four of five patients, and paresis was present in the other patient. Recovery of the left phrenic nerve occurred in all patients, complete in one and partial in four, but was delayed and continued for up to 12 months. We conclude that phrenic nerve recovery is delayed after CAB-associated injury and may be incomplete up to 14 months later, in keeping with rates of regeneration of other peripheral nerves.
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Affiliation(s)
- P G Wilcox
- Department of Medicine, University of British Columbia, Vancouver, Canada
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35
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Colbert WE, Wilson BF, Williams PD. Effects of temperature on the experimental reliability of the isolated rat phrenic nerve/diaphragm preparation. JOURNAL OF PHARMACOLOGICAL METHODS 1990; 24:53-7. [PMID: 2170772 DOI: 10.1016/0160-5402(90)90049-q] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- W E Colbert
- Toxicology Division, Lilly Research Laboratories, Eli Lilly and Company, Greenfield, Indiana 46140
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36
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Graham DR, Kaplan D, Evans CC, Hind CR, Donnelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg 1990; 49:248-51; discussion 252. [PMID: 2306146 DOI: 10.1016/0003-4975(90)90146-w] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Unilateral paralysis of the diaphragm due to nonmalignant disease is an uncommon disorder previously thought to have benign implications. Some patients, however, experience dyspnea and orthopnea with impairment of pulmonary function. Unilateral diaphragmatic plication was performed on 17 patients (16 men and 1 woman with a mean age of 53.7 years [range, 28 to 74 years]) during the last 10 years. Preoperatively each patient was shown to have paradoxical movement of the paralyzed diaphragm on sniffing and to have a reduction in forced vital capacity and lung volumes. These reductions were greater when the patient was in the supine position. All patients had moderate hypoxemia (mean arterial oxygen tension, 73.1 +/- 10.9 mm Hg). Plication was performed by imbricating the diaphragm in layers through a thoracotomy incision. After plication, all patients showed both subjective and objective improvement. Six patients were reassessed 5 or more years after plication (range, 5 to 7 years), and the improvement was maintained. Diaphragmatic plication is a safe and effective procedure for adult patients with dyspnea due to unilateral diaphragmatic paralysis; furthermore, the initial improvement is maintained.
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Affiliation(s)
- D R Graham
- Regional Adult Cardiothoracic Unit, Broadgreen Hospital, Liverpool, United Kingdom
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37
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Robicsek F, Duncan GD, Hawes AC, Rice HE, Harrill S, Robicsek SA. Biological thresholds of cold-induced phrenic nerve injury. J Thorac Cardiovasc Surg 1990. [DOI: 10.1016/s0022-5223(19)35647-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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38
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Curtis JJ, Nawarawong W, Walls JT, Schmaltz RA, Boley T, Madsen R, Anderson SK. Elevated hemidiaphragm after cardiac operations: incidence, prognosis, and relationship to the use of topical ice slush. Ann Thorac Surg 1989; 48:764-8. [PMID: 2596912 DOI: 10.1016/0003-4975(89)90667-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We have reviewed chest roentgenograms of 745 patients before hospital dismissal after cardiac operations and serially to determine the incidence and prognosis of elevated hemidiaphragm and any relationship to the use of topical ice slush (TIS) in myocardial preservation. All patients had similar myocardial preservation techniques including moderate systemic hypothermia and 4 degrees C saline solution poured over the heart at aortic clamping. During a 12-month period, TIS was added to the saline bath. Two (2.4%) of 84 patients before TIS and 5 (2.5%) of 201 consecutive patients operated on since discontinuing TIS had elevated hemidiaphragm on the predismissal roentgenogram. Of 460 patients in whom TIS was employed, 109 (23.7%) had elevated hemidiaphragm (p less than 0.001). When TIS was employed, elevated hemidiaphragm developed in 72 (26%) of 280 patients without internal mammary artery takedown versus 13 of 33 patients (39.4%) with takedown of the internal mammary artery (p = 0.047). Ninety-nine patients with elevated hemidiaphragm were available for follow-up at 1 month, at which time 79 (79.8%) continued to have elevated diaphragm. At 1 year, 14 (21.9%) of 64 patients had persistent diaphragm elevation. We conclude that TIS predisposes to elevated diaphragm and that the incidence is increased when the internal mammary artery is harvested.
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Affiliation(s)
- J J Curtis
- Division of Cardiothoracic Surgery, University of Missouri, Columbia 65212
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39
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Velardi AR, Widmer SJ, Cilley JH, Witkowski TA, DelRossi AJ, Spence RK. Right ventricular myocardial protection through intracavitary cooling in cardiac operations. J Thorac Cardiovasc Surg 1989. [DOI: 10.1016/s0022-5223(19)34321-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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40
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Robicsek F, Duncan GD, Rice HE, Robicsek SA. Experiments with a bowl of saline: The hidden risk of hypothermic-osmotic damage during topical cardiac cooling. J Thorac Cardiovasc Surg 1989. [DOI: 10.1016/s0022-5223(19)34587-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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41
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Bogers JJ, Nierop G, Bakker W, Huysmans HA. Is diaphragmatic elevation a serious complication of open-heart surgery? SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1989; 23:271-4. [PMID: 2617246 DOI: 10.3109/14017438909106007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Diaphragmatic elevation or paralysis after open-heart surgery was retrospectively analyzed in 370 consecutive operations performed on 365 adult patients. The incidence of the complication was 7.2%. It was significantly correlated with ipsilateral pleural effusion and lower-lobe atelectasis, but no predisposing or causal factors could be identified. Diaphragmatic elevation did not prolong the hospital stay. Actuarial analysis of data from follow-up chest radiograms showed normalization of the diaphragmatic position within 6 months in 44% and within a year in 90% of the patients.
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Affiliation(s)
- J J Bogers
- Department of Thoracic Surgery, University Hospital, Leiden, the Netherlands
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42
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Wilcox P, Baile EM, Hards J, Müller NL, Dunn L, Pardy RL, Paré PD. Phrenic nerve function and its relationship to atelectasis after coronary artery bypass surgery. Chest 1988; 93:693-8. [PMID: 3258227 DOI: 10.1378/chest.93.4.693] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Atelectasis following coronary artery bypass surgery (CAB) occurs in the majority of patients. To determine the importance of operative variables in the development of postoperative atelectasis and the incidence of phrenic nerve injury caused by topical cold cardioplegic solution, we studied 57 patients (53 male, four female) undergoing CAB. Their mean age, +/- SD, was 58 +/- 13 years. Transcutaneous stimulation was used to evaluate phrenic nerve function preoperatively and postoperatively in 52 patients. An unequivocal paresis of the phrenic nerve was documented in five patients. In an additional 27 patients, the amplitude of the compound diaphragm action potential was reduced postoperatively. However, methodologic limitations did not allow the conclusion that this was secondary to a phrenic axonal degeneration. Discriminant analysis of intraoperative variables showed more severe atelectasis with a larger number of grafts, with a longer operative and bypass time, when the pleural space was entered, when a right atrial drain and a cardiac insulating pad were not used, and with a lower body temperature. It is concluded that phrenic paresis may occur after CAB and topical cold cardioplegia, but that other factors must explain the atelectasis found in the majority of patients.
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Affiliation(s)
- P Wilcox
- University of British Columbia Pulmonary Research Laboratory, St. Paul's Hospital, Vancouver, Canada
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43
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LoCicero J, Hoyne WP, LoCicero MS, Cochard L, Sanders JH. Anatomic variations of the phrenic nerve at the superior thoracic aperture (thoracic inlet): Implications for the cardiothoracic surgeon. Clin Anat 1988. [DOI: 10.1002/ca.980010206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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44
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45
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46
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47
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Watanabe T, Trusler GA, Williams WG, Edmonds JF, Coles JG, Hosokawa Y. Phrenic nerve paralysis after pediatric cardiac surgery. J Thorac Cardiovasc Surg 1987. [DOI: 10.1016/s0022-5223(19)36251-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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Esposito RA, Spencer FC. The effect of pericardial insulation on hypothermic phrenic nerve injury during open-heart surgery. Ann Thorac Surg 1987; 43:303-8. [PMID: 3827375 DOI: 10.1016/s0003-4975(10)60619-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Phrenic nerve injury was evaluated prospectively in 133 patients undergoing open-heart surgery using iced saline slush for topical hypothermia. In the control group of 70 patients no attempt was made to shield the phrenic nerves from direct exposure to ice. Phrenic nerve damage occurred in 73% of these patients, as assessed by persistent diaphragm paralysis evident on inspiratory chest roentgenogram. In 2 patients the paralysis was bilateral. In the second group of 63 patients a pericardial insulation pad was used to prevent contact of the iced slush to the phrenic nerve. Diaphragm paralysis was observed in 17% of these patients. This difference was highly significant (p less than .001). Diaphragm paralysis in the control group was clinically significant; life-threatening respiratory complications developed in 7 patients (14%), frequently resulting in multiple reintubations, tracheostomy, and prolonged mechanical ventilation. In addition, 4 patients with phrenic nerve injury exhibited a clinical syndrome consistent with gastric ileus, which may possibly represent hypothermic injury to the thoracic vagi. The likelihood of phrenic nerve injury when iced saline slush is used for topical myocardial cooling and the possibility of developing serious respiratory disability would support the routine use of pericardial insulation when this method of hypothermia is used.
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49
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Daily PO, Pfeffer TA, Wisniewski JB, Steinke TA, Kinney TB, Moores WY, Dembitsky WP. Clinical comparisons of methods of myocardial protection. J Thorac Cardiovasc Surg 1987. [DOI: 10.1016/s0022-5223(19)36409-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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50
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Daily PO, Dembitsky WP, Peterson KL, Moser KM. Modifications of techniques and early results of pulmonary thromboendarterectomy for chronic pulmonary embolism. J Thorac Cardiovasc Surg 1987. [DOI: 10.1016/s0022-5223(19)36444-x] [Citation(s) in RCA: 93] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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