Impact of Phrenic Nerve Palsy and Need for Diaphragm Plication Following Surgery for Pulmonary Atresia With Ventricular Septal Defect and Major Aortopulmonary Collaterals

Surgical repair of peripheral pulmonary artery stenosis: A 2-decade experience with 145 patients

BACKGROUND

Peripheral pulmonary artery stenosis (PPAS) is a relatively rare form of congenital heart disease often associated with Williams syndrome, Alagille syndrome, and elastin arteriopathy. This disease is characterized by stenoses at nearly all lobar and segmental ostia and results in systemic-level right ventricular pressures. The current study summarizes our experience with the surgical treatment of PPAS.

METHODS

This was a retrospective review of 145 patients who underwent surgical repair of PPAS. This included 43 patients with Williams syndrome, 39 with Alagille syndrome, and 21 with elastin arteriopathy. Other diagnoses include tetralogy of Fallot with PPAS (n = 21), truncus arteriosus (n = 5), transposition (n = 3), double-outlet right ventricle (n = 2), arterial tortuosity syndrome (n = 3), and other (n = 8).

RESULTS

The median preoperative right ventricle to aortic peak systolic pressure ratio was 1.01 (range, 0.50-1.60) which was reduced to 0.30 (range, 0.17-0.60) postoperatively. The median number of ostial repairs was 17 (range, 6-34) and median duration of cardiopulmonary bypass was 398 minutes (range, 92-844). There were 3 in-hospital deaths (2.1%). The median duration of follow-up was 26 months (range, 1-220) with 4 late deaths (2.9%). Eighty-two patients have subsequently undergone catheterization and 74 had a pressure ratio <0.50.

CONCLUSIONS

The surgical treatment of PPAS resulted in a 70% reduction in right ventricular pressures. At 3 years, freedom from death was 94% and 90% of those evaluated maintained low pressures. These results suggest that the surgical treatment of PPAS is highly effective in most patients.

Fluorographic findings of diaphragmatic paralysis with spontaneous recovery

BACKGROUND

Postoperative diaphragmatic paralysis is an unavoidable complication of cardiovascular surgery. Although diaphragmatic plication, as a surgical treatment, can be performed, spontaneous recovery is possible. We aimed to identify differences in fluorographic findings of diaphragmatic paralysis between pediatric patients with and without spontaneous recovery within 1 year of intrathoracic surgery.

METHODS

Ten children, who had been followed-up for at least 1 year post-surgery and who had not received diaphragmatic plication were included and classified into those with or without spontaneous recovery. The presence or absence of the paradoxical movement of the diaphragm and mediastinum was evaluated based on fluorographic findings. Fisher's exact test was used to compare the presence or absence of paradoxical movement between the groups.

RESULTS

Eight patients experienced spontaneous recovery. The mean ± standard deviation time to spontaneous recovery was 150 ± 114 days (range, 18-338 days). In the spontaneous recovery group, no patient had paradoxical movement of the mediastinum, and a significant between-group difference was observed in the presence of the paradoxical movement of the mediastinum (present/absent in patients with vs. without spontaneous recovery: 0/8 vs. 2/0, P = 0.02). There was no significant between-group difference in paradoxical movement of the diaphragm (present/absent in patients with vs. without spontaneous recovery: 1/7 vs. 2/0, P = 0.07). Pediatric patients without paradoxical movement of the mediastinum spontaneously recovered within 1 year of intrathoracic surgery.

CONCLUSIONS

Pediatric patients without paradoxical movement of the mediastinum, based on fluorography findings, spontaneously recovered within 1 year of surgery. The timing of spontaneous recovery varied between cases.

Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography

Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.

Diaphragm Paralysis After Pediatric Cardiac Surgery: An STS Congenital Heart Surgery Database Study

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.

The Use of Massage Therapy as a Nonpharmacological Approach to Relieve Postlaparoscopic Shoulder Pain: a Pediatric Case Report

INTRODUCTION

Postlaparoscopic shoulder pain (PLSP) has been well documented to effect patients following an abdominal or thoracic laparoscopic surgery. PLSP is characterized by referred pain that can occur both unilaterally or bilaterally, and is typically caused by phrenic nerve irritation. Current literature has focused on pharmacological treatment; however, there is limited evidence for the use of nonpharmacological management of PLSP in the pediatric population.

CASE DESCRIPTION

This retrospective case report study explores the use of a single-session massage therapy treatment for a 17-year-old patient with PLSP following laparoscopic abdominal surgery.

INTERVENTION AND RESULTS

Therapy intervention included a 25 min Swedish massage involving the effected shoulder with an emphasis on passive touch to the shoulder and at the level of the diaphragm. Pain was assessed using the Visual Analog Scale (VAS) pre- and postintervention. Following therapy the patient reported 0/10 pain.

CONCLUSION

This case report provides evidence for the use of massage therapy treatment as a noninvasive, nonpharmacological approach to reducing or eliminating PLSP in a pediatric patient.

Cervical spinal stenosis and risk of pulmonary dysfunction

Background:

Cervical spinal stenosis (CSS) is defined as an abnormal narrowing of the cervical spinal canal. The essential clinical challenges with CSS are altered cervical spinal cord function and cervical radiculopathy. Phrenic nerve palsy leading to hemidiaphragmatic paresis may be a temporary or persistent phenomenon after cervical cord injury and CSS.

Objective:

The objective of the study is to elucidate the potential effect of CSS on the pulmonary functions.

Methods:

This is a case–control study which included 40 patients divided into two groups 30 females and 10 males patients with CSS (C5 and above) and 60 healthy volunteers with body mass index (BMI) <30 Kg/m². Pulmonary function tests have been done for all the patients.

Results:

The present study showed that VC in expiration (VC EX%), forced expiratory volume (FEV%), forced vital capacity % (FVC%), PEF%, and mean voluntary ventilation % (MVV%), were low in patients CSS compared with the control groups; P < 0.001, P < 0.001, P < 0.001, P = 0.042, and P = 0.037, respectively. As well, VC EX%, FEV1%, and FVC% were low in male patients in comparison to the controls P < 0.05. Besides, there were no significant differences regarding age, BMI, VC in inspiration (VC IN%), PEF%, FEV1/FVC%, and MVV%. Moreover, VC EX%, FEV1%, and FVC% were low in female patients compared to the controls, P < 0.001. Whereas, there were no significant differences that had been identified between female patients and female controls regarding age, BMI, VC IN%, PEF%, FEV1/FVC%, and MVV%. On the other hand, weight, height, and MVV% were low in female patients compared to male patients, P < 0.001.

Conclusion:

Chronic CSS leads to subclinical pulmonary dysfunction due to the involvement of the phrenic nerve. FEV% is the most sensitive parameter in the detection these disorders.

Pulmonary Artery Reconstruction After Failed Pulmonary Artery Stents

BACKGROUND

Pulmonary artery stents are widely deployed in patients with stenoses in the branch pulmonary arteries. However, stents do not address more peripheral sites of stenosis and invariably develop in-stent restenosis. The purpose of this study was to review our experience with pulmonary artery reconstruction after failed pulmonary artery stents.

METHODS

This was a retrospective study of 56 patients who underwent pulmonary artery reconstruction after failed pulmonary artery stents. These patients had undergone a median of 2 (range, 0-5) previous surgical procedures and 2 (range, 1-4) pulmonary artery stents.

RESULTS

The median age at stent surgery was 5 (range, 0.3-23.6) years. The majority of stents (79%) were completely removed and patch augmented. The minority of stents (21%) were felt to be unremovable and thus were split longitudinally and reconstructed using a pulmonary artery homograft. There was 1 (1.8%) operative mortality. The mean pulmonary artery-to-aortic pressure ratio decreased from a preoperative value of 0.91 ± 0.21 to a postoperative value of 0.31 ± 0.07 (P < .001). The median hospital length of stay was 10 days. The median duration of follow-up was 1.8 years. There has been no midterm mortality. Six patients have undergone balloon dilation postoperatively for residual pulmonary artery stenosis.

CONCLUSIONS

Pulmonary artery reconstruction resulted in a significant decrease in pulmonary artery-to-aortic pressure ratios. The subsequent need for reintervention on the pulmonary arteries has been relatively low (11% to date). These results suggest that patients with pulmonary artery stents can be successfully treated with surgical reconstruction.

Surgical Repair of Peripheral Pulmonary Artery Stenosis in Patients Without Williams or Alagille Syndromes

Peripheral pulmonary artery stenosis is a relatively rare form of congenital heart disease typically associated with genetic syndromes, such as Williams or Alagille syndromes. However, some patients present with severe stenosis without associated syndromes. The purpose of the study was to review our surgical experience in such patients. This was a retrospective review of 30 patients who underwent surgical repair for peripheral pulmonary artery stenosis. Concomitant anatomical diagnoses in 20 patients (67%) included supravalvar aortic stenosis (n = 8), tetralogy of Fallot (n = 4), d-transposition of the great arteries (n = 2), truncus arteriosus (n = 2), hypoplastic left heart syndrome (n = 2), ventricular septal defect (n = 1), and patent ductus arteriosus (n = 1). Additional medical diagnoses in 15 patients (50%) included elastin arteriopathy (n = 9), pulmonary artery calcinosis (n = 1), arterial tortuosity syndrome (n = 1), DiGeorge syndrome (n = 1), and Noonan syndrome (n = 1). Median age at surgery was 3.6 years (interquartile range 1.6-7.4 years). Seventeen patients (57%) had prior cardiac operations, and 16 patients (53%) previously underwent percutaneous intervention. With surgery, mean right ventricle-to-aortic systolic pressure ratio decreased from 0.95 ± 0.2 to 0.28 ± 0.08 (P< 0.0001). Median duration of cardiopulmonary bypass was 369 minutes. There was 100% survival to hospital discharge, with no mortality at mean follow-up of 2.3 years. No patient required reoperation, while 4 underwent balloon dilation. Freedom from pulmonary artery catheter-based reintervention was 95% and 80% at 12 and 36 months, respectively. Patients with peripheral pulmonary artery stenosis without either Williams or Alagille syndrome can successfully undergo surgical repair with a significant reduction in right ventricle-to-aortic pressure ratios.