Postoperative diaphragmatic paralysis after cardiac surgery in children: incidence, diagnosis and surgical management.

BACKGROUND: Cardiac surgery for congenital heart disease covers a wide spectrum from simple to complex cardiac and extracardiac malformations. Innovations in pediatric cardiac surgery and perioperative care over the past decades have allowed surgical correction or at least palliation in almost all complex congenital heart defects in the first years of life. Diaphragmatic paralysis (DP) due to phrenic nerve injury after congenital cardiac surgery is an important respiratory complication resulting with respiratory insufficiency, lung infections, prolonged hospital stay time and even death. METHODS: Between April 2001 and December 2010, among patients undergoing cardiac surgery for congenital heart disease, postoperative DP was diagnosed in 47/10 200 (0.46%) patients. Diaphragmatic placation was performed in 37/47 patients. DP was suspected in children who failed to wean from mechanical ventilation or in those with persistent respiratory distress when there is no cardiac cause. Decreased respiratory sounds in auscultation, paradoxical breathing during spontaneous ventilation and elevated hemidiaphragm on chest X-ray led us to use fluoroscopy, ultrasound and/or electromyogram (EMG). When chest X-rays did not have a diagnostic value in patients with persistent respiratory distress, bilateral DP was suspected and immediate fluoroscopy of EMG was performed for diagnosis. In all patients, diaphragmatic placation was performed using a thoracic approach, through the sixth or seventh intercostals space with lateral thoracotomy. RESULTS: A total of 47 patients (21 females and 26 males) with a median age of 7.21 months (range 0.27-71 months) were diagnosed DP after cardiac surgery. The incidence of DP was 0.46% after cardiac surgery. The paralysed hemidiaphragm was left side in 26/47 (55.3%), right side in 17/47 (36.2%) and bilateral in 4/47 (8.5%) cases. The assisted ventilation time after cardiac surgery was (450±216) (116-856) hours. The median time from cardiac surgery to surgical placation was (24±14) (5-56) days. No patient died in this study. The follow-up period was (26.2±16.8) months. The position of the plicated diaphragm was normal on chest X-ray, in all plicated survivors within the 1st, 6th and 12th months after discharge. CONCLUSIONS: DP caused by phrenic nerve injury during surgical intervention for congenital heart disease is an important risk factor in terms of morbidity during the postoperative period. Diaphragmatic placation appears a good option, especially in newborns and small children, to wean patients from mechanical ventilation and to prevent long-term side effects of mechanical ventilation.

Intraoperative hybrid cardiac surgery for neonates and young children with congenital heart disease: 5 years of experience.

OBJECTIVE: This study intends to summarize 5 years of intraoperative hybrid procedure (IHP) experience with neonates and young children having congenital heart disease (CHD). METHODS: From March 2003 to March 2009, a total of 152 consecutive patients younger than 2 years old who had undergone IHP were enrolled. In the balloon plasty group (n = 72), transventricular pulmonary valvuloplasty, or transaortic balloon dilatation were performed for pulmonary atresia, pulmonary stenosis, or coactation of the aorta. In the device group (n = 43), transventricular device closure was performed for ventricular septal defect (VSD), or transatrial device closure for atrial septal defect (ASD). In the collateral arteries occlusion group (n = 37), the major aortopulmonary collateral arteries (MPCAs) were occluded with coils for tetralogy of Fallot or other cyanotic CHDs. All procedures were image guided and performed in a specially designed hybrid operation room. All surviving patients were followed up, and the major adverse cardiovascular events that occurred were recorded. RESULTS: In the balloon plasty group, all patients received successful transventricular valvuloplasty or transaortic balloon angioplasty. However, severe right ventricle outflow obstruction was observed in 2 cases. One patient was transferred to regular open-heart surgery immediately, and another underwent regular open-heart procedure after discharge. Furthermore, 1 neonate with pulmonary atresia with intact ventricular septum died from liver failure 6 months after IHP. In the device closure group, the device closure failed to be performed in 3 cases (2 with ASD and 1 with VSD). One young child with VSD died from pneumonia, even after successful device closure. No device malposition was observed in the device closure group during follow-up. All patients who received MPCA occlusion and associated open-heart correction were eventually discharged. CONCLUSION: IHP could avoid or shorten the application of cardiopulmonary bypass and reduce surgical trauma for selected young children with CHD. Although IHP is feasible and safe, the image outfits, image-guided technology, and IHP-related devices should be developed and improved.