The advantage of early plication in children diagnosed with diaphragm paresis

Towards Zero Phrenic Nerve Injury in Reoperative Pediatric Cardiac Surgery: The Value of Intraoperative Phrenic Nerve Stimulation

BACKGROUND

Phrenic nerve injury is a devastating complication that results in significant morbidity and mortality. We developed a novel technique to localize the phrenic nerve and evaluate its success.

METHODS

Two groups of children underwent repeat sternotomy for a variety of indications. Group I (69 patients, nerve stimulator) and Group II (78 patients, no nerve stimulator).

RESULTS

There was no significant difference in the mean age and weight between the two groups: (6.4 ± 6.5 years vs. 5.6 ± 6.4 years; p = 0.65) and (25.2 ± 24.1 vs. 22.6 ± 22.1; p = 0.69), respectively. The two groups were comparable in the following procedures: pulmonary conduit replacement, bidirectional cavopulmonary anastomosis, aortic arch repair, and Fontan, while Group I had more pulmonary arterial branch reconstruction (p = 0.009) and Group II had more heart transplant patients (p = 0.001). There was no phrenic nerve injury in Group I, while there were 13 patients who suffered phrenic nerve injury in Group II (p < 0.001). No early mortality in Group I, while five patients died prior to discharge in Group II. Eleven patients underwent diaphragm plication in Group II (p = 0.001). The mean number of hours on the ventilator was significantly higher in Group II (137.3 ± 324.9) compared to Group I (17 ± 66.9), p < 0.001. Group II had a significantly longer length of ICU and hospital stays compared to Group I (p = 0.007 and p = 0.006 respectively).

CONCLUSION

Phrenic nerve injury in children continues to be associated with significant morbidities and increased length of stay. The use of intraoperative phrenic nerve stimulator can be an effective way to localize the phrenic nerve and avoid its injury.

Hemi-Diaphragm Plication and/or Tracheostomy Are Valuable Adjunctive Procedures After Repair of Congenital Heart Defects in Children: A Systematic Review

Diaphragmatic paralysis (DP), whether unilateral or bilateral, often leads to extended recovery and more severe complications, particularly in neonates and infants undergoing congenital heart surgery. This condition's impact is most pronounced after single-ventricle palliative procedures. Tracheostomy prevalence is rising in pediatric patients with congenital heart disease (CHD) despite its association with high resource utilization and in-hospital mortality. This study examines the reported incidence of diaphragmatic paralysis and timing of tracheostomy in pediatric patients undergoing surgery for congenital heart disease in the literature and a retrospective analysis of cases in our institution between 2018 and 2023, offering insights for prospective management. An electronic search of PubMed databases retrieved 10 studies on pediatric tracheostomy and 11 studies on DP. Our retrospective analysis included 15 patients, of whom 10 underwent tracheostomy, four underwent diaphragmatic plication, and one underwent both. Postoperative tracheostomy had an 11.8% mortality rate in our systematic review, rising to 40% in our observational study. Diaphragm repair and early diagnosis can reduce morbidity, prevent complications, and improve patients' quality of life.

Right Phrenic Nerve Palsy following Long-gap Esophageal Atresia and Tracheoesophageal Fistula Repair

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) are surgically correctable congenital anomalies with reported surgical common complications such as anastomotic leaks, recurrent TEF, and esophageal strictures; however, phrenic nerve injury (PNI) is a very rare but possible complication which we have highlighted in our case report. Here, we report a baby girl operated for long-gap EA and TEF having respiratory distress and failed attempts to wean off oxygen support. Serial chest X-rays showed elevated right hemidiaphragm, whereas ultrasound thorax confirmed our diagnosis of right PNI causing diaphragmatic palsy. Conservative management with the hope of spontaneous recovery failed, so diaphragmatic plication was done at 5 weeks from index surgery. Postplication, the baby was weaned off oxygen and pressure support the very 1st day and had improved respiratory physiology.

Transcutaneous electromyography as a tool to assess recovery of hemidiaphragmatic paresis: A case report

In this case report, we describe two repeated transcutaneous electromyography of the diaphragm (dEMG) measurements in an infant with suspected paresis of the right hemidiaphragm after cardiac surgery. The first measurement, performed at the time of diagnosis, showed a lower electrical activity of the right side of the diaphragm in comparison with the left side. The second measurement, performed after a period of expectative management, showed that electrical activity of the affected side had increased and was similar to the activity of the left diaphragm. This finding was accompanied by an improvement in the clinical condition. In conclusion, repeated measurement of diaphragmatic activity using transcutaneous dEMG enables the observation and quantification of spontaneous recovery over time. This information may assist the clinician in identifying patients not responding to expectative management and in determining the optimal timing of diaphragmatic surgery.

Outcome analysis of a conservative approach to diaphragmatic paralysis following congenital cardiac surgery in neonates and infants: a bicentric retrospective study

 

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.

Early diagnosis of diaphragm palsy after pediatric cardiac surgery and outcome after diaphragm plication - A single-center experience

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.

Risk factors for morbidity and mortality after a bidirectional Glenn shunt in Northern Thailand

OBJECTIVES

Owing to the evolution of surgical techniques, the survival rate of patients undergoing a bidirectional Glenn shunt has improved. However, the morbidity and mortality are still high. The aims of this study were to determine the survival rate and risk factors influencing the morbidity and mortality in patients with a functional univentricular heart after a bidirectional Glenn shunt.

METHODS

One hundred and fifty-one patients who had undergone a bidirectional Glenn operation were enrolled. Early worse outcomes were defined as postoperative death within 30 days and a hospital stay ≥ 30 days.

RESULTS

The median age was 7.1 years (range 0.3-26 years). The median age at the time of the Glenn operation was 2.2 years (range 0.2-15.9 years). The survival rates of patients at 1-, 5-, 10- and 15-year after the Glenn operation were 89%, 79%, 75%, and 72%, respectively. The predictors for the mortality were preoperative mean pulmonary artery pressure ≥ 17 mmHg, preoperative pulmonary vascular resistance index ≥ 3.1 Wood Units·m² and atrioventricular valve regurgitation. In addition, the independent predictors of an early worse outcome included preoperative mean pulmonary artery pressure ≥ 17 mmHg and diaphragmatic paralysis.

CONCLUSION

The presence of preoperative atrioventricular valve regurgitation, preoperative mean pulmonary artery pressure ≥ 17 mmHg, preoperative pulmonary vascular resistance index ≥ 3.1 Wood Units·m², or diaphragmatic paralysis were found to be independent risk factors requiring the good patients' selection for the Glenn operation and early aggressive management of the diaphragmatic paralysis for reducing morbidity to ensure successful candidature for Fontan completion.

Thoracoscopic repair of diaphragmatic eventration in children: a comparison of two repair techniques

BACKGROUND

Thoracoscopic plication has gained popularity in the management of diaphragmatic eventration, and several suturing techniques have been described. However, the superiority of one technique over the other has not been demonstrated. The purpose of this study is to report our experience with diaphragmatic plication and to compare the thoracoscopic interrupted and pleated suture techniques in pediatric patients with diaphragmatic eventration.

METHODS

This is a retrospective cohort study (level of evidence: 3) performed on 14 patients with diaphragmatic eventration. All patients were symptomatic and had diaphragmatic plication via thoracoscopy. The patients were further divided into two groups according to the repair technique; interrupted repair (n = 9) and pleated repair (n = 5). Preoperative, operative and postoperative data were compared between the two groups.

RESULTS

The median age was 9.5 months (25th- 75th percentiles: 6 to 15 months), and 8 (57%) were males. Twelve patients (85.71%) had right side eventration, and nine patients (64.29%) had congenital diaphragmatic eventration. One case was converted to open thoracotomy because of adhesions. There was no difference in the preoperative characteristics between both groups. Median operative time was 117 min (25th- 75th percentiles: 101-129 min) and 77 min (25th- 75th percentiles: 73-83 min) in the interrupted and pleated groups, respectively (p = 0.004). One patient had a postoperative elevation of the diaphragm (incomplete repair) in the pleated group (p = 0.357). No recurrence was reported during the follow-up.

CONCLUSION

Thoracoscopic plication is an effective technique for management of diaphragmatic eventration in children. Pleating technique is easy, fast, and associated with a marked reduction in operative time.

TYPE OF THE STUDY

Retrospective cohort study.

LEVELS OF EVIDENCE

Level of evidence: 3.

Predictors for plication performance following diaphragmatic paralysis in children

INTRODUCTION AND OBJECTIVES

Diaphragmatic paralysis (DP) in children can result from various etiologies. Guidelines for patient selection for diaphragmatic plication (DPL) are lacking. Our objectives were to describe the etiologies of DP and to determine the risk factors and predictors for DPL in the pediatric population.

METHODS

Retrospective data were retrieved from departmental databases on patients with DP from the pediatric, cardiac, and neonatal intensive care departments of Safra Children's Hospital from 2010 to 2017.

RESULTS

DP was diagnosed in 88 patients, 29 with noncardiac surgery-related etiologies, for example, congenital, surgery, trauma, and shock and 59 with cardiac surgery-related etiologies. In total, 27 (31%) patients underwent DPL, and they had significant comorbidities involving respiratory, central nervous, and cardiovascular systems, higher lung injury scores, and lower weight compared with the patients who did not undergo DPL (P = .002, P = .002, P < .001, P = .012, and P = .013, respectively). A multivariate regression model revealed significant independent predictors for DPL, including morbidities of central nervous (odds ratio [OR = 9.651, P = .005), respiratory (OR = 4.875, P = .039), and cardiovascular systems (OR = 23.938, P = .001).

CONCLUSIONS

Etiologies of DP are very diverse in the pediatric population. Comorbidities of respiratory, central nervous, and cardiovascular systems are risk factors for plication requirement in respiratory support-dependent pediatric patients with DP. Early DPL should be considered in these patients.

Characteristics and outcomes of children with congenital heart disease needing diaphragm plication

BACKGROUND

Diaphragm dysfunction following surgery for congenital heart disease is a known complication leading to delays in recovery and increased post-operative morbidity and mortality. We aimed to determine the incidence of and risk factors associated with diaphragm plication in children undergoing cardiac surgery and evaluate timing to repair and effects on hospital cost and length of stay.

METHODS

We conducted a multi-institutional retrospective observational cohort study. Forty-three hospitals from the Pediatric Health Information System database were included, and a total of 112,110 patients admitted between January 2004 and December 2014 were analysed.

RESULTS

Patients less than 18 years of age who underwent cardiac surgery were included. Risk Adjustment for Congenital Heart Surgery was utilized to determine procedure complexity. The overall incidence of diaphragm dysfunction was 2.2% (n = 2513 out of 112,110). Of these, 24.0% (603 patients) underwent diaphragm plication. Higher complexity cardiac surgery (Risk Adjustment for Congenital Heart Surgery 5-6) and age less than 4 weeks were associated with a higher likelihood of diaphragm plication (p-value < 0.01). Diaphragmatic plication was associated with increased hospital length of stay (p-value < 0.01) and increased medical cost.

CONCLUSIONS

Diaphragm plication after surgery for congenital heart disease is associated with longer hospital length of stay and increased cost. There is a strong correlation of prolonged time to plication with increased length of stay and medical cost. The likelihood of plication increases with younger age and higher procedure complexity. Methods to improve early recognition and treatment of diaphragm dysfunction should be developed.

Impact of Phrenic Nerve Palsy on Late Fontan Circulation

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.

Diaphragmatic palsy after cardiac surgery in adult and pediatric patients

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.