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Diaphragm Paralysis After Pediatric Cardiac Surgery: An STS Congenital Heart Surgery Database Study
Charles D Fraser1, William Ravekes2, Dylan Thibault3
1Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
Insights
Diaphragm paralysis (DP) after pediatric heart surgery is uncommon but linked to worse outcomes. While half of affected children undergo plication, practice variability suggests areas for quality improvement in pediatric cardiac surgery care.
Area of Science:
- Pediatric Cardiac Surgery
- Thoracic Surgery
- Critical Care Medicine
Background:
- Diaphragm paralysis (DP) following pediatric cardiac surgery is a known complication.
- Previous studies, primarily single-center, reported variable incidence (0.3%-12.8%) and associated adverse outcomes.
- A multicenter study was needed to better define DP incidence and its associations.
Purpose of the Study:
- To determine the incidence of diaphragm paralysis (DP) after pediatric cardiac surgery.
- To investigate the associations between DP and various surgical procedures and patient outcomes.
- To explore the relationship between center volume and DP rates and plication practices.
Main Methods:
- A multicenter retrospective study using the Society of Thoracic Surgeons Congenital Heart Surgery Database (2010-2018).
- Identified pediatric patients undergoing cardiac surgery with and without DP.
- Compared baseline characteristics and postoperative outcomes; analyzed plication use and center volume associations.
Main Results:
- Diaphragm paralysis (DP) occurred in 1.2% (2214/191,463) of pediatric cardiac surgery patients.
- DP was associated with significantly higher mortality, major morbidity, tracheostomy, prolonged ventilation, and 30-day readmission rates.
- Half of DP patients (49.9%) underwent plication, with wide center variation; no correlation found between center volume and DP or plication rates.
Conclusions:
- Diaphragm paralysis (DP) is a rare but serious complication of pediatric heart surgery, significantly worsening patient outcomes.
- Plication is performed in approximately half of DP cases, but practices vary widely across institutions.
- Variability in plication suggests a need for quality improvement initiatives to standardize care for pediatric patients with DP.
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.
