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Phrenic nerve paralysis after pediatric cardiac surgery. Retrospective study of 125 cases
Insights
Phrenic nerve paralysis occurs in 1.6% of pediatric cardiac surgeries, particularly after reoperations. While 84% of children recover function, diaphragmatic plication offers a safe solution for severe cases in young children.
Area of Science:
- Pediatric Cardiac Surgery
- Thoracic Surgery
- Neurology
Background:
- Phrenic nerve paralysis is a known complication of cardiac surgery.
- The incidence and risk factors in pediatric populations require further elucidation.
Purpose of the Study:
- To determine the incidence of phrenic nerve paralysis following pediatric cardiac surgery.
- To identify specific procedures associated with higher risk.
- To evaluate the outcomes and management of phrenic nerve paralysis in children.
Main Methods:
- Retrospective review of 7,670 pediatric cardiac surgical procedures over 12 years.
- Analysis of phrenic nerve paralysis incidence, associated procedures, patient demographics, and outcomes.
- Evaluation of diaphragmatic plication as a treatment modality.
Main Results:
- Phrenic nerve paralysis occurred in 1.6% of cases, with higher incidence in open-heart (1.9%) vs. closed-heart (1.3%) procedures.
- Higher rates were observed after reoperations, with specific procedures like Mustard (6.7%) and RVOT reconstruction (5.6%) showing increased risk.
- Mortality was 5.6%, and mechanical ventilation duration was significantly longer in younger patients; diaphragmatic plication was safe and effective.
Conclusions:
- Phrenic nerve paralysis is a significant morbidity following pediatric cardiac surgery, especially reoperations.
- Most children (84%) experience eventual recovery of phrenic nerve function.
- Diaphragmatic plication is a safe and effective intervention, particularly for children under two requiring prolonged ventilation.
Abstract:
Phrenic nerve paralysis was diagnosed in 125 children (1.6%) from a series of 7,670 cardiac surgical procedures in infants and children during a 12 year period. The incidence was 1.9% for open heart and 1.3% for closed heart operations. In order of decreasing incidence, the open heart procedures included Mustard procedure (6.7%), right ventricular outflow tract reconstruction (5.6%), and repair of tetralogy of Fallot (2.7%). The closed heart procedures included Glenn anastomosis (6.2%), Blalock-Hanlon atrial septectomy (5.9%), and right Blalock-Taussig shunt (5.1%). Procedures following previous operations or thoracotomies had almost twice the incidence of phrenic nerve paralysis: Mustard procedure 9.9%, right ventricular outflow tract reconstruction 10.8%, and tetralogy repair 5.5%. Seven patients (5.6%) with phrenic nerve paralysis died. Patients less than 2 years old with phrenic nerve paralysis were intubated for 0 to 57 (average 15.7) days after their cardiac operations and those over 2 years old for 13 to 35 (average 7.2) days (p less than 0.001). Twelve patients had diaphragmatic plication without mortality and were extubated 0 to 6 (average 2.3) days after plication. We have made the following conclusions: (1) Phrenic nerve paralysis may occur after both open and closed cardiac procedures and is more common in children requiring reoperation; (2) it is associated with considerable morbidity; (3) eventual recovery of phrenic nerve function occurs in 84% of children; and (4) diaphragmatic plication is safe, reliable, and of most value in patients who are under 2 years of age and require mechanical ventilation for more than 2 weeks.