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Eur J Cardiothorac Surg 1998;13:206-208
© 1998 Elsevier Science NL
Case report |
a Clinics of Cardiovascular and Thoracic Surgery, Geneva, Switzerland
b Department of Anesthesiology, Pharmacology/Surgical Intensive Care, University Hospital of Geneva, CH-1211 Geneva 14, Switzerland
Received 16 June 1997; accepted 16 December 1997.
Corresponding author. Tel.: +41 22 3827403; fax: +41 22 3727690.
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Abstract |
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 Top Abstract Introduction
Case history
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Key Words: Surgery • Diaphragmatic plication • Monitoring: spirometry, capnography • Thorax: diaphragmatic paralysis
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Introduction |
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TopAbstractIntroduction
Case history
Discussion
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Case history |
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TopAbstractIntroduction
Case history
Discussion
References |
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The decision to proceed to surgical plication was made by considering that, the patient’s quality of life was severely limited as a result of a restrictive pulmonary pattern most likely attributed to left diaphragmatic paralysis.
A left double-lumen tube was positioned in the left bronchus and perioperative analgesia was conducted with a thoracic epidural catheter. An in-line respiratory monitor (AS3 Datex Instrum. Corp. Helsinki, Finland) was used for continuous measurements of airway pressure, end expiratory CO2 concentration (PETCO2), as well as breath-by-breath calculation of respiratory dynamic compliance.
A left posterolateral thoracotomy was performed and on examination, the hemidiaphragm appeared flaccid, atrophic and devoid of muscular fibres. The remaining fibrotic hemidiaphragm was plicated by folding its lateral and posterior portions with a series of ten pledgeted 1-0 nonabsorbable sutures until it was tense to palpation. The plicated segment was then oversewn with a continuous monofilament suture. After re-expansion of the collapsed lung, respiratory compliance improved dramatically (36 vs. 26 ml/cm H20 before surgical incision) and was accompanied by higher PaO2/FIO2 ratio (79.3 vs. 64.7 kPa before surgical incision) and smaller arterial-to-end expiratory CO2 gradient.
The patient was extubated in the operating room and the chest roentgenogram taken 2 h postoperatively, showed the left hemidiaphragm in a near normal position. As early as 4 h after the end of surgery, spirometric data recovered baseline values and improved thereafter. Within 6 weeks postoperatively, the patient had recovered the ability to perform her daily activities, FVC and FEV1 were increased by 33 and 47%, while arterial PO2 on room air increased from 8.8 to 9.7 kPa (Table 1). After 1 year follow-up, the patient is still doing well and no deterioration have been observed.
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Discussion |
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In adults, unilateral diaphragmatic paralysis is either idiopathic or related to neoplastic infiltration, viral or bacterial infection, or trauma [1] [3]. In this case, chest X-rays was unremarkable before cardiac operation, whereas, a raised hemidiaphragm was noted 7 years postoperatively. After open heart surgery, an elevated hemidiaphragm is encountered in about 25% and may be related to the use of ice/slush topical hypothermia, pleural effusion, operative trauma or jugular cannulation [4]. Unilateral diaphragmatic dysfunction does not dramatically compromise ventilation in patients with normal lung function and it usually recovers within 1–18 months [5]. In 1994, Glassman et al. [6] reported the first case of successful plication for diaphragmatic paralysis and subsequent acute respiratory failure following coronary artery bypass surgery. In the present case, an ‘asymptomatic’ raised hemidiaphragm was documented following cardiac surgery and the delayed onset of respiratory symptoms was likely explained by an age-dependent decrease in pulmonary reserve capacity.
Some beneficial physiological changes were already detected intraoperatively by continuous spirometry and capnometry. Re-expansion of the left lung following diaphragmatic plication was accompanied by a significant increase in dynamic compliance of the left lung and of the whole respiratory system, as well as by a decrease in arterial-to-end expiratory CO2 gradient that likely reflected improved ventilation/perfusion matching and greater functional respiratory volumes.
As early as 4 h after thoracotomy, FVC and FEV1 recovered preoperative values and gradually increased thereafter. Epidural analgesia could hasten the onset of physiological improvements by alleviating pain and suppressing the inhibitory reflexes acting on the right diaphragm [7]. Long term improvements are better explained by structural and physiological reconfiguration of the thoracic cavity and may persist for as long as 10 years after operation [3]. First, enlargement of the hemithorax by fixing the paralyzed hemidiaphragm in a lower position produces greater functional residual capacity. Second, as the intercostal and accessory muscles operate in series with the diaphragm [8], plication of the noncontractile hemidiaphragm attenuates its lengthening during contraction of the other inspiratory muscles. Third, a change in the configuration and position of the left hemidiaphragm allows better recruitment of the ipsilateral inspiratory muscles and the contralateral hemidiaphragm [9]. In agreement with these hypotheses, a significant increase in maximal transdiaphragmatic pressure and greater changes in gastric and esophageal pressures have been observed after plication that are consistent with an improved ability of contractile inspiratory muscles to act as pressure generators [8].
In conclusion, diaphragmatic plication should be considered in adults suffering from immediate or delayed respiratory insufficiency following cardiac surgery. Early physiological improvements induced by surgical plication can be detected intraoperatively with in line respiratory monitor and are manifested postoperatively by greater functional lung volumes and better exercise capacity.
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Discussion
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This article has been cited by other articles:
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  L. A. Bockeria, A. Kim, D. Ryabtsev, and T. Grygoryants ICVTS on-line discussion A Diaphragmatic plication as a complication in cardiac surgery Interactive CardioVascular and Thoracic Surgery, June 1, 2007; 6(3): 282 - 282. [Full Text] [PDF]
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 A. Di Giorgio, C. L. Cardini, P. Sammartino, S. Sibio, and E. Naticchioni Dual-layer sandwich mesh repair in the treatment of major diaphragmatic eventration in an adult J. Thorac. Cardiovasc. Surg., July 1, 2006; 132(1): 187 - 189. [Full Text] [PDF]
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