AB 64. Early hemi-diaphragmatic plication through a video assisted mini-thoracotomy in postcardiotomy phrenic nerve paresis
Background: New symptom onset of respiratory distress without other cause, and new hemi-diaphragmatic elevation on chest radiography postcardiotomy, are usually adequate for the diagnosis of phrenic nerve paresis. The symptom severity varies (asymptomatic state to severe respiratory failure) depending on the degree of the lesion (paresis vs. paralysis), the age, and the co-morbidity (respiratory/cardiac disease, morbid obesity, etc). Surgical treatment (hemi-diaphragmatic plication) is indicated only in the presence of symptoms. The timing of surgery depends on the severity and the progression of symptoms. In infants and young children with postcardiotomy phrenic nerve paresis the clinical status is usually severe (failure to wean from mechanical ventilation), and early plication is indicated. Adults with postcardiotomy phrenic nerve paresis usually suffer from chronic dyspnoea, and, in the absence of respiratory distress, conservative treatment is recommended for 6 months -2 years, since improvement is often observed. Nevertheless, earlier surgical treatment is indicated in non-resolving respiratory failure. We present early hemi-diaphragmatic plication, in a high risk patient with postcardiotomy phrenic nerve paresis.
Patient and methods: A 72 year old woman, with bioprosthetic mitral valve endocarditis, native aortic valve endocarditis, and acute renal failure, underwent urgent redo mitral valve replacement and aortic valve replacement (predicted mortality Euroscore II: 23.86%). Despite good valve and cardiac function, infection control, and weaning from mechanical ventilation she had respiratory failure (dyspnoea, tachypnoea, orthopnoea, hypoxaemia, need for continuous oxygen supplementation). Chest radiography revealed a new right hemi-diaphragm elevation, with severe progressing lung atelectasis. Right hemi-diaphragm postero-anterior plication was performed through a video assisted right mini-thoracotomy on the 25th postoperative day.
Results: Early extubation was achieved, adequate respiratory function was established, chest radiography was normalized (normal right hemidiaphragm position, right lung expansion). After mobilization and rehabilitation the patient was discharged home on the 8th day after plication.
Conclusions: Several techniques and approaches are employed for diaphragmatic plication (thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery). The early plication through a video assisted mini-thoracotomy was safe and effective, offering minimal surgical trauma, short operative time, minimal blood loss and postoperative pain, leading to fast rehabilitation and avoidance of prolonged hospitalization complications.
