Phrenic nerve injury after paediatric heart surgery: is aggressive plication of the diaphragm beneficial?

OBJECTIVES Phrenic nerve injury after paediatric heart surgery is associated with significant morbidity. Surgical plication of the diaphragm is believed to be beneficial to the patient, with difficult weaning from ventilation; however, the optimal timing remains unclear. We aimed to compare the outcome after two different strategies for treating hemidiaphragmatic paresis. METHODS A retrospective analysis of all patients with paresis of the diaphragm between 2000 and 2010 was performed, with special attention to the rate of reintubations, ventilation and intensive care unit (ICU) stay and the rate of plication. In 2005, the strategy for treating diaphragmatic paresis in our institution changed from conservative treatment with plication after multiple extubation efforts towards an aggressive one with plication after a single unsuccessful extubation. We compared the outcome of all patients and that of the newborns separately from the two periods. RESULTS During the study period, 148 patients with diaphragmatic paresis were diagnosed and included. Median age at the cardiac operation was 7 months (1 day-18 years), ventilation time ranged from 4 h to 41 days (median 7 days), 42 (28.4%) of the patients required at least one reintubation and ICU stay ranged from 2 to 63 days (median 11 days). A total of 63 plications were performed-5 (9%) before 2004 and 58 (62%) after 2005, P < 0.001. There were no significant differences in the ventilation time-6 (1-40) vs 8 (0-41) days, P = 0.36, reintubation rate-28 vs 29%, P = 0.85 and ICU stay-10 (3-63) vs 12 (2-55) days, P = 0.41 between both groups. The newborn patients, treated with the different strategies, also did not differ significantly in their outcome: ventilation time-12 (2-40) vs 11.5 (3-34) days, P = 0.38; reintubation rate-43 vs 41%, P = 0.62; ICU stay-16 (6-63) vs 15 (7-55) days, P = 0.55. CONCLUSIONS Changing the strategy for phrenic nerve injury after paediatric heart surgery towards a more aggressive one with early plication of the diaphragm was not associated with the better outcome. Prospective randomized studies are needed to determine the optimal management of this complication.